the HOT well... runs hot. in all the infinite wisdom of the engineers, the "output" leg of the HOT is attached to the tab (the die is soldered to the tab) and is all attached together. this would make the heatsink charged to high voltages.
as such the tab needs to be isolated, but it also has to have heat drawn away from it...but they also have to conform with certain safety rules to become certified. (underwriters, electrical code, etc.) and it's not so safe to have a large piece of metal charged to several hundred volts. so, what they do is insulate the tab from the heatsink using a silicone pad or a mica sheet. that way, the heat is drawn away, and the heatsink is insulated from high voltage.
BUT, they also say that all exposed metal be grounded. so the heatsink is grounded.
whew.
so if you attach the HOT to the heatsink without protection, it's effectively grounded out.