ESTABLISHING A DOL CLAIM FOR FEDERAL WORKERS COMPENSATION
When filing a workers’ compensation claim, the burden of proof is on the employee. Therefore, it is the employee’s responsibility to show a causal relationship between his or her disability and an on-the-job injury, or his or her claimed occupational disease and conditions of employment.
Burden of Proof
•It is the claimant's responsibility to establish the five basic requirements of a claim, which is known as the "burden of proof."
•It is OWCP’s responsibility to establish willful misconduct, injury caused by intoxication, or intent to cause an injury (Statutory Exclusions) during the adjudication phase of the claim.
Burden of Proof - Employee Responsibilities
•The burden of proof to establish the essential elements of the claim
•Submit factual evidence as required by OWCP
•Provide medical evidence as requested
•Keep supervisor informed of condition
•Return to work as soon as medically able
* Only OWCP has the authority to approve/disapprove a claim.
ELEMENTS OF A CLAIM
| •Time •Civil employee •Fact of injury •Performance of duty •Causal relationship | ALL 5 ELEMENTS MUST BE MET BEFORE BENEFITS CAN BE AWARDED Time: 1 element The Federal Regulations administering the Federal Employees’ Compensation Act at §10.110 require a Federal employerto complete and transmit Forms CA-1 and CA-2 to OWCP within 10 working days after receipt of notice from the employee, if the injury or disease will likely result in: a medical charge against OWCP; disability for work beyond the day or shift of injury; the need for more than two appointments for medical examination and/or treatment on separate days, leading to time loss from work; future disability; permanent impairment; or the payment of continuation of pay. An original claim for compensation for disability or death must be filed within three years after: •Date of Injury (DOI) •Date when the injured employee becomes aware, or reasonably should have been aware of a possible work related disease or condition •Date of Last Exposure Time – Traumatic Injury Claims •An injured worker (IW) has three years to file a traumatic injury (TI) claim. •In a TI claim, time begins to run from the date of injury where the injury can be identified as to time, place, and circumstances of occurrence. •NOTE: A claim for continuation of pay (COP) must be filed within 30 days of DOI on Form CA-1.
Time – Occupational Illness, injury or Disease Claim Form CA-2
•An IW has three years to file an occupational disease (OD) claim.
•In Occupational Disease claims, the condition generally arises gradually over a period of time. (remember what I taught you in previous podcasts, CA—2 claims must be over a date range of two or more shifts)
•Time begins to run when the IW becomes aware, or reasonably should have been aware, of a possible relationship between the disease or condition and the employment, WHICHEVER IS LATER.
•Where the exposure to possible injurious employment-related conditions continues after this knowledge, time begins to run on the employee’s last exposure to the injurious conditions.
•If the employing agency (EA) has a testing program that detected a condition, this would establish that the Employing Agency had knowledge of the condition, and the time requirement would be met.
2nd element- Civil Employee- that you are employed or contracted with the government and are qualified for Federal Workers Compensation coverage.
3rd element- Fact of Injury (FOI) = Two Parts There are two kinds of evidence under FECA
•Factual: factual, which refers to evidence submitted by the you the employee; and medical, which refers to evidence submitted by qualified and approved physicians. FACTUAL injury evidence Must establish the that you the claimant actually experienced the accident, untoward event, or employment factor which is alleged to have occurred.
•Medical: Must establish a medical condition diagnosed in connection with the accident/incident/exposure.
In addition to factual evidence, reliable and substantial medical evidence which establishes an accurate history of injury in traumatic injury claims, or an accurate description of working conditions in occupational illness claims must be submitted in order to establish a causal relationship. This medical information must be provided by a qualified physician defined as one of the following: medical doctor (M.D.), osteopath (D.O.), podiatrist, optometrist, dentist, clinical psychologist, psychiatrist, or chiropractor (if manipulation of the spine is involved).
Fact of Injury - Factual
•An Injured Worker’s statement alleging that an incident occurred at a given time, place and in a given manner is of great probative value, and will stand unless refuted by strong or persuasive evidence. Now remember we covered this in detail in one of our first two podcasts. Your witness statement is very important and must address 5 important things….
