Gerry Realin was at a Chick-fil-A restaurant in Orlando, Florida, with his family this past summer when he started feeling dizzy.

His wife Jessica Realin said they had been talking about money in the days leading up to the episode.

About how he had nearly used up all his accrued vacation time after being a police officer for 12 years. About whether he would ever be back to his old self and return to work. About taking care of his family. About what comes next.

The usually healthy 36-year-old hadn’t been back on duty with the Orlando Police Department in over a month. He tried to go back to work two weeks after helping collect dead bodies at Pulse nightclub, where on June 12 a gunman had killed 49 and wounded more than 50 others in one of the deadliest shootings in U.S. history.

But his anxiety and nightmares led to insomnia, which led to passing out from exhaustion while idling in his police cruiser.

That episode then led to a diagnosis of anxiety and post-traumatic stress disorder.

His doctor told him not to return to work — that his work had damaged him.

In Florida, like most states, however, first responders are unable to collect workers compensation for PTSD caused by what they see on the job.

Some states such as Maryland allow first responders to receive workers comp for PTSD under certain conditions, but the individual has to generally be directly involved in the incident, such as when a police officer has to kill a suspect or is physically injured.

A police office in Stamford, Connecticut, tried to claim PTSD under workers comp after having to kill an aggressive chimpanzee that had torn off the face and hands of a woman in 2009; his claim was initially denied, but lawmakers in 2010 changed the law to include life-threatening attacks involving animals.

Experts say each state has their own laws for first responders, as states do for employees in general, but that few to none will allow PTSD claims for an event an officer or firefighter witnesses on the job.

“They say it’s normal for officers to see this,” said Ms. Realin in an interview with Business Insurance — her husband has been told by the police department to not talk to the media because he is still employed, she said. “There is nothing normal about (it).

The anger and magnitude was different than anything he had ever seen.” According to the Bethesda, Maryland-based National Institute of Mental Health, PTSD is a disorder that develops in some people who have experienced a shocking, scary or dangerous event.

Symptoms may include flashbacks, nightmares and recurring thoughts about the event. For first responders, the disorder can be triggered by one event or an accumulation of events, according to Ron Clark, Middlebury, Connecticut-based chairman of the Badge of Life, an organization that advocates for police officers suffering from PTSD.

The Realins in Florida and Mr. Clark in Connecticut are part of a growing group of families, lawmakers, police unions, mental health experts and law enforcement advocates nationwide that are trying to change the laws in several states to provide workers comp benefits for first responders with PTSD.

But difficulties in tying PTSD to first responders’ work and the cost of providing benefits for PTSD have so far stymied the efforts in many states.

Hurdles to coverage

Earlier this year, a measure that would provide comp coverage for first responders with diagnosed PTSD was introduced in Connecticut, where police officers and emergency medical professionals were among the first to see classrooms full of dead children after the Sandy Hook shooting in Newtown in 2012.

Several other states also have seen lobbying and bills introduced: Arkansas, Colorado, North Dakota, Ohio and South Carolina. The legislation has lingered in committees or failed altogether.

Meanwhile, Ontario in April became the latest jurisdiction to pass legislation that would cover PTSD under workers comp for first responders under the presumption that their job caused their mental disorder.

The move applies to some 73,000 first responders in the Canadian province.

Workers comp experts say the presumption issue is problematic: Was the first responder psychologically injured because of something on the job, or was there a pre-existing medical condition?

“It can be related to an adverse childhood event, or it could be potentially exacerbated by a situation unrelated to employment,” said Joe Paduda, Skaneateles, New Yorkbased principal for Health Strategy Associates L.L.C. “The primary concern in

tying the PTSD to an event that occurred in the course of employment is it will take significant resources to get to conclusions.” Financial roadblocks

Financial concerns over providing workers comp benefits to first responders with PTSD were aired in Connecticut during debates over the legislation that was introduced.

“You stick us with another unfunded mandate like (PTSD), and somebody’s going to lose their job,” Danbury, Connecticut, Mayor Mark Boughton testified at a labor and public employee committee hearing in March, according to an article in the Hartford Courant.

Connecticut state Sen. Cathy Osten, a Democrat who supported the bill, told the committee that a fraction of a percentage of workers comp claims are related to PTSD, according to the article.

Meanwhile, in South Carolina, lawmakers who opposed extending comp benefits to first responders with PTSD argued that there would be more claim activity.

