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Tuesday, April 12, 2011

Types of Claims; What's the Difference?

Some claimant's get confused over what type of claim they have. Today, we're going to discuss the different types of claims (except death claims, which are obvious). The type of claim you have depends on what caused the injury.

No matter what type of claim you file, you have the burden of establishing the claimed condition is causally related to the factors of your Federal employment and you must show sufficient cause for OWCP to proceed with processing and adjudicating a claim. In order to do this, you must submit medical evidence including a medical narrative and any diagnostic tests. OWCP's responsibility is to aid you in the process by giving detailed instructions for developing the required evidence.

Traumatic Injury: FECA Manual part 2 at 2-0807 describes a traumatic injury as:
"A condition of the body caused by a specific event or incident, or series of events or incidents, within a single workday or shift. Such condition must be caused by external force, including stress or strain, which is identifiable as to the time and place of occurrence and member or function of the body affected."
What this means is your injury occurs due to a specific event or series of events during one work shift. For instance a car accident, or you were hit by a car, something fell on you, a wrench hit you in the head, you lifted something and couldn't move or heard something pop, you sprained your ankle, you fell off a ladder or the wing of a plane, you broke a bone, a dog attacked you, you slipped on ice, etc...

For your claim to be a traumatic injury, you and your physician must be able to say; on this day, at approximately this time, this specific event occurred and you were injured because of it. If you can pinpoint the exact date and event or you require immediate medical care, your claim is traumatic.

A traumatic injury is filed using form CA-1.

Occupational Injury: The FECA Manual part 2 at 2-0800-2(d) describes an occupational injury as:
"A condition which is produced by continued or repeated exposure to elements of the work environment such as noxious substances or damaging noise levels over a period longer than one work day or shift"
This means your injury happens over time. For example, your job is repetitious which requires you to perform the same physical tasks everyday and over time a medical condition develops such as carpal tunnel syndrome, or a shoulder condition or a spinal condition or your job caused a pre-existing condition to worsen or become symptomatic.

An occupational injury is filed using form CA-2. You have three years from the date you first realized the injuries were work-related unless you were being exposed to something and you weren't aware you were being exposed, then the clock starts on the date of the last injurious exposure. Asbestos, toxic fumes, etc...fall under this category.

Recurrence of Disability (a work stoppage which occurs after an employee has returned to work after a period of disability: FECA Manual part 2 at 2-1500-3(b) describes a recurrence of disability as:
"(a) A spontaneous material change, demonstrated by objective findings, in the medical condition which resulted from a previous injury or occupational illness without an intervening injury or new exposure to factors causing the original illness;

(b) A return or increase of disability due to an accepted consequential injury; or

(c) Withdrawal of a light duty assignment made specifically to accommodate the claimant's condition die to the work-related injury. This withdrawal must have occurred for reasons other than misconduct or non-performance of job duties."
A recurrence injury claim is extremely difficult to prove because you need to show a spontaneous change in your condition. A spontaneous change means the condition developed without any apparent external influence, force or cause of treatment. This means if you were bending, pushing, pulling, reaching, lifting, etc.... and something happens, it is not a recurrence because the act of bending, pushing, pulling, reaching or lifting is an external force.

When you file a recurrence claim, you have to prove the spontaneous change. If you describe your injury by saying you were doing this or that and the injury occurred, this is NOT a recurrence because whatever you were doing is an external force.

Agencies often tell an employee to file for recurrence. Your Agency does not always accurately inform a claimant of which type of claim they have and what paperwork to file. To avoid complications later, do not listen to your agency without verifying the information is accurate.

A recurrence injury is filed using a CA-2a.

Consequential Injury: FECA Manual part 2 at 2-0805-6 describes a consequential injury as:
"This kind of injury occurs because of weakness or impairment caused by a work-related injury, and it may affect the same part of the body as the original injury or a different area altogether. For instance, a claimant with an accepted knee injury may fall at home because the weakened knee has buckled. This incident will constitute a consequential injury whether the affected part of the body is the knee or some other area, such as the back or arm. Or, a claimant with an injured eye may compensate for loss of functioning by overuse of the other eye, which may result in a consequential injury."
Consequential injuries happen because of a worsening or progression of your original conditions or because of your original injuries, another part of your body is affected. If your right knee was damaged and you develop a limp that causes hip problems, the hip conditions are consequential to the knee conditions. If Stenosis is accepted you may develop Myleopathy (spinal cord compression). The Myleopathy is consequential to the Stenosis. If you have an accepted shoulder condition and the other shoulder develops problems because of overuse, the new shoulder injuries are consequential to the original shoulder injuries.

Likewise, if you're sent to a Functional Capacity Evaluation, (FCE) and you're injured or your conditions worsen, those injuries are consequential. If you attend physical therapy for your accepted conditions and you're hurt or your conditions worsen during your physical therapy those injuries are consequential. If you're approved for surgery and any complications arise because of that surgery, those injuries are consequential. Any new injury or worsening of your original injuries because of any treatment you receive is a consequential injury.

The most common consequential injury is a psychological condition due to pain. When you're injured and in constant or chronic pain, or you can no longer do the things you used to do, it affects you psychologically. Both the chronic pain and the resulting psychological condition is consequential.

There is no specific form for consequential injuries. To request consequential injuries, send a letter with your medical narrative and request the consequential injuries be added to your files. You can also read the 04/03/2011 post titled "Consequential Injuries" for more information.

You will have to fight to get any additional conditions added to your claim. Just because your claim is denied, does not mean you should stop fighting to get your conditions accepted. With any denial of services or any claim, get a formal decision so you have appeal rights. If your CE does not provide a formal decision with appeal rights, send a letter to OWCP requesting the formal decision. If OWCP doesn't reply within 30 days, go up the "food chain" to the District Director.

If the District Director doesn't reply to your request send a letter to your Congress person requesting help in getting a formal decision.

5 comments:

  1. Appreciate this post!

    - MovingOn

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  2. I filed for a recurrence and was denied. Can I just change it to a cosequential injury in my appeal?

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  3. There's not enough information here to say whether or not you have consequential injuries. Contact me directly at owcpslayer@gmail.com

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  4. I broke my ankle and now have hip and back pain because it. Physical therapy has been helping me with all three, ankle, back and hip. Do I need to see a doctor for back and hip for a diagnoses before I claim for consequential injury. And also, How