Virginia's Workers' Compensation System And Disease Presumptions
Commonwealth of VirginiaDecember 16, 2019Report to the Governor and the General Assembly of VirginiaVirginia’s Workers’ Compensation Systemand Disease Presumptions2019JOINT LEGISLATIVE AUDITAND REVIEW COMMISSION
Joint Legislative Audit and Review CommissionSenator Thomas K. Norment, Jr., ChairDelegate Terry AustinDelegate Betsy CarrDelegate M. Kirkland CoxSenator Emmett W. Hanger, Jr.Delegate Charniele L. HerringSenator Janet D. HowellDelegate S. Chris JonesSenator Ryan T. McDougleDelegate Robert D. Orrock, Sr.Delegate Kenneth R. PlumSenator Frank M. Ruff, Jr.Delegate Christopher P. StolleMartha S. Mavredes, Auditor of Public AccountsJLARC staffHal E. Greer, DirectorTracey Smith, Associate DirectorDrew Dickinson, Project LeaderDanielle ChildressBrittany UtzKeegan EdgarInformation graphics: Nathan SkresletManaging Editor: Jessica SabbathJLARC Report 530 2019 Joint Legislative Audit and Review Commissionjlarc.virginia.gov
ContentsSummaryRecommendations and OptionsiviiChapters1. Virginia’s Workers’ Compensation System12. Timeliness of the Workers’ Compensation System113. Fairness in the Workers’ Compensation System234. Appropriateness of Disease Presumptions415. Establishing and Rebutting Virginia’s Disease Presumptions636. Preventing Fraudulent or Inaccurate Workers’81Compensation BenefitsAppendixesA: Study resolution93B: Research activities and methods95C: Virginia’s disease presumptions104D: Alternative benefit programs in Colorado, Georgia, and New York106E: Examples of other approaches to address concerns107with disease presumptionsF: Agency responses109
Summary: Virginia’s Workers’ Compensation Systemand Disease PresumptionsWHAT WE FOUNDClaims are generally handled by VWC in atimely and fair mannerDisputes between employers/insurers and workersinvolving workers’ compensation claims areadjudicated by the Virginia Workers’ CompensationCommission (VWC) in a timely manner, andworkers’ and employers’ attorneys are generallysatisfied with the timeliness and fairness of VWC’shandling of disputed claims. However, VWC couldtake steps to improve the timeliness of hearings heldin the Fairfax office and deputy commissioners’issuance of opinions.Delays in the claims process sometimesoccur before claims reach VWCEmployers’ workers’ compensation insurers makethe first determination about the compensability ofa worker’s injury. The timeliness of insurers’compensability determinations was noted as thesecond most common challenge experienced byfirefighters who had filed a workers’ compensationclaim during the past five years. Virginia is one ofonly a few states that does not require insurers tomake claims decisions within a statutorily specifiedtimeframe.WHY WE DID THIS STUDYIn December 2018, the Joint Legislative Audit andReview Commission (JLARC) directed staff to conduct areview of Virginia’s workers’ compensation system anduse of disease presumptions. Specifically, staff weredirected to assess whether workers’ compensationclaims were reviewed and processed promptly and fairly(including as part of VWC’s dispute resolution process),assess the measures in place to minimize the potentialfor fraud and abuse in the system, and determinewhether Virginia’s disease presumptions are appropriateand whether the level of evidence required to claim orrebut them is reasonable and appropriate.ABOUT WORKERS’ COMPENSATIONThe workers’ compensation system is intended to protect workers from the economic burden of work-relatedinjuries or diseases. When Virginia workers are unable towork because they have been injured on the job or havecontracted a work-related disease, they may receive partial wage replacement, known as “indemnity benefits,”coverage of associated medical costs, and/or coverageof vocational rehabilitation expenses. Certain publicsafety workers can also seek compensation for certaindiseases considered “presumptive diseases,” which theGeneral Assembly has decided must be presumed tohave developed through employment unless an employer can provide compelling evidence to rebut theconnection.Workers are not well informed about theprocess to file claims or their rights to dispute insurers’compensability decisionsWorkers are sometimes confused about how to access and navigate Virginia’s workers’ compensation system. Workers have an insufficient understanding of the processto file for workers’ compensation benefits and the role that VWC plays in resolvingdisputes between workers and their employers. The information that VWC providesto workers about their rights and responsibilities in the workers’ compensation system is (1) scattered across VWC’s website, (2) not well organized within each docu-i
