What is a Definition Essay?
A definition essay is writing that explains what a term means. Some terms have definite, concrete meanings, such as glass, book, or tree. Terms such as honesty, honor, or love are abstract and depend more on a person's point of view.
Three Steps to Effective Definition
- Tell readers what term is being defined.
- Present clear and basic information.
- Use facts, examples, or anecdotes that readers will understand.
Choosing a Definition
Choosing a definition is a key step in writing a definition essay. You need to understand the term before you can define it for others. Read the dictionary, but don't just copy the definition. Explain the term briefly in your own words. Also, it's important to limit your term before you start defining it. For example, you could write forever on the term "love." To limit it, you would write about either "romantic love," "platonic love," or "first love."
Thesis Statement of a Definition Essay
The thesis statement usually identifies the term being defined and provides a brief, basic definition.
(term) (basic definition)
Ex: Assertiveness is standing up for your rights.
How To Write an Effective Definition
- Create a definition. There are several ways to define a term. Here are a few options.
- Define by function. Explain what something does or how something works.
- Define by structure. Tell how something is organized or put together.
Define by analysis. Compare the term to other members of its class and then illustrate the differences. These differences are special characteristics that make the term stand out. For example, compare a Siberian husky to other dogs, such as lap dogs, mutts, or sporting dogs.
(term) (precise definition)
Ex: A Siberian husky is a dog reputed for its ability to tolerate cold, its distinctive features, and its keen strength and stamina.
- Define by what the term does not mean. This distinction can sometimes clarify a definition and help a reader to better understand it.
- Use understandable facts, examples, or anecdotes. Select facts, examples, or anecdotes to fully explain your definition. Ask yourself, "Which examples will best help readers understand the term? What examples would most appeal to my readers? Will a brief story reveal the term's meaning?" Do not use any examples that will not support the definition.
Remember: A definition essay is writing that explains what a term means. When writing a definition essay, remember to tell readers what term is being defined, to present a clear and basic definition, and to use facts, examples, or anecdotes that readers will understand
Here are the examples of popular definition essay topics:
- Sense of Humor
Whatever essay topic you choose, you should be interested in the subject and familiar with it. It would be great if you had your personal experience in the matter you are going to define.
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
Chapter 9. Agency Management of Compensation Claims
9-1 Obtaining Information
Appendix A. Basic Forms
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.