Office of Workers' Compensation Programs (OWCP)
Injury Compensation for Federal Employees
A Handbook for Employing Agency Personnel
(Rev. Feb. 1994)
Material contained in this publication is in the public domain and may be reproduced, fully or partially, without permission of the Federal Government. Source credit is requested but not required. Permission is required only to reproduce any copyrighted material contained herein. This material will be made available to sensory impaired individuals upon request. Voice phone: 202-219-8743 TDD* phone: 1-800-326-2577 *(Telecommunications Device for the Deaf)
This material was prepared by the Office of Workers' Compensation Programs (OWCP), Employment Standards Administration, U. S. Department of Labor. It is meant to serve as a handbook for Federal agency personnel specialists, compensation specialists, and supervisors (the term "supervisor" is used generically to refer to individuals in all of these roles).
This handbook replaces FPM Chapter 810, and it incorporates all material published through the OPM issuance system which specifically addresses the Federal employees' compensation program through FPM Letter 810-22.
For information concerning any aspect of the program which is not addressed in this manual, contact the OWCP district office which serves your agency
(Click on the underlined Chapter Heading to speed your way right to the Chapter you are interested in.)
1-2 Exclusiveness of Remedy
1-3 OWCP Structure
1-5 Information and Records
2-1 Exposure to Infectious Agents
2-2 Traumatic Injury
2-3 Occupational Disease
3-2 Civil Employee
3-3 Fact of Injury
3-4 Performance of Duty
3-5 Causal Relationship
3-6 Statutory Exclusions
4-1 Administrative Matters
4-2 Burden of Proof
4-3 Questionable Claims
4-4 Decisions and Notification
5-1 Definition and Entitlement
5-2 Use of Leave Instead of COP
5-4 Pay Rate for COP Purposes
5-6 Light Duty Assignments
5-8 Terminating COP
5-9 Reporting COP--Form CA-3
6-2 Definition of Physician
6-3 Choice of Physician
6-4 Medical Treatment and Evaluation
6-5 Exclusion of Providers
6-6 Payment of Bills
7-1 Disability Benefits
7-2 Death Benefits
7-3 Other Considerations
7-4 Computing Compensation
8-1 Initial Actions by OWCP
8-2 Restoration Rights
8-3 Nurse Services
8-4 Reemployment with the Agency
8-5 Vocational Rehabilitation Services
8-6 Assisted Reemployment
8-7 Payment of Relocation Expenses
8-8 Employees in Light Duty Status
8-9 Separation from Employment
9-1 Obtaining Information
Appendix B. Injury/Illness Type and Source Codes
Appendix C. Occupational Disease Checklists
List of FECA Offices
Chapter 1. Overview
This chapter provides basic information concerning the administration of the Federal Employees' Compensation Act (FECA).
The FECA provides compensation benefits to civilian employees of the United States for disability due to personal injury or disease sustained while in the performance of duty. The FECA also provides for the payment of benefits to dependents if a work-related injury or disease causes an employee's death. The FECA is intended to be remedial in nature, and proceedings under it are non-adversarial.
1-2. Exclusiveness of remedy
Benefits provided under the FECA constitute the sole remedy against the United States for work-related injury or death. A Federal employee or surviving dependent is not entitled to sue the United States or recover damages for such injury or death under any other statute.
1-3. OWCP Structure
The Division of Federal Employees' Compensation (DFEC) administers the FECA. The Director of the program, in conjunction with regional managers, has authority over the operations of the 12 district offices. Each of these offices is headed by a District Director, who has overall responsibility for office functions.
In each district office are two or more Supervisory Claims Examiners, who are responsible for the operation of individual claims units, and a number of Senior Claims Examiners and Claims Examiners, who have primary responsibility for handling claims. Individuals at each level of authority from Claims Examiner to District Director have been delegated specific responsibilities for issuing decisions on claims.
The jurisdictions of the 12 district offices are as follows (Click HERE for addresses):
District 1--Boston, MA: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont.
District 2--New York, NY: New Jersey, New York, Puerto Rico, and the Virgin Islands.
District 3--Philadelphia, PA: Delaware, Pennsylvania, and West Virginia.
District 6--Jacksonville, FL: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee.
District 9--Cleveland, OH: Indiana, Michigan, and Ohio.
District 10--Chicago, IL: Illinois, Minnesota, and Wisconsin.
District 11--Kansas City, MO: Iowa, Kansas, Missouri, and Nebraska; Department of Labor employees.
District 12--Denver, CO: Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming.
District 13--San Francisco, CA: Arizona, California, Hawaii, and Nevada; Pacific territories and possessions.
District 14--Seattle, WA: Alaska, Idaho, Oregon, and Washington.
District 16--Dallas, TX: Arkansas, Louisiana, New Mexico, Oklahoma, and Texas.
District 25--Washington, DC: Maryland, Virginia, the District of Columbia; employees injured overseas; employees claiming injury due to radiation, Agent Orange, or HIV infection; Peace Corps and VISTA volunteers; Members of Congress and their staffs; White House officials and employees; Reserve Officer Training Corps (ROTC) Cadets; members of the Coast Guard Auxiliary and temporary members of the Coast Guard Reserve; employees whose cases involve security considerations; and certain non-Federal claims.
1-5. Information and Records
Individual case files are protected under the Privacy Act, and only the employee, his or her representative (if any), and agency personnel may routinely have access to the file. Any of these parties may inspect the file at the district office which has custody of the file; an appointment should be requested ahead of time. If it is not possible to inspect the record at the district office, arrangements may be made to have the case sent to another Department of Labor office for review.
Employees and their representatives may have access to records (including medical reports) which OWCP has released to the agency from the case file. The records must, however, be safeguarded in the same manner as other personnel material. Each agency is responsible for determining whether such information may properly be released in accordance with the regulations contained in 29 CFR 70 (a).
The regulations at 20 CFR 10.23 provide that:
a. Any person who knowingly makes, or knowingly certifies to, any false statement, misrepresentation, concealment of fact, or any other act of fraud with respect to a claim under the FECA or who knowingly accepts compensation to which that person is not entitled, is subject to criminal prosecution and may, under appropriate U.S. Criminal Code provisions (e.g., 18 USC 287 and 1001), be punished by a fine of not more than $10,000 or imprisonment for not more than five years, or both.
b. Any person who, with respect to a claim under the FECA, enters into any agreement, combination, or conspiracy to defraud the United States by obtaining or aiding to obtain the payment or allowance of any false, fictitious or fraudulent claim is subject to criminal prosecution and may, under appropriate U.S. Criminal Code provisions (e.g., 18 USC 286), be punished by a fine of not more than $10,000 or imprisonment for not more than 10 years, or both.
c. Any person charged with the responsibility of making reports in connection with an injury who willfully fails, neglects, or refuses to do so; induces, compels, or directs an injured employee to forego filing a claim; or willfully retains any notice, report, or paper required in connection with an injury, is subject to a fine of not more than $500 or imprisonment for not more than one year, or both.
Moreover, claimants convicted of fraudulently claiming or obtaining benefits under the Federal Employees' Compensation Act (FECA) on or after October 21, 1993, the effective date of Public Law 103-112, will lose entitlement to medical benefits, compensation for wage loss, and any other benefits payable under the FECA.
Agencies should maintain an adequate supply of the basic forms needed to process claims, as follows:
Form . . . . .Title
CA-1. . . . . . . . . Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay
CA-2 . . . . . . . . . Federal Employee's Notice of Occupational Disease and Claim for Compensation
CA-2a . . . . . . . . Notice of Employee's Recurrence of Disability and Claim for Pay
CA-3 . . . . . . . . . Report of Termination of Disability and/or Payment
CA-5 . . . . . . . . .Claim for Compensation by Widow, Widower and/or Children
CA-5b . . . . . . . .Claim for Compensation by Parents, Brothers, Sisters, Grandparents/children
CA-6 . . . . . . . . .Official Superior's Report of Employee's Death
CA-7 . . . . . . . . .Claim for Compensation on Account of Traumatic Injury/Occupational Disease
CA-8 . . . . . . . . .Claim for Continuing Compensation on Account of Disability
CA-16 . . . . . . . .Authorization for Examination and/or Treatment
CA-17 . . . . . . . .Duty Status Report
CA-20 . . . . . . . .Attending Physician's Report (attached to Form CA-7; also available separately)
CA-20a . . . . . . .Attending Physician's Supplemental Report (attached to Form CA-8)
CA-35, a-h . . . . Occupational Disease Checklists
OWCP-1500a . .Health Insurance Claim Form
A chart showing the use of each form is found in Appendix A. Forms may be ordered from the Superintendent of Documents, U. S. Government Printing Office, Washington, D. C. 20402. The purchase order must include the agency appropriation symbol and the requestor's signature. Forms may also be ordered by telephone at 202-783-3238.
Several resources describing the provisions of the law and how they are applied are available.
a. The Federal Employees' Compensation Act as amended, 5 USC 8101 et seq., is the source of entitlement to compensation benefits for Federal workers. Because virtually all of the provisions of the FECA have been interpreted and more fully described through OWCP directives and decisions of the Employees' Compensation Appeals Board, other resources will usually prove more helpful than the FECA itself except in locating citations found in OWCP decisions. Copies may be obtained at no charge from the district offices.
b. The Code of Federal Regulations, 20 CFR Chapter 10, Part A, more fully describes the provisions of the law and contains additional information concerning administration of the program. References to the regulations may occasionally be found in letters and decisions of OWCP. Copies may be obtained free of charge from the district offices.
c. The Federal (FECA) Procedure Manual describes in detail the procedures used by OWCP personnel in processing claims. It is divided into several sections by subject area; the section most likely to be of use to agency personnel is Part 2, Claims. One copy of this volume may be provided free of charge to each agency's National headquarters. Other interested parties may obtain it for $35 per copy. It may be ordered from:
Division of Federal Employees' Compensation
Office of Workers' Compensation Programs
200 Constitution Avenue N. W., Room S-3229
Washington, D. C. 20210
d. Questions and Answers About the Federal Employees' Compensation Act (Pamphlet CA-550) describes in non-technical language the basic provisions of the law and includes information concerning the most common issues about entitlement and claims processing. It is intended for use
primarily by employees, who may obtain single copies by contacting the district office. Agencies may order copies from GPO at the address shown in Chapter 1-7.
e. Decisions of the Employees' Compensation Appeals Board may be found in bound volumes in most law libraries. The most recent issues can also be purchased from GPO.
OWCP has developed several kinds of instructional materials to assist agencies in processing compensation claims. The following courses are provided in response to requests from agency personnel:
a. The FECA Seminar provides an overview of the law for first line supervisors as well as middle and senior level managers. The seminar, which is comprised of lectures and visual aids, may range from one to six hours, and it may be given for either small or large groups. The seminar is usually held at the requesting agency and may be given to single or multi-agency groups as well as to Federal labor unions.
b. The Basic Compensation Specialist Workshop provides a three day formal training session in a classroom setting. It is intended for agency personnel who are primarily responsible for processing OWCP claims and for those who spend at least 50% of their time handling OWCP claims. The training stresses skills needed to counsel injured employees, review claim forms for accuracy, document continuation of pay, and develop a record-keeping system.
c. The Advanced Compensation Specialist Training is a self-instructional unit requiring approximately 12 hours to complete. It is primarily intended for compensation specialists who have attended the basic course and who have nine to twelve months of experience. The course stresses management of agency compensation case files with regard to third party matters, review of chargeback reports and billings, light duty assignments, and reemployment of the long-term disabled.
d. The FECA Supervisors Workshop is tailored to meet the needs of the agency requesting training. The training generally covers supervisory responsibilities to employees who are injured at work. It includes reviewing initial reporting forms; counseling employees about continuation of pay; determining whether the claim should be controverted; and offering light duty assignments for injured employees. The length of this course varies according to the kind and amount of material presented.
Arrangements for delivery of these courses may be made with the Technical Assistant of the district office which serves your agency.Return to TABLE OF CONTENTS
Chapter 2. Initiating Claims
This chapter describes the difference between exposure to an infectious agent, which is not compensable, and actual injury. The forms and procedures to be used by employees and agency personnel in initiating claims for traumatic injury, occupational disease, recurrence of disability, and death are then outlined. Agency personnel are cautioned never to prevent employees from filing claims under any circumstances.
2-1. Exposure to Infectious Agents
The FECA does not provide for payment of any expenses associated with simple exposure to an infectious disease, without the occurrence of a work-related injury. Such infectious disease may include tuberculosis, hepatitis, and HIV (human immunodeficiency virus).
Under regulations published by the Occupational Safety and Health Administration addressing the health risks posed by bloodborne pathogens in the workplace, an "exposure incident" is defined as a "specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee's duties" (29 CFR 1910.1030).
Both a work-related injury and exposure to a known carrier must occur before OWCP can pay for diagnostic testing. A puncture wound from a needle used to draw blood from a patient not known to be infected with HIV would entitle the worker to benefits only for the effects of the puncture wound, and the supervisor would not issue Form CA-16 to authorize precautionary testing since no indication exists that a communicable disease has been contracted on duty. However, a puncture wound from a needle used to draw blood from a patient who was known to be infected with HIV would entitle the worker to benefits for the effects of the puncture wound and to payment for diagnostic studies to rule out the presence of a more serious condition, because exposure to a known carrier would be involved.
Similarly, fear of exposure to an infectious agent does not entitle the worker to benefits under the FECA since no definable injury has occurred. For instance, the act of searching an individual known to have hepatitis, or an individual who is believed to belong to a high-risk group for HIV infection, would not entitle an employee to benefits. In these situations, the supervisor should not issue Form CA-16 as no injury or exposure has occurred.
However, employees who have encountered persons with HIV infection may suffer anxiety for their health, and employing agencies should take these concerns seriously when actual exposure (as opposed to fear of exposure) has occurred. In such cases, the supervisor may use the authority provided by 5 USC 7901 to authorize testing or counseling. This section of the law allows agencies to provide screening and associated health services to their own employees, and the services offered may be geared to the particular occupational hazards to which an agency's employees are commonly exposed.
It may also be useful to consider performance of surveillance testing, which monitors a population at risk for a certain condition (as opposed to diagnostic testing, which is performed to assess the specific nature of an individual's illness when a medical condition is known to exist). To arrange for HIV testing or employee counseling, you may wish to contact the appropriate regional office of the Public Health Service.
2-2. Traumatic Injury
A traumatic injury is defined as a wound or other condition of the body caused by external force, including stress or strain. The injury must be identifiable by time and place of occurrence and member of the body affected; it must be caused by a specific event or incident or series of events or incidents within a single day or work shift. Traumatic injuries also include damage to or destruction of prosthetic devices or appliances, including eyeglasses and hearing aids if they were damaged incidental to a personal injury requiring medical services. (Personal property claims can be made only under the Military Personnel and Civilian Employees' Claims Act, 31 USC 240.)
a. Notice of Injury--Form CA-1. When an employee sustains a traumatic injury in the performance of duty, he or she should give a written report on Form CA-1 to the supervisor as soon as possible but not later than 30 days from the date of injury. If the employee is incapacitated, this action may be taken by someone acting on his or her behalf, including a family member, union official, representative, or agency official. The form must contain the original signature of the person giving notice. The supervisor should:
(1) Review the front of the form for completeness and accuracy, and assist the employee in correcting any deficiencies found;
(2) Complete and sign the reverse of Form CA-1, including a telephone number in case OWCP personnel have questions about the injury. Also, insert the appropriate codes on both the front and back of the form. Codes should be included for occupation, type and source of injury, agency identification, and location of duty station by zip code (Appendix B of this publication describes the type and source of injury codes and their use).
(3) Sign and return to the employee the receipt attached to Form CA-1 and give a copy of the form to the employee if requested;
(4) Authorize medical care if needed in accordance with paragraph (b) below;
(5) Inform the employee of the right to elect continuation of regular pay (COP) (discussed in detail in Chapter 5), or annual or sick leave if time loss will occur;
(6) Advise the employee whether COP will be controverted, and if so, whether pay will be terminated. The basis for the action must be explained to the employee. (Controversion is discussed in Chapter 5-3; the reason for controverting a claim must always be shown on Form CA-1.)
(7) Advise the employee of his or her responsibility to submit prima facie medical evidence of disability within 10 working days or risk termination of COP (see Chapter 5-8).
If the employee incurs medical expense or loses time from work beyond the date of injury, the supervisor should submit Form CA-1 to the district office with supporting information as soon as possible but no later than 10 working days after receipt of Form CA-1 from the employee. If one or more visits for medical care are required during duty hours after the date of injury, or if two or more such visits are required during non-duty hours after the date of injury, the case should be submitted to OWCP as a first aid injury. If no medical expense will be incurred and no time will be lost from work beyond the date of injury, the notice of injury should be retained in the Employee Medical Folder.
b. Medical Treatment--Form CA-16. If an employee requires medical treatment because of the injury, the supervisor should promptly complete the front of Form CA-16 within four hours of the request whenever possible. If the supervisor doubts whether the employee's condition is related to the employment, he or she should so indicate on the form. In an emergency, where there is no time to complete a Form CA-16, the supervisor may authorize medical treatment by telephone and then forward the completed form to the medical facility within 48 hours. Retroactive issuance of Form CA-16 is usually not permitted under other circumstance.
(1) Delayed Report of Injury. If an employee has reported an injury several days after the fact, or did not request medical treatment within 24 hours of the injury, the supervisor may still authorize medical care using Form CA-16. Agency personnel are encouraged to use discretion in issuing authorizations for medical care under such circumstances, but employees should not be penalized for short delays in reporting injuries. The supervisor may, however, refuse to issue a CA-16 if more than a week has passed since the injury on the basis that the need for immediate treatment would normally have become apparent in that period of time. An employee may not use Form CA-16 to authorize his or her own medical treatment.
