TABLE OF CONTENTS
Paragraph and Subject Date Trans. No.
Chapter 2-1500 Consequential Conditions
Table of Contents. . . . . . . . . . 03/16 16-05
1 Purpose and Scope. . . . . . . . . . 03/16 16-05
2 Defining a Consequential
Condition . . . . . . . . . . . . 03/16 16-05
3 Claims for Consequential
Conditions. . . . . . . . . . . . 03/16 16-05
4 Claim Development. . . . . . . . . . 03/16 16-05
5 Metastasized Cancer(s) . . . . . . . 03/16 16-05
6 Conditions Resulting from Medical
Treatment . . . . . . . . . . . . 03/16 16-05
7 Independent Intervening Causes . . . 03/16 16-05
8 Pre-existing Conditions. . . . . . . 03/16 16-05
9 Psychological Conditions . . . . . . 03/16 16-05
10 Accepting or Denying the
Consequential Condition . . . . . 03/16 16-05
11 Impairment and Wage-Loss . . . . . . 03/16 16-05
12 State Workers’ Compensation (SWC)
Claims, Lawsuits and Fraud. . . . 03/16 16-05
1 Sample Listing of Consequential
Illnesses 03/16 16-05
2 Sample Letter Decision 03/16 16-05
1. Purpose and Scope. This chapter discusses the Claims Examiner’s (CE) role when developing claims for consequential conditions. It also discusses the types of injuries, illnesses, impairments, or diseases that may be considered as consequential conditions.
a. OWCP Imaging System (OIS). Anyone undertaking development action with regard to a claim for consequential conditions is to ensure that documents generated or received during the evaluation process for consequential conditions are properly bronzed/scanned into the OIS. This guidance applies to any of the procedures described throughout this chapter.
2. Defining a Consequential Condition. The effect of an accepted occupational illness under Part B and/or covered illness under Part E in causing, contributing to or aggravating an injury, illness, impairment, or disease is considered a consequential condition. A CE is to accept as compensable any claimed consequential condition(s) that is documented properly by substantive, well-rationalized medical evidence. Consequential conditions can arise for any reason established as being medically linked to a previously accepted work-related illness. In some instances, a “chain of causation” can result in a series of injuries, illnesses, impairments, or diseases, which are a direct consequence of an accepted work-related illness. When medical evidence is present to establish such a scenario, the resulting consequential condition(s) in the causal chain are all compensable under the EEOICPA. The acceptance of a consequential condition(s) results in medical coverage for that condition(s) under Part B and/or Part E as appropriate. Additionally, under Part E, any diagnosed illness, injury, impairment, or disease shown by medical evidence to be a consequence of a covered Part E condition may affect the calculation of an impairment rating and/or wage-loss.
3. Claims for Consequential Conditions. The claimant must file a claim for all consequential condition(s) in writing and may use any method of written notification. However, while documents containing written words of claim for a consequential condition(s) are acceptable to begin the adjudication process, the CE is to obtain a completed and signed Form EE-1/2 associated with the consequential claim before issuing a decision. A signed claim form is also required for all metastatic cancers. Ideally, the claimant should concurrently send a written statement identifying the specific nature of the consequential condition claimed, along with a signed EE-1/2. A signed EE-1/2 is required because it provides notice to the claimant of his or her responsibilities in filing for benefits under the Act.
a. For each distinct medical condition claimed as a consequence of a previously accepted condition, the CE undertakes a careful examination of the evidence presented in support of the claim. If the evidence demonstrates the existence of a diagnosed consequential illness and the CE decides that the medical justification is sufficient to link reasonably the condition to a previously accepted condition, he or she proceeds with issuing a letter decision of acceptance (refer to 10a on acceptances). In those claims situations where insufficient evidence exists, after development, to establish a consequential claim, the CE issues a recommended decision of denial.
