Episode 21 Federal Workers Compensation Coffee Break Podcast - Initial OWCP Claim Acceptance & Denials

Federal Workers Compensation Coffee Break Podcast is about all things related to Federal Workers Compensation, FECA, OWCP, DOL & Longshore claim filing as an injured federal worker.  The podcast is an educational and informative training on how to navigate the DOL -OWCP claims filing process for all types of injured US government and federal workers. The podcaster has 27 years in assisting with federal workers compensation as a consultant and trainer. The podcast is free and is educational. If you need help with anything related to a federal workers compensation claim...help is just a cup of coffee away.

When the Office of Workers’ Compensation Programs (OWCP) has determined that there is sufficient factual and medical evidence to accept the claim, a formal decision is issued which explains which conditions were accepted as arising out of the claimed factors.
 •    Where medical evidence establishes that a pre- existing condition was aggravated, an 
         aggravation should be accepted, not the underlying condition itself.
•      Whether the claim is a Traumatic Injury or an Occupational Disease, the same criteria 
         need to established.
•       In Traumatic Injury cases with resulting disability, continuation of pay (COP) should be 
         authorized unless one of the nine reasons to controvert COP have been established.
•       In either type of case, with resulting disability, the claimant should be notified of 
         placement into disability management (QCM) and the purpose of the QCM program.

If either the physician or claimant indicate that the accepted conditions require expansion or modification, OWCP should request a detailed explanation as to how the additional conditions are related to the original injury or resulting residuals.  Claims for consequential conditions should be referred to the District Medical Advisor for review.  If OWCP denies an initial claim, a formal denial will be issued. The decision will contain the following:

 •       describe the nature of the injury;
 •        summarize the evidence initially submitted with the claim and provide an explanation as              to why it was deficient;
 •        summarize what was requested upon development;
 •        describe all evidence received after development; and
 •        explain why the evidence is insufficient to support the claim.

Dr. Taylor's educational podcast utilizes his experience and history as a DOL - OWCP provider and his years of consulting and teaching all things federal workers compensation related. This is an educational short form format for learning how to successfully file federal workers compensation claims. So grab a cup of coffee and lets begin.

Dr. Taylor's contact information for more information or assistance is:
https://fedcompconsultants@protonmail.com

If you need a provider or assistance with a DOL claim in Tampa, Jacksonville or other areas of Florida you can make an appointment to see him and the other providers at the clinic at 813-877-6900

Transcript

 When the Office of Workers’ Compensation Programs (OWCP) has determined that there is sufficient factual and medical evidence to accept the claim, a formal decision is issued which explains which conditions were accepted as arising out of the claimed factors.

 •              Where medical evidence establishes that a pre- existing condition was aggravated, an aggravation should be accepted, not the underlying condition itself. 

•              Subluxation of the spine can be accepted only if x-ray results showing the subluxation are available. A chiropractor’s interpretation of the x-ray is acceptable. 

•              Asbestosis can be accepted only with full range of findings as required by Chapter 3-600 in the Federal Employees’ Compensation Act (FECA) Procedure Manual.

(This is a lot to cover here so I advise you to go read the chapter 3-600 of the DFEC procedure manual if your filing an asbestosis claim. 

•              Whether the claim is a Traumatic Injury or an Occupational Disease, the same criteria need to established.

•              In Traumatic Injury cases with resulting disability, continuation of pay (COP) should be authorized unless one of the nine reasons to controvert COP have been established.

•              In either type of case, with resulting disability, the claimant should be notified of placement into disability management (QCM) and the purpose of the QCM program.

The QCM program is vocational rehabilitation.   This is a disability management program to attempt to reduce disability numbers and attempt reemployment by asking your treating doctor or a second opinion doctor to refer a currently disabled federal worker to a suitable training program for the injured worker, and formal determination of wage-earning capacity following vocational services. The purpose of the OWCP rehabilitation program is to assist disabled employees who are covered by the Federal Employees’ Compensation Act (FECA) and the Longshore and Harbor Workers’ Compensation Act (LHWCA) to minimize their disabilities and return to gainful work.  Injured workers who are no longer able to return to their original employer that are on permanent long term disability or temporary disability from  things like major surgery  etc.  and do not have a job to go back to …can be retrained to go back to gainful employment  with  job opportunities that the disabled federal worker can perform with their current  disability that prevents them from  going back to their original employer. This vocational retraining  placement is only for 

Federal workers in jobs where disability does not prevent then from competing with non-disabled employees.

I will probably go into this in more detail in a future podcast. So moving onto more information about your initial acceptance of your claim.  