(2) Choice of Physician. The employee is entitled to select the physician or facility which is to provide treatment. The provider must meet the definition of "physician" under the FECA and must not have been excluded from payment under the program (refer to Chapter 6 for guidance in authorizing providers). An agency may make its own facilities available for examination and treatment of injured employees, but may not mandate use of its facilities to the exclusion of the employee's choice. Physicians employed by or under contract to the agency may examine the employee at the agency's facility in accordance with OPM regulations, but the employee's choice of physician must be honored, and treatment by the employee's physician must not be delayed.
(3) Obtaining Treatment. Along with Form CA-16, the supervisor should give the employee Form OWCP-1500, which is used for billing (this form is discussed in Chapter 6). The physician should complete the reverse of Form CA-16 and the OWCP-1500 and forward them to OWCP; the supervisor may ask the physician for a copy of the report as well. The employee may be furnished transportation and/or reimbursed for travel and incidental expenses. OWCP generally considers 25 miles from the agency or the employee's home a reasonable distance to travel for medical care unless appropriate care is not available within that radius.
(4) Referral. The original treating physician may wish to refer the employee for specialized treatment or for further testing. He or she may do so on the basis of the Form CA-16 already issued; it is not necessary to issue additional authorizations for treatment. Both the original physician and any physician to whom the employee is referred is guaranteed payment for 60 days from the date of issue of Form CA-16 unless OWCP terminates this authority at an earlier date. Treatment may continue at OWCP expense if the claim is approved.
Should the employee wish to change physicians after the initial choice, he or she must contact OWCP in writing for approval and include the reasons for requesting the change.
c. Medical Reports--Forms CA-20, CA-20a, and CA-17. In cases sent to OWCP, a medical report from the attending physician is required. This report may be made on Form CA-16 or on Forms CA-20 or CA-20a, which are attached to compensation claim forms. It may also be made by narrative report on the physician's letterhead stationery, or in the form of an emergency room summary. In all instances, however, the physician's original signature must appear on the report. The supervisor should supply medical report forms to the employee for completion by the physician as often as needed. These reports should be submitted in original form to OWCP.
Agency personnel should use Form CA-17, Duty Status Report, to obtain interim medical reports concerning the employee's fitness for duty; it may be issued initially with Form CA-16. The supervisor should complete the agency's portion of the form by describing the physical requirements of the employee's job and noting the availability of any light duty. The physician should forward the original Form CA-17 to the agency and a copy to the district office. The supervisor may send Form CA-17 to the physician at reasonable intervals (but not more often than once a week) to monitor the employee's medical status and ability to return to light or full duty. (Agency offers of light duty during the COP period are discussed in Chapter 5.)
d. Wage Loss/Permanent Impairment--Form CA-7. If disability is anticipated at the time of injury, the employee may elect to use leave or COP (which is discussed in Chapter 5) on Form CA-1. An employee who cannot return to work when COP terminates, or who is not entitled to receive COP, may claim compensation for wage loss on Form CA-7. In controverted cases where pay is terminated, Form CA-7 should be submitted with Form CA-1.
(1) When to File. If disability is expected to continue beyond the period of entitlement to COP, the employee may claim compensation or use leave to cover his or her absence from work. If it is not clear whether the employee will remain disabled after the 45 days of COP are used, claim for compensation should be initiated. Employees who have filed claims should be carried in LWOP status. If an employee returns to work after Form CA-7 has been filed, however, the supervisor should notify OWCP by telephone to avoid overpayments, and later provide written confirmation of return to duty.
(2) Completion. If compensation is to be claimed, the supervisor should give Form CA-7 to the employee on the 30th day of COP with instructions to complete the front and return the form to the agency within one week. (If the employee has not returned it by the 40th day of COP, the supervisor should contact him or her by telephone and request that it be submitted as soon as possible). The supervisor should also indicate the address of the district office in the box on the reverse of the Form CA-20 which is attached to the claim form.
When the form is returned, the supervisor should complete the reverse of the form, including the name and the telephone number of an agency official with direct knowledge of the claim. The employee should arrange to provide medical evidence to support the period of disability claimed; this evidence may be submitted with the Form CA-7 or sent to OWCP separately.
(3) Submission. After completing the form, the supervisor should submit it to OWCP along with any new medical evidence in the agency's possession. OWCP will use the pay data supplied by agency personnel to determine the rate at which compensation is to be paid. (Submission should not be delayed for computation of shift differential, Sunday or holiday pay, or other incremental pay; these elements, which are discussed in Chapter 8, may be computed and submitted separately). The dates of compensation claimed should represent the period of disability supported by the medical evidence or the interval until the employee's next medical appointment.
(4) Leave Repurchase. An employee who uses sick or annual leave to avoid possible interruption of income may repurchase that leave, subject to agency concurrence, if the claim is approved. Form CA-7 may be used for this purpose as well. The employee and supervisor should supply the factual and medical evidence described above, and the supervisor should also provide a detailed breakdown of leave used, showing the number of hours charged for each day claimed and whether sick or annual leave was used. (The relationship between COP use and leave use is discussed in Chapter 5-2.)
(5) Lost Wages for Medical Treatment. An employee who has returned to work but continues to require medical treatment during work hours may claim compensation for lost wages while undergoing or traveling to and from the treatment. Such a claim may be made on Form CA-7, and it should be accompanied by a statement from the supervisor showing the exact period of time and the total amount of wages lost due to the treatment, the rate of pay and the number of hours or days the employee would have worked if available.
Form CA-7 may also be used to claim a schedule award for permanent impairment as a result of traumatic injury (entitlement to such awards is discussed in Chapter 7-1).
e. Continuing Wage Loss--Form CA-8. If disability is expected to continue, the supervisor should give the injured employee Form CA-8 ten days before the period claimed on Form CA-7 expires. The supervisor should indicate the address of the OWCP district office in the box on the back of CA-20a which is attached to the form. The employee should complete the front and return it to the supervisor, which should complete the reverse of the form. As with the Form CA-7, the employee is responsible for obtaining medical support for the period claimed, and the dates of compensation claimed should represent the period of disability supported by the medical evidence or the interval until the employee's next medical appointment.
The completed form should be sent to OWCP at least five days before the end of the period claimed on Form CA-7. During the period of disability a Form CA-8 should be submitted every two weeks absent other instructions from OWCP. Form CA-8 may also be used to claim additional periods of leave repurchase; an itemized breakdown of leave used should be provided as described in paragraph (d) above. Here again, if the employee returns to work after a claim has been submitted, the supervisor should notify the district office by telephone immediately so that an overpayment can be avoided. Written confirmation of return to duty should also be supplied to the district office.
If the employee is examined or treated at the agency's medical facilities or by medical providers under contract to the agency, and this examina- tion or treatment occurs during working hours beyond the date of injury, the supervisor should submit Form CA-1 to OWCP. In doing so, the supervisor should add the words "first aid" to the upper right corner of the agency's portion of Form CA-1. "First aid" injuries also include those requiring two or more visits to a medical facility for examination or treatment during non-duty hours beyond the date of injury, as long as no leave or continuation of pay is charged and no medical expense is incurred.
If the employee obtains no medical care, or obtains only agency-sponsored care on the date of injury, and no time loss is charged to either leave or continuation of pay, the supervisor should place Form CA-1 in the worker's Employee Medical Folder (EMF) instead of sending it to OWCP.
2-3. Occupational Disease
An occupational disease is defined as a condition produced in the work environment over a period longer than one work day or shift. It may result from systemic infection, repeated stress or strain, exposure to toxins, poisons, or fumes, or other continuing conditions of the work environment.
a. Notice of Occupational Disease--Form CA-2. The injured employee, or someone acting on his or her behalf, should give notice of occupational disease on Form CA-2. The supervisor should issue to the employee two copies of the appropriate checklist, Form CA-35a-h, for the disease claimed. (Specific checklists have been devised for various conditions in order to facilitate submission of evidence--see Appendix C.) The supervisor should also explain the need for detailed information to the employee and advise him or her to furnish supporting medical and factual information requested on the checklist. If possible, this information should accompany the form when it is submitted. Upon receiving Form CA-2, the supervisor should:
(1) Review the front of the form for completeness and accuracy, and assist the employee in correcting any deficiencies found;
(2) Complete and sign the reverse of Form CA-2, including a telephone number in case OWCP personnel have questions about the claim. Also, show the appropriate codes for occupation, type and source of injury, agency identification, and location of duty station by zip code. (Appendix B describes the type and source of injury codes and their use.)
(3) Sign and return to the employee the receipt attached to Form CA-2 and give a copy of the form to the employee if requested;
(4) Review the employee's portion of the form and provide comments on the employee's statement requested in (5);
(5) Prepare a supporting statement to include exposure data, test results, copies of reports of previous medical examinations, and/or witness statements, depending on the nature of the case. The checklist may be used to coordinate compilation of material by agency personnel, including compensation specialists and safety and health officers;
(6) Advise the employee of the right to elect sick or annual leave or leave without pay, pending adjudication of the claim.
The supervisor should submit completed Form CA-2 to the district office within 10 working days of receipt from the employee. It should not be held for receipt of supporting documentation.
b. Medical Treatment--Form CA-16. Only rarely do employing agency personnel authorize medical care in occupational disease claims. The supervisor must contact OWCP before issuing a Form CA-16 in such a claim.
c. Wage Loss--Form CA-7. Form CA-7 is used to file an original claim for compensation because of pay loss resulting from an occupational disease. The claim should be filed within 10 days after pay stops or when the employee returns to work, whichever occurs first.
(1) Leave Repurchase. The employee may wish to use sick or annual leave pending adjudication of the claim. If so, the employee may initiate repurchase of this leave, subject to agency concurrence, using Form CA-7. The supervisor should certify the amount and kind of leave used for each day claimed, and the employee should arrange for submission of medical evidence supporting the period of repurchase requested.
(2) Lost Wages for Medical Treatment. An employee who has returned to work but contin-ues to require medical treatment during work hours may claim compensation for lost wages while undergoing or traveling to and from the treatment. Such a claim may be made on Form CA-7, and it should be accompanied by a statement from the supervisor showing the exact period of time and the total amount of wages lost due to the treatment, the rate of pay and the number of hours or days the employee would have worked if available.
Form CA-7 may also be used to initiate a claim for schedule award for permanent impairment resulting from occupational disease. Chapter 7-1 addresses entitlement to such awards.
d. Continued Wage Loss--Form CA-8. Form CA-8 may be used to claim continuing compensation after the initial period claimed on Form CA-7, or to claim additional periods of leave repurchase.
A recurrence is defined as a spontaneous return 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 (defined in Chapter 3-5). A recurrence differs from a new injury in that with a recurrence, no event other than the previous injury accounts for the disability. Follow-up medical care for an injury or disease which causes time loss is considered part of the original injury rather than a recurrence unless the employee was previously released from treatment.
a. Claim for Recurrence--Form CA-2a. If a recurrence develops, the employee and supervisor should complete Form CA-2a and submit it to OWCP. If the employee was entitled to use COP and the 45 calendar days of COP have not been exhausted, he or she may elect to use the remaining days if 90 days have not elapsed since first return to duty (see Chapter 5-7 for detailed information). Otherwise, the employee may elect to use sick or annual leave pending adjudication of the claim for recurrence. The employee should arrange for submission of the factual and medical evidence described in the instructions attached to the form, paying particular attention to the need for "bridging" information which describes his or her condition and job duties between the original injury and the recurrence.
b. Medical Treatment--Form CA-16. The supervisor, at his or her discretion, may issue Form CA-16 to authorize examination or treatment for a recurrence of disability if it resulted from an injury previously recognized as compensable by the OWCP. The supervisor may not authorize examination or treatment when OWCP has disallowed the original claim or when more than six months have elapsed since the employee last returned to work.
c. Claim for Wage Loss--Forms CA-7 and CA-8. If an employee wishes to claim compensation because of a recurrence, Form CA-7 is required if one was not previously submitted. If a Form CA-7 was submitted, then the employee is to complete a Form CA-8 and submit it to the supervisor along with supporting medical evidence. A Form CA-8 is to be completed and submitted every two weeks until OWCP notifies the employee otherwise.
When an employee dies because of an injury incurred while in performance of duty, the supervisor should immediately notify the district office by telephone or facsimile message. The supervisor should also contact any survivors, provide them with claim forms, and assist them in preparing the claim as much as possible. The forms should be submitted even if a disability claim had previously been filed and benefits were paid. Continuation of benefits is not automatic, as it must be shown that the death resulted from the same condition for which the disability claim was accepted.
a. Claims for Death Benefits--Forms CA-5 and CA-5b. The survivors of a deceased employee should use Form CA-5 or CA-5b to submit claims for death benefits. The survivor should complete the front of the appropriate form, while the attending physician should complete the medical report on the reverse and forward it to OWCP. The submission should include a copy of the death certificate which has been certified by the issuing authority. It should also include a certified marriage certificate if a spouse is making claim, and a copy of any divorce or annulment decree if the decedent or spouse was formerly married. The submission should include certified copies of birth certificates of any children for whom claim is made.
b. Agency Notice--Form CA-6. The supervisor uses this form to report the work-related death of an employee.Return to TABLE OF CONTENTS
Chapter 3. Conditions of Coverage
Each claim for compensation must meet certain requirements before it can be accepted. This is true whether the claim is for traumatic injury, occupational disease, or death. While the requirements are examined somewhat differently according to the type of claim, they are always considered in the same order. This chapter will describe these requirements as well as the three statutory prohibitions to payment of compensation. It will also describe the kind of information which should be submitted by the supervisor and employee for each issue.
All cases must first satisfy the statutory time requirements of the FECA.
a. Provisions of the Law. For injuries and deaths on or after September 7, 1974, the law provides that a claim for compensation must be filed within three years of the injury or death. Even if claim is not filed within three years, however, compensation may still be allowed if written notice of injury was given in 30 days or the immediate superior had actual knowledge of the injury or death within 30 days after occurrence. This knowledge may consist of written records or verbal notification; an entry into an employee's medical record may also satisfy this requirement if it is sufficient to place the agency on notice of a possible work-related injury or illness.
The law also provides that the filing of a disability claim because of injury will satisfy the time requirements for a death claim based on the same injury. OWCP may excuse failure to comply with the three year time requirement because of exceptional circumstances (for example, being held prisoner of war).
For injuries occurring before September 7, 1974, different provisions apply with respect to timeliness. Contact the district office concerning any case in this category.
b. When Time Begins to Run. For traumatic injury, the statutory time limitation begins to run from the date of injury. For a latent condition, it begins to run when an injured employee who has a compensable disability becomes aware, or reasonably should have been aware, of a possible relationship between the condition and the employment. In situations where the exposure to possibly injurious employment-related conditions continues after this knowledge, the time for filing begins to run on the date of the employee's last exposure to the implicated conditions.
In death cases resulting from traumatic injury, time begins to run from the date of death. Where death is due to disease, time begins to run when the beneficiary is aware, or reasonably should have been aware, of causal relationship between the death and the factors of employment. For a minor, the time limitations do not begin to run until the person reaches the age of 21 or has a legal representative. For a person who is mentally incompetent, the time limitations do not begin to run until the person has a legal representative.
c. Written Notice. Form CA-1 or CA-2 constitutes notice of injury. A claim for compensation (Form CA-7 in disability cases, CA-5 or CA-5b in death cases) may also constitute notice of injury. Moreover, OWCP will accept as a notice of injury or death any written statement which is signed by the person claiming benefits or someone acting on his or her behalf and which states the name of the employee; the name and address of the person claiming benefits; the time and location of the injury or death; and the cause and nature of the injury or death.
d. Actual Knowledge. An agency official may acquire actual knowledge through firsthand observation of the incident, from another employee, or from medical personnel at the agency's medical facility. This knowledge must place the employing establishment reasonably on notice of an on-the- job injury or death. An entry into the employee's medical records may be considered actual knowledge, as may the results of tests conducted by agency personnel in connection with known occupational hazards. The date on which the agency or OWCP receives written notice will be considered the date of filing. Information addressing the issue of actual knowledge is needed only when the agency did not receive written notice within three years.
3-2. Civil Employee
If the claim is timely filed, it must be determined whether the injured or deceased individual was an "employee" within the meaning of the law. This is always the second requirement considered.
a. Provisions of the Law. The FECA covers all civilian Federal employees except for non-appropriated fund employees. In addition, special legislation provides coverage to Peace Corps and Vista volunteers; Federal petit or grand jurors; volunteer members of the Civil Air Patrol; Reserve Officer Training Corps Cadets; Job Corps and Youth Conservation Corps enrollees; and non- Federal law enforcement officers under certain circumstances involving crimes against the U. S.
b. Other Considerations. Temporary employees are covered on the same basis as permanent employees. Contract employees, volunteers, and loaned employees are covered under some circumstances; such determinations must be made on a case by case basis once a claim is filed. Federal employees who are not citizens or residents of the U.S. or Canada are covered subject to certain special provisions governing their pay rates and computation of compensation payments.
3-3. Fact of Injury
If the issues of "time" and "civil employee" have been resolved affirmatively, it must be established whether the employee in fact sustained an injury or disease. Two factors are involved in this determination:
a. Occurrence of Event. Whether the employee actually experienced the accident, event, or employment factor which is alleged to have occurred. This is resolved on the basis of factual evidence, including statements from the employee, the supervisor, and any witnesses. An injury need not be witnessed in order to be compensable. A supervisor who believes, however, that the employee's testimony is contrary to the facts should supply pertinent information to support this belief.
b. Medical Condition. Whether the accident or employment factor resulted in an injury or disease; this is determined on the basis of the attending physician's statement that a medical condition is present which may be related to the incident. Simple exposure, for instance to a contagious condition or dusty environment, does not constitute an injury.
