Causal Relationship in OWCP Federal Workers Compensation Claims

by Lenin V. Perez

Causal Relationship: General

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.

To qualify for workers’ compensation, the employee must be covered under the Federal Employees’ Compensation Act (FECA); there must be an injury or disease claimed to be related to employment; the employee must make a timely filing of the claim within the provisions of FECA; the injury or disease must be the result of activity in the performance of duty; and the employee’s injury or disease must have been proximately caused by, or aggravated by, a work-related injury or by employment conditions, ie., there must be a causal relationship.

There are two kinds of evidence under FECA: factual, which refers to evidence submitted by the employee; and medical, which refers to evidence submitted by physicians.

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).

The employee must first write a statement describing 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 his or her 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 or disease because the claims examiner and OWCP doctor will not otherwise have the necessary information to properly discuss and decide a claim. For example, if the employee is claiming an injury to a knee that resulted from repeated dismounting and mounting, he or she should describe in minute detail what is involved in getting in and out of the postal vehicle used and how many dismounts a day are involved; the employee can then multiply that daily amount by the number of workdays per year to get the yearly number.

The employee statement should also include information on the employee’s hobbies and activities outside of work. (Please see the book “Federal Workers Compensation Made Easy”, by Lenin V. Perez, Chapter 6, for further details of employee statements that can win claims.) He or she must then ensure that his or her physician reads the statement and completes the five medical requirements for a valid claim.

Causal Relationship In An On The Job Injury Claim: CA-1

If the employee is claiming a disability based on an on-the-job injury, OWCP form CA-1 should be used. The five requirements of the medical evidence are as follows:

(1) The employee’s physician should read the employee’s statement and refer to it in his or her own medical statement indicating that he or she has read the employee’s description of the injury sustained and has knowledge of the injury. This gives the physician a frame of reference upon which to base a medical opinion. The physician should state something like the following: “I have read the statement dated ______ prepared by ___________ regarding the injury sustained on ______.”

(2) The physician must give a definitive, conclusive diagnosis, referring to any relevant tests, x-rays, etc. Impressions do not satisfy this requirement.

(3) The physician must give a definitive, conclusive opinion that the employee’s disability was caused, aggravated, precipitated or accelerated by the work-related injury. Speculative language such as the use of the words “perhaps related,” “probably related” or “might be” will not support the claim. If the disability is temporary, the opinion must state the time during which the employee will be disabled.

(4) The physician must give his or her medical reasoning (or rationale) for the diagnosis and opinion. In other words, the physician must show how he or she reached the opinion given, ie., what are the medical reasons for the opinion.

(5) The physician must state the period of time the disability will last and the extent of the disability. If the disability is partial, the statement must indicate the work limitations of the employee during the period of disability.

Causal Relationship In An Occupational Illness Claim: CA-2

If the employee is claiming an occupational illness or disease, OWCP form CA-2 should be used. The five requirements of the medical evidence are as follows:

(1) The employee’s physician should read the employee’s statement and refer to it in his or her own medical statement indicating that he or she has read the employee’s description of the conditions of employment which caused the disease or illness. This gives the physician a frame of reference upon which to base a medical opinion. The physician should state something like the following: “I have read the statement dated ______ prepared by ___________ regarding the conditions of employment at___________ during the period from ______ to ______ .”

(2) The physician must give a definitive, conclusive diagnosis, referring to any relevant tests, x-rays, etc. Impressions do not satisfy this requirement.

(3) The physician must give a definitive, conclusive opinion that the employee’s disability was caused, aggravated, precipitated or accelerated by the conditions of employment described by the employee. Speculative language such as the use of the words “perhaps related,” “probably related” or “might be” will not support the claim. If the disability is temporary, the opinion must state the time during which the employee will be disabled.

(4) The physician must give his or her medical reasoning (or rationale) for the diagnosis and opinion. In other words, the physician must show how he or she reached the opinion given, ie., what are the medical reasons for the opinion.

(5) The physician must state the period of time the disability will last and the extent of the disability. If the disability is partial, the statement must indicate the work limitations of the employee during the period of disability.

 


Federal Workers Compensation Consultants

Workers Compensation and Disability Retirement Specialists

9639 N. Armenia Avenue

Tampa, Florida 33612

Telephone 813-931-1984

Fax 813-931-4905

bill.hackney@verizon.net

vivi.perez@verizon.net

http://www.federal-workers-comp.com

Se Habla Espanol – 813-931-1984

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