OWCP - DOL CONDITIONS OF COVERAGE for FEDERAL WORK INJURIES TUTORIAL

OWCP Claims for Compensation for federal - civil employees injuries, must meet certain requirements before being accepted.  These five (5) requirements ( also known as the 5 elements of coverage determination criteria) must be met within the sequence below and if not, claim will be adjudicated or held up by requesting information from the injured work to satisfy each of the 5 element requirement in sequential order to be given due process:

A. Time                                                                                                                                        

B. Civil Employee                                                                                                                    

C. Fact of Injury or Occupational Disease or Illness                                                          

Two factors are involved in the determination of whether the employee did in fact suffer the injury: 

                 1) Occurrence of the Event                                                                                                              2) Existence of a Medical Condition          

D. Performance of Duty                                                                                                        

E. Causal Relationship  

Each of these 5 requirements (elements) for establishing conditions of coverage criteria are covered in detail in this podcast episode to assist civil employees with successful claim adjudication of an on the job injury or illness.  This episode is utilizing OWCP claims examiner training materials to explain how to meet the eligibility requirements from the claims examiner's training and understanding. It helps to understand how to speak the language that the OWCP claims examiner is trained in. 

Click on the transcript for more information to source for Initiating Claims with OWCP

The podcaster is Dr. Stephen Taylor, OWCP legal consultant for Oberheiden Law Firm.  Dr. Taylor’s contact information is:

https://fedcompconsultants@protonmail.com If you need a medical provider or assistance with an OWCP /  DOL claim in Tampa, Jacksonville, Pensacola Florida, Southern Mississippi or Da

Transcript

HI,  I’m Dr. Stephen Taylor a Federal Workers Compensation Consultant and a medical provider in Alabama & Florida who has been helping government employees with work-related injuries, disability, FERS Disability, VA disability and other types of Federal program filings for 30+ years. The name of this tutorial podcast is  Federal Workers Compensation Coffee break Podcast.  Here at this podcast we discuss all sorts of topics related to federal workers compensation, Department of Labor, OWCP, FECA ACT, FERS, longshore-maritime, DOD contractors, VA benefits over a cup of coffee. I cover these relevant topics in a short coffee break style format because in order to discuss topics that  government employees always ask for assistance on for all of these years.  I do this to assist you the government employee, you and your doctor if they want or need help or your coworkers with claim filing denials or with appropriate filing of benefit claims, disability or injured worker claims. The best part about this podcast and all of it’s tutorials for successfully navigating DOL, FERS & OWCP benefits… is that I do it all for free. All you need is a cup of coffee and a notebook.

Welcome to episode 2 of Season 5 of the podcast. I have decided this year to dedicate this season to explaining how OWCP works from an OWCP Claims examiner's training. I want the listeners to understand how claims examiners are trained to adjudicate case filings. In order to be successful with communication with an OWCP claims examiner, it is important to understand what they are trained to do, trained to look for and how to meet the eligibility requirements from their training and understanding. It helps to understand how to speak the language that the OWCP claims examiner are trained in. 

So we are going to cover section 2 of the OWCP reference claims examiner's training guide for the OWCP Claims examiner. Section 1 topics we covered last week were: INITIATING CLAIMS WITH OWCP

Today we dive into section 2 which covers: CONDITIONS OF COVERAGE

So let's get our coffee going and get our notebooks out and learn conditions of coverage requirement from the claims examiners reference guide handbook. 

Claims for Compensation must meet certain requirements before being accepted.  These five (5) requirements ( also known as the 5 elements of coverage determination criteria) must be met within the sequence below and if not, claim will be adjudicated or held up by requesting information from the injured work to satisfy each of the 5 element requirement in sequential order to be given due process:

A. Time

Claim for compensation must be filed within 3 years of the injury or death. However, if a claim is not filed within 3 years, compensation may still be paid if written notice of the injury was given within 30 days, or the employer had actual knowledge of the injury within 30 days after it occurred.

For a disease or illness, the employee should file for compensation within 30 days of when the employee realized the disease or illness was caused or aggravated by the employment; reasonably should have been aware of a relationship between medical condition and the employment; or date of employee’s last exposure.

B. Civil Employee

If the claim is timely filed, it is then determined if the claimant was an

“employee” within the meaning of the law.  The FECA covers all civilian Federal employees except for non-appropriated fund employees. Temporary employees are covered on the same basis as permanent employees.  Also, part-time, seasonal, and intermittent employees are covered.

C.        Fact of Injury or Occupational Disease or Illness

Once the requirements of time and civil employee have been met, the employee must establish the burden of proof if an injury or disease was sustained.  Injuries sustained in the performance of duty are separated into two categories:

Two factors are involved in the determination of whether the employee did in fact suffer the injury: 

Occurrence of the Event:  Did the incident occur at the time, place and in the manner claimed?  Determination is based on factual evidence, including statements from employees, manager/supervisor, and any witnesses.  An injury need not be witnessed in order to be compensable.  A manager/supervisor who believes, however, that the employee’s testimony is contrary to the facts, manager/supervisor should supply pertinent information to support his/her beliefs.  To controvert Continuation of Pay (COP) and/or to Challenge the claim, this process should be done at time of submission and employee should be advised.   

2) Existence of a Medical Condition:  Determination must be made to decide whether accident or employment factor resulted in an injury or disease?  The attending physician’s statement will determine that a medical condition is present that could be related to the accident or employment factor, though the medical report need not relate the condition to the incident.  The FECA does not provide for payment of expenses associated with simple exposure to an infectious disease without the occurrence of a work-related injury.  Both a work-related injury and exposure to a known carrier must occur before OWCP can pay for diagnostic testing.  (Fear of exposure to an infectious agent does not entitle the worker to benefits under the FECA, since no definable injury has occurred.)