3-4. Performance of Duty
If the first three criteria have been accepted, it must be determined whether the employee was in the performance of duty when the injury occurred.
a. Agency Premises. An employee who is injured on agency premises during working hours has the protection of the FECA unless engaged in an activity which removes him or her from the scope of employment. Coverage includes injuries which occur while the employee was performing assigned duties or engaging in an activity which was reasonably associated with the employment. Such activities include use of facilities for the employee's comfort, health, and convenience as well as eating meals and snacks provided on the premises. The premises include areas immediately outside the building, such as steps or sidewalks, if these are Federally owned or maintained. The supervisor should document an injury occurring in such an area by submitting a diagram showing where it happened.
(1) Outside Working Hours. Coverage is extended to employees who are on the premises for a reasonable time before or after working hours. It is not extended, however, to employees who are visiting the premises for non-workrelated reasons. The supervisor should verify the time of the injury and provide any information in its possession about the employee's purpose in being on the premises at the time of injury.
(2) Representational Functions. Injuries to employees performing representational functions entitling them to official time are covered. Injuries to employees engaged in the internal business of a labor organization, such as soliciting new members or collecting dues, are not covered. The supervisor should advise whether the employee was entitled to official time when injured.
(3) Parking Facilities. The agency's premises include the parking facilities which it owns, controls, or manages. An employee will usually be covered if injured on such parking facilities. Information submitted by the supervisor should include a statement indicating whether it owns or leases the parking lot, and if the latter, the name and address of the owner (this information may be needed for purposes of developing the third-party aspect of the claim, which is described in Chapter 4-1). If the parking lot is not immediately adjacent to the building, the supervisor should also supply a diagram showing where the injury took place in relation to the parking lot and building.
(4) Agency Housing. An employee is covered if injured during the reasonable use of premises which he or she is required or expected to occupy, and which are furnished or made available by the agency. (Employees using such housing include firefighters and Job Corps enrollees.) Any claim for injury occurring under such circumstances should be accompanied by a full description of the living arrangements and the requirements and expectations surrounding their use.
b. Off-Premises Injuries. Coverage is extended to workers such as letter carriers, chauffeurs, and messengers who perform service away from the agency's premises. It is also extended to workers who are sent on errands or special missions and workers who perform services at home.
(1) To and From Work. Employees do not have the protection of the FECA when injured en route between work and home, except where the agency furnishes transportation to and from work, the employee is required to travel during a curfew or an emergency, or the employee is required to use his or her vehicle during the work day. Such claims should be accompanied by a description of the circumstances.
(2) Lunch Hour. Injuries which occur during lunch hour off the premises are not ordinarily covered unless the employee is in travel status or is performing regular duties off premises.
(3) Travel Status. Employees in travel status are covered 24 hours a day for all reasonable incidents of their TDY. Thus, an employee injured on a sightseeing trip in the city to which he or she was assigned may not be covered, while an employee injured in the hotel shower would be covered. All claims for injuries occurring in travel status should be accompanied by a copy of the travel authorization.
(4) Vehicular Accidents. Any claim involving a traffic accident should be accompanied by a copy of the police report, if any, and a diagram or map showing the location of the accident in relation to the places where official duty was last performed and next scheduled.
c. Other Factors. Some injuries occur under circumstances which are not governed, or not completely governed, by the premises rules. Injuries involving any of the circumstances indicated below must be determined on a case-by-case basis.
(1) Recreation. An employee is covered while engaged in formal recreation for which he or she is paid or is required to perform as a part of training or assigned duties. Also covered are employees engaged in informal recreation, such as jogging, while on the agency premises. Under other circumstances, the agency must explain what benefit it derived from the employee's participation, the extent to which the agency sponsored or directed the activity, and whether the employee's participation was mandatory or optional.
(2) Horseplay. An employee who is injured during horseplay is covered if the activity was one which could reasonably be expected where a group of workers is thrown into personal association for extended periods of time. In this kind of case, it must be determined whether the particular activity was a reasonable incident of the employment or was an isolated event which could not reasonably have been expected to result from close association.
(3) Assault. An injury or death caused by the assault of another person may be covered if it is established that the assault was accidental and arose out of an activity directly related to the work or work environment. Coverage may also be extended if the injury arose out of a personal matter having no connection with the employment if it was materially and substantially aggravated by the work association. The supervisor should submit copies of any internal or external investigation to which the agency has access as well as witness statements from parties having knowledge of the incident.
(4) Emergencies. Coverage is extended to employees who momentarily step outside the sphere of employment to assist in an emergency, such as to extinguish a fire or assist a person in imminent danger.
3-5. Causal Relationship
After the four factors described above have been considered, causal relationship between the condition claimed and the injury or disease sustained is examined. Unlike fact of injury, which is discussed in paragraph (3) above and which involves the determination that a medical condition is present, causal relationship involves establishment of a connection between the injury and the condition found. This factor is based entirely on medical evidence provided by physicians who have examined and treated the employee. Opinions of the employee, supervisor or witness are not considered, nor is general medical information contained in published articles.
a. Kinds of Causal Relationship. An injury or disease may be related to employment factors in any one of four ways:
(1) Direct Causation. This term refers to situations where the injury or factors of employment result in the condition claimed through a natural and unbroken sequence.
(2) Aggravation. If a pre-existing condition is worsened, either temporarily or permanently, by a work-related injury, that condition is said to be aggravated.
(a) Temporary aggravation involves a limited period of medical treatment and/or disability, after which the employee returns to his or her previous physical status. Compensation is payable only for the period of aggravation established by the medical evidence, and not for any disability caused by the underlying disease. This is true even if the employee cannot return to the job held at time of injury because the pre-existing condition may be aggravated again. For example, if exposure to dust at work temporarily aggravates an employee's pre-existing allergy, compensation will be payable for the period of work-related disability but not for any subsequent period, even though further exposure in the work place may cause another aggravation.
(b) Permanent aggravation occurs when a condition will persist indefinitely due to the effects of the work-related injury or when a condition is materially worsened by a factor of employment such that it will not return to the pre-injury state.
(3) Acceleration. A work-related injury or disease may hasten the development of an underlying condition, and acceleration is said to occur when the ordinary course of the disease does not account for the speed with which a condition develops.
(4) Precipitation. This term refers to a latent condition which would not have manifested itself on this occasion but for the employment. For example, an employee's latent tuberculosis may be precipitated by work-related exposure.
b. Medical Evidence. The issue of causal relationship almost always requires reasoned medical opinion for resolution. This opinion must be obtained from a physician who has examined or treated the employee for the condition claimed. In any case where a pre-existing condition involving the same part of the body is present, the physician must provide rationalized medical opinion which differentiates between the effects of the employment-related injury or disease and the pre-existing condition. Such evidence will permit the proper kind of acceptance (temporary vs. permanent aggravation, for instance).
To establish causal relationship, additional medical opinion may be requested of OWCP's District Medical Director/Adviser or from a specialist in the medical field pertinent to the injury or disease. In a claim for a psychiatric condition, a report from a psychiatrist or licensed clinical psychologist will be required to meet this criterion. In claims for occupational hearing loss and pulmonary disease, the OWCP will refer the employee for examination by an appropriate specialist after exposure to the hazardous substance or condition has been established. Chapter 6 may be consulted for further information concerning medical examinations.
c. Consequential and Intervening Injuries. Sometimes an injury occurring outside performance of duty may affect the compensability of a work-related injury.
(1) A consequential injury is a new injury which occurs as the result of a work-related injury; for example, it occurs because of weakness or impairment caused by a work-related injury. Included in this definition are injuries sustained while obtaining medical care for a work-related injury. Consequential injuries are compensable.
(2) An intervening injury is one which occurs outside the performance of duty to the same part of the body originally injured. The resulting condition will be considered related to the original injury unless the second injury alone is established as its cause.
3-6. Statutory Exclusions
Sometimes the circumstances of a case raise the issues of willful misconduct, intention to bring about the injury or death of oneself or another, or intoxication. If any of these factors is established as the cause of the injury or death, benefits must be denied. Agency or OWCP personnel must assert and prove these factors.
a. Willful Misconduct. The question of deliberate willful misconduct may arise when the employee violated a safety rule, disobeyed other orders
of the employer, or violated a law. Because safety rules have been established for the protection of the worker rather than the employer, simple negligent disregard of such rules is not sufficient to deprive an employee or beneficiary of entitlement to compensation. Disobedience of such orders may destroy the right to compensation only if the disobedience is deliberate and intentional as distinguished from careless and heedless.
b. Intoxication. In any case involving intoxication (whether by alcohol or any other drug) the record must establish both the extent to which the employee was intoxicated at the time of the injury and the particular manner in which the intoxication caused the injury. It is not sufficient just to show that the employee was intoxicated; it must be shown that the intoxication proximately caused the injury. This requirement does not, however, provide agency personnel with any additional authority to test employees for drug use beyond that which may exist under other statutes or regulations.
c. Intention to Bring About Injury or Death to Oneself or Another. Where it appears that the employee brought about his or her own injury or death, or that of another, intention must be established. If the factual and medical evidence shows that the employee was not in full possession of his or her faculties, the injury may be compensable. Thus, suicide may be compensable if the injury and its consequences directly caused a mental disturbance or physical condition which produced a compulsion to commit suicide and prevented the employee from exercising sound discretion or judgment so as to control that compulsion.Return to TABLE OF CONTENTS
Chapter 4. Processing Claims
This chapter describes general procedures and responsibilities for case handling once the proper forms and information have been filed with OWCP. It also describes the steps which agency personnel should take if it believes a claim to be questionable.
4-1. Administrative Matters
a. Initial Handling. The notice of traumatic injury, occupational disease or death should be filed with the district office with jurisdiction over the location of the employing agency. (After adjudication, the claim may be transferred to the district office with jurisdiction over the location of the employee's residence, if different.) When possible, the notice should be accompanied by supporting documents such as medical reports and statements from the employee, the supervisor, and witnesses. When the notice is received, OWCP will send the employee and the supervisor a postcard (Form CA-801) advising the claim number assigned to the case.
Uncontroverted claims with medical bills totalling less than $1000, no claim for compensation benefits, and no potential third-party liability will be administratively closed after payment of any outstanding medical bills. Claims not meeting these criteria will be assigned to a Claims Examiner for formal adjudication, as will those which pass the $1000 threshold for medical bill payment.
The Claims Examiner will determine if information in addition to the initial submission is required to adjudicate the claim. If so, the information will be requested of the employee and/or the supervisor with a copy to all parties to the claim. While the requirements for accepting a claim are considered in the order shown in the previous chapter,
OWCP will attempt to request information on all unresolved aspects of the claim simultaneously in the interests of efficient case handling.
b. Obtaining Information. Agencies and employees usually communicate with OWCP in writing. Most district offices have a contact office which can provide information on the status of a claim and answer general questions. When more detailed information is needed, the Claims Examiner responsible for the case file can often satisfy the inquiry. A supervisor with questions about common themes identified in a number of claims should contact the Assistant District Director or District Director for clarification of the procedure in question. Only inquiries which cannot be resolved in this manner should be referred to OWCP's National Office, and any such matter should be referred through the agency's headquarters. Policy questions may also be referred to OWCP's National Office.
Under the Privacy Act, the employee or representative is entitled to receive one copy of the case file from OWCP free of charge; additional copies will be sent at a cost of $.10 per page. It is not necessary to request the records under the Freedom of Information Act. Ordinarily, a complete copy of the record is sent directly to the requestor; occasionally, if sensitive medical information is involved, the district office will choose to forward the medical reports to a physician of the employee's choice so that the contents may be properly interpreted to the employee. Sensitive medical information may be released to the employee's representative, with the proviso that it not be disclosed to the employee, without the attending physician's permission.
c. Conferencing. Telephone conferences conducted by a Senior Claims Examiner are often held in cases involving complicated adjudicatory and case management issues. Conferences may be used to address the agency's controversion; the occurrence of an injury as claimed; the occurrence of an injury in performance of duty; occupational disease cases involving voluminous factual evidence or complex determinations; overpayments; and return to work efforts. Conferences may also be held where the employee is not able to express himself or herself well in writing. A representative of the employing agency may be asked to participate in such a conference, either with the Senior Claims Examiner alone or together with other parties to the claim. After the conference, the Senior Claims Examiner completes a Memorandum of Conference which describes what each party said, then asks the participant to provide any comments on this document within 15 days. The Senior Claims Examiner then makes findings on the issue for resolution and issues a decision accordingly.
d. Representation. The FECA provides that an employee may be represented if he or she so desires, but it is not required. A representative need not be an attorney; a union representative or friend, for example, may act in this capacity. The employee must designate any representative in writing before OWCP will recognize him or her. The law contains no provision for OWCP to pay representatives' fees. It does require, however, that OWCP approve such fees prior to payment. OWCP does not honor contingency fee agreements, and the employee should not pay any fee prior to approval by OWCP, unless the fee is paid into a true escrow account.
e. Third Party. When a party other than the employee or agency personnel appears to be responsible for an injury or death, the employee may be asked to seek damages from that party, which may be an individual or product manufacturer. Agency personnel are encouraged to investigate the third party aspect of any claim and submit all information gathered to OWCP. The employee will be contacted with specific instructions concerning this aspect of the claim; he or she should not attempt to settle such a claim without first obtaining advice and approval from the Solicitor of Labor through OWCP.
While a claim is pending against the third party, OWCP will pay medical and compensation benefits to which the beneficiary is entitled. If a recovery is made, the beneficiary must first pay outstanding legal fees and costs. He or she is then entitled to retain 20 percent of the remaining amount, plus an amount equivalent to a reasonable attorney's fee in proportion to the sum which will be owed to OWCP. The latter amount generally includes the total medical and compensation payments made by OWCP up to the time of settlement. Any money remaining is retained by the beneficiary and credited against future claims for benefits. OWCP will resume payment of compensation benefits and medical bills only after the beneficiary has submitted claims which equal the amount of money remaining.
4-2. Burden of Proof
The employee is responsible for establishing the essential elements of the claim as described in Chapter 3. OWCP will assist the employee in meeting this responsibility, which is also termed burden of proof, by requesting evidence needed to fulfill the requirements of the claim if such information is not included with the original submission.
OWCP will attempt to obtain any pertinent medical evidence in the possession of another Federal facility, including the employing agency, but this assistance does not relieve the employee of his or her burden of proof. Agencies are required by law to provide medical and factual evidence requested by OWCP in order to adjudicate a claim. Agencies and employees alike are always entitled to present information not specifically requested by OWCP.
When information is not submitted in a timely manner, delays in adjudicating cases and paying claims often result. To minimize such delays, OWCP will ask the employee and supervisor to submit the required evidence within a specific period, usually 30 days from the date of the request. A copy of any request to the supervisor for information will be sent to the employee, and vice versa. Following is a description of the procedures which OWCP uses with respect to requests for information from agencies.
a. Traumatic Injury Cases (Including Recurrence and Death).
(1) The factual evidence required from an employer in a traumatic case will often concern the circumstances surrounding the injury. By anticipating the information which OWCP will need, as described in the preceding chapter, agency personnel will often be able to avoid handling correspondence which would otherwise be generated. Each submission of forms should contain a clear description of how the injury occurred, including the time and place, whether it happened during working hours, the presence of witnesses, etc.
If this information is not included in the original submission, OWCP will request it. If a second request for such information is needed, OWCP will advise that absent a response the case will be processed on the basis of the evidence submitted by the employee as follows:
(a) If the employee's statement is sufficiently detailed and/or credible, OWCP will accept the statement and adjudicate the claim accordingly.
(b) If the employee's statement is not sufficient and/or credible, the claim will be denied for the reason that one or more of the five basic elements required to approve a claim has not been established.
(2) Medical evidence in possession of the agency may also be requested.
(a) In an unadjudicated claim, the supervisor should submit copies of medical records pertaining to the injury and any relevant pre-existing condition at the time of initial submission to OWCP. This evidence will be requested of the agency if it is not sent with the original submission.
(b) In an accepted case, if the employee receives continuing care from an agency physician (or its contract provider), the supervisor should include supporting medical evidence for disability with claims submitted. Otherwise, the agency will be asked to submit the relevant medical evidence if the file does not support disability for the claimed period.
If the file contains prima facie medical evidence of disability for the period claimed but additional support is needed, OWCP will authorize payment for a reasonable period and request the evidence from the employer. If another claim is received and the previously requested evidence has not been submitted, OWCP will again authorize payment of compensation for a reasonable period and refer the employee to a medical specialist for examination.
(3) Payment information needed will usually involve the employee's salary or the days of LWOP claimed or leave used during the period involved. Agencies can speed the payment process by advising OWCP of any elements of the pay rate which should be included, such as night and Sunday differential, and whether the employee has received these increments regularly (in which case the biweekly amount should be indicated) or sporadically (in which case the employee's entire earnings in the relevant pay category for the year preceding the injury should be provided).
Where the pay rate is in question, OWCP will begin paying compensation using the lower salary and request clarification from the supervisor. If a second request is necessary, the employee will be advised that documentation is necessary to support the higher pay rate and asked to submit any documentation in his or her possession. If the agency fails to reply and the employee submits adequate documentation (e.g., pay stubs), OWCP will adjust compensation. Until sufficient documentation is received from either the supervisor or the employee, compensation will be paid at the lower rate.