Summary: Virginia’s Workers’ Compensation System and Disease Presumptionsment, (3) unclear, and (4) incomplete. Moreover, employers and their workers’ compensation insurers do not consistently provide information to workers about theirrights to dispute initial compensability decisions.Workers’ lack of awareness about workers’ compensation procedures can jeopardizetheir ability to fully pursue and potentially receive compensation for their work-relatedinjuries. For example, over 200 firefighters with a work-related injury or disease reported that they were unaware of their right to dispute a denial by their employer’sinsurer to VWC. Additionally, a number of firefighters who had been diagnosed withcancer or cardiovascular disease told JLARC staff they thought they had filed a claimwith VWC because they reported their injury to their employer. This misperceptioncould prevent them from fully pursing and potentially receiving workers’ compensation benefits.Virginia is the only state where employers are not obligated tocompensate workers for work-related cumulative trauma injuriesIn contrast to the 49 other states, Virginia does not provide a remedy through theworkers’ compensation system for injuries due to repetitive work activities, such aslifting boxes over several weeks (also known as “cumulative trauma injuries”). As aresult, Virginia workers are required to bear the costs associated with cumulativetrauma injuries, even when they arise out of and in the course of employment.Employer costs have been cited by multiple stakeholders as the primary reason whyVirginia’s workers’ compensation system does not cover cumulative trauma injuries.However, it does not appear that cumulative trauma injuries are a major cost driver ofworkers’ compensation premiums in other states.Employers in Virginia pay comparatively high medical costs forworkers’ compensation claimsThe cost of medical services paid by insurers to treat injuries or diseases appears to becomparatively high. Medical fee schedules that were put in place in 2018 to providegreater cost certainty for insurers appear to have somewhat reduced costs, but at leastsome reimbursement rates in Virginia’s medical fee schedules appear to be highcompared with other states.Best available scientific evidence indicates that existing and proposedcancer presumptions are appropriateDisease presumptions are intended to relieve workers in certain occupations of theneed to prove a causal connection between their work and their disease. A key premiseof disease presumptions is that a plausible connection exists between a presumptivedisease and the workers’ occupation, but evidence to prove a connection is difficult orimpossible to obtain.ii
Summary: Virginia’s Workers’ Compensation System and Disease PresumptionsAccording to epidemiologists at Johns Hopkins University’s Bloomberg School ofPublic Health, who conducted a systematic review of the existing scientific researchrelated to Virginia’s disease presumptions, research is mixed on the extent of a causalconnection between firefighting and the 10 existing and proposed cancer presumptions. Although mixed, the existing research is sufficient to support a plausible connection between firefighting and the cancers currently included as presumptive diseases in the Code of Virginia. A plausible connection also exists between firefightingand three cancers that House Bill 1804 (2019) proposed adding to Virginia’s statute:colon, testicular, and brain cancer. Among these three, the evidence of a link betweenfirefighting and colon cancer is the least strong but still plausible according to epidemiological research.Requirements to establish cancer presumptions are unreasonablyburdensome and not supported by scienceMost disputed cancer claims from 2009 to 2018 resulted in firefighters not receivingbenefits, primarily because firefighters failed to prove their exposure to the specificcarcinogen that caused their cancer (a requirement in existing case law) or failed tomeet the presumption’s disability requirement. The application of these two statutoryrequirements—to prove contact with a toxic substance that caused a firefighter’s cancer and to prove a period of disability—is unreasonably burdensome and possiblycounter to legislative intent.According to Johns Hopkins University researchers, it is unreasonable to require firefighters to document exposure to carcinogens that cause their particular cancer, because doing so is difficult or impossible with existing technology and is cost prohibitive. Additionally, requiring a firefighter to identify a single carcinogen that is knownto cause his or her type of cancer appears counter to the purpose of the presumption,which is to relieve firefighters of the need to prove that their occupation caused thedisease.The application of the disability requirement has been problematic because, in somecases, a firefighter’s cancer was not presumed to be caused by work simply because theworker did not have a period of wage loss. Whether a firefighter loses wages becauseof his or her disease does not appear to be relevant to whether his or her employmentcaused the disease.Virginia’s cancer presumption statute also requires firefighters to serve 12 or moreyears of continuous service in the occupation, but the basis for this service requirement is unclear and does not align with research on cancer among firefighters. JohnsHopkins University researchers identified scientific evidence that some exposure durations shorter than 12 years can lead to increased cancer risk. Virginia’s 12-year requirement is one of the longest service requirements to claim a cancer presumptionamong states.iii