There may be instances where a claimant files words of claim or an EE-1/2 for a condition but it is not clear whether the claimant’s intent was to file the condition as resulting from toxic substance exposure or as a consequential condition. In most cases, the condition will be processed as a primary diagnosed condition resulting from toxic substance exposure. However, if the medical or factual information provided with the words of claim or the EE-1/2 alludes to the fact that the condition may be a consequence of a previously approved condition, the CE is to contact the claimant to obtain clarification on whether he or she wants the claim to be processed as a primary condition or as a consequential condition. Once the CE obtains clarification, he or she documents the claimant’s intent in ECS and begins appropriate development for that condition.
In those cases where only words of claim was filed, the CE requests that the claimant submit a completed and signed EE-1/2 clearly indicating that the condition is consequential, prior to issuing any decision. (Note: if a completed and signed EE-1/2 was already submitted and the CE just needed to seek clarification of the claimant’s intent, a new updated EE-1/2 is not needed).
(1) For any consequential condition(s) where the CE has requested a completed and signed Form EE-1/2, the CE allows a period of 30 days for the claimant to submit the required documentation. After 30 days, the CE administratively closes the claim if the claimant has not submitted a signed EE-1/2 claim form. The CE is to mail a notice to the claimant(s) that no further action will occur on the claim for that medical condition until receipt of a completed and signed claim form.
b. In some situations, the CE may find evidence contained in a case record that suggests that an unclaimed medical condition is consequential to an accepted condition. If there is sufficient reason to discern that the evidence of record communicates the existence of a likely consequential condition, the CE is to contact the claimant to ascertain whether he or she wants to claim that condition as consequential to a previously accepted illness. If the claimant states that he or she wants to file a claim for that condition, the CE instructs the claimant to submit a completed and signed EE-1/2 form. The mere fact that the CE identifies an unclaimed condition in the medical evidence is not sufficient reason to seek a new claim. Evidence has to be present in the case record to lead the CE to a reasonable conclusion that the condition is consequential to an approved primary condition.
c. Where a claimant previously filed Form EE-1/2 for a condition due to toxic substance exposure that was denied, but later claims that the denied condition is consequential to an accepted condition, the claimant is to file a new Form EE-1/2 claiming the condition as a consequential illness. In this scenario, the CE treats it as new claim filed under the EEOICPA. As this is a new claim filed under the EEOICPA, a Director’s Order vacating the prior denial of the same condition based on toxic substance exposure is unnecessary.
4. Claim Development. When assessing a claim for a consequential condition, medical evidence is required to document clearly the relationship that creates the nexus between a consequential condition and an accepted work related illness. The medical documentation is to contain information identifying the diagnosis of the consequential condition. In addition, the medical evidence is to include a physician’s opinion that presents a convincing and well-rationalized conclusion linking the consequential condition to a previously accepted illness. The opinion of the physician regarding a consequential condition is to be sufficiently probative and compelling to allow the CE to assign the weight of medical evidence to the conclusion offered. Physicians offering vague, equivocal, speculative positions on the relationship between a consequential condition and a work-related illness require additional investigation by the CE. Additional development is also required when a physician offers opinions that the CE considers to be unsupported by any reasonable medical justification.
a. Exhibit 1 provides a sample listing of secondary medical conditions that are known to result from Chronic Beryllium Disease (and treatment), silicosis, prednisone treatment, and other conditions. This list is not all-inclusive but serves as a guide for identifying some commonly known consequential illnesses. While the Exhibit serves as a guide and lists potential secondary illnesses, the CE is to exercise discretion when developing for these conditions. The fact that a condition appears as “secondary” on the Exhibit in no way establishes that the condition truly resulted from the claimant’s approved underlying condition. The CE is to ensure that the claimant submits sufficient medical evidence to substantiate the relationship between the underlying condition and the claimed consequential condition.