Where the days and hours of LWOP or leave status during a claimed period are in question, OWCP will request clarification from the supervisor. Any follow-up request needed will also advise the employee of the need for documentation and invite him or her to submit a detailed account for the period in question. If the employee provides such an account, OWCP will send a copy to the supervisor for review and advise that unless OWCP is notified of any inaccuracies in a timely manner, the employee's accounting will be used to compute the payment.
b. Occupational Disease Claims (Including Recurrence and Death).
(1) OWCP will require factual information from the employer according to the type and severity of the medical condition involved. (Simple occupational disease claims, for example a claim for poison ivy where the job duties involved exposure to the plant, and the medical evidence confirmed the diagnosis, require less evidence to adjudicate.) The information specified in the instructions for completing Form CA-2 and on the evidence checklist appropriate to the disease in question should be forwarded with the initial submission. If sufficiently detailed descriptions of the circumstances surrounding development of the claimed condition are not received, OWCP will request whatever additional information is considered necessary for adjudication.
If a second request is necessary, the agency will be advised that if timely response is not received the OWCP will process the claim based on the evidence submitted by the employee. As with traumatic injury cases, if that evidence is sufficient and/or credible, the employee's statements will be accepted and the claim will be adjudicated accordingly. If the evidence is not sufficient and/or credible, the claim will be denied because one or more of the five basic elements required to approve a claim has not been established.
(2) Medical examination and treatment will generally not have been provided solely by an agency medical facility. An employee who has also been seen by a private physician must submit supporting medical evidence from that physician. If additional evidence from the agency is needed, the employee will be advised that OWCP is attempting to obtain it but that the burden of proof still rests upon the employee and that he or she should also try to obtain that evidence.
(3) As with traumatic injury cases, wage loss information needed from the agency will probably involve the employee's pay rate or the days on LWOP or leave during the period claimed, and the procedures described for obtaining such information in traumatic injury cases will apply. The extensive development of medical evidence during the initial adjudication process should provide sufficient information concerning the nature and extent of disability to permit adjudication of the wage loss claim. If not, OWCP will follow the procedures for developing medical evidence in a traumatic wage loss claim.
Once OWCP accepts a claim, the burden of proof shifts from the employee to the OWCP. To rescind the acceptance of a condition or to make a retroactive determination that an employee was not disabled for a period during which compensation was paid, OWCP must demonstrate not only that an error was made but that the weight of the evidence supports its new conclusion concerning the merits of the claim.
4-3. Questionable Claims
If the supervisor questions the validity of a claim, he or she should investigate the circumstances and report the results to OWCP. All such allegations must be supported by specific factual evidence before OWCP can consider them. Situations which may prompt the supervisor to conduct such an investigation, and actions which the agency may take, are as follows:
a. Differing Versions. If the employee has given differing versions of the incident to different people, or several witnesses give differing accounts of the facts surrounding the injury, the supervisor should request a written statement from each person which details his or her knowledge of the situation.
b. Previous Injury. If the employee reported to work on the date of the claimed injury with the appearance of a pre-existing condition or injury, the agency should obtain statements detailing the relevant observations from witnesses.
c. Time Lags. If a lengthy period elapses between the alleged injury and the time it is reported, and the employee appears to be able to perform normal duties, a written statement detailing the situation should be composed.
d. Other Employment. If an employee who has claimed injury is reported to be working at another job, the supervisor should first ask him or her about the requirements of the other employment. Depending on the reply, the supervisor may wish to ask the employee for permission to contact the other employer for information concerning duties and periods of employment.
OWCP will consider all information submitted and correspond further with the parties involved if necessary. Also, OWCP may investigate the claim on its own authority, whether or not the agency has conducted an investigation. The authority to determine any aspect of a claim rests with OWCP, however, and while the agency is entitled to an explanation of the basis of OWCP's action, it must accept the determination rendered.
4-4. Decisions and Notification
The employee will be notified by letter of the acceptance of his or her case if disability is expected to ensue or continue. The letter will state the condition for which the claim is accepted and advise how to claim compensation benefits and payment or reimbursement of medical bills. In cases involving potential long-term disability, OWCP will notify the employee of his or her obligation to seek work when disability is no longer total. The supervisor will receive a copy of this notification to the employee and will also be asked to submit a copy of the employee's job description and SF-171 in order to prepare for eventual reemployment (this process is described in Chapter 8).
During the life of a claim, decisions may be rendered on various issues. Employees are usually notified by letter about such matters as approval or denial of surgical procedures and other forms of medical care, and payment of medical bills by OWCP. Appeal rights are not usually included in such determinations, but formal decisions may be issued on such matters if requested.
Any determination, whether affirmative or negative, which sets forth OWCP's findings with respect to the case and which includes a description of the employee's appeal rights is known as a formal decision. When a beneficiary is placed on the compensation rolls for schedule award, loss of wage-earning capacity, or death, he or she will receive a formal decision. Likewise, a formal decision is issued any time an adverse decision involving entitlement is reached, such as denial of an initial claim or denial of continuing benefits. Three avenues of appeal are provided for employees; the agency is not entitled to appeal. The employee may request only one form of appeal at a time.
a. Hearing. The employee is entitled to either an oral hearing before an office representative or a review of the written record (but not both), as long as written request is made within 30 days of the formal decision, and a reconsideration has not already been requested. The employee may change his or her hearing request in writing within 30 days of OWCP's acknowledgement of the initial request. The request should be sent to the Branch of Hearings and Review at the address included with the appeal rights; no special form is needed. If an oral hearing is requested, it will be held within 100 miles of the employee's home, and he or she may present written evidence or oral testimony in support of the claim. If a review of the written record is selected, the employee may not present oral testimony, but may submit written evidence or argument.
If an oral hearing is requested, the agency will be notified when it is scheduled and advised that it may request a copy of the transcript and/or send a representative to the hearing. The agency representative may not participate in the proceed-ings, however, unless specifically invited to do so by the employee or the OWCP representative. If a review of the written record is requested, the agency representative will be given 15 days to submit comments and/or additional documents, which will be subject to review and comment by the employee within an additional 15 days.
After the hearing is held or the review of the written record is completed, OWCP will issue a formal decision, including a description of the employee's further appeal rights.
b. Reconsideration. The employee may ask OWCP to reconsider a formal decision made by the district office. The request should be addressed to the district office handling the claim; no special form is required, but the request should clearly state the ground on which it is based. It must also be accompanied by relevant evidence not previously submitted or arguments for error in fact or law in reaching the contested decision. A reconsideration must be requested within one year of the date the contested formal decision was issued.
For any request which meets these criteria, OWCP will provide the agency representative with a copy of the employee's request, and allow 15 days for submission of comments and/or documents, which will in turn be subject to employee review and comment within 15 days. Following OWCP reconsideration, a new formal decision, which includes a description of the employee's further appeal rights, will be issued.
c. Review by Employees' Compensation Appeals Board (ECAB). An employee may request review by the ECAB, which is the highest authority in Federal workers' compensation claims. The employee should file for such review directly with the ECAB at the address included with the formal decision. The ECAB's review is based solely upon the case record at the time of the formal decision; new evidence is not considered. Employees residing within the continental United States or Canada should file application for review within 90 days of the date of the decision. Employees residing elsewhere should file within 180 days of the date of the decision. For good cause shown the ECAB may excuse failure to timely file an application for review if it is filed within one year of the date of the decision.Return to TABLE OF CONTENTS
Chapter 5. Continuation of Pay (COP)
This chapter describes the employee's entitlement to continuation of his or her regular pay for periods of disability or medical care which occur shortly after a traumatic injury.
5-1. Definition and Entitlement
The FECA provides that an employee's regular pay may be continued for up to 45 calendar days of wage loss due to disability and/or medical treatment following a traumatic injury. The intent of this provision is to eliminate interruption in the employee's income while the claim is being adjudicated. COP is not considered compensation and is therefore subject to income tax, retirement and other deductions. After entitlement to COP is exhausted, the employee may apply for compensation or use leave.
An employee is entitled to receive COP when he or she is absent from work due to disability or medical treatment or when he or she is reassigned by formal personnel action to a position with a lower rate of pay due to partial disability. Because informal assignment of light or restricted duties without a personnel action does not result in pay loss, time worked in such a position may not be charged to COP. An employee whose work schedule is changed, however, so that a loss of salary or premium pay (e.g., Sunday pay or night differential) results, is entitled to COP for such wage loss whether or not the change in schedule was accomplished by a formal personnel action.
Temporary employees are entitled to COP on the same basis as permanent employees. If a termination date has been set for an employee prior to the injury, however, COP need not be continued past the date of termination as long as Form SF-52 showing the date of termination has been completed. Compensation will be paid after employment has ceased, regardless of how many days of COP have been used. Like any other employee, a temporary worker who first reports a traumatic injury after the employment is terminated is not entitled to COP.
5-2. Use of Leave Instead of COP
An employee may use annual or sick leave to cover all or part of an absence due to injury. If an employee elects to use leave, each full or partial day for which leave is taken will be counted against the 45 days of entitlement. Therefore, while an employee may use COP intermittently along with sick or annual leave, entitlement is not extended beyond 45 days of combined absences.
An election of sick or annual leave during the 45-day period is not irrevocable. If an employee who has elected leave for the period wishes to elect COP, the supervisor must make such a change on a prospective basis from the date of the employee's request. Where the employee wishes to have leave restored retroactively, the supervisor must honor the request, provided he or she receives prima facie medical evidence of injury-related disability for the period.
Sometimes a supervisor objects to paying a claim for continuation of pay, either for one of the reasons provided by regulation or for some other reason. This action is called controversion. The supervisor may controvert a claim by completing the indicated portion of Form CA-1 and submitting detailed information in support of the controversion to OWCP. Even though a claim is controverted, the agency must continue the employee's regular pay unless at least one of the conditions set forth below applies:
a. The disability is a result of an occupational disease or illness;
b. The employee comes within the exclusions of 5 USC 8101 (1) (B) or (E) (which refer to persons serving without pay or nominal pay, and to persons appointed to the staff of a former President);
c. The employee is neither a citizen nor a resident of the United States, Canada, or the territory under the administration of the Panama Canal Commission (i.e., a foreign national employed outside the areas indicated);
d. The injury occurred off the employing agency's premises and the employee was not engaged in official "off-premises" duties;
e. The employee caused the injury by his or her willful misconduct, or intended to bring about his or her injury or death or that of another person, or the employee's intoxication was the proximate cause of the injury;
f. The injury was not reported on a form approved by OWCP (usually Form CA-1) within 30 days following the injury;
g. Work stoppage first occurred more than 90 days following the injury;
h. The employee initially reported the injury after employment was terminated;
i. The employee is enrolled in the Civil Air Patrol, Peace Corps, Job Corps, Youth Conservation Corps, work study program, or other group covered by special legislation.
The agency may not continue pay under any of the above circumstances.
The agency may dispute an employee's right to receive COP (and/or the validity of the claim as a whole) on other grounds, for instance on the basis that the employee was not performing assigned duty when the injury occurred, or that the condition claimed is not the result of a workrelated injury. Any such objection should be supported by objective evidence such as witness statements, pictures, accident investigations, or time sheets. If the validity of a claim is disputed for reasons other than the nine conditions listed above, regular pay must be continued for up to 45 calendar days and may not be interrupted during the 45-day period unless one of the conditions in Chapter 5-6 or 5-8 is met.
5-4. Pay Rate for COP
An employee's regular pay is his or her average weekly earnings, including premium pay, night or shift differential, Sunday or holiday pay, and other extra pay, including pay authorized by the Fair Labor Standards Act for employees who receive annual premium pay for standby duty and who also earn and use leave on the basis of their entire tour of duty, including periods of standby duty. Overtime pay should not be included, however, except for administratively uncontrollable work covered under 5 USC 5545(c)(2).
a. Standard Number of Hours. For a full-time or part-time worker, either permanent or temporary, who works the same number of hours per week, the weekly pay rate equals the number of hours regularly worked each week times the hourly pay rate on the date of injury, excluding overtime.
b. Non-standard Number of Hours. For a part-time worker, either permanent or temporary, who does not work the same number of hours per week, the weekly pay rate equals the average weekly earnings for the one-year period prior to the date of injury, excluding overtime.
c. Intermittent Work. For an intermittent or part time worker, either permanent or temporary, who does not work each week of the year (or the period of appointment), the weekly pay rate equals the average of the employee's weekly earnings during the one year before the injury.
It is computed on the basis of the total earnings divided by the number of weeks worked (partial weeks worked are counted as whole weeks). The annual earnings used for this computation must not, however, be less than 150 times the average daily wage earned within one year before the date of injury (the daily wage is the hourly rate times eight).
d. Increments of Pay. Premium, night, or shift differential as well as Sunday, holiday, or other extra pay should be included, but overtime pay may not be considered.
e. Changes in Pay. Within-grade increases or promotions, demotions, terminations of temporary details, etc. which the employee would have received but for the injury are included in COP since this payment represents salary and not compensation. Moreover, an employee who does not exhaust his or her entitlement to COP at the time of injury and who is later entitled to use COP while employed at a higher paying job than the one held at the time of injury is entitled to receive COP at the higher rate of pay. Where the weekly COP rate is based on the employee's average weekly earnings over the one-year period prior to the date of injury, the COP rate should be changed by the same percentage as the change in hourly pay or salary.
f. Lost Elements of Pay. The effects of the injury sometimes result in loss of elements of pay such as night or Sunday differential (e.g., a night shift worker is reassigned to the day shift to perform prescribed light duty). In such situations COP should be granted for the lost elements of pay (e.g, the night differential). Each day for which COP is granted to cover lost elements of pay will count as one full day of COP toward the 45-day limit.
Unless the injury occurs before the beginning of the work day, time loss on the day of injury should be charged to administrative leave. The period to be charged to COP begins with the first day or shift of disability or medical treatment following the date of injury, provided that the absence began within 90 days after the injury. COP should be charged for weekends and holidays if the medical evidence shows the employee was disabled on the days in question; for example, if the physician indicates that disability will continue only through Saturday for an individual who has Saturday and Sunday off, COP will be charged only through Saturday.
If work stoppage occurs for only a portion of a day or shift, a full day of COP will be counted against the 45 calendar day entitlement, even though the employee is not entitled to COP for the entire day or shift. For example, if an employee who has returned to work must lose three hours in order to receive physical therapy for the effects of the injury, he or she is entitled to only three hours of COP even though one full calendar day will be charged against the 45 day limit. If the employee is absent for all or part of the remaining work day, the time loss should be covered by leave, LWOP, AWOL, etc., as appropriate, since absence beyond the time needed to obtain the physical therapy cannot be charged to COP.
If the employee is only partially disabled following the injury, and continues to work several hours each work day, each day or partial day of absence from work is chargeable against the 45-day period.
5-6. Light Duty Assignments
When the physician's report indicates that the employee is no longer totally disabled, he or she is required to accept any reasonable offer of suitable light or limited duty. Such an offer may be made by telephone but must be confirmed in writing in order to be valid; it should include a description of the duties and requirements of the offered position. If a personnel action is involved, the employee must be furnished with a copy of it prior to the effective date.
COP should be paid if the employee has been assigned light duty by formal personnel action and pay loss results (e. g., the employee is placed in a light duty position at lower pay). COP should also be paid if the light duty consists of work at regular duties for fewer than the usually scheduled number of hours. The dollar amount of COP will be the difference between the pay rates of the job held on date of injury and the light duty position. One full day of COP should be charged for each day of light duty, even though the employee is working a full shift.
If the employee refuses to accept the work offered, COP should be terminated as of the date of the employee's refusal or after five workdays from the date of the offer, whichever is earlier. OWCP will then determine entitlement based on the medical reports and the duties of the offered position and issue a formal decision concerning payment of COP. A discussion of the criteria used in making such determinations is contained in Chapter 8-4.
In many cases, an employee will return to work without using all 45 days of entitlement of COP. Should such an employee suffer a recurrence of disability, he or she may use COP if no more than 90 days have elapsed since the date of first return to work, including part-time work and light duty, following the first work stoppage. If the recurrence begins later than 90 days after the first return to work, the agency should not pay COP even though some days of entitlement remain unused. A period which begins before the 90 day deadline and continues beyond it may be charged to COP as long as the period of time is uninterrupted. If a third-party credit has been established, the supervisor should contact OWCP before paying COP.
5-8. Terminating COP
COP should not be stopped except under the following circumstances:
a. Medical Evidence is Not Submitted Within 10 Workdays. This period should be counted from the date the employee claims COP or the disability begins (or recurs), whichever is later. If the agency has not received prima facie medical evidence of injury-related disability within that period, COP may be discontinued. However, the agency may not wait 10 days to request such evidence, which is defined as medical evidence showing that the employee is disabled for the job held at the time of injury because of an employment injury. Pay may be continued without such evidence if the supervisor is satisfied that the employee sustained a disabling traumatic injury. For the purposes of this provision:
(1) The 10-workday period begins the workday after the employee claims COP or the disability begins (or recurs).
(2) A "workday" means the business day of the office or facility where the employee works or reports such that the medical evidence could be submitted by the employee to an authorized agency official.
b. The Employee is No Longer Disabled. The agency should terminate COP if it receives medical information from the attending physician stating that the employee is no longer disabled for regular work, if a partially disabled employee returns to full-time light duty with no pay loss, or if the employee refuses a suitable offer of light duty.
c. OWCP Notifies the Agency That Pay Should be Terminated.
d. The 45 Calendar Day Period Expires.
An employee who is scheduled to be separated and reports a traumatic injury on or before the separation date should still be separated; he or she is entitled to COP up to the date of termination and to compensation thereafter.