Summary: Virginia’s Workers’ Compensation System and Disease PresumptionsCardiovascular disease presumption is difficult, but not impossible,for employers to rebutRebuttal requirements for Virginia’s cardiovascular disease presumption are more difficult to meet than those of some states. However, workers’ compensation is intendedto favor injured workers, and presumptions are not supposed to be easy to rebut.Moreover, Virginia’s cardiovascular disease presumption is not impossible to rebut—23 percent of cardiovascular disease cases decided by VWC between 2009 and 2018were successfully rebutted by employers.Risk of cardiovascular disease increases with years of serviceScientific evidence supports that public safety workers’ risk of work-related cardiovascular disease increases over time. Unlike Virginia, other states have a years of servicerequirement for public safety workers to benefit from a cardiovascular disease presumption. Establishing a years of service requirement would be consistent with epidemiological research, put Virginia more in line with other states’ practices, and helpensure that employers and workers’ compensation insurers do not pay for the costs ofnon-work-related diseases.Virginia should pursue improvements to the existing system beforeconsidering an alternative benefit programSince 2017, several states have created disease benefit programs for firefighters, inplace of workers’ compensation programs, to address employer and worker frustrations with disease presumption statutes. Creating such a program in Virginia may notbe necessary at this time. Implementing this report’s recommendations to addressshortcomings in the current system could be considered before pursuing such a wholesale change.RECOMMENDATIONSLegislative action Establish a timeframe in statute for insurers to make initial compensabilitydeterminations on injuries and diseases reported to them and require VWCto monitor compliance with the requirement and impose financial penaltiesfor noncompliance. Require workers’ compensation insurers, including employers who are selfinsured, to notify injured workers about their right to dispute insurers’denials of workers’ compensation benefits. Allow cumulative trauma injuries to be compensable. Authorize and direct VWC to include as part of its biennial reviews ofworkers’ compensation medical costs a comparison of Virginia’s medicalfees to Medicare reimbursement rates.iv
Summary: Virginia’s Workers’ Compensation System and Disease Presumptions Modify the cancer presumption to allow firefighters to meet the toxicexposure requirement through evidence that they responded to fires. Clarify that the disability requirement for claiming a disease presumptioncan be met through medical evidence. Reduce the years of service requirement for the cancer presumption.Executive action Hire at least one additional deputy commissioner to be assigned to theFairfax office. Review and revise all written materials for communicating with andinforming workers, employers, and insurers to ensure that information isaccurate and clear and develop a comprehensive guide for injured workersexplaining their rights and the role of VWC. Notify, as soon as practicable, all injured workers who have not yetsubmitted a claim for benefits, about their right to dispute insurers’ denialsand the need to file a claim directly with VWC within the statute oflimitations to preserve their right to benefits.Policy options Add brain, colon, and testicular cancers to the list of cancers presumed tobe caused by firefighting. Add a years of service requirement to the cardiovascular diseasepresumption.The complete list of recommendations and policy options is available on page vii.v
Summary: Virginia’s Workers’ Compensation System and Disease Presumptionsvi
Recommendations and Options: Virginia’s Workers’Compensation System and Disease PresumptionsRECOMMENDATION 1The Virginia Workers’ Compensation Commission should appoint at least one additional deputy commissioner assigned to handle hearings and mediations for the Fairfaxoffice. (Chapter 2)RECOMMENDATION 2The Virginia Workers’ Compensation Commission should ensure that its chief deputycommissioner issues guidance to deputy commissioners that communicates that theyhave discretion to prioritize the order in which they write their opinions so that theycan maximize the number of opinions issued within 21 days. (Chapter 2)RECOMMENDATION 3The Virginia Workers’ Compensation Commission should (i) modify its electronic reporting capabilities to calculate the number of days that each deputy commissionerhas taken to issue opinions after the record close date; (ii) generate quarterly reportsthat will identify any deputy commissioners who have taken longer than the 21-daygoal