Claim Denied for Failure to Establish 5th FECA Element
As an injured workers’ OWCP Representative, I have assisted numerous physicians in establishing a causal relationship.
Unless a doctor is well-schooled in the nuances of the Federal Employees Compensation Act [FECA] requirements to establish a causal relationship, the Office of Workers’ Compensation Programs (OWCP) will deny the claim. Medical reports that a doctor can write that are perfectly acceptable in the private sector, by the State or even with Federal Employee’s Health Benefit Insurance Carriers just won’t be sufficient with the OWCP. For it is not what the physician says but how he says it that will get cases accepted and medical procedures authorized. Most times, after numerous rejections by the OWCP, the physician will just throw in the towel. I would estimate that the majority of cases denied by the OWCP are due to the failure of the attending physician to establish a causal relationship.
For a complex injury, a physician has to write a comprehensive objective narrative report using explicit FECA language, citing in detail the results of X-Rays, EMGs and MRIs. The physician also needs to describe other medical reports they reviewed, illustrate a clear understanding of your work duties, illustrate how your work duties caused the injury, and then validate his opinion with what is called “a reasonable degree of medical certainty”. This all-inclusive, meticulous, comprehensive narrative report has to stand on its own volition by dotting all the I’s, crossing all the T’s and connecting all the dots to establish causal relationship. A Claims Examiner [CE] is not going to make any logical assumptions or give the physician any benefit of the doubt. A doctor’s report practically has to become redundant in nature by repeating itself in several areas.
Even if a causal relationship is established on appeal, it does not mean the OWCP will automatically pay you. Without the doctor explaining in thorough detail that, as a result of the work-related injury, you are temporary total disabled, unable to work, and provide a reasonable expectation of when you will be able to do some type of light-duty or modified job work, the CE will not pay monetary compensation.
In some simple traumatic injury cases where the cause of the injury is obvious, such as, tripping over a computer wire and hurting your ankle, the first medical report may only provide a diagnosis of an ankle sprain which is what the Claims Examiner [CE] is going to accept. Then, after further medical development, the doctor may find a torn ankle ligament that was a result of the fall. At that point, problems can occur. Having the OWCP add medical conditions, which they call expanding a case, is an extremely difficult task to accomplish. At that juncture, the OWCP is going to want a more comprehensive report as described above. However, once an examiner has accepted the initial injury, he or she will seldom read another medical report in your file unless it is specifically requested. A CE is not going to add anything on his or her own accord. Unless you have the knowledge in how to force the issue with the CE, it just isn’t going to happen.
Sad but true; without FECA-Competent Representation, the chances of having your claim accepted are slim at best.