5-9. Reporting COP--Form CA-3
a. Time Cards. Time loss for an employee who is receiving COP should be recorded as "COP" on the Time and Attendance Report. A diminishing record of the 45 day limitation is to be maintained in the "Remarks" block.
b. Completion of Form CA-3. Sometimes, return to duty information is shown on Form CA-1 when the injury is first reported. If not, the agency may (but is not required to) complete Form CA-3 and submit it to OWCP when entitlement to COP ends, the employee returns to work, or the disability ceases. The CA-3 should state the specific days and hours charged to COP and/or leave, and attachments may be used if necessary. The amount of money shown should reflect only the amount paid for COP; it should not include wages paid for light duty or for parts of days actually worked. In cases of intermittent or delayed disability, time charged to COP may be reported by narrative letter instead of by Form CA-3.
If the disability ends before the expiration of the 45 day period, the agency should terminate COP. An employee who is no longer disabled must return to work upon notification by the attending physician that he or she is able to perform full regular duty or suitable and available light duty. If the employee does not return to duty, an overpayment may result which is subject to collection by the agency.
c. Formal Decision. In all cases OWCP has the final authority to determine whether the agency's action in paying or terminating COP is correct. If entitlement is denied, OWCP will inform the employee and the supervisor by formal decision (Form CA-1050 is usually used for this purpose). Payment made may then be charged, at the employee's option, to sick or annual leave or be deemed an overpayment subject to collection by the agency.Return to TABLE OF CONTENTS
Chapter 6. Medical Benefits and Care
This chapter addresses the employee's entitlement to medical benefits under the FECA.
The FECA at 5 USC 8103 authorizes medical services needed to provide treatment or to counteract or minimize the effects of any condition which is causally related to factors of Federal employment. No limit is imposed on the amount of medical expenses paid or on the length of time for which they are paid, as long as the charges represent the reasonable and customary fees for the services involved and the need for the treatment can be demonstrated.
Federal employees are entitled to all services, appliances, and supplies prescribed or recommended by qualified physicians which, in the opinion of OWCP, are likely to cure, give relief, reduce the degree or the period of disability, or aid in lessening the amount of monthly compensation. Medical care includes examination, treatment, and related services such as hospitalization, medications, appliances, supplies, and transportation incident to securing them. Preventive care may not be authorized, however.
6-2. Definition of Physician
The term "physician" includes surgeons, osteopathic practitioners, podiatrists, dentists, clinical psychologists, optometrists, and chiropractors within the scope of their practice as defined by State law. Naturopaths, faith healers, and other practitioners of the healing arts are not recognized as physicians within the meaning of the law.
a. Chiropractors. Under the FECA, the services of chiropractors may be reimbursed only for treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist. The term "subluxation" is defined as an incomplete dislocation, off-centering, misalignment, fixation or abnormal spacing of the vertebrae anatomically which must be demonstrable on any X-ray film to individuals trained in the reading of X-rays. Chiropractors may interpret their own X-rays, and if a subluxation is diagnosed the chiropractor's assessment of any disability caused by it will be accepted. If a Form CA-16 is issued to a chiropractor for emergency care and the condition diagnosed is other than a subluxation, charges will be honored until OWCP terminates the authority of Form CA-16. In this situation the employee is entitled to select another attending physician, who will need to submit a report substantiating the condition found and addressing any disability for work in order for the claim to be accepted.
b. Excluded Physicians. The term "qualified physician" does not include those whose licenses to practice medicine have been suspended or revoked by a state licensing or regulatory authority or who have been excluded from payment under the FECA (see paragraph (5) below).
6-3. Choice of Physician
a. Initial Choice. An employee is entitled to initial selection of physician for treatment of an injury. He or she may choose any licensed physician in private practice who is not excluded, or he or she may choose to be treated at a government facility where one is available. Such facilities include medical officers and hospitals of the Army, Navy, Air Force, and Department of Veterans Affairs.
Agency personnel may not interfere with the employee's right to choose a physician, nor may they require an employee who claims an injury to go to a physician who is employed by or under contract to the agency before going to the physician of the employee's choice. Agency personnel may contact the attending physician by telephone only to obtain additional information about or clarify the employee's duty status or medical progress.
b. Referral by Attending Physician. The attending physician may engage the services of other facilities which provide X-ray or laboratory services or of specialists whom the physician feels it necessary to consult. Charges for such services will usually be paid if they were requested by the attending physician.
c. Change of Physician. Except for referral by the attending physician, any change in treating physician after the initial choice must be authorized by OWCP. Otherwise, OWCP will not be liable for the expenses of treatment. The employee should request any such change in writing with an explanation of the reasons for the request. If a physician initially selected by an employee is later excluded from participation under the regulations, the employee should choose another physician. Otherwise, and upon notification by OWCP, he or she will be liable for payment of the bills from the excluded provider.
d. Transfer of Medical Care. The agency does not have authority to transfer medical care from one physician to another. If adequate medical care is not available locally or agency personnel believe that transfer of medical care is advisable for other reasons, OWCP must be contacted for instructions.
6-4. Medical Treatment and Evaluation
a. Employee Requests. Some forms of medical treatment should be approved by OWCP in advance in order to guarantee payment. Among such services are:
(1) Non-emergency surgery; a second opinion examination may be included in the approval process. (OWCP may not require an employee to undergo surgery or any other invasive procedure, such as a myelogram);
(2) Private hospital room accommodations (only semi-private rooms will be authorized unless the employee's condition necessitates private accommodations;
(3) Hospital beds, traction apparatus, wheelchairs, and similar equipment;
(4) Orthopedic appliances and shoes;
(5) Nursing home care;
(6) Courses of physical therapy;
(7) Hearing aids and lip reading services;
(8) The services of hearing and seeing eye dogs;
(9) Membership in health clubs.
Request for any of these services should be made by the attending physician, who should include his or her reasons for believing the services to be necessary. Prior authorization need not be obtained to purchase minor appliances such as a sacroiliac belt or an ankle strap, or for such items as crutches and canes if prescribed by the attending physician.
b. OWCP Requests. In addition to the attending physician, other medical personnel may be asked to evaluate an employee and/or file. Evaluations may be requested in connection with original or continuing entitlement to benefits, the percentage of the employee's permanent impairment or ability to return to full or light duty, or other issues. Physicians who may be asked to examine the employee and/or file are as follows:
(1) District Medical Director/Advisor (DMD/DMA). Each district office has one or more physicians on staff or under contract who respond to questions raised by OWCP staff. Issues include interpretation of medical issues posed by the treating physician and provision of the DMD/DMA's own opinion on medical questions. The DMD/DMA also considers requests for surgery and other modalities of treatment requiring OWCP approval. The DMD/DMA does not, however, examine employees except where a claim for disfigurement of the face, head or neck is involved.
(2) Medical Specialist (Second Opinion Referral). Medical issues sometimes arise which cannot be resolved on the basis of opinions given by the attending physician and the DMD/DMA. Opinion will then be requested from a physician who specializes in the field of medicine pertinent to the issue. The appointment for examination may be made by OWCP, or the employee may be asked to make the appointment. In either case, OWCP will pay for the examination, reasonable travel expenses, and wage loss incurred in connection with it. The employee may bring a physician paid by him or her to the examination if desired. The compensation of an employee who fails to attend an OWCP-scheduled examination without good reason will be suspended until the employee reports for examination.
(3) Referee Medical Specialist. A conflict of medical opinion may be created when differing opinions of approximately equal weight appear in the file. Medical opinion from a referee specialist will then be arranged to resolve the conflict of opinion, which may concern the relationship of a condition to factors of employment, or the extent of disability, for example. The physician is chosen on the basis of rotation among the available specialists within a given geographical area who practice the pertinent area of medicine. OWCP will arrange the appointment and advise the employee of the arrangements. As with second opinion referral, OWCP will pay the cost of the examination, reasonable travel expenses, and the amount of lost wages. Here again, the compensation of an employee who fails to attend the examination without good reason will be suspended until the employee reports for examination.
c. Agency Requests. The FECA does not address the issue of medical examinations desired by the agency. Parts 339 and 353 of OPM's regulations grant broad authority to agencies to arrange for examination of any employee who files a compensation claim by a physician of the agency's choice, at the agency's expense. However, the purpose of such examinations is solely to determine if the individual is able to work in some capacity, thereby facilitating return to work.
Examinations may not be used to intimidate employees. While agencies must send the results of such examinations to OWCP and notify OWCP if the individual refuses to be examined, and the results of such examinations per se do not affect entitlement to compensation.
6-5. Exclusion of Providers
Certain providers may be excluded from participation in the Federal employees' compensation program. The services of such providers may not be reimbursed by OWCP during the period of exclusion.
a. Fraud. Providers who have been convicted under a criminal statute for fraudulent activities in connection with a Federal or state program which makes payments to providers for medical services are automatically excluded from participation in the FECA program. This means that OWCP will not honor their bills for services. Providers who are excluded or suspended from similar Federal or state programs, including Medicare, are also automatically excluded from participation in the FECA program.
b. Other Grounds. OWCP will initiate exclusion procedures upon receipt of information that a provider has knowingly made a false statement or misrepresented a fact in connection with a claim for reimbursement or request for payment; charged more than the provider's customary fee for similar services without good cause; failed to reimburse an employee who has paid a bill for treatment which was also paid by OWCP; repeatedly failed to submit full and accurate medical reports or failed to respond to requests for medical information; or furnished treatment substantially beyond the employee's needs, or which fails to meet professionally recognized standards.
c. Due Process. The regulations appearing at 20 CFR 10.450-457 include due process at every step to protect the rights of providers. These rights include administrative review of decisions and consideration of reinstatement after a period of exclusion if reasonable assurances exist that the action which led to the exclusion will not be repeated. Providers reinstated to participation in Medicare by the Health Care Financing Administration are automatically reinstated by OWCP.
d. Notification. OWCP will periodically distribute to agencies the names and addresses of excluded medical providers along with those who have been reinstated. Before authorizing medical services on Form CA-16, the supervisor should ensure that the medical provider selected by the employee is not among those excluded. An excluded physician may be reimbursed only for services rendered in a medical emergency. Designated agency officials should report instances of fraud or abuse coming to their attention to the district office.
e. Medical Charges. On receipt of a bill from an excluded provider, OWCP will determine whether either the agency or OWCP notified the employee that the provider was excluded from the program. If not, OWCP will honor the bill and advise both the provider and the employee that further treatment may not be paid in accordance with the regulations. An employee whose initially chosen attending physician is excluded will be given the opportunity to choose a new physician.
6-6. Payment of Bills
Medical support is required to substantiate that services for which payment or reimbursement is requested were required for the accepted, workrelated injury. Documentation usually takes the form of a report or clinical notes from the physician. Hospital bills should be supported by a copy of the discharge summary.
a. Forms. Most providers must submit their bills on the American Medical Association Standard Health Insurance Claim Form (HCFA-1500). A version of the form which includes instructions for submitting bills to OWCP carries the form number OWCP-1500. In some states the local version of the form may not be designated "HCFA-1500" or may differ from the standard AMA form in other ways. Such local variations are acceptable if they are otherwise complete.
The following providers are required to use Form HCFA-1500 to submit bills: physicians; nursing services; laboratories and X-ray facilities; chiropractors; therapists; and suppliers of medical equipment and goods.
The following providers are encouraged, though not required, to use the HCFA-1500: dentists (may use standard ADA form); and pharmacists (may use standard pharmacy billing form).
Hospitals must use Form UB-82 or UB-92, and nursing homes are encouraged to use these forms as well.
Bills rendered by ambulance services may be submitted on billhead, as may bills from foreign providers. VA facilities may submit bills using Form VA-10-9014.
b. Requirements. To be accepted for payment, the bill must include the following information:
(1) Employee's name;
(2) Provider's name and address;
(4) Itemized list of services, with charges; and
(5) Tax identification number (the provider's Employer Identification Number or Social Security Number).
c. Itemization. All bills must be sufficiently itemized to allow for evaluation of the charges. The Current Procedural Terminology (CPT) code for each medical, surgical, X-ray or laboratory service should be shown on the HCFA-1500, and bills should show the dates when the services or supplies were furnished. Individual dates are not necessary if the bill is for repetitive charges over a period of time. In such cases the billing should show the beginning and ending dates of service, and the number of units of service.
d. Time Limitation on the Payment of Bills. No bill will be paid unless it is submitted to OWCP on or before December 31st of the year following the calendar year in which the expense was incurred or the claim (or specific condition, as appropriate) was first accepted as compensable by OWCP, whichever is later. This provision applies to any bill for which the later of the two dates falls on or after January 1, 1987.
e. Disallowance of Charges. Unless the amount involved is minor, OWCP will advise the payee fully of any adjustments to the bill by letter which explains the amount of the deletion or reduction, the particular charge affected, the reasons for the action, and the amount for which the bill is being approved. If a bill is reduced because the charges exceed the amount allowed by the OWCP fee schedule, a separate notice will be provided.
f. Reimbursement. An employee who has paid a provider may request reimbursement by submitting either receipted bills from the provider or a completed HCFA-1500 signed by the provider. Hospital bills must be stamped paid or otherwise certified to indicate that payment was made. Cash sales receipts that bear imprints of mechanical cash registers may be accepted if the nature of sale is identified. Photocopies of cancelled checks may be accepted in lieu of receipts but must be accompanied by itemized bills or other evidence of the charge for which payment was made. Prescription receipts must include the name of the drug and the date the prescription was filled.
g. Insurance Companies. The employee should advise medical providers to submit bills for services to OWCP. In some cases, however, bills are submitted to the employee's health insurance carrier. The carrier may request reimbursement for such charges by submitting a completed HCFA-1500 or similar OWCP-approved form. The form should list procedures and charges for each provider, and copies of paid bills and cancelled checks should be attached. It should also include the carrier's Tax Identification Number.
h. Transportation Expenses. When transportation to obtain medical care is not furnished by the government, the employee may be reimbursed for travel expenses. Travel should be undertaken by the shortest route and by public conveyance such as bus or subway unless the employee's medical condition requires the use of a taxicab or specially equipped vehicle. An employee who uses his or her automobile will be reimbursed at the standard mileage rate for government travel.
Standard Form 1012 should be used to claim reimbursement for travel expenses. All items will be reimbursed on the basis of actual expense; a per diem allowance is not payable. Wages and travel expenses of an attendant to accompany the employee may be approved if his or her condition is such that travel cannot be accomplished otherwise. Authorization for this expense should be obtained in advance of the travel if possible.
i. Incorrect Payments. An employee who receives a reimbursement for medical expense which he or she knows to be incorrect, either partially or totally, should return the check to OWCP immediately. If an overpayment occurs, OWCP will determine whether the beneficiary is with fault in creation of the overpayment. Only if a beneficiary is determined to be without fault may waiver of the overpayment be considered.Return to TABLE OF CONTENTS
Chapter 7. Compensation Benefits
This chapter describes the various forms of compensation benefits which are available to injured employees and survivors in death claims. It also includes a section on computation of compensation benefits.
7-1. Disability Benefits
An employee who suffers employment-related disability may be eligible for one or more types of wage loss compensation. Such benefits are classified according to the nature and extent of disability incurred.
a. Temporary Total Disability. Compensation based on loss of wages is payable after the end of continuation of pay where entitlement exists (see Chapter 5) or from the beginning of pay loss. An employee without dependents is entitled to compensation at the rate of 66 2/3% of his or her salary. With dependents, he or she is entitled to 75% of the salary.
(1) Dependents. The following are considered dependents for compensation purposes:
(a) A wife or husband residing with the employee or receiving regular support payments from him/her, either court-ordered or otherwise;
(b) An unmarried child who lives with the employee or who receives regular contributions of support from him or her, and who is under the age of 18, or over the age of 18 and incapable of self-support due to physical or mental disability;
(c) A student between 18 and 23 years of age who has not completed four years of post-high school education and who is regularly pursuing a full time course of study.
(d) A parent who is wholly dependent upon and supported by the employee.
(2) Waiting Days. A three-day waiting period, for which no compensation is payable, applies except in cases where disability extends more than 14 days or permanent disability results. In these cases compensation will be paid for the three days.
An employee who receives long-term disability payments will be notified by letter of the amount of compensation to be paid, including the pay rate and compensation rate. Compensation payments for total disability may continue as long as the medical evidence substantiates total disability. Only rarely is an employee declared permanently and totally disabled; benefits provided to such an employee are the same as those provided for temporary total disability.
b. Schedule Awards. Compensation is provided for specified periods of time for the permanent loss, or loss of use, of certain parts and functions of the body. Partial loss or loss of use of these parts and functions is compensated on a proportional basis.
(1) Compensation Schedule. Following is a table which shows the number of weeks payable for each schedule member if the loss or loss of use of the function or part of the body is total:
Member. . . . . . . . . . . . . . . Weeks
Arm . . . . . . . . . . . . . . . . . . . . . .312
Leg . . . . . . . . . . . . . . . . . . . . . .288
Hand . . . . . . . . . . . . . . . . . . . . 244
Foot . . . . . . . . . . . . . . . . . . . . .205
Eye . . . . . . . . . . . . . . . . . . . . .160
Thumb . . . . . . . . . . . . . . . . . . . 75
First finger . . . . . . . . . . . . . . . . 46
Great toe . . . . . . . . . . . . . . . . .38
Second finger . . . . . . . . . . . . . 30
Third finger . . . . . . . . . . . . . . . 25
Toe other than great toe . . . . . . 16
Fourth finger . . . . . . . . . . . . . . 15
Loss of hearing--monaural . . . . 52
binaural. . . . . . . . . . . . . . . . 200
Breast . . . . . . . . . . . . . . . . . 52
Kidney . . . . . . . . . . . . . . . .156
Larynx . . . . . . . . . . . . . . . .160
Lung . . . . . . . . . . . . . . . . .156
Penis . . . . . . . . . . . . . . . . 205
Testicle . . . . . . . . . . . . . . . 52
Tongue . . . . . . . . . . . . . . .160
Fallopian tube) . . . . . . . . . .52
Uterus/cervix. . . . . . . . . . .205
Vulva/vagina. . . . . . . . . . 205
Compensation for loss of binocular vision or for loss of 80 percent or more of the vision of an eye is the same as for loss of the eye. The degree of loss of vision or hearing for a schedule award is determined without regard to correction; that is, improvements obtainable with use of eyeglasses and hearing aids are not considered in establishing the percentage of impairment. The law contains no provision for payment of a schedule award on account of permanent impairment to the back, heart or brain.