to issue a majority of their opinions; (iii) require the chief deputy commissionerto work with deputy commissioners to develop strategies to improve the timelinesswith which these deputy commissioners issue opinions; and (iv) require the chief deputy commissioner to report annually to the full Commission on the timeliness withwhich deputy commissioners are issuing their opinions. (Chapter 2)RECOMMENDATION 4The Virginia Workers’ Compensation Commission should expand the number of timeslots available for full and final mediation by allowing staff attorneys to conduct fulland final mediations in cases where neutral facilitation is selected by the parties. (Chapter 2)RECOMMENDATION 5The Virginia Workers’ Compensation Commission should no longer refer to issue mediation (or issue facilitation) those dispute types that are infrequently resolved throughissue mediation. (Chapter 2)RECOMMENDATION 6The Virginia Workers’ Compensation Commission should assign at least one deputycommissioner to the Fairfax office who is certified to conduct mediations. (Chapter 2)vii
Recommendations: Virginia’s Workers’ Compensation System and Disease PresumptionsRECOMMENDATION 7The General Assembly may wish to consider amending Title 65.2 of the Code ofVirginia to require (i) workers’ compensation insurers, including those employers whoare self-insured, to make a determination as to whether a worker’s injury or disease isaccepted as compensable and notify the worker, as well as the Virginia Workers’ Compensation Commission, of this decision within 30 days of receiving notice of the injury or disease, and (ii) VWC to enforce this requirement through monetary penaltiesimposed on insurers and self-insured employers for noncompliance. (Chapter 2)RECOMMENDATION 8The General Assembly may wish to consider including language in the AppropriationAct to direct the Virginia Workers’ Compensation Commission to report annually on(i) the extent to which workers’ compensation insurers, including those employers whoare self-insured, are making compensability determinations and notifying workers oftheir decisions in a timely manner after receiving notice of work-related injuries anddiseases and (ii) actions taken by VWC to ensure the timeliness of these decisions. Thefirst report should be submitted by VWC to the House Appropriations and SenateFinance committees no later than June 30, 2022. (Chapter 2)RECOMMENDATION 9The Virginia Workers’ Compensation Commission should provide interpreters for mediations upon request. (Chapter 3)RECOMMENDATION 10The Virginia Workers’ Compensation Commission (VWC) should develop a comprehensive and easy-to-understand guide for injured workers, publish this guide online,and provide this guide to all Virginia workers who are reported to have been injuredat work. At a minimum, the guide should include information on the rights of Virginiaworkers under the Workers’ Compensation Act, the role of VWC in Virginia’s workers’compensation system, the process for filing a claim and resolving disputes, servicesavailable at VWC, and how injured workers can find an attorney to represent them.(Chapter 3)RECOMMENDATION 11The Virginia Workers’ Compensation Commission (VWC) should review by January1, 2021 all of its written and online materials for communicating with and informingworkers, employers, and insurers, to ensure that all materials are as clear, accurate,comprehensive, and accessible as possible. (Chapter 3)viii
Recommendations: Virginia’s Workers’ Compensation System and Disease PresumptionsRECOMMENDATION 12The General Assembly may wish to consider amending § 65.2-200 of the Code ofVirginia to create an ombudsman office within the Virginia Workers’ CompensationCommission, led by an attorney in good standing with the Virginia State Bar. Theoffice should (i) provide timely and confidential educational information and assistance to unrepresented parties to help them understand their rights under the Workers’Compensation Act and the various processes available to them; (ii) carry out dutieswith impartiality and not provide legal advice; and (iii) maintain data on inquiries received, types of assistance requested, and actions taken. (Chapter 3)RECOMMENDATION 13The General Assembly may wish to consider amending the Code of Virginia to requireworkers’ compensation insurers, including those employers who are self-insured, toinclude a notice in any letter denying workers’ compensation benefits that the injuredworker has a right to dispute the claim denial through the Virginia Workers’ Compensation Commission (VWC). The notice should indicate (i) VWC’s neutral role withinthe workers’ compensation system to adjudicate disputed claims; (ii) the need to file aclaim for benefits with VWC within the applicable statute of limitations; and (iii) contact information for VWC. (Chapter 3)RECOMMENDATION 14The Virginia Workers’ Compensation Commission (VWC) should send a notice to allinjured workers for whom it has received a First Report of Injury, but who have notyet submitted a claim for benefits to VWC