Tuesday, April 19, 2011

Causal Relationship; What's the Difference?

In order for your claim to be accepted, you must prove causal relationship. Causal relationship means the relationship between you, your work and the injuries you claim.

There are four ways your medical conditions can be related to your employment:

1. Direct Causation is shown through a natural and unbroken sequence resulting in the condition claimed. If you broke a bone after a fall, the broken bone is caused by the fall. If you were injured in a motor vehicle accident, the accident is the cause of the injuries. If you were attacked by a dog, the dog attack is the cause of the injuries, etc...

An unbroken sequence means that nothing interferes with the sequence of events. Nothing saves you from falling. Nothing keeps you from being in an accident. Nothing stops the dog from attacking you. An unbroken sequence means that from start to finish the events lead to injury.

Occupational injuries fall under direct causation, but are also known as "proximately caused" and the medical evidence to prove your occupational injury more than likely will require greater medical rationale in order to have your claim accepted.

Medical rationale is the HOW of the injury. For example; you fell from a height and landed on a concrete floor. When you hit the concrete floor, you broke your leg. Falling from a height and landing hard on concrete caused your leg to break. The broken leg required immediate medical attention. If you had not fallen from a height and had not landed on concrete, you would not have broken your leg and would not have required medical attention.

When it comes to medical rationale, your doctor must be specific. What is obvious to claimants and their physician's is not obvious to OWCP. There should be no question where you were, who you were working for and exactly how the injury occurred. Again, although obvious, it is not enough for your doctor to say you fell off a ladder at work and broke your leg.

Once accepted, there is no limitation on the duration or severity of the condition. As long as the medical evidence shows disability and/or the need for medical treatment, there is no time limit on how long compensation and/or medical treatment will be paid.

2. Aggravation occurs if you have a pre-existing condition and that condition is worsened, either temporarily or permanently by an injury arising in the course of your employment. For example, you have a heart condition and your heart condition is aggravated by your employment. You have degenerative disc disease and you sustain a traumatic injury which aggravates your degenerative disc disease. You have a respiratory condition and dust aggravates your condition.

A temporary aggravation involves a temporary (or limited) period of medical treatment and/or disability after which you return to your previous physical status.Compensation is payable only during the period of time the aggravation lasts. When the aggravation ends, compensation and/or medical treatment is no longer payable. A temporary aggravation involves only the aggravation and not the underlying disease. Benefits are paid only for the aggravation that made your condition worse, not the condition itself.

OWCP must determine through medical evidence a temporary aggravation has resolved. Your benefits cannot be terminated without notification and proper medical evidence. Normally, OWCP does this through one of its medical examinations.

A 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 and will not revert to its previous level of severity. For instance if you suffer from allergies and you were exposed to dust or fumes and the exposure to dust or fumes causes your allergy attacks to be more severe, that would be a permanent aggravation. If your spinal condition was aggravated and you lose range of motion that you don't recover, that would be a permanent aggravation. A permanent aggravation means that the worsening isn't expected to get better.

There is no additional benefit to you for a permanent aggravation, but OWCP does not like to accept permanent aggravations because it is easier for OWCP's physician's to say your temporary aggravation ended so OWCP can terminate your benefits. If your aggravation is permanent it's harder for OWCP's physician's to say there are no residuals of the aggravation. If your physician believes your medical condition was permanently aggravated, they should say so in every report.

3. Acceleration means that the injury or illness hastened the development of an underlying condition. An acceleration is when the speed in which your condition develops is faster than if you were not exposed to injury or illness. If you're young and you have a knee injury that results in a total knee replacement, your condition was probably accelerated because knee replacement is normally done when you're older. If a hectic, erratic work schedule prevents you from regular eating and your diabetes gets worse, your diabetes was accelerated by your employment. If you have a spinal injury and your degenerative disc disease which was not symptomatic, suddenly becomes severe, your degenerative disc disease may have been accelerated by your employment.

4. Precipitation is when your condition is latent and would not have developed without factors of your employment. If you have tuberculosis that is latent and you become symptomatic after an exposure at work, your tuberculosis was precipitated by the new exposure.

Like a temporary aggravation, only the work-related precipitation is compensable. Once the condition returns to a latent condition, your entitlement to benefits ends. If the condition does not return to its previous state, then there would be no limit on the duration of acceptance. In other words, as long as the condition is present, you're entitled to benefits.

You can find information about causal relationship in the FECA Manual part 2 at 2-0805-2.

1 comment:

  1. Thank you so very much! Have dev disk disease. Back surgery 8 months ago for herniated disk. Fell in parking lot jarred my back. Lying here waiting for claim acceptance so I can get much needed TREATMENT! Five weeks now. So scary. I am 62 9/19/11. Don't know what is going to happen to single earner me.