(2) Medical Evidence Required. Before payment of a schedule award can be considered, the condition of the affected part of the body must reach maximum improvement. This determination involves a medical judgment that the condition has permanently stabilized. In most cases the percentage of impairment is determined in accordance with the American Medical Association's Guides to the Evaluation of Permanent Impairment, and the evaluation on which the award is based must conform to the guidelines set forth in that publication.
(3) Claim and Payment. If a claim for wage loss has not previously been submitted, Form CA-7 may be used to initiate a claim for schedule award. Otherwise, consideration may be requested by narrative letter. Compensation for schedule awards is computed by multiplying the indicated number of weeks times 66 2/3 percent (without dependents) or 75 percent (with dependents) of the pay rate (see paragraph (1) above for more information concerning dependents).
(4) Decision. When a schedule award is issued, the employee and agency will be notified of the length of the award (in number of weeks or days), the starting date of the award (the date of maximum medical improvement), the pay rate on which benefits are computed, and the compensation rate. The decision will include a description of the employee's appeal rights should he or she disagree with any element of the decision.
Schedule awards can be paid even if the employee returns to work. Employees may not, however, receive wage loss compensation and schedule awards benefits concurrently for the same injury. If an employee sustains a period of temporary total disability during the course of the award, it may be interrupted to pay the period of disability; the schedule award will resume afterwards. If an employee dies during the course of a schedule award from causes unrelated to the compensable injury, his or her dependents are entitled to the balance of the award at the rate of 66 2/3 percent.
c. Loss of Wage-Earning Capacity. When the medical evidence shows that the employee is no longer totally disabled, OWCP will take steps to effect reemployment of the employee, either with the original agency or with another employer (this process is described in Chapter 8). If the employee is reemployed at a job paying less than the original position, or if it is otherwise determined that he or she can perform the duties of a specific job that is deemed suitable, medically and otherwise, compensation will be payable based on this loss of wage-earning capacity.
(1) Payment. The FECA provides that employees who are partially disabled by an illness or injury causally related to Federal employment shall be compensated at a rate equal to 66 2/3 (without dependents) or 75 (with dependents) percent of the wage loss incurred as a result of the disability (see paragraph (1) above concerning dependents). Benefits are paid for the duration of the wage loss due to the work- related disability.
(2) Decision. A formal decision containing the basis for OWCP's determination that the employee can perform the duties indicated and that the position is otherwise suitable is issued before benefits are reduced. The decision also shows the formula used to compute the new level of benefits and contains a description of the employee's appeal rights should he or she disagree with any element of the decision.
d. Disfigurement. In cases where the employee suffers injury to the face, neck, or head, and disfigurement results, the FECA provides for payment of an award of compensation not to exceed $3500 if the disfigurement will likely prove to be a handicap in securing or maintaining employment. As with schedule awards, payment of an award for disfigurement cannot be considered until maximum medical improvement has occurred. It should be noted that such awards can be considered only for seriously disfiguring scars and deformities.
e. Attendant's Allowance. If an injury is so severe that the employee is unable to care for his or her physical needs, such as feeding, bathing, or dressing, an attendant's allowance of up to $1500 per month may be paid in addition to compensation for loss of wages. The assistance required must be personal in nature; an attendant's allowance cannot be paid for housekeeping services. An employee who believes he or she is entitled to such an allowance should contact the district office by letter for instructions on how to apply for this benefit.
f. House and Vehicle Modifications. An employee whose injury severely restricts mobility and independence in the normal functions of living, either permanently or for a prolonged period, may be entitled to house or vehicle modifications. Examples of such conditions include blindness, profound bilateral deafness, and total loss of use of limbs such that a prosthesis, wheelchair, or leg brace is required. An employee may apply for such modifications by narrative letter. They must be recommended by the attending physician and must be consistent with the employee's pre-injury standard of living.
7-2. Death Benefits
The survivors of a Federal employee whose death is causally related to employment are entitled to benefits in the form of compensation payments, funeral expenses, transportation expenses for the remains, if necessary, and payment for termination of the deceased's status as a Federal employee.
a. Entitlement. The following individuals are entitled to compensation:
(1) A widow or widower;
(2) An unmarried child under the age of 18, or over the age of 18 who is incapable of self-support due to mental or physical disability;
(3) A child between 18 and 23 years of age who has not completed four years of post high school education and is regularly pursuing a full-time course of study;
(4) A parent, brother, sister, grandparent, or grandchild who was wholly or partially dependent on the deceased.
b. Compensation Payments. Compensation is paid at the following rates:
(1) A surviving spouse with no eligible children is entitled to compensation at the rate of 50% of the deceased employee's salary. Benefits are paid to the spouse until death or remarriage if he or she is under age 55. If a spouse under age 55 remarries, OWCP makes a lumpsum payment equal to 24 times the monthly compensation at the time of remarriage. The benefits of a spouse who remarries after the age of 55 will not be affected by the marriage.
(2) If children are eligible in addition to the spouse, he or she may receive compensation equal to 45 percent of the employee's regular pay, plus an additional 15 percent for each child, to a maximum of 75 percent of the deceased employee's regular pay. The children's portion is paid on a share and share alike basis.
(3) If the deceased employee leaves no spouse, the first child is entitled to 40 percent and each additional child is entitled to 15 percent of the employee's salary, up to a maximum of 75 percent, payable on a share and share alike basis.
(4) Other surviving dependents may be entitled to compensation benefits at various percentages specified by the FECA according to the degree of dependence. Contact the district office for information concerning claims in this category.
c. Funeral and Burial Expenses. Up to $800 will be paid for funeral and burial expenses. If the employee dies away from his or her area of residence, the cost of transporting the body to the place of burial will be paid in full. Itemized funeral bills should be submitted to OWCP for consideration of payment or reimbursement. In addition, a $200 allowance will be paid in consideration of the expense of terminating the deceased's status as a Federal employee.
7-3. Dual Benefits
The FECA prohibits payment of compensation and certain other Federal benefits at the same time. This prohibition does not, however, prevent an individual from filing for benefits from more than one government program at the same time. For instance, a claimant for disability benefits may file for a retirement annuity, either regular or disability, while his or her claim with OWCP is pending. Similarly, a claimant for death benefits may file for retirement benefits while his or her claim with OWCP is pending. Only if both benefits are approved will the rules governing dual benefits be invoked.
a. Office of Personnel Management (OPM). Except for schedule awards, a person may not receive disability benefits from OWCP concurrently with a regular or disability annuity (either CSC or FERS), nor may a person receive death benefits from OWCP concurrently with a survivor's annuity (either CSC or FERS). Therefore, a beneficiary who is entitled to both benefits must elect between them. The election may be offered by either OWCP or OPM depending on the order in which entitlement is determined. An individual may, however, receive disability benefits from OWCP or an annuity from OPM on his or her own behalf along with death benefits from the other agency which are payable on account of a spouse's death.
The beneficiary may change his or her election for different periods of time based on the benefits which are more advantageous. In either case, however, the beneficiary must be fully advised of the amount which will be forthcoming and the nature and frequency of any increases which will accrue so that he or she can make an informed election.
b. Department of Veterans Affairs (VA). Beneficiaries who receive compensation from the VA may also be required to elect between the benefits paid by that agency and those paid by OWCP. Such an election is required when the disability or death resulted from an injury sustained in civilian Federal employment and the VA has held that it was caused by military service, or when the VA increases a service-connected disability award due to an injury sustained in Federal civilian employment (in the latter case the election involves only the increase in VA benefits due to disability incurred during civilian employment). No election is required between OWCP benefits and those granted by the VA for strictly service-related disability. In death claims, any payment made by the VA for funeral or burial expenses may not be duplicated by OWCP, and the total payable by both agencies may not exceed $800.
c. Social Security Administration. An employee may receive Social Security payments payable on account of non-Federal employment and OWCP benefits at the same time, subject to income limitations imposed by the Social Security Administration. OWCP will offset Social Security benefits earned on account of Federal service.
d. Other Federal Income. An employee may receive compensation concurrently with military retired pay, retirement pay, retainer pay or equivalent pay for service in the armed forces or other uniformed services subject to reduction of such pay in accordance with 5 USC 5532 (b).
An employee may receive severance pay concurrently with compensation for a schedule award or for loss of wage-earning capacity, but not with compensation for temporary total disability. Separation pay may constitute a dual benefit, and an agency which is offering such payments should contact OWCP for further guidance.
Finally, an employee may receive unemployment compensation benefits concurrently with OWCP benefits.
7-4. Computing Compensation
While compensation is usually claimed in two-week increments to conform to standard Federal pay periods, compensation checks are issued on a weekly or four-weekly basis, depending on the kind of benefit and the length of time benefits are paid. Payments of compensation for very brief periods of temporary total disability or schedule impairment are issued on a weekly basis, while longer-term payments for disability and death are made every four weeks. Checks may be sent to the beneficiary or to a financial institution designated by him or her to receive the funds, but they may not be sent in care of the employee's representative unless guardianship or conservatorship is established.
Compensation payments for wage loss are based on a percentage of the employee's salary (or a statutory pay rate). Payments are computed by multiplying the applicable percentage by the wage rate and increasing the result by any costof-living increases to which the beneficiary is entitled.
a. Pay Rate. For both disability and death claims, the pay rate used to compute compensation payments is the one in effect on the date of injury, date of recurrence, or date disability began, whichever is higher. Thus, the pay rate for compensation purposes may change over the life of a claim. The salary used to compute compensation is not affected, however, by general increases in the rate paid for the employee's grade and step. Moreover, the pay rate is not affected by any promotion or raise the employee might have received but for the injury.
b. Additional Elements of Pay. Included in the salary are: night shift; Sunday differential; holiday pay; hazard pay; dirty work pay; quarters allowance and post differential for overseas employees; and extra pay authorized by the Fair Labor Standards Act (FLSA) for employees who receive annual premium pay for standby duty and who also earn and use leave on the basis of their entire of tour of duty, including periods of standby duty. Overtime pay is not included, however, except for administratively uncontrollable work covered under 5 USC 5545(c)(2).
In reporting these elements of pay, the supervisor should indicate the weekly or biweekly amount if the employee has a regular schedule. If not, the supervisor should compute and submit to OWCP the dollar amount paid in each category for the calendar year preceding the effective date of the pay rate.
c. Compensation Rate. The compensation rate is the percentage applied to the salary in order to determine the monetary amount of the compensation payment. These rates are described in Chapters 7-1 for disability cases and 7-2 for death cases.
d. Cost-of-Living Increases. Each March 1 the increase in the cost of living for the preceding calendar year is determined. If the beneficiary has been entitled to compensation for at least one year prior to March 1, a cost-of-living increase is applied to the benefits.
e. Minimum and Maximum Rates. The law provides for minimum and maximum payments of compensation.
(1) Disability. Compensation for temporary total disability or schedule awards may not exceed 75 percent of the monthly salary of an employee at the highest step of the GS-15 level. For total disability, it may not be less than 75 percent of the monthly salary of an employee at the first step of the GS-2 level or actual pay, whichever is less.
(2) Death. Compensation for death may not exceed 75 percent of the highest step of the GS-15 level, and it may not be less than the minimum pay of the first step of the GS-2 salary. In no case may it exceed the employee's salary except when the excess is created by cost-of-living increases.
f. Buy-back of Leave. Compensation entitlement for leave repurchase is computed in the same way as compensation for temporary total disability. Because leave is paid at 100% of the usual wage rate and compensation is paid as a percentage, the employee will generally owe the agency money for the leave repurchase. When OWCP advises the employee and the agency of the amount payable, the employee should consult with the agency to determine how much money he or she will need to repay.
The amount to be recovered by the agency should be the value of the salary or wages paid to the employee while in a leave status. If the employee wishes to complete the transaction, the agency and employee will decide whether the compensation should be paid directly to the employee or refunded to the agency. The agency will be asked to state the amount paid to the employee for the leave to be repurchased; this amount may be either net or gross.
g. Lump Sum Payments. The FECA was designed to provide for the periodic payment of compensation in order to ensure that beneficiaries have a continuing source of income to offset wage loss. With few exceptions such benefits are free from speculation, fluctuation, and attachment by creditors, and they are also generally free from taxes. Lump sum payments of compensation will be considered only for payments of schedule awards or survivors' benefits to widows or widowers who remarry before age 55.
h. Incorrect Payments. An employee who receives a compensation payment which he or she knows to be incorrect, either partially or totally, should return the check to OWCP immediately. If an overpayment occurs, OWCP will determine whether the beneficiary is with fault in creation of the overpayment. Only if a beneficiary is determined to be without fault may waiver of the overpayment be considered.
i. Health Benefits. OWCP will make deductions for health benefits coverage for beneficiaries who are entitled to continue their enrollment. Deductions cannot be made for periods less than 14 days, and compensation must be paid for at least 28 days in order for deductions to be made.
(1) Criteria. The following requirements must be met to continue enrollment:
(a) Disability. An employee may continue enrollment if he or she was enrolled (or covered as a family member) in a health benefits plan during the five years of service immediately preceding the start of compensation; during all service since his or her first opportunity to enroll; or continuously for the full period or periods of service beginning with the enrollment which became effective not later than December 31, 1984.
(b) Death. A beneficiary in a death case may continue enrollment if the three conditions noted above have been met and, in addition, the deceased employee was enrolled for self and family at time of death and at least one covered family member is receiving compensation from OWCP.
(2) Transfer. If the beneficiary will likely be on OWCP rolls for longer than six months, transfer in will be requested from the employing agency. If an employee returns to duty, the enrollment will be transferred back to the agency even if he or she is receiving compensation for loss of wage-earning capacity. If compensation benefits are terminated or if the employee elects an annuity from OPM over benefits from OWCP, OWCP will transfer enrollment to OPM. Similarly, enrollment will be transferred to OPM for a retired employee who is receiving a schedule award.
Beneficiaries are entitled to change health benefits plans during open season in the same manner as other Federal employees.
j. Optional Life Insurance (OLI). Basic life insurance is continued at no cost to the employee while he or she is receiving compensation unless the employee has elected Post-Retirement Basic Life Withholdings at 100% or 50% of the original value. An employee may retain OLI while receiving compensation if he or she is eligible to continue regular insurance and has been enrolled for no less than the five years of service immediately preceding the disability, or the full period or periods of service during which OLI was available, if less than five years. Questions about basic life insurance coverage should be referred to OPM, while questions about OLI may be directed to OWCP.Return to TABLE OF CONTENTS
Chapter 8. Managing Disability Claims
This chapter describes how OWCP manages disability claims, including reemployment of partially disabled employees. It also describes the sanctions applied to employees who do not cooperate with this effort.
8-1. Initial Actions by OWCP
Where it appears that disability will continue for at least 60 days, the employee is placed on the short-term roll, advised that payment is being made, and asked when he or she plans to return to work, if this has not already occurred. An employee who has not returned to full duty, or who does not have plans to do so within the immediate future, is referred to an OWCP Staff Nurse.
The employee is advised that compensation will continue only through the date specified by OWCP's medical matrix or other procedural guidance or the attending physician's report; that he or she is expected to return to duty as soon as possible; and that he or she is expected to contact the agency concerning the availability of light duty.
At the same time, the agency is asked to send a copy of the employee's job description, including physical requirements, and a copy of his or her SF-171 or other employment application form. Information concerning the employee's earnings and dependents will be requested periodically during the course of disability.
When the medical evidence shows that total disability has ended, the employee will be advised that he or she is expected to seek work. In accordance with the provisions of 5 USC 8106, which provides for payment of compensation to partially disabled employees, OWCP will make every reasonable effort to arrange for employment of such employees. These efforts will concentrate
initially on the agency, and only if reemployment with the agency is not possible will OWCP attempt to place the employee with a new employer.
8-2. Restoration Rights
Federal employees who have fully or partially recovered from an employment-related injury have certain job retention rights. While these rights are provided by the FECA, the pertinent section of the law is actually administered by OPM. An employee who recovers within one year of beginning compensation has mandatory restoration rights to his or her old position or its equivalent, regardless of whether he or she is still on the agency rolls. If full recovery occurs after one year, or the employee is considered partially recovered, he or she is entitled to priority consideration provided that application is made within 30 days of the date compensation ceases.
Such employees incur no loss of benefits which they would have received but for the injury or disease. The regulations on retention rights are contained in 5 CFR 353, 302, and 330.
When an injured employee resumes Federal employment, the agency should verify that the employee had been receiving compensation during the entire period of absence from work whether in LWOP status or separated.
Employees originally hired on or after January 1, 1984 are covered for retirement purposes by the Social Security Act rather than the Civil Service Retirement Act (CSRA). An employee hired before that date will retain CSRA coverage if reemployed by a Federal agency, regardless of the length of time he or she has been receiving compensation, and regardless of whether he or she is in LWOP status or separated.
