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Sunday, April 3, 2011

Consequential Injuries

If you work with OWCP claimant's long enough, you'll find that certain claims are easier (not easy, just easier) to get accepted than others. For instance, a death claim is the hardest to prove since the claimant has died and can no longer fight for themselves. No one can examine the claimant, no one can question the claimant.

Emotional conditions rank number two on my list followed by a recurrence. I advise claimant's to avoid a recurrence claim if at all possible because it's really a trap. A recurrence must be a spontaneous change in your condition. It's the spontaneous part of a recurrence that's hard to prove.

Consequential injuries are much easier to get accepted because most CE's have no idea how to process consequential injury claims. They don't understand OWCP's own policies regarding consequential injuries.

OWCP will accept a sprain/strain injury simply because a strain/sprain is going to heal. There's not many of us that have seen a sprain/strain last for years. When OWCP sends you to a second opinion, it's easy for that physician to say the sprain/strain resolved. The problem is most people have more than a sprain/strain when they're injured at work.

A consequential injury is the natural progression of an injury or illness and also covers any complication of your injury or illness, such as complications from surgery or medications. Unless there is an intervening cause of your own making, a consequential injury is compensable.

What is an intervening cause of your own making? If you are aware of your injuries, limitations and restrictions and you do something you're not supposed to do, that's an intervening cause of your own making. For instance, you play a sport you shouldn't be playing and you get hurt or re-injury yourself. If you go hiking and fall off a cliff when you weren't supposed to be climbing in the first place, that's an intervening cause of your own making. Your not supposed to drive, but you do and get into a car accident and are injured. You have a heart condition and aren't supposed to run, but you enter a marathon. An intervening cause is something you do that is unreasonable in light of what you know about your accepted medical conditions.

On the other hand if you have a medical condition that affects your ability to walk and you fall, that is not an intervening cause. For instance, you have a knee condition where your knee gives out and you fall and injure yourself. You have a muscle spasm that causes you to crash your car. That is not an intervening cause of your own making. An intervening cause is something you have control over. It's something you do that you shouldn't do based on what you know about your injuries.

A lot of medical conditions progress to conditions that are worse than your original injuries. If you have a spinal condition, you may develop Myelopathy (spinal cord compression), a bulging disc may burst, your chronic pain may cause insomnia, a shoulder impingement may lead to a rotator cuff tear, your torn ACL may lead to a torn MCL, you developed pneumonia after surgery. Most degenerative conditions will progress into worse conditions. If any new condition develops because of your original injuries those are consequential injuries.

As with anything else in the OWCP system, getting your consequential injuries accepted begins with a narrative medical report from your physician. Your physician must state how the consequential injuries are related to the original injuries and provide exam results and a diagnosis with ICD-10 codes and any test results.

The word progression is important for any degenerative condition. Your physician should also explain how s/he knows a degenerative condition isn't 100% age related. During the natural aging process your degenerative condition will change and plateau. If your condition doesn't plateau, it just keeps getting worse and worse, that is not normal aging. If you're 35 years old and you've been diagnosed with Stenosis, that is not the aging process since it is known that Stenosis does not develop until age 50 in the normal population.

You can help your physician out by going to the Merck Manuals and researching your conditions. Some conditions are known to progress to worse conditions. Every OWCP district must have the Merck Manuals for reference, so you and your physician can use the Merck Manuals to back up your diagnosis. Some conditions in the Merck Manuals state the expected progression of the condition. If your physician states that this condition is not exclusive to you, that the information is readily available in places such as the Merck Manuals, it makes it much harder for OWCP to deny your claim because they'd have to discount their own reference materials. I've put a link to the Merck Manuals on the "Links" page.

In addition to a medical narrative, you need to submit a factual statement stating exactly how your injuries have changed, how the injuries affect your ability to do the normal things in your life, what pain or other symptoms the injuries cause, any medications you're taking, etc...

When you have your medical narrative and your statement, you should write a letter to your CE indicating that you request your consequential injuries be accepted and that your attaching a medical narrative and a factual statement. You should include at least one passage from Larson's on Workers' Compensation and at least one ECAB decision in your letter. It is the Larson's that OWCP does not understand and again is required in every District as reference materials. I've put the parts of Larson's that pertain to consequential injuries on the "Useful Stuff" page.

Even if OWCP denies your claim the appeal for consequential injuries is straight forward. Your arguments are the information contained in Larson's on Workers' Compensation, the FECA Manuals and ECAB decisions. All the information you need for a consequential injury appeal is on the "Links" and "Useful Stuff" pages.

If you allow OWCP to only accept a sprain/strain injury, you will not receive the proper treatment you need and OWCP will overturn your claim based on your sprain/strain injury resolving itself. If your injuries caused more than a sprain/strain, you have to fight to get an accurate diagnosis. It affects the entire future of your claim if you don't. If your conditions have progressed into new or worse conditions, you have to fight to have those consequential injuries accepted as well.

20 comments:

  1. thank you very much for the information and where to go to get more!

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  2. JESSE... I LOVE YOU!! I WISH I HAD THIS INFO BEFORE!!