and are still within the applicable statute oflimitations, which explains (i) the rights of injured workers to dispute an insurer’s denial of workers’ compensation benefits with VWC; (ii) the existence and role of VWCin Virginia’s workers’ compensation system; and (iii) the importance of filing a claimwith VWC within the statute of limitations to protect the worker’s right to benefits.This notice should be sent to all applicable injured workers as soon as possible, but nolater than January 31, 2020. (Chapter 3)RECOMMENDATION 15The General Assembly may wish to consider including language in the AppropriationAct to direct the Virginia Workers’ Compensation Commission (VWC) to hire an independent and reputable national research organization with expertise in workers’compensation policy to (i) develop options for covering workers’ cumulative traumainjuries through Virginia’s workers’ compensation system and (ii) summarize key policyconsiderations associated with modifying statute to cover cumulative trauma injuries.The research organization should take into consideration (i) the annual number ofcumulative trauma injuries in Virginia and other states; (ii) other states’ evidentiaryrequirements for claiming workers’ compensation benefits for such injuries; (iii) necessary changes to Virginia’s statutory provisions; and (iv) impacts on workers, employers, and insurers. VWC should ensure the proposed options and policy considerationsare submitted to the House Appropriations and Senate Finance committees by November 30, 2020. (Chapter 3)ix
Recommendations: Virginia’s Workers’ Compensation System and Disease PresumptionsRECOMMENDATION 16The General Assembly may wish to consider amending Title 65.2 of the Code ofVirginia to make cumulative trauma injuries compensable under the Workers’ Compensation Act. (Chapter 3)RECOMMENDATION 17The General Assembly may wish to consider amending § 65.2-605.2 of the Code ofVirginia to authorize and direct the Virginia Workers’ Compensation Commission(VWC) to include in its existing biennial reviews of Virginia’s workers’ compensationmedical costs a comparison of Virginia’s medical fees to Medicare reimbursement ratesfor the same services in Virginia. (Chapter 3)RECOMMENDATION 18The General Assembly may wish to consider amending §65.2-101 of the Code ofVirginia to specify that psychological injuries can be compensable even if the eventcausing the psychological injury could have been reasonably expected by the workerto have occurred as part of his or her job responsibilities. (Chapter 4)RECOMMENDATION 19The General Assembly may wish to consider amending Title 65.2 of the Code ofVirginia to establish a process for reviewing the scientific research on proposed newpresumptions or modifications to existing presumptions under the Virginia’s Workers’Compensation Act prior to legislative action, with consideration given to (i) thestrength of the association between the occupation and the disease and the relevanthazards to which workers in the occupation are exposed and (ii) the relevance, quality,and quantity of the literature and data available to determine the strength of evidence.(Chapter 4)RECOMMENDATION 20The General Assembly may wish to consider amending § 65.2-402.C of the Code ofVirginia to provide that a firefighter may meet the toxic exposure requirement eitherby demonstrating (i) exposure to a toxic substance, as is currently required, or (ii) participation in responses to fire scenes, either during the fire or afterwards as part ofclean-up or investigation. (Chapter 5)RECOMMENDATION 21The General Assembly may wish to consider amending § 65.2-402 of the Code ofVirginia to clarify that, for the purposes of establishing the presumptions, (i) a total orpartial disability may be demonstrated through wage loss, lost work time, or medicalevidence and that (ii) workers seeking only medical benefits may demonstrate a totalor partial disability solely through medical evidence. (Chapter 5)x
Recommendations: Virginia’s Workers’ Compensation System and Disease PresumptionsRECOMMENDATION 22The General Assembly may wish to consider amending § 65.2-402.C of the Code ofVirginia to reduce the years of service requirement from 12 years. (Chapter 5)RECOMMENDATION 23The General Assembly may wish to consider amending § 65.2-402.C of the Code ofVirginia to remove the word “continuous” from the years of service requirement.