That’s a major issue, said Josh Rhodes, Columbia, South Carolina-based assistant general counsel for the South Carolina Association of Counties.

“Premiums would skyrocket … we have no idea” by how much, he said in an interview.

“Actuaries can’t tell us; there are too many unknowns. We have no idea about the extent of the claims and the extent of the awards because of all the unknowns.” Pinnacol Assurance, a workers comp insurer in Denver, opposed a PTSD bill in Colorado earlier this year. In a statement at the time, the insurer said the bill was “unnecessary and would create uncertainty in statute, drive litigation costs and potentially increase workers compensation premiums.” In addition, the statement said current law “recognizes that certain occupations have stresses that are inherent in their duties. Workers compensation insurance cannot prevent or mitigate inherent exposures such as an emergency room doctor seeing blood.”

To date, there is no accurate estimate on what broadening coverage would cost for cities and states who provide workers comp benefits to first responders.

Mr. Rhodes in South Carolina said widening the scope of comp benefits could result in fraud. He referred to the American Medical Association Guide to the Evaluation of Disease and Injury Causation, which states that “PTSD is diagnosed in only 7% to 12% of generalpopulation individuals who are exposed to accidents, rates of 83% have been documented when the accident created an opportunity to seek compensation.” “I could see how the costs could mount,” said Jeffrey M. Adelson, Santa Ana, Californiabased managing partner and general counsel with Adelson, Testan, Brundo, Novell & Jimenez, a workers comp defense law firm.

Appropriate remedies

Mr. Rhodes said his organization is more in favor of expanding health care coverage by setting up a fund to assist with copays for first responders who need counseling.

“Workers comp is not the appropriate remedy,” he said.

Mr. Paduda said some of the concerns over costs result from experiences with the “heart and hypertension clauses,” or changes in state presumption laws that provided workers comp to first responders who suffered from heart attacks and other physical ailments that are not scientifically proven to have happened on the job, and met certain criteria.

“It’s not that (municipalities) don’t want to compensate first responders for legitimate issues; it’s that they have been burned by this before, and they want to be very careful,” said Mr. Paduda.

Mr. Clark, who works with Badge of Life as a counselor and served as a police officer for 25 years, said mandating comp benefits for PTSD would result in better wellness programs for first responders, which could limit future claims.

“It’s starting to catch on,” he said. “Emotional wellness is now part of some training.” Dr. Joel Fay, a retired police officer and psychologist who help found the Napa, California-based First Responders Support Network, said he expects the push to extend comp benefits for first responders nationwide to continue.

“If an officer hurts himself fighting off a suspect, do we say that it’s part of his job? To deny that we are not impacted by what we experience, to have that attitude, it’s almost criminal,” he said.

Limited options

The options for a first responder suffering from PTSD are to resign or retire, Dr. Fay said.

Or they can use up their paid leave time, hope for the best and then reassess, as Mr. Realin was doing that day in Chick-fil-A with his family.

Since the shooting, several everyday items have triggered anxiety attacks for her husband, Ms. Realin said: the sight of another shopper in a grocery store wearing a San Francisco 49ers football jersey, the same number of bodies they collected in the nightclub; or whenever he sees a Sharpie marker, the type of pen they used to record the names and numbers over the course of the 12 hours it took to clear the bodies.

She drove him to the emergency room after the anxiety attack in Chick-fil-A.

That’s when a diagnosis of hypertension eventually led to a viable workers comp claim because his mental injury led to a physical one, said his attorney Geoff Bichler, a partner with Orlando-based Bichler, Oliver, Longo & Fox P.L.L.C.

“We have seen horrible cases of PTSD in first responder communities going back years,” he said.

“I’m not saying every single first responder has PTSD,” added Mr. Bichler. “There’s a real distinction. It’s a very specific, disabling condition.”

Lou Turriaga, Los Angeles-based director for the Los Angeles Police Protective League and a 28-year police officer, said he hopes the issue gets more attention, just as PTSD for veterans has made headlines.

But he wants to move the focus from high-profile incidents such as mass shootings to mental health intervention for officers who reach their tipping point through their everyday work.

“There are things that happen to little kids, rape victims, domestic disputes, the fact that officers are now targets,” he said, adding that the effects for some are the same as what soldiers in a war zone face. “We should have a safety net for those people who are asked to handle the absolute worst humankind throws at them.

A police officer is a human being. It’s ridiculously simple, but people don’t remember that.”