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Injury Compensation Specialist

Injury Compensation Specialist

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Injury Compensation Specialist

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  1. Injury Compensation Specialist Training By Eileen Padar and Janet Sonera

  2. FECA Overview • Federal Employees’ Compensation Act passed in 1916. • Provides compensation to civilian employees of the US for disability due to personal injury or disease sustained in the performance of duty. • Provides benefits to dependents if a work-related injury or disease causes death.

  3. FECA Overview • Funded through agency charge-backs. • Remedial in nature. • Non-adversarial – an attorney is not required. • Sole remedy – a federal employee or surviving dependent is not entitled to sue the US or recover damages for injury or death under any other law.

  4. FECA Overview • Administered by the Department of Labor, Office of Workers’ Compensation Programs, Division of Federal Employees’ Compensation. • National Office Organization. • OWCP adjudicates the claim. • 12 District offices.

  5. FECA Overview • Individual cases are protected under the Privacy Act – only the employee, his/her representative and agency personnel may routinely have access to information concerning the compensation claim. • HIPAA does not apply to OWCP or employing agencies as it relates to information concerning the compensation claim. • No one may require an employee or other claimant to waive his/her right to claim benefits.

  6. Traumatic Injury • Wound or other condition of the body caused by external force, including stress or strain. • Caused by a specific event or series of events or incidents within a single work day or work shift.

  7. CA-1 • Must be submitted to employing agency within 30 days of date of injury to be eligible for COP – however can be submitted up to three years after the injury. • Must be transmitted to OWCP within 10 work days from the date the agency received it. DO NOT HOLD!

  8. CA-1 – Agency Responsibilities • Review for completeness. • Authorize medical care. • Form CA-16 • Advise employee of the right to elect COP. • Advise employee of his/her responsibility to submit medical evidence.

  9. CA-1

  10. CA-1

  11. Medical – CA-16 • Shall be issued within 4 hours of the claimed injury. • If verbal authorization is given, must be issued within 48 hours. • Not required to issue more than one week after the date of injury. • Should not be issued for Occupational Disease claims (CA-2)

  12. Medical - Treatment • Emergency • When an employee sustains a work-related traumatic injury that requires medical examination, medical treatment or both, the employer shall authorize such examination and/or treatment by issuing a Form CA-16. • Choice of Physician • The employee has the right to choose their own physician.

  13. CA-16

  14. Occupational Disease • Condition attributable to exposure to work factors over a period longer than one work day or shift. • COP is not provided. • CA-16 is not issued.

  15. CA-2 • Must be submitted to employing agency within 3 years of the date when the employee becomes aware, or reasonably should have been aware, of a possible relationship between the medical condition and the employment, or the date of last exposure. • Must be transmitted to OWCP within 10 work days from the date the agency received it. DO NOT HOLD!

  16. CA-2 • Checklist • CA-35a – Occupational Disease in General • CA-35b – Hearing Loss • CA-35c – Asbestos-Related Illness • CA-35d – Coronary / Vascular Condition • CA-35e – Skin Disease • CA-35f – Pulmonary Illness (Not Asbestosis) • CA-35g – Psychiatric Illness • CA-35h – Carpal Tunnel Syndrome

  17. CA-2

  18. CA-2

  19. CA-2a • No medical treatment is authorized at OWCP expense until the claim is adjudicated. • If employee was entitled to COP and 45 calendar days of COP have not been exhausted, he/she may elect to use remaining days, as long as 45 days have not elapsed since the first return to work. • Employee may use sick or annual leave pending adjudication of claim.

  20. Conditions of Coverage • Time • Civilian Employee • Fact of Injury • Performance of Duty • Causal Relationship

  21. Conditions of CoverageTime • Employee has three years from: • Date of Injury • Date of First Awareness • Date of Last Exposure

  22. Conditions of CoverageCivilian Employee • FECA covers all civilian employees except for non-appropriated fund employees. • Temporary employees covered on the same basis as permanent employees. • Contract employees, volunteers, and loaned employees are covered under some circumstances.