(Chapter 5)RECOMMENDATION 24The Auditor of Public Accounts (APA) should conduct an audit to (i) determine thefrequency and magnitude of errors in calculating and paying wage replacement benefits for workers’ compensation and the Virginia Sickness and Disability Program; (ii)assess the extent to which these errors are ultimately corrected; and (iii) identify opportunities to better coordinate payments between these two programs. (Chapter 6)RECOMMENDATION 25The Department of Human Resource Management and the Virginia Retirement System should convene a stakeholder group composed of staff from the Department ofAccounts and payroll and human resources staff from various state agencies to improve training and resources to be provided to state agencies for appropriately calculating the benefits that should be paid to workers eligible for workers’ compensationbenefits and Virginia Sickness and Disability Program benefits. (Chapter 6)OPTION 1The General Assembly could amend § 65.2-402 of the Code of Virginia to add brainand testicular cancers to the list of cancers that are presumed to have been caused byfirefighting. (Chapter 4)OPTION 2The General Assembly could amend § 65.2-402 of the Code of Virginia to add coloncancer to the list of cancers that are presumed to have been caused by firefighting.(Chapter 4)OPTION 3The General Assembly could consider amending § 65.2-402 of the Code of Virginiato specify that the presumptions for breast, colon, ovarian, and pancreatic cancerscovered by the statute shall not apply to workers’ compensation claims submitted afterJune 30, 2030. Prior to June 30, 2030, the General Assembly could direct an examination of the latest national research on the association between firefighting and thesecancers. (Chapter 4)xi
Recommendations: Virginia’s Workers’ Compensation System and Disease PresumptionsOPTION 4The General Assembly could amend § 65.2-402 of the Code of Virginia to requirethat workers’ compensation claimants have completed a minimum number of yearsof service as a firefighter or police officer, including any time spent in required training, to claim the cardiovascular disease presumption. (Chapter 4)xii
1Virginia’s Workers’ Compensation SystemSUMMARY Workers’ compensation systems are designed to compensate workers who areinjured at work or who develop an occupation-related disease. The Virginia Workers’ Compensation Act outlines employer requirements and the benefits awarded to workers for compensable injuries and diseases. All workers with a compensable injury or disease are entitledto medical benefits to fully cover the cost of medical care related to the injury or disease.Workers may also receive wage replacement benefits if they experience a period of disabilityand cannot work. These benefits are paid by employers through their workers’ compensationinsurers. For workplace injuries or diseases occurring between 2014 and 2016, workers’ compensation benefits were provided to 42,442 Virginia workers, with a median total benefitvalue of approximately 11,600 over the first two years after the injury. The Virginia Workers’Compensation Commission (VWC) oversees the system by maintaining records of injuriesreported by employers and injured workers; adjudicating or mediating disputes between injured workers and their employers or insurers; and ensuring that employers and insurers arecomplying with relevant state laws related to workers’ compensation.In 2018, the Joint Legislative Audit and Review Commission (JLARC) directed its staffto review Virginia’s workers’ compensation system. The study resolution directed staffto assess whether: workers’ compensation claims are reviewed and processed promptlyand fairly by the Virginia Workers’ Compensation Commission (VWC); VWC’s disputeresolution process is timely, effective, and equitable to all parties; Virginia’s diseasepresumptions are appropriate; the level of evidence required to claim or rebut a diseasepresumption is reasonable and appropriate; appropriate measures are in place to minimize the potential for fraud and abuse; and workers’ compensation benefits are appropriately coordinated with other benefits available to injured workers. (See AppendixA for study resolution.)To address the study resolution, JLARC staff interviewed VWC staff including commissioners and deputy commissioners, workers’ compensation attorneys, workers’compensation insurers, public safety officers and associations, federal and academicexperts in occupational health and epidemiology, and staff in other states. JLARC staffalso surveyed firefighters who have experienced a work-related injury or disease andworkers’ compensation attorneys. Staff analyzed data provided by VWC on workers’compensation injuries, claims, awards, and payments, and contracted with occupationalhealth experts at Johns Hopkins University to review the medical and scientific evidence regarding Virginia’s disease presumptions. JLARC staff also contracted with actuarial consultants to project costs of disease presumptions proposed in 2019. (SeeAppendix B for more detail on the research methods used in this study.)1
Chapter 1: Virginia’s Workers’ Compensation SystemWorkers’ compensation systems were created as acompromise between employers and workersAll 50 states have workers’ compensation systems, but there is
1. Virginia's Workers' Compensation System 1 2. Timeliness of the Workers' Compensation System 11 3. Fairness in the Workers' Compensation System 23 4. Appropriateness of Disease Presumptions 41 5. Establishing and Rebutting Virginia's Disease Presumptions 63 6. Preventing Fraudulent or Inaccurate Workers' 81 Compensation Benefits
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