5. Metastasized Cancer(s). Metastasized cancer(s) is a type of cancer that originates from a primary cancer site but spreads or invades other organ systems. Metastatic cancer has the same name and the same type of cancer cells as the original, or primary, cancer (Under a microscope metastatic cancer cells generally look the same as cells of the original cancer). For example, breast cancer that spreads to the lung and forms a tumor is metastatic breast cancer, not lung cancer. In many situations, there will be evidence in the form of pathology or other diagnostic evidence that identifies a cancer as “metastatic” or “secondary” to a primary cancer type. A CE may accept a claimed metastatic cancer as a consequential condition if the diagnostic or other medical evidence is sufficiently descriptive to identify it as being caused by another primary cancer accepted as work-related. If the evidence is unclear or does not establish a relationship between the cancers, the CE undertakes additional development to include collecting the opinion of a treating physician or an assessment of the record by a Contract Medical Consultant (CMC).
a. The evidence relating to a metastatic cancer is to include the following:
(1) The diagnosis of each secondary cancer; and
(2) The date of diagnosis for each secondary cancer(s).
If the medical evidence is inconclusive and the CE is unable to determine if the cancer is a metastasis, the CE seeks clarification from the treating physician and/or a CMC.
b. Examples of Metastasized Cancers. It is widely accepted that certain carcinomas and/or sarcomas metastasize from a primary site. For example:
(1) Carcinomas of the lung, breast, kidney, thyroid, and prostate tend to metastasize to the lungs, bone, and brain.
(2) Carcinomas of the gastrointestinal tract, reproductive system, and abdomen tend to metastasize to the abdominal lymph nodes, liver, and lungs. Later in their course, these carcinomas can metastasize to the brain and other organs.
(3) Sarcomas often first metastasize to the lungs and brain.
(4) Primary malignant tumors of the brain seldom metastasize to other organs, but they can spread to the spinal cord.
6. Conditions Resulting from Medical Treatment. Consequential conditions can arise from treatment modalities imposed on an employee because of an accepted work-related illness. This can include any injury, illness, impairment or disease arising from any form of medical treatment, including effects from prescription medication.
a. Consequential Conditions Resulting from Medical Treatment for Accepted Conditions. As part of a patient’s medical treatment or protocol, a patient may undergo treatment and/or other drug therapy that will produce side effects that can be considered as common consequential conditions.
Examples of such conditions are:
(1) Radiation pneumonitis as a result of radiation treatment;
(2) Skin rashes and radiation burns because of radiation treatment;
(3) Osteoporosis (which causes weakening of the bones and injuries such as spontaneous hip fractures) as a result of steroid treatment.
b. Developing evidence for conditions resulting from medical treatment. When the CE receives a claim for a consequential condition caused by medical treatment of the accepted condition (also known as iatrogenic), the CE investigates the submitted documentation to ensure that the medical evidence supports the claim.
(1) Medical evidence is to identify the medical diagnosis of an illness or injury that is due to the treatment of an accepted work-related illness.
(2) A physician opinion or narrative is to be present that discusses the causal relationship between the consequential condition and a treatment modality made necessary because of the accepted condition. The physician’s opinion should present a reasonable chronology of the onset of a consequential condition following a treatment regimen. In addition, the physician is to offer a well-rationalized position on the relationship that exists between a newly diagnosed problem and the treatment of an accepted illness. Vague, speculative or unsubstantiated positions taken by a physician require additional development including a review of the situation by a CMC, if necessary.
7. Independent Intervening Causes. Consequential conditions can arise from an injury arising from an action or event that is reasonably linked to the accepted work-related illness. An example would be an injury sustained by the claimant as a result of a slip and fall on his or her way to or from a medical appointment for the accepted work-related illness. Other examples include injuries to the claimant resulting from accidents involving wheelchairs or scooters, improper Durable Medical Equipment (DME) use, medical transport, etc. When assessing claims of this sort, the CE is to collect documentation that describes the circumstances of the injury, along with the medical evidence that diagnoses a medical condition linked to the event.
a. The CE is to obtain a signed written statement from the claimant that describes the circumstances of the event that resulted in an injury. For example, “I tripped down the stairs when exiting the doctor’s office and broke my arm.” The claimant’s statement is to be sufficiently descriptive to explain the circumstances of the event or accident, along with an explanation as to how it is linked to the accepted work-related illness.
b. A physician opinion or narrative is to be present that discusses the causal relationship between the event or accident that is somehow linked to the accepted work-related illness and the onset of a new diagnosed medical condition. The physician is to explain the sequence of events that led to the consequential condition, along with his or her explanation as to how the event or accident is related to the accepted work-related illness. If the physician is unable to provide a rational explanation, or there are other contradictions in the evidence that lead the CE to question the sufficiency of the claim, additional development should occur, including a review of the situation by a CMC. In situations where the claimant sustains an injury on his or her way to a medical appointment, it may be necessary to confirm the date, time and location of the appointment to assist with determining that the claimant was in fact on his or her way to an appointment related to the accepted condition.