Performance of Duty

If the first three requirements have been accepted, performance of duty (POD) when the injury occurred must be established.  An injury is generally said to have occurred in the performance of duty if the injury arose as specified below.

1)        Agency Premises includes areas immediately outside the building, such as steps and sidewalks if they are federally owned or maintained.

a.        Outside Working Hours - Coverage is extended to employees who are on the premises for a reasonable time before or after working hours.  (Not extended if visiting the premises for non-work related reasons.)

b.        Representation Functions - Injuries to employees performing representation functions entitling them to official time are covered.

c.        Parking Facilities - owned, controlled or managed are considered agency premises

2)        Off-Premises Injuries coverage is extended to workers who are sent on errands or special missions and workers who perform services at home.

a.        To and From Work - Employees are not eligible for coverage when injured en route between work and home, except when the agency furnishes transportation to and from work, when employee required to travel during a curfew or emergency, or the employee is  required to use their personal vehicle during the workday.

b. Lunch Hour - Lunch hour injuries off the premises are not covered

unless the employee is in travel status or is performing regular duties off premise.

c. Travel Status - Employees in a travel status may be covered for reasonable incidents of their temporary duty. When filing a claim for injuries that occur in a travel status, a copy of the travel authorization should be included.

d. Vehicular Accidents - A police report should be attached to any claim involving a traffic accident, along with a diagram or map showing the location of the accident.

3) Other Factors. Injuries that occur under other circumstances not governed by the premises rules must be determined on a case by case basis. They may include, but not limited to:

a. Recreation - Formal recreation, for which an employee is paid or required to perform as a part of training or assigned duties. Informal recreation, such as a physical fitness or physical training activity, agency sponsors or directs.

b. Horseplay - Horseplay is covered if the activity was one, which could be reasonably expected where a group of workers are closely associated for extended periods of time. Determination must be made on whether activity was a reasonable incident of the employment or if it was an isolated event.

c. Assault - Injury or death caused by another person may be covered if it is established that the assault was accidental and resulted out of an activity directly related to the work.

d. Emergencies - Employees who may step outside the realm of employment to assist in an emergency situation are covered.

E. Causal Relationship

Between the condition claimed and the injury or disease sustained is determined after the four (4) previous factors have been considered. This factor is based entirely on medical evidence provided by physicians who have examined and treated the employee.

1) Kinds of Causal Relationship. Relationship to the injury or disease may be determined in any one of four (4) ways:

a. Direct Causation - Injury or factors of employment result in the condition claimed through a natural and unbroken sequence.

b. Aggravation - Pre-existing condition is worsened, either temporarily or permanently, by a work-related injury.

c. Acceleration - Work related injury or disease may hasten the development of an underlying condition.

d. Precipitation - Latent condition, which would not have manifested itself on this occasion but for the employment.

2) Medical Evidence. Medical opinion is required, and must come from a physician who has examined or treated the employee for the condition claimed, for resolution. Medical must also be provided for pre-existing conditions involving the same part of the body, differentiating the effects of the employment-related injury or disease from the pre-exiting condition. OWCP district medical director/advisor may request additional medical opinion from a specialist in the medical field pertinent to the injury or disease.

3) Consequential and Intervening Injuries. An injury that occurs outside the performance of duty that affects the compensability of a work-related injury.

a. A new injury, which occurs as a work-related injury, is considered a consequential injury.

b. An injury, which occurs outside the performance of duty to the same part of the body originally injured, is considered an intervening injury.

F. Statutory Exclusions

Circumstances of a claim may raise the issues of willful misconduct, intention to bring about the injury or death of oneself or another, or intoxication. Benefits may not be payable if an injury is sustained as a result of:

• Willful misconduct – Deliberate.

• Intoxication (whether by alcohol or illegal drugs). The record must establish both the extent to which the employee was intoxicated at the time of injury and the particular manner in which the intoxication caused the injury. My advice on this one…is to get a lawyer or consultant to assist you. Medical intoxication is not easy to prove or disprove and takes specialized toxification tests that can be misinterpreted or misused. I have seen attorneys win these type of cases over the years. 

• Intent to injure self or others. If the factual and medical evidence show that the employee was not in full possession of their faculties, the injury may be compensable.

Ok I think we have covered enough for one Podcast session. I think we will stop here and pick up next time on OWCP  Continuation of Pay  topics.

So, I want to thank you for listening and want to remind you to share this podcast with other federal workers you think would benefit from this information. Also be kind enough to leave a 5 star review on the platform you found this podcast, like or subscribe to any of the major podcast platforms or our youtube channel so others will also find this information. Also if you need an approved  medical provider for your DOL -OWCP Or Longshore case in Florida or Alabama you can  make a consultation with me to discuss your case or if you know someone if Florida or Alabama who you thinks need my help  or is  recently injured you can call the clinic at 813-215-4356 or 813-877-6900 or go  to our website at https://fedcompconsultants.com/    & https://mrtherapycenter.com/   & https://fwcmedicalcenters.net/ Also if you are in  another state and you want me to assist you with claim questions or assistance for your  doctor you can email me at fedcompconsultants@protonmail.com  

Ok… I think that is enough for today…I need to warm up this coffee and get going. As usual I want to thank all of you who put on that uniform, that badge, deliver that mail, take care of our veterans and make this government run… a big thank you. I do this for free just for you…We could not do this  without all of the work all of you out there do…so this is my big  thank you. And remember if you  have an injured federal claim and you need assistance….I am  here to help!. Also remember there is power in prayer. Pray for your nation, coworkers and for God's providence in current times of unrest. 

See you next time.