 denotes special
FedupFeds topic pages |
| CFR authority |
See TITLE
20 CHAPTER 1 SUBCHAPTER B PART 10 Subpart B -- Filing Notices and Claims; Submitting
Evidence Evidence and Burden of Proof.
See esp. Directed Medical
Examinations (secops, IMEs). |
| Standard of proof & supporting evidence |
On the
question of how much the work needs to contribute to the condition, and how much proof the
doctor needs, see Cause of Injury by H.L. Graham. Regulations
provide compensation for disability when an underlying or
pre-existing condition exists, but disability results when it is aggravated, acccelerated, or precipitated by work factors. Only medical evidence from treating or examining
physicians can establish causal relationship to support
a claim. The evidence and rationalized medical opinion needed depends on the kind of
causal relationship. The role of evidence and opinion is
epecially critical in aggravation of underlying or pre-existing conditions, in consequential injuries, or stress. On evidence needed for underlying medical
conditions, See FECA Procedure Manual Part 2-0805 -3 Evidence
Needed e.Evidence Needed if an Underlying Condition Exists.
Very useful sources are Evidence Needed
for Your Claim from OWCP Region IV, Medical
reports--what is expected from your doctor from OWCP Region IX, and FECA Procedure
Manual Part 2-0805-4 Evaluating Medical Opinions.
See ECAB rulings on medical reports and causal
relationship in ECABS
"Proving causal relationship-reprise"
-Bert Doyle, NALC. What the physician statement should include in cases that are not
obviously job related-- IMPORTANT --This is where the physician
needs to verify that he has read/included the employee's statement of work activity that
he bases the injury-work connection on! In some cases they will claim that your
doctor is basing his opinion on a work activity or condition that did not even occur.
Barb, FedupFeds Director,
recommends keeping a copy of your current job description, as well as a narrative of the
work activities you normally carry out, or may be expected to carry out, as a
precaution. This is an important part of your file to give to your doctor when you
need to describe or document the work that contributed to your condition.
"Medical
rationale" - Bert Doyle, NALC
"It is essentially an explanation of how the physician
arrived at his or her medical opinion-and should contain, as a minimum, an explanation of
the pathological or other medical relationship between the diagnosis and the injury or
conditions of employment. The need for medical rationale has been stressed in hundreds of
Employees’ Compensation Appeals Board decisions..."
See also "Causal relationship",
"Proving causal relationship",
"Weighing’ medical evidence"
& "Burden of proof" from Bert Doyle, NALC |
| Reports for medical restrictions, light duty, SECOPS/IMEs |
Besides
supporting the claim, medical reports are needed to support specific work restrictions for Light/limited
duty .
See use of CA-17 Duty Status Report in CFR changes . See esp. Directed Medical Examinations
(secops, IMEs).
See also Referee physicians , Perez documents on
IME , ,
Burden of proof in Help Index . |
(This is procedures for medical
reports from CA-810
2-2. Traumatic Injury)
.....
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.)
(Here is what the CA-810
says in 3-5 Causal Relationship)
..... 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. |
TRAP
# 5. not explaining red tape to the doctor
|
This
includes the need for rationalized medical opinion (how the condition was caused by
specific work activity -- see medical rationale below),
based on proper medical evidence to support the kind of claim, a thorough list of all
medical restrictions for light duty work, and written verification that the doctor has
read your description of work activities in the file that his opinion is based on.
Also advise doctors that if disability continues, they should include that fact in all
reports to OWCP, and those reports should be kept current. Further, all
communications from your agency to the doctor must be in writing.
Many times in the written reports to
OWCP, the doctor is not specific enough about HOW the exact activities caused the medical
condition. This work connection statement can be especially critical in occupational
illness cases, and in cases where your condition becomes worse unexpectedly, or you have a
secondary condition as a result of the first.
You can't assume your doctor knows how to handle OWCP paperwork.
Explain IN ADVANCE about the paperwork needed from the doctor (including medical
rationale for causal relationship), and their other duties to respond to OWCP. Tell
the doctor you want to pick up copies of all correspondence between them and OWCP, and be
notified of all other contacts with your agency, OWCP, or an "intervention
nurse"
Your doctor's statement of your medical
limitations on CA-17 must cover ALL limitations. This is what you have to refer
to when you tell OWCP that a job offer is not within your limitations and therefore
unsuitable. Don't even think about arguing a limitation that your own doctor did not
include on CA-17 or other current report.
They will argue that pain per se is not a disabling
condition. Make sure your doctor cites the condition causing the pain, rather than
the pain itself, as a limiting factor on your activities.
|
 |
|
|