(1) An independent intervening incident caused by, or attributed to, the employee’s own conduct. Injuries, illnesses, impairments or diseases suffered as a result of the employee’s own actions will not be accepted as consequential conditions. For example, if an employee is involved in an automobile accident on his or her way to a doctor’s appointment for treatment of an accepted condition, but it is determined through medical evidence/police report that the claimant was under the influence of drugs or alcohol at the time of the accident, then the results of the accident could not be considered as a consequential illness or injury.
8. Pre-existing Conditions. Pre-existing conditions are conditions that pre-exist the diagnosis date of an accepted work-related condition. If medical evidence supports that the pre-existing condition became aggravated or worsened by the accepted condition, it is considered a consequential condition. To accept a claimed pre-existing condition as a consequential illness, a medical report is required that includes the diagnosis of the pre-existing condition and a well-rationalized explanation of how the condition was worsened or aggravated by the accepted condition. The medical evidence has to support an increase in the symptoms or disability that would not have otherwise occurred, or treatment that would not have been necessary, but for the accepted condition. An example of a pre-existing condition affected by a covered condition includes Chronic Obstructive Pulmonary Disease (COPD) that aggravates a pre-existing heart disease such as Coronary Artery Disease. The “Eligibility Begin” date is the filing date of the underlying accepted condition.
9. Psychological Conditions. Psychological conditions can arise as a consequence of the accepted illness and/or treatment of that condition. They can also arise with no physiological basis. Depression, anxiety, and/or chemical imbalance are a few examples of psychological conditions that may have no physiological basis. In addition to a specific diagnosis, these conditions may be described as “psychogenic pain disorder,” “conversion disorder,” or “psychological syndrome.” However described, the symptom or pain is quite real to the individual involved although there is no demonstrable physical disorder.
To accept a claimed psychological condition, the claimant must provide diagnostic evidence and a well-rationalized medical opinion from a qualified physician supporting a causal connection between the psychological condition and the covered condition. A qualified physician must be a clinical psychologist or psychiatrist. In situations where clarification on the causal relationship between the psychological condition and an accepted condition cannot be obtained from a qualified physician, the CE forwards the claimant’s case file to a CMC or refers the claimant to a qualified second opinion physician for evaluation and opinion concerning causal relationship.
A CE may authorize social worker services for the treatment of a consequential psychological condition when prescribed under the supervision of a qualified physician. However, the physician is to specify the justification for such services, along with the submission of a narrative report that describes the plan of care with regard to the extent and duration of social services.
10. Accepting or Denying the Consequential Condition. The CE is responsible for taking the appropriate steps in developing any claimed consequential condition. This includes notifying the claimant of any deficiencies in the evidence and allowing him or her the opportunity to respond and submit additional evidence.
a. Acceptances. If the consequential condition is going to be accepted, the CE accepts the consequential condition under Parts B and E, if the primary underlying condition is also accepted under both Parts. The CE notifies the claimant in a letter decision. All letter decisions should contain two signature blocks; one for the CE who drafted the letter, and one for his or her supervisor (or another management official designated by the district director), who will certify the sufficiency of the decisional outcome. Exhibit 2 provides a sample decision letter for approvals of consequential conditions.