  23. Conditions of CoverageFact of Injury • Factual – Actual occurrence of an accident, incident, or exposure in time, place, and manner alleged. • Medical – A medical condition diagnosed in connection with that accident, incident or exposure.

  24. Conditions of CoveragePerformance of Duty • Injury occurred while performing assigned duties or engaging in an activity reasonably associated with the employment. • Injury occurred on work premises. • Use of facilities for personal comfort. • Includes parking facilities owned by employer. • Coverage extended for a reasonable time before or after work hours.

  25. Conditions of CoveragePerformance of Duty • Injury occurred off premises while engaging in work activities. • Employees are not covered en route between work and home unless the agency furnishes transportation, the employee is required to travel during a curfew or emergency or the employee is required to use their personal vehicle during the work day.

  26. Conditions of CoveragePerformance of Duty • Other factors • Recreation • Horseplay • Assault • Harassment or Teasing • Idiopathic Falls • Emergencies • Union Representation

  27. Conditions of CoveragePerformance of Duty • Recreation: an employee is considered in the performance of duty while engaged in formal recreation when either the employee is paid for participating or the recreational activity is required and prescribed as a part of the employee’s training or assigned duties.

  28. Conditions of CoveragePerformance of Duty • Horseplay: an employee is considered to be in the performance of duty if the horseplay was of a character that could reasonably be expected where workers are thrown into personal association for extended periods of time.

  29. Conditions of CoveragePerformance of Duty • Assault: an employee is considered to be in the performance of duty if the assault was accidental or arose out of an activity directly related to the work or work environment. An assault is not compensable if it arose out of a personal matter having no connection with the employment.

  30. Conditions of CoveragePerformance of Duty • Harassment / Teasing: Employees who are harassed, teased or called derogatory names by coworkers are considered to be in the performance of duty provided that the reasons for the harassment or teasing are not imported into the employment from the employee’s domestic or private life.

  31. Conditions of CoveragePerformance of Duty • Idiopathic Falls: Defined as one where a personal, non-occupational pathology causes an employee to collapse. Injuries that can be attributed to the intervention or contribution of some hazard or special condition of the employment, including normal furnishings of an office or other workplace are compensable.

  32. Conditions of CoveragePerformance of Duty • Emergencies: Coverage is extended to employees who momentarily step outside the sphere of their employment to assist in an emergency such as to extinguish a fire or help a person hit by a car.

  33. Conditions of CoveragePerformance of Duty • Emotional Reaction: an employee who suffers from a medical condition resulting from factors of employment that result in an emotional reaction can be considered to be in the performance of duty. • Personnel actions such as the regular administrative functions of an agency (leave usage, disciplinary actions, etc.), performance ratings, performance assessments and informal discussions of performance, standing alone, are not sufficient to provide coverage under the FECA. For a personnel action to be compensable, the employee must establish an error or abuse of administrative authority by the agency. Without this showing, the emotional reaction is considered to be self-generated.

  34. Conditions of CoverageStatutory Exclusions • Willful Misconduct – deliberate and intentional disobedience of rules / orders. Not carelessness. • Drug or Alcohol intoxication – proximately caused the injury. • Intent to injure self or others – intent must be established.

  35. Conditions of CoverageCausal Relationship • Link between work-related exposure/injury and any medical condition found. • Based entirely on medical evidence provided by physicians who have examined and treated the employee. • Opinions of employee, supervisor, or witnesses not considered – nor is general medical information contained in published articles.

  36. Conditions of CoverageCausal Relationship • Direct Causation – injury or factors of employment result in condition claimed through natural and unbroken sequence. • Aggravation – preexisting condition worsened, either temporarily or permanently, by a work-related injury. • Acceleration – a work-related injury or disease may hasten the development of an underlying condition. • Precipitation – a latent condition that would not have manifested itself on this occasion but for the employment.