OWCP's case management procedures emphasize return to work before the expiration of the employee's one-year entitlement to the same or an equivalent job.
8-3. Nurse Services
Independent studies and OWCP's own experience both indicate that the use of nurses may shorten periods of disability and increase the likelihood of return to work. Registered Nurses (RNs) under contract to OWCP meet with employees, physicians, and agency representatives to ensure that proper medical care is being provided and to assist employees in returning to work.
OWCP offers this service to all employees with approved traumatic injury claims who have continuing disability, and on a selective basis to employees with approved occupational illness claims who have continuing disability.
a. Contacting the Interested Parties. The RN contacts the employee, attending physician, and supervisor as needed to address the employee's questions about medical care; obtain treatment plans, return to work dates, and descriptions of work limitations; and explore availability of light duty jobs. These contacts, which may be by telephone or in person, generally occur after the 45 day COP period has ended.
b. Return to Work. Conference calls may be held to arrange for the employee's return to work. Such a call should always include the agency official who has the authority to offer a light duty job. When an employee returns to work, the RN may accompany him or her on a walk-through of the job to ensure that the duties are within the employee's work limitations and that both the employee and the supervisor understand the duties and limitations.
c. Agency Nurses. The RN may occasionally coordinate care with an agency nurse. As a rule, however, agencies should not assign their own nurses to work with employees simultaneously with OWCP RNs.
8-4. Reemployment with the Agency
When the medical evidence shows that total disability has ended, the agency may consider reemployment even if notification from OWCP has not yet been received. The following procedures apply to all employees still on agency rolls, regardless of how long they have received compensation.
a. Medical Evidence. To make an appropriate job offer, the agency will need medical evidence pertinent to the employee's work tolerance limitations (in some cases OWCP will provide this information). Medical information which addresses current medical limitations will usually be sufficient for the purpose of making a job offer. If the employee refuses to provide sufficient medical information for the agency to evaluate the propriety of a job offer, the agency should so notify OWCP.
b. Degree of Recovery. If the employee is expected to return eventually to the job held at the time of injury, the agency may offer light or modified duty pending full recovery. Any such offer should be made in accordance with the procedures outlined in paragraph d below. If the residuals of the injury will prohibit the employee from returning to the position held at the time of injury and the employee has received compensation for more than one year, the agency should consider reemployment in the following order of preference:
(1) Return to the position held at the time of injury with modifications to accommodate the employee's limitations;
(2) Employment in another position at the same salary as the position held at the time of injury; or
(3) Employment in another position at a lower salary than the position held at the time of injury.
c. Guidelines for Reemployment. In identifying potential jobs, the agency should try to minimize any disruption to the employee. The position should be compatible with the employee's medical condition and should take into account any nonwork-related medical condition, which either pre-existed the work-related injury or has developed since it occurred. If a temporary position is offered, it must be at least 90 days in duration.
Generally, an employee who is capable of working four or more hours a day should be offered a position providing at least that much work, since employment of less than four hours a day is regarded as sheltered work and is reserved for the severely disabled. (On the other hand, an offer of less than four hours work a day is suitable for an employee who cannot work longer hours.)
The agency must ensure that any position offered will be available throughout the period required to allow him or her to respond.
d. Elements of Job Offer. The agency may contact the employee by telephone to advise that the job is available, but the offer must be confirmed as soon as possible in writing. A copy of the offer must be sent to the OWCP at the same time. The offer should include:
(1) A description of the duties to be performed;
(2) The specific physical requirements of the position and any special demands of the workload or unusual working conditions;
(3) The organizational and geographical location of the job;
(4) The date on which the job will be available;
(5) The date by which a response to the job offer is required.
The agency should not, however, request election of OPM benefits if the employee declines the job offer. Obtaining such an election is solely the responsibility of OWCP.
e. Advising the Employee. If the job offer is found to be suitable, and it fairly and reasonably represents the employee's wage-earning capacity, OWCP will so notify the employee in writing and advise that he or she is expected to accept the job or to show reasonable cause for refusal. OWCP will advise the employee that the failure to accept the job or to respond within 30 days will result in termination of compensation payments and allow 30 days for response.
f. Employee's Response. The agency should provide a copy of the employee's response to OWCP when it is received.
(1) Acceptance. If the employee accepts the job, the agency should notify OWCP as soon as possible of the date of return to duty so as to avoid overpayments of compensation. If the employee accepts the position offered, compensation will be terminated if no loss of pay has resulted, or reduced if the new job pays less than the old, effective the date of return to duty.
(2) No Response. If no answer is received, benefits will be terminated and a formal decision will be issued on the basis that the employee has refused suitable work.
(3) Refusal with No Explanation. If the employee refuses the offer without explanation, OWCP will issue a formal decision and terminate benefits.
(4) Refusal with Explanation. If the employee refuses the offer but provides reasons in support of the refusal, OWCP will evaluate them and determine whether reasonable cause has been shown. If reasonable cause is shown, OWCP will advise the employing agency and compensation will continue at a level reflecting the degree of disability while further attempts at placement are made. If not, the employee will be so advised and allowed an additional 15 days to return to work. If the employee still does not return to work, a formal decision will be issued and benefits will be terminated.
The success of efforts to return employees to gainful employment while providing procedural due process requires close cooperation between employing agencies and OWCP. Early notification of job offers and complete information about the offers will aid OWCP in making its decisions. For its part OWCP recognizes its responsibility to evaluate job offers and to notify employees quickly to avoid undue delays.
8-5. Vocational Rehabilitation Services
The FECA at 5 USC 8104 provides that vocational rehabilitation services may be provided to disabled employees to assist them in returning to gainful employment consistent with their physical, emotional, and educational abilities. An employee with extended disability may be considered for rehabilitation services if requested by the attending physician, the employee, or agency personnel. In addition, OWCP will routinely consider a case for rehabilitation services if the agency cannot reemploy the employee so that placement with another employer may be considered.
a. Services Provided. An OWCP Rehabilitation Specialist will contact the employee for an initial interview. The employee will then be referred to a state or private Rehabilitation Counselor for development of a rehabilitation plan. A plan may include one or more of the following services: selective placement with the previous employer, placement with a new employer, counseling, guidance, testing, work evaluations, training, and job follow-up. Each employee is evaluated to provide the most appropriate services to him or her, and not all of the services indicated will be included in any given plan.
b. Advice to Employee. When suitable jobs are identified, the employee will be advised that it appears that he or she has a wage-earning capacity of a specific dollar amount which will likely determine future compensation entitlement; that he or she is expected to return to work in a job similar to the one identified, and that only partial compensation based on the wage-earning capacity of the indicated job will probably be paid at the end of this effort; and that when any necessary training or other preparation is completed, OWCP will provide 90 days of placement services.
c. Benefits Payable. An employee in an approved vocational rehabilitation program may be paid an allowance in connection with this program not to exceed $200 per month. The employee is also entitled to compensation at the rate for total disability during the rehabilitation program (payment of a schedule award meets this requirement).
When the employee returns to work, compensation will be reduced to reflect his or her wage-earning capacity if the new job pays less than the old. If reemployment is at the same or higher pay rate than the job held at time of injury, compensation benefits will be terminated. Even if the employee does not return to work, his or her compensation will in all likelihood be reduced.
d. Penalties. Should an employee involved in a rehabilitation program refuse to cooperate or make a good faith effort to obtain reemployment, OWCP may reduce or terminate compensation depending on the circumstances of the refusal.
e. Constructed Positions. In some situations reemployment is not feasible despite the best efforts of both the employee and OWCP. When this happens, the employee's wage-earning capacity may be determined on the basis of a position which the medical evidence indicates the employee can perform and which is available in his or her commuting area. The suitability of the position must be determined in accordance with the following factors:
(1) The nature of the injury;
(2) The degree of physical impairment;
(3) The usual employment;
(4) The employee's age;
(5) Qualifications for other employment, including education, previous employment, and training.
A formal decision, including appeal rights, will be issued in any case where the benefit level is affected.
f. Continued Disability Payments. Only after aggressive medical and vocational development will OWCP determine that an employee has no current wage-earning capacity, and should therefore be carried on the long-term compensation rolls at the rate for total disability.
8-6. Assisted Reemployment
As part of a demonstration project, the OWCP may reimburse an employer who was not the employer at the time of injury for part of the salary of a reemployed worker. This wage subsidy is intended to assist in reemploying workers who have been difficult to place with their former employers. It is available to other Federal employers as well as to State and local governments and the private sector.
a. Eligibility. To be eligible, the agency cannot have been the worker's employer at the time of the injury, as identified by OWCP chargeback billings, appropriations account number and agency hiring authority. Intra-departmental salary reimbursements are limited to agencies with a separate appropriation number from that of the employing agency at the time of injury. It is not proper to use the assisted reemployment approach for transfers within the agency, or where an agency uses more than one appropriation number but hiring is controlled at a higher organizational level.
b. Conditions of Participation. The rate of reimbursement may not exceed 75 percent of the employee's gross wage. The actual rate of reimbursement available must therefore be decided on a case-by-case basis by OWCP staff in negotiation with the agency.
Salary reimbursement may extend for up to 36 continuous months, but it may not be interrupted by a recurrence of disability due to the accepted condition. The subsidy may not be transferred from one employer to another.
An agency interested in participating in the Assisted Reemployment project should contact the District Director or a Rehabilitation Specialist at the regional OWCP office. Where a job opening has been identified which may be suitable for a particular worker, the Rehabilitation Counselor assigned to that worker will meet with agency personnel to explain details of the program.
For OWCP to consider reimbursement of salary expenses, the job offer must be found suitable, medically and otherwise (see paragraph 5 above). To make such a finding, OWCP needs several items of information, including a copy of the position description which includes a statement of the physical requirements of the job. With this information, OWCP staff will make a suitability determination.
c. Elements of Agreement. When the worker accepts a suitable job offer, the new employing agency and OWCP will enter into an Assisted Reemployment Cooperative Agreement. Each Agreement will include the following elements:
(1) Employee's name and OWCP claim number;
(2) Employer's name and address;
(3) A description of the procedures for claiming reimbursement and the payment schedule, including the method and maximum amount of wage reimbursement payments from OWCP to the employer for each employee hired under the project;
(4) A job description and statement of starting wage rate.
d. Transfer of Funds. Once agreement is reached concerning financial and administrative arrangements, OWCP staff will contact the agency to determine the most effective method of payment and transfer of funds. The preferred method of reimbursement by the OWCP is through the U. S. Treasury's GOALS/OPAC (On-Line Payment and Collection) system. Agencies which do not process payments through the U.S. Treasury will be reimbursed by check from OWCP.
OWCP will then advise the agency in writing of the specific accounting procedures for transferring funds. Payment is made after OWCP receives an authorizing document certifying that the employee was actually employed and received wages during the quarter for which reimbursement is requested. Regardless of the method of reimbursement, OWCP will require quarterly submission of records of the wages paid to these reemployed workers and the periods covered by those payments.
8-7. Payment of Relocation Expenses
OWCP's regulations provide at 20 CFR 10.123(f) that an injured employee who relocates to accept a suitable job offer after termination from the agency rolls may receive payment or reimbursement of moving expenses from the compensation fund. This regulation further states that Federal travel regulations (issued by GSA) pertaining to permanent change of duty station moves are to be used as a guideline in determining whether expenses claimed are reasonable and necessary.
a. Locations of Old and New Jobs. Relocation expenses may be paid for a former employee who is partially recovered from compensable injury and who is offered a job in either the same or a different commuting area from the former one. OPM regulations governing the restoration rights of injured workers require consideration of partially recovered employees only in the former commuting area. Thus, the extent to which an agency considers partially recovered employees for jobs outside the commuting area is a matter for agency personnel to decide.
Former employees who move voluntarily to other locations and are offered reemployment at their former installations are generally not entitled to payment of relocation expenses. (See GSA's Federal travel regulations and pertinent Comptroller General decisions governing relocation in the Government's interest.) The extent to which relocation expenses are payable when a fully or partially recovered employee is still on the agency's rolls is governed by Federal travel regulations pertaining to permanent change of duty station moves.
However, OWCP's regulations state specifically that "the agency may offer suitable employment at the employee's former duty station or other alternate location" and that relocation expenses will be payable in either case. Therefore, employing agencies should not discourage applications for payment of relocation expenses to the previous duty station. Given the considerable savings in compensation costs which accrue to employing agencies which return their injured workers to the rolls, payment of relocation expenses to the original duty station are considered to be in the interest of the Government.
b. Eligibility. The distance between the two locations must be at least 50 miles, and the job must be found medically and vocationally suitable. OWCP will authorize payment of expenses incurred to accept a temporary position as long as it is expected to lead to a permanent assignment. The employee need not demonstrate financial need for relocation expenses to be paid, and payment/reimbursement of relocation expenses may be considered after the fact as long as the move took place after June 1, 1987, the effective date of the provision governing such moves.
OWCP staff will determine whether relocation expenses can be approved and will notify the employee and agency personnel. While payment by the agency with reimbursement by OWCP through the U. S. Treasury's GOALS/OPAC (On-Line Payment and Collection) system is preferred, direct withdrawal from the compensation fund may be authorized where necessary.
c. Arranging the Move. Because employing agencies have expertise in arranging PCS moves, OWCP will ask the agencies to calculate the costs and coordinate the activities involved in such moves insofar as possible. OWCP will be responsible for resolving any disputes between the employee and the agency as to allowable costs in accordance with government travel regulations.
d. RITA Payments. The IRS considers at least a portion of PCS payments to be reportable as income even though such payments are intended to reflect actual expenses, and employing agencies usually include a Relocation Income Tax Allowance (RITA) to offset the additional income tax liability incurred because of PCS reimbursements. Compensation benefits are not considered taxable, however, and for this reason the RITA should not be included in paying relocation expenses under the FECA.
8-8. Employees in Light Duty Status
Many agencies place both newly injured and long-term disabled employees in light duty jobs. Such placements usually benefit both employers and employees. However, when employees continue to hold light-duty assignments after they are able to return to full duty, the availability of such light duty assignments for more recently injured employees is decreased.
Therefore, it is the policy of OWCP to monitor injured employees who hold light duty jobs until they have returned to full duty, or until the medical evidence firmly establishes that they will never be able to return to full duty. Employing agencies can aid in this effort by identifying employees who have been in light duty status for over three months.
8-9. Separation from Employment
a. Reductions in Force. When a formal loss of wage-earning capacity has been determined, the employee has the burden to establish further entitlement to compensation. Therefore, the status of an employee with an established wage-earning capacity who is removed due to an across-the-board reduction in force (RIF) or the closing of an installation (as opposed to the elimination of only light duty jobs) does not change with regard to receipt of FECA benefits unless a formal claim for recurrence is filed. When no formal finding with regard to wage-earning capacity has been made, and the employee has worked in the position for at least 60 days, OWCP may consider a retroactive loss of wage-earning capacity determination.
b. Removal for Cause. An employee who is separated for misconduct and whose removal is wholly unconnected to the work-related injury is not entitled to further compensation benefits.Return to TABLE OF CONTENTS
Chapter 9. Agency Management of Compensation Claims
This chapter describes actions agency personnel may take to learn more about individual claims of current and former employees, and to manage their compensation programs.
9-1. Obtaining Information
Claims personnel are instructed to provide agency personnel with copies of all significant correspondence to employees, even when the employees are no longer on the agency's rolls. Under the routine use provisions of the regulations governing release of information under the Privacy Act, agencies are entitled to obtain copies of other materials in their employees' compensation files as well. The use of these copies must, however, be consistent with the reason the information was collected. In practice, this means that the use must generally be connected in some way with the compensation claim.
To safeguard the privacy of information in compensation files, much of which is inherently sensitive, the following procedures are followed:
a. Making Specific Requests. Requests from the agency for materials in a case file should include the specific reason for requesting the information (e.g., to verify that the employee actually worked for the agency, or to attempt reemployment of the worker). OWCP will release the requested information either by telephone or in writing once satisfactory identification is presented. (This requirement needs to be met only once if an agency designates a particular individual as a liaison or principal contact with the district office.) Representatives of an investigative body within an agency may also obtain information upon presentation of proper identification as long as the purpose for the request is stated.
b. Inspecting Files. An agency representative may ask to inspect files at the district office. All such requests will be accommodated subject to logistical and physical limitations, including reasonable advance notice of the visit and a list of
cases to be reviewed. Here again, the purpose should be stated specifically and the identity of the reviewer should be established in advance of the visit. A picture ID must be presented at the time of the visit unless the reviewer is known to the office. Generic requests will be honored when several cases are to be inspected for the same reason.
c. Penalties Under the Privacy Act. It is not appropriate for agency personnel to inspect records without a specific and valid purpose for doing so (that is, curiosity is not an acceptable reason for review). Agency personnel who review files should be conversant with the restrictions of the Privacy Act and the penalties stipulated for violations. These penalties include fines and imprisonment. Any individual who improperly uses information from OWCP files will not be given further access to them.
d. Contractors. If the agency wishes to designate a private contractor to inspect the records, the agency should contact the OWCP National Office in writing to obtain approval for the arrangement. The agency should ensure that the contractor observes the pertinent regulations governing the privacy of employees' records as they review the files and report their findings to the agency.