Additional Conditions: 

–        If either the physician or claimant indicate that the accepted conditions require expansion or modification, OWCP should request a detailed explanation as to how the additional conditions are related to the original injury or resulting residuals. Example will be if you have a right knee injury and you get an initial claim acceptance of a right knee injury claims but with a minimal diagnosis of a contusion or sprain…and your doctor finds that you sustained a meniscus tear. The meniscus tear would need to be ADDED as part of your accepted condition which would require an expansion.

–        Claims for consequential conditions should be referred to the District Medical Advisor for review.

–        Here  are some tips on how to expand your injuries areas, or for  more extensive and accurate diagnosis. 

–        Have your doctor do an expansion diagnosis or area causality statement narrative report. Then place a clover sheet with the medical narrative asking for the listed additional consequential  injuries be added or expanded BE… reviewed by a District Medical Advisor aka DMA. If you only upload the medical narrative without a cover sheet asking for a DMA review your claims examiner will either not know what the report is requesting or will purposely ignore it or send you a letter of denial without any explanation other than the narrative does satisfy the requirements of causality. A common denial tactic by a claims examiner. If you send this expansion with a cover sheet requesting the DMA review it…a medical professional will read and offer an opinion on your doctors causality statement of the expansion request. This is important if you want to be successful with expanding your diagnosis to be more accurate or definitive. 
Ok… lets review quickly…Remember…

 1)       When OWCP has determined that there is sufficient factual and medical evidence to accept the claim, a formal decision is issued which explains which conditions were accepted as arising out of the claimed factors.

 2)       Subluxation of the spine can be accepted only if x-ray results showing the subluxation are available.   A chiropractor’s interpretation of the x-ray is acceptable. 

3)       In Traumatic Injury cases with resulting disability, continuation of pay (COP) should be authorized unless one of the nine reasons to controvert COP have been established. Continuation of Pay (COP) is the continuance of the

employee's regular pay for a period not to exceed 45 calendar days of disability. An EA’s objection to paying COP for one of nine reasons

provided by regulation is called “controversion”. COP

may be controverted only if one of the following applies:

1. Disability is a result of occupational disease or illness

2. Claimant’s status as an employee is defined by 5 USC 8101 (1) (B) or (E) (volunteers)

3. Employee is neither a citizen nor resident of the US or Canada

4. Injury occurred off EA’s premises and the employee was not engaged in official “off premises” duties

5. The injury resulted from the employee's willful misconduct, the employee's intention to bring about the injury or death of himself or herself or of another person, or the employee's intoxication by alcohol or illegal drugs

6. Injury not reported on a form approved by OWCP within 30 days following the injury

7. Work stoppage first occurred more than 45 days after the injury

8. Employee reported injury after employment was terminated

9. Employee is enrolled in Civil Air Patrol, Peace Corps, or other group covered by special legislation

 Also remember …       If either the physician or claimant indicate that the accepted conditions require expansion or modification, OWCP will request a detailed explanation as to how the additional conditions are related to the original injury or resulting residuals.

 If medical evidence establishes that a pre-existing condition was aggravated, OWCP will accept:

a)       The aggravation of the condition- correct

b)      The pre-existing condition

c)       Both the pre-existing condition and the aggravation 

The same 5 basic criteria need to be met when accepting either a Traumatic Injury or Occupational Disease. 

b)    True- correct

c)      False

 Burden of Proof:

–        The claimant has the burden to establish the components of his/her claim.

 –        However, the Office of Workers’ Compensation Programs (OWCP) is not a disinterested arbiter. 

–        Thus OWCP shares in the responsibility to establish the claim if prima facie evidence has been established.

If OWCP denies an initial claim, a formal denial will be issued. The decision will contain the following:

–        describe the nature of the injury;

–        summarize the evidence initially submitted with the claim and provide an explanation as to why it was deficient;

–        summarize what was requested upon development;

–        describe all evidence received after development; and

–        explain why the evidence is insufficient to support the claim.

So remember these few things…

1)      You the injured worker have the burden to establish the components of his/her claim. (not your doctor or clinic…but YOU!) You need a medical narrative and a causality statement but it is your responsibility to provide this information to OWCP claims examiner. 

2)      OWCP shares in the responsibility to establish the claim if prima facie evidence has been established.

3)      A denial decision will describe which of the five basic elements have or have not been met, the specific element upon which the claim is being denied, and a clear discussion of the necessary evidence to support the claim. (You will receive a denial letter that is either mailed to you or is placed in ECOMP) Which is why I tell everyone to setup a ECOMP account! You can receive OWCP responses much quicker in ECOMP than in regular mail. 

Ok.. so let me ask you a couple of questions to see if you  are paying attention. 

If prima facie evidence has not been submitted, who has the burden to establish the 5 basic elements of a claim? 

a)       The injured employee

b)      The employing agency

c)       The Office of Workers’ Compensation Programs

All formal denials must include appeal rights.

 b)      True

c)       False

 Well that does it for this episode of Federal Workers Comp Coffee break  Podcast.