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  3. I thank God for this blog

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  4. My gosh you are knowledgeable. I wanted to know what you would call an injury that never resolved, but my doc said it did. Second op doc said it didn't. strange, I know, I was put back to work, lasted two weeks max, and back out. I just submitted a CA-7 and CA-17 from new doc. What can I expect? seems owcp overrode their own doc and used my docs recommendation. by the way, my doc, I found out works many cases for owcp. I did not know that at the time trying to find one.

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  5. OWCP is always going to go with the physician that states you can work. Since you returned to work and have now filed the CA-7 and CA-17 your claim will basically start over. OWCP will look at the evidence and decide whether or not to pay benefits.

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  6. I had thoracic surgery removal of my right upper Lobe, muscles and nerves were cut in my back and two ribs removed causing contain pain to my back. chest and arm would that be considered as Consequential Injuries

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  7. OWCP considers pain a symptom and not a diagnosis. So you would need your physician to discuss where the pain is coming from. If the pain is caused from new conditions that are a result of the original accepted conditions, then yes that would be consequential injuries.

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  8. Hi Jesse
    I filed a consequential injury claim after having surgery 7-12-12 on my right shoulder (rotator cuff) and receiving 4 screws in my shoulder. I filed a CA-2a on 7-2014 as a consequential injury after several months seeing a doctor, but never received a denial letter. I just received a letter from a District Medical Advisor stating that my doctor report do not support a causal relationship between the accepted right shoulder injury and the development of left shoulder symptomatology based on overuse of the left shoulder resulting from the right shoulder injury. He denied my claim saying that "favoring" is not supported as a reasonable cause. What should my doctor say or how should he word it, because I took a MRI a month ago, now I have a tear, which the District Medical Advisor also looked.

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  9. This isn't a question that can be answered here. Contact me directly at owcpslayer@gmail.com to discuss your options.

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  10. I'm in Sacramento, CA. Had spine surgery, my surgeon moved, new surgeon took MRI of neck and I have severe deg disc disorder needing another fusion. I saw it on the MRI, it's terribly obvious. Not to mention I live with the pain. My surgeon refused to give a diagnosis and do any paperwork on my 40th day of the 45 COP. He said on the CA-17 I should be able to lift 40 pounds and bend/twist/stoop/ etc continuously for 8 hours a day! Then he said as he handed it to me, FECA is too much work I don't want you as a patient. And he was mean and very serious. He threw me away like a cigarette butt. He initially said he would do FECA, I checked before I saw him the first time. Any advice?

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  11. Find a new physician ASAP that will take you as a patient. First and foremost, you don't want a doctor that treats you like that.

    If you can, get a letter from the doctor saying he won't treat you. This will make changing physicians easier for you.

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  12. I wrote a letter and called my claims examiner a "nasty ass person" I know it was childish and regret it but what can I do about it now,

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  13. Cam: While your statement may be true, you did something you regret in the heat of anger.

    You have two choices, you can apologize or just chalk it up to a lesson and ignore it. If you choose to apologize, you can just write something short saying it was in the heat of anger.

    There should be no adverse action in regard to your claim because you called your CE a name and let's be honest, there were much worse names you could have called the CE.

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  14. How long should I wait for a denial or acceptance letter or should I contact the CE. I had DJD in both knees unrelated to work. While working a few months ago, one container bumped into another and knocked down. I went to ER by Resue, then followed up with my Dr.who did MRI and diagnose new meniscus tears in both knees. My doctor said that because i had preexisting knee condition and replacement was needed before the accident, i have to get the replacement under my own insurance, is that correct.

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  15. If the container hitting you caused new injuries, then those injuries would be work-related. If the new injuries contribute to your need for a TKR, then the TKR could be approved by OWCP.

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  16. Hi I'm new here and I am hoping you can give me some info on what I should do. I was involved in a vehicle accident while delivering mail. This was in 2005. Since about 2006 til 2013 I was on numerous types of medications most had Tylenol in them. I have been diagnosed with cirrhosis of liver. I am in the process of finding a liver specialist. My own personal medical doctor is the one who sent me for tests and procedures to get this diagnosis. It seems that it was the combination of medications that caused my liver to be damaged. When my doctor eliminated the offending medications, my liver improved. I am now off the pain meds with no relief for pain. I take Nucynta and Baclofen. I had to reduce the Nucynta as my liver enzymes increased. My personal physician and my primary both have said that I need to have my liver damage included in my accepted conditions since it was my meds that caused it. I am not a drinker. How do I go about it? I read above to get the medical narrative and is it a personal statement from me that I need to send to CE? Have you ever heard of anyone getting their liver damage due to meds included in their accepted conditions? Thank you for any help you can provide. BTW thanks for this site. It is very informative.

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  17. This isn't really a question and answer forum. If you're interested in discussing your issue, you can contact me directly at owcpslayer@gmail.com or post a question on my forum at http://theowcpclassroom.freeforums.net/

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  18. Interesting comments ! I was fascinated by the facts , Does anyone know if my business can get ahold of a blank DoL CA-7 form to type on ?

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  19. You can find a CA-7 here: https://www.dol.gov/owcp/regs/compliance/CA-7.pdf

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