  37. Medical Benefits • Treatment • CA-16 • Preventive Care • Physical Therapy • Chiropractors • Surgery • Attendant Allowance • Weighing Evidence • Termination of

  38. Medical Benefits - Treatment • Medical services, appliances or supplies necessary to treat the work related injury. • Any qualified physician or hospital may provide such services, appliances and supplies.

  39. Medical – Physical Therapy • Physical Therapy is authorized if prescribed by the treating physician. • PT is authorized for a period of 120 days from the date of injury. • Additional justification needed if exceeds 120 days. • Specific modalities. • Diagnosis for which therapy is administered. • Specific functional deficits which are to be treated. • Expected duration and frequency of the treatment. • Specific functional goals of the additional therapy.

  40. Medical - Chiropractors • The services that may be reimbursed are limited to manual manipulation to correct a spinal subluxation. • Cost of testing performed by or required to diagnose such a subluxation are also payable. • A chiropractor may also provide services in the nature of physical therapy under the direction of a qualified physician.

  41. Medical - Surgery • Emergency Surgery: Any procedure which needs to be performed promptly after the onset of a condition or injury in order to preserve life or function of an organ or body part. • Elective Surgery: Any procedure which is necessary for the adequate function of an organ or body part, but which does not need to be performed promptly after the onset of the condition in order to achieve its purpose.

  42. Medical - Surgery • Emergency • No prior authorization is required • Elective • Prior authorization is required. • Requires the name of the procedure; diagnosis of the condition; the type of surgery; and the reason surgery is needed. • Second opinion examination may be necessary.

  43. Medical – Attendant Allowance • OWCP will pay for the services of an attendant up to a maximum of $1,500 per month, where the need for such services has been medically documented.

  44. Medical – Weighing Evidence • District Medical Adviser • Second Opinion • Independent Medical Exam

  45. Medical – Weighing Evidence • District Medical Adviser • Used when the Claims Examiner needs medical guidance to weigh the reports in file. • Evaluation of medical evidence and rendering of medical opinion. • Interpretation and clarification of other physician’s reports. • Has no authority to decide the facts in a case. • May create a conflict in medical opinion necessitating referee evaluation. • May represent the weight of medical evidence for Schedule Award claims.

  46. Medical – Weighing Evidence • Second Opinion • Employee must submit to examination. • Employee may have a qualified physician, paid by him or her, present at examination. • Employee is not entitled to have any one else present unless authorized by OWCP. • OWCP may send a case file for a second opinion review where actual examination is not needed. • A physician who performed a fitness for duty for an Agency can not be considered a second opinion specialist.

  47. Medical – Weighing Evidence • Referee Examination • A difference in medical opinion sufficient to be considered a conflict occurs when two reports of virtually equal weight and rationale reach opposing conclusions. • If a conflict exists between the medical opinion of the treating physician and the medical opinion of either a second opinion physician or an OWCP Medical Advisor, OWCP shall appoint a third physician to make an examination.

  48. Medical – Weighing Evidence – Outcomes • Based on its determination of the weight of the medical evidence, OWCP may: -establish the work tolerance limitations; -deny, terminate or reduce wage loss compensation; -deny or terminate medical benefits; -resolve other claims issues that hinge on medical evidence.

  49. Medical – Termination of • OWCP may terminate medical benefits when: • Medical documentation supports that there is no need for further treatment. • Medical documentation supports that the effects of the work-related condition have ceased. • Employee has been convicted of fraud against the FECA.

  50. Recurrence • A spontaneous return of symptoms or increase of disability due to a previous injury or occupational disease without intervening cause, or a return or increase of disability due to a consequential injury. • A recurrence of a medical condition is defined as a documented need for further medical treatment for the accepted condition or injury when there is no accompanying work stoppage. • Wage loss resulting from the withdraw of light duty accommodation. • No event other than the previous injury accounts for the disability.