The CE should be aware that once he or she accepts a consequential condition by letter decision, any pending claim for that same condition being affiliated with a toxic substance exposure can be administratively closed. For example, when a letter accepting glaucoma as a consequential condition occurs, there is no need to then issue a recommended accept/deny for glaucoma based on toxic substance exposure. The “Eligibility Begin” date for consequential conditions is the filing date of the underlying accepted condition.
b. Denials. If the CE has determined that insufficient medical evidence exists to accept a claim for consequential condition, and the CE provided the claimant the opportunity to submit supportive evidence, he or she issues a recommended decision specifically denying the claim for a consequential illness. The CE does not issue a letter decision denying a consequential condition. A recommended decision issued to deny a consequential condition must contain a clear explanation to the claimant of the deficiencies in the medical evidence, including any interpretation of medical opinion from a physician, that is not considered sufficiently well-rationalized to support the claim.
c. Issuing the Decision. A CE cannot issue a letter decision accepting a consequential condition or a recommended decision denying a consequential condition without a preceding final decision accepting a primary covered condition. In those situations where a case is in posture for the CE to accept a primary covered condition and a potential consequential condition exists, the CE proceeds with the immediate release of a recommended decision for the primary condition. A CE does not delay issuance of a recommended decision accepting a primary covered condition while development occurs for a consequential condition. However, if the case is in posture for concurrent acceptance of both a primary and a consequential illness, the CE includes both in the recommended decision.
11. Impairment and Wage-Loss. Consequential conditions may cause additional impairment or wage-loss under Part E, but do not result in an additional lump-sum award under Part B.
a. Impairment rating. An impairment rating assesses the functionality of the whole organ or system. The DEEOIC does not apportion impairment by disease (see EEOICPA PM 2-1300 for further discussion of impairment ratings). The effect of this methodology means that an impairment rating encompasses all illnesses causing damage to an organ system, so long as one is an accepted work-related illness. For conditions accepted as consequential, the CE determines if the acceptance of a new consequential illness requires action to initiate an impairment rating under Part E. If the CE is reviewing case evidence to make a decision on an initial claim for impairment, he or she includes all accepted primary or consequential claims in the assessment of impairment.
(1) The acceptance of a consequential illness that involves an organ system previously included in an impairment rating will not trigger a new impairment evaluation if it is less than two years from the date of the final decision awarding impairment benefits.
(2) For situations where a new consequential illness is accepted after an initial impairment rating has occurred, the CE proceeds with a new impairment rating if the consequential condition affects an organ system that was not previously evaluated for impairment. For example, the primary accepted condition is lung cancer. FAB issued a final decision one year ago to award a 50% impairment due to whole person impairment rating to the pulmonary system. A consequential illness is accepted for stomach ulcers as a result of medication required to treat the cancer. The CE may immediately proceed with a new impairment assessment because the consequential illness effects an organ system (digestive) that was not included in the prior impairment assessment.
If the claimant’s treating physician or a CMC identifies a consequential illness during an impairment evaluation that is not included in the SOAF as an accepted condition (regardless of whether or not it is included in the impairment), the CE contacts the claimant and asks if he or she wants to file a claim for the condition (refer to paragraph 3). If the claimant answers in the affirmative, the CE instructs him/her to submit a completed and signed Form EE-1/2. The processing of the impairment claim should not be delayed if the condition is for the same organ/body system.
b. Wage-Loss. With the acceptance of a new consequential illness, the CE has to determine if sufficient evidence is present to undertake development for wage-loss. CEs calculate wage-loss using the first day that the employee lost wages due to the covered illness and/or consequential illness (see EEOICPA PM 2-1400 for further discussion of wage-loss).
In certain instances, the consequential condition may be the initial cause of the employee’s wage-loss. For example, a claimant is approved for CBD due to beryllium exposure under Parts B and E. A year later, the claimant files a claim for pulmonary hypertension as a result of CBD. The medical evidence supports this finding and the assigned CE accepts the pulmonary hypertension as a consequential condition to the approved condition of CBD. The CE obtains evidence showing that the employee has had to stop work due to breathing and cardiac difficulties. The claimant is now entitled to wage-loss benefits under Part E for any lost wages due to pulmonary hypertension.
12. State Workers’ Compensation (SWC) Claims, Lawsuits and Fraud. For each consequential injury that is to be accepted, the CE may need to obtain a newly signed Form EN-16 SWC/Tort/Fraud affidavit from the claimant. The EN-16 is valid for one year from the date of claimant signature for all future claims related to that consequential condition, including claims for impairment and wage-loss.