1.What date and time did the injury or incident occur? So this is the WHEN did it occur.
2. What specific event occurred? Describe in detail the incident. HOW it occurred
3. Where did the incident occur? Make sure you make clear that you were required to be there as part of your job.
4. What body parts or functions were injured? Example: lower back and shoulders.( this is the What)
5. Why did this happen? Explain the why if it is relevant to the incident story.
The injured worker written statement should describe the work-related injury or work-related illness, the conditions of employment, including daily on-the-job activities, and how the employee believes specific work activities and conditions caused their injury or illness. This statement (whether it be for traumatic injury (CA-1) or occupational illness (CA-2)) must go into specific detail of work activities and conditions relevant to the claimed injury because your claims examiner and OWCP doctor will not have all of the necessary information to properly discuss and decide a claim. When this happens you will receive a 5 elements letter asking for more information in the mail or ECOMP. For example, if the employee is claiming an injury to a back that resulted from repeated lifting or carryng, they should describe in great detail what all is involved in day to day required activities of your job and how many times a day are those activities involved; the employee can then multiply that daily amount by the number of workdays per year to get the weekly, monthly or yearly number.
The employee statement should also include information on the employee’s hobbies and activities outside of work.
•However, OWCP also considers circumstances surrounding the claimed injury, in determining if Fact Of Injury is established, such as: unexplained delay in filing claim and ambiguous/inconsistent statements.
Fact of Injury - Medical
•A medical report is required from a qualified physician, as defined in 5 U.S.C. 8101(2), which states that, "'physician' includes surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined by State law.”
•The medical report must provide a diagnosis linked to the doctor standing with a nurse. injury, except in cases of visible injury.
•The diagnosis does not have to match the exact condition claimed and does not need to address the issue of causal relationship in order for FOI- Medical to be substantiated.
4th element - Performance of Duty The injury and/ormedical condition must have arisen during the course of employment and within the scope of compensable work factors.
Ok, Lets break this statement down…In order to establish that the claimed injury occurred in the “performance of duty”, the employee must establish the following:
•“In the course of employment”: This deals with the work setting, locale, time, and circumstances.
•“Arising out of the employment”: This is the requirement that an employment factor caused the injury; it must be related to the performance of day-to-day regular duties, to specially assigned duties, or to a requirement imposed by the employment.
Statutory Exclusions
Three Statutory Exclusions exclude coverage under the FECA if basic requirements are met:
•Willful Misconduct
•Drug or Alcohol Intoxication
•Intention to Bring About Injury or Death to Self or Another
5th element - Causal Relationship
•Causal Relationship is the link between work related exposure/injury and medical condition found on examination
•Based entirely on medical evidence provided by physicians who have examined and treated the employee
•Opinions of employee, supervisor, injury compensation specialist,or witness are not considered – nor is general medical information contained in published articles
Type of Causal Relationship:
•Direct cause
•Aggravation (worsening of a pre-existing condition)
•Acceleration (hastening of an underlying condition)
•Precipitation (a latent condition which would not have become manifest but for the employment)
So in review…There are 5 basic elements that are required to process an OWCP – DOL injured worker claim…
In review of the 5 basic elements that are required to determining eligibility, OWCP requires that five basic issues be addressed satisfactorily in order to establish a injured worker claim.
(1) Coverage: whether the claimant is an employee within the meaning of the Federal Employees Compensation Act (F.E.C.A.).
(2) Timely filing: whether employee met all applicable time limitations.
(3) Personal Injury: whether a work-related injury actually occurred. Remember The term work-related injury includes all diseases caused or aggravated by the employment.
(4) Performance of duty: whether the personal injury occurred in the performance of duty.
(5) Causal Relationship: whether the disability claimed is causally related to a work-related injury sustained in the performance of duty, or to conditions of employment. The term “causal relationship” includes direct cause, as well as aggravation, acceleration and/or precipitation.