9-2. Managing Compensation Programs
Agencies are encouraged to develop comprehensive plans for managing their compensation programs to provide good service to employees while containing costs. Ideally, management of compensation claims should be considered a personnel rather than a safety and health function. Throughout this handbook, numerous suggestions and directives have been provided to help agencies to manage their programs. The following is a summary of the most important actions agencies can take:
a. Training. Ensure that sufficient training in technical and managerial skills is provided to those personnel who routinely handle compensation claims and that resource materials are avail-able to those who handle them infrequently. A list of the courses provided and resources for understanding the program is provided in Chapter 1.
b. Administration. Establish a record-keeping system which will enable the agency to maintain copies of claim forms, medical reports, correspondence with OWCP, and other materials related to each compensation claim in an orderly fashion. Designate a representative within each organizational unit who will serve as a liaison with OWCP concerning unusually difficult claims.
c. Documentation. Ensure that the facts surrounding each injury are adequately investigated at the time of injury. This step will enable OWCP to obtain full documentation and enable agencies to substantiate claims it feels are questionable.
d. Medical. Obtain medical information from OWCP or the injured employees as often as necessary within OWCP and OPM regulations to assess the possibility of return to regular or light duty. Advise physicians of any light duty assignments available and their specific requirements to provide the best possible chance for reemployment. This step will also allow the agency to monitor the medical care provided and notify OWCP if it believes action should be taken in this regard.
e. Reemployment. Maintain contact with injured employees while they are receiving compensation, identify jobs suitable for them, and initiate efforts to reemploy recovered or recovering employees as soon as the medical evidence indicates that this is possible.
f. Financial. Conscientious application of the above principles will result in savings to the agency and better service to injured employees. Agencies should also pay special attention to chargeback billings and arrange to charge costs to the lowest organizational level practicable to make managers more aware of costs. The chargeback system is discussed in detail in paragraph 9-4.
Employing agencies often retain documents in connection with workers' compensation claims. Rules governing release, retention, and disposal of such records differ according to the nature and source of the document involved.
a. Documents in Employee Medical Folder (EMF). A notice of injury not filed with OWCP is to be placed in the employee's EMF and retained in accordance with OPM regulations governing disposal of the EMF.
b. Documents in OWCP Case File. These documents include medical reports, copies of letters and decisions, and any other material which is part of the case file, regardless of its source. The agency may use and release such material consistent with the provisions of the Privacy Act, and consistent with the reason for which the material was collected. It may not be used in connection with EEO complaints, disciplinary actions, or other administrative actions without the employee's consent. Any questions concerning use or release of records should be directed to the district office with jurisdiction over the claim.
These documents should be maintained in folders apart from the EMF or OPF, but such folders are not considered a "system of records" separate from the case file. Rather, they are considered an alternate location for the records, which remain under the jurisdiction of the OWCP. Their retention and disposal is covered by the OWCP Records Retirement Schedule, which mandates that case file material should be maintained for two years after case closure.
The FECA program is financed by the Employees' Compensation Fund, which consists of monies appropriated by Congress or contributed from operating revenues. The chargeback system is the mechanism by which the costs of compensation for work-related injuries and deaths are assigned to employing agencies annually at the end of the fiscal accounting period, which runs from July to June for chargeback purposes. Each year OWCP furnishes each agency with a state-ment of payments made from the fund on account of injuries suffered by its employees. The agencies include these amounts in their budget requests to Congress. The resulting sums appropriated or obtained from operating revenues are deposited in the fund.
a. Identification. A compensation claim is identified as belonging to a particular agency based on the agency code that is entered into the OWCP data processing system when the case is created. The agency should pre-code all initial notices of injury, disease and death in order to reduce errors in the chargeback system. The agency will receive a postcard (Form CA-801) from OWCP each time a case is created for one of its employees. OWCP also provides each agency quarterly listings of the cases and charges that will appear on the yearly chargeback bill.
b. Errors. To prevent incorrect entries from appearing on the quarterly chargeback report and yearly bill, agencies should review Forms CA-801 and report errors to district offices as soon as possible. If no objection is raised upon receipt of the form, OWCP assumes that the chargeback code is correct and charges costs associated with the case to that agency's account.
If an agency which receives a Form CA-801 which it believes to be incorrect, it should notify OWCP in writing within 60 days. The district office will then review the disputed case to determine whether a keying or coding error occurred and make any necessary corrections to the agency code.
c. Quarterly Chargeback Report. Each agency receives a quarterly report which provides a breakdown of cases and costs for which charges will appear on the yearly chargeback bill. This report can be used to identify and correct errors before the agency is billed for them. When an agency believes that a case appearing on its chargeback report does not belong on its account, it should check current personnel and payroll records as well as search the service record file and/or send an inquiry to the Federal Records Center. OWCP also welcomes authorized agency personnel to review case files at the district office to resolve such discrepancies.
d. Requesting Changes. Requests for changes based on review of the quarterly chargeback report should be addressed to the District Director of the district office having jurisdiction over the case in question. The request should be made within 90 days of receipt of the report, and it must be accompanied by appropriate documentation such as copies of an SF-50, service record card (SF-7), or response from the Federal Records Center. OWCP will review the case file and supporting evidence to determine whether an incorrect agency code was assigned. If the evidence does not support the agency's request, OWCP will send the agency a copy of the Form CA-1, CA-2, or CA-6 from the case file and explain the basis for its finding.
If the evidence indicates that the disputed case belongs on another agency's account, OWCP will notify the new agency and forward a copy of Form CA-1, CA-2 or CA-6 from the case file. Prior to changing the agency code, OWCP will provide the agency 60 days to respond in the event that it disputes ownership of the case. Due to the time needed for verification and correction, errors brought to the attention of OWCP during the fourth quarter of a fiscal year may not be corrected in time for that year's bill. If incorrect charges appear on the bill, adjustment will be handled as described below.
If the assigned chargeback code represents the wrong organization or command within the agency, the request for change of code must be made by an agency official with the authority to speak for the entire department rather than for a single command or organizational unit.
e. Adjustments to the Chargeback Bill. When an adjustment to the yearly chargeback bill is desired, the request must be sent directly to the OWCP National Office. It must be accompanied by documentation which shows that the disputed charge did not involve an employee of that agency, or by a complete explanation of the basis for the agency's objection. OWCP will make a determination and correct verified errors by crediting the subsequent year's billing statement.
If another agency should have been charged, OWCP will so notify that agency and a debit will appear on its next bill. Credits or debits will be made only for charges appearing on the agency's most recent bill. Adjustments will be made only if there is an effect on the total for the particular billing entity. Transfers of charges from one organization to another on the same bill will not be made.Return to TABLE OF CONTENTS
Appendix A. Basic Forms
Completed Forms Sent to
Federal Employee's Notice of
Traumatic Injury and Claim for
Continuation of Pay/Compensation
Notifies supervisor of a traumatic injury and serves as the report to OWCP when (1) the employee has sustained a traumatic injury which is likely to result in a medical charge against the compensation fund; (2) the employee loses time from work on any day after the injury date, whether the time is charged to leave or to continuation of pay; (3) disability for work may subsequently occur; (4) permanent impairment appears likely; or (5) serious disfigurement of the face, head, or neck is likely to result
Employee or someone acting in employee's behalf; witness (if any); supervisor
By employee within 30 days (but will meet statutory time requirements if filed no later than three years after the injury); by supervisor within 10 work days following receipt of the form from the employee
Supervisor, by employee or someone acting on employ- ee's behalf; then to appropriate OWCP office by supervisor
Federal Employee's Notice of
Disease and Claim for Compensation
Notifies supervisor of an occupational disease and serves as the report to OWCP when (1) the disease is likely to result in a medical charge against the compensation fund; (2) the employee loses time from work because of the disease, whether the time is charged to leave or the employee claims injury compensation; (3) disability for work may subsequently occur; (4) permanent impairment appears likely; or (5) serious disfigurement of the face, head, or neck is likely to result
Employee or someone acting on employee's behalf; witness (if any); supervisor
By employee within 30 days (but will meet statutory time requirements if filed no later than three years after the injury); by supervisor within 10 work days after receipt of the form from the employee
Supervisor, by employee or someone acting on employee's behalf; then to appropriate OWCP office by supervisor
Completed Forms Sent to
Notice of Employee's Recurrence of Disability and Claim for Pay/ Compensation
Notifies OWCP that an employee, after returning to work, is again disabled due to a prior injury or occupational disease. It also serves as a claim for continuation of pay or for compensation based on the recurrence of a previously reported disability
Immediately upon receiving notice that the employee has suffered a recurrence. An employee who stops work as a result of recurring disability shall advise the supervisor whether he or she wishes to continue receiving regular pay (if eligible) or charge the absence to sick or annual leave
Supervisor, by employee or someone acting on employee's behalf, then to appropriate OWCP office. An employee no longer employed by the Federal government should complete Parts A and C and submit all materials directly to appropriate OWCP office
Disability and/or Payment
Notifies OWCP that disability from injury has terminated and/or that continuation of pay has terminated and/or that employee has returned to work
Immediately after disability or continuation of pay terminates, or the employee returns to work
Appropriate OWCP office
Compensation by Widow, Widower and/or Children
Claims compensation on behalf of these dependents when injury results in death
Person claiming compensation (for self or on behalf of children) and attending physician
Within 30 days, if possible, but no later than three years after death. If the death resulted from an injury for which a disability claim was timely filed, the time requirements for filing the death claim have been met
Supervisor, by claimant or someone acting on claimant's behalf; then to appropriate OWCP office
Completed Forms Sent to
Compensation by Parents, Brothers, Sisters,
Grandparents, or Grandchildren
Claims compensation for these dependents when injury results in death
Person claiming compensation (or guardian on behalf of children) and attending physician
Within 30 days, if possible, but not later than three years after death. If the death resulted from an injury for which a disability claim was timely filed, the time requirements for filing the death claim have been met
Supervisor, by claimant or someone acting on claimant's behalf; then to appropriate OWCP office
Official Superior's Report of Employee's Death
Notifies OWCP of the work-related death of an employee
Within 10 work days after knowledge by supervisor of an employee's work-related death
Appropriate OWCP office
Compensation on Account of Traumatic Injury
or Occupational Disease
Claims compensation if (1) medical evidence shows disability is expected (and is not covered by COP in traumatic cases); (2) the injury has resulted in permanent impairment involving the total or partial loss, or loss of use, of certain parts of the body or serious disfigurement of the face, head or neck; (3) loss of wage-earning capacity has resulted
Employee or someone acting on employee's behalf; supervisor, and attending physician (on attached Form CA-20)
In traumatic injury cases, the form must be completed and filed with OWCP not more than five work days before the termination of the 45 days of COP, or within 10 days following termination of pay. In occupational disease cases, the form should be submitted as soon as pay stops
Supervisor, by employee or someone acting on employee's behalf; then to appropriate OWCP office by the supervisor
Completed Forms Sent to
Compensation on Account of
Claims compensation when loss of pay continues beyond the time covered by the claim on Form CA-7
Employee or someone acting on employee's behalf; supervisor, and attending physician (on attached Form CA-20a)
At least five days before the end of the period claimed on Form CA-7 or CA-8 for the period of disability supported by medical evidence
Supervisor, by employee or someone acting on employee's behalf; then to the appropriate OWCP office by the supervisor
Authorization for Examination and/or Treatment
Authorizes an injured employee to obtain examination and/or treatment for up to 60 days and provides OWCP with initial medical report. Treatment may be obtained from a local hospital or physician (who may be a surgeon, osteopath, podiatrist, dentist, clinical psychologist, optometrist, or, under certain circumstances, a chiropractor), or from a U. S. medical facility, if available. May also be used for illness or disease if prior approval is obtained from OWCP. The employee may initially select the medical provider of his or her choice but must request any change from OWCP
Part B--Attending Physician
Part A--By supervisor, in duplicate, within 48 hours following first examination and/or treatment
Part B--By attending physician or medical facility as promptly as possible after initial examination
Part A--Physician or medical facility
Part B--Appropriate OWCP office
Duty Status Report
In traumatic injury cases, provides supervisor and OWCP with interim medical report containing information as to employee's ability to return to any type of work
Supervisor and attending physician
Promptly upon completion of examination or most recent treatment
Original to employing agency, which should send copy to appropriate OWCP office
Completed Forms Sent to
Attending Physician's Report
Provides medical support for claim and is attached to Form CA-7; provides OWCP with medical information
Promptly upon completion of examination or most recent treatment
Appropriate OWCP office
Provides OWCP with additional medical information in connection with supplemental claim filed on attached Form CA-8
Promptly upon completion of examination or most recent treatment
Appropriate OWCP office
Federal Employee's Compensation
Program Medical Provider's Claim Form
Provides OWCP with standard billing form to facilitate payment of medical bills. The form should accompany the CA-16 when employee is referred to a physician
Attending physician; employee must sign in item 12
Promptly upon completion of
examination or treatment; physician may submit in usual billing cycle
Appropriate OWCP office.
Return to TABLE OF CONTENTS
Appendix B. Injury/Illness Type and Source Codes;
INJURY/ILLNESS TYPE CODES
110 Struck by
111 Struck by falling object
120 Struck against
200 FELL, SLIPPED, TRIPPED
210 Fell on same level
220 Fell on different level
230 Slipped, tripped (no fall)
310 Caught on
320 Caught in
330 Caught between
400 PUNCTURED, LACERATED
410 Punctured by
420 Cut by
430 Stung by
440 Bitten by
510 Contact with (motion of person)
511 Rubbed, abraded
520 Contact by (motion of object)
510 Lifted, strained by (single action)
620 Stressed by (repeated action)
800 TRAVELING IN
999 UNCLASSIFIED OR INSUFFICIENT DATA
INJURY/ILLNESS SOURCE CODES
0100BUILDING OR WORKING AREA
(floor, street, curbs, porches)
0140Furniture, furnishings, office equipment
0150Boiler, pressure vessel
0160Equipment layout (ergonomic)
0210Temperature extreme (indoor)
0220Weather (ice, rain, heat, etc.)
0230Fire, flame, smoke (not tobacco)
0300MACHINE OR TOOL
0310Hand tool (powered: saw, grinder, etc.)
0320Hand tool (non-powered)
0330Mechanical power transmission apparatus
0340Guard, shield (fixed, moveable, deadman)
0350Video Display Terminal
0360Pump, compressor, air pressure tool
0410Privately-owned vehicle (includes rental)
0430Common carrier (airline, bus, etc.)
0440Aircraft (not commercially scheduled)
0450Boat, ship, barge
0500MATERIAL HANDLING EQUIPMENT
0510Earthmover (tractor, backhoe, etc.)
0520Conveyor (for material and equipment)
0530Elevator, escalator, personnel hoist
0540Hoist, sling chain, jack
(for material and equipment)
0600DUST, MIST, VAPOR, ETC.
0610Dust (silica, coal, grain, cotton)
0640Mist, steam, vapor, fume
0700CHEMICAL, PLASTIC, ETC.
0810Box, barrel, container, etc.
0830Metal item, mineral
0880Personal clothing, apparel, shoes
0950Human (communicable disease)
0960Bacteria, virus (not human contact)
1000PERSONAL PROTECTIVE EQUIPMENT
1010Protective clothing, shoes, glasses/
1030Safety belt, harness
9999UNCLASSIFIED OR INSUFFICIENT
Note: Select most specific type and source for event which initiated injury/illness.
Use heading as "other" for that category.
Use TYPE as "verb" and SOURCE as "noun" to describe incident.
EXAMPLE: Employee slipped on ice, cut hand on rock.
TYPE: 210, fell on same level
SOURCE: 0220, weather
For Postal Service employees, the occupation code consists of the characters "PS" plus the first four numbers of the appropriate occupation code. For all other Federal employees, the code begins with the two letters of the employee's pay plan (i.e., "GS", "GM", "WG", etc.) followed by the four numbers of the occupation series. For workers who perform services for the Federal government but who do not have job titles which fall under the usual job classification systems, a list of "non-standard" occupation codes and titles follows. Each code begins with the characters "??" instead of the usual pay plan letters.
013600Peace Corps Volunteer
024300Job Corps Enrollee
350100Contract Job Cleaner
046200Forest Service Volunteer
134100Volunteer Weather Observer
009900State Maritime Academy Cadet
18100Civil Air Patrol Volunteer
68500Volunteer Hospital Worker
024300Youth Conservation Corps Volunteer
47500County Agent, Dept. of Agriculture
20400Coast Guard Reserve Member
024000Coast Guard Auxiliary Member
02300National Park Service Collaborator
09900College Work/Study Participant ??006000Chaplain
86300State/Local Agriculture Inspector
03000Sports Clinic Performer
046000Forest Service Cooperator
131600Gage Reader, Corps of Engineers
470100Maintenance Worker, Dept. of Housing and Urban Development
002600National Park Service Volunteer
020400National Defense Executive Reserve
174000National Teacher Corps Member
063000Nutritional Aide, USDA
174000Reader for the Blind
101600Trust Employee, Smithsonian
045700Soil/Water Conservation District
024300Youth/Adult Conservation Corps Enrollee
009900Military Academy Cadet
000600Volunteer Trainee Probation Officer
000600Urban Crime Prevention Program Volunteer
034500Congressional Staff MemberReturn to TABLE OF CONTENTS
Appendix C. Occupational Disease Checklists
The Federal Employees' Compensation program has developed eight checklists to assist employees and agency personnel in gathering and submitting material required for adjudication of occupational disease claims. The forms, which are illustrated on the following pages, are:
Form No. Condition Addressed Revision Date
CA-35a Occupational Disease in GeneralAugust 1988
CA-35b Hearing Loss August 1988
CA-35c Asbestos-Related Illness October 1987
CA-35d Coronary/Vascular Condition August 1988
CA-35e Skin Disease August 1988
CA-35f Pulmonary Illness (not Asbestosis) August 1988
CA-35g Psychiatric Illness August 1988
CA-35h Carpal Tunnel Syndrome October 1987
Appendix D-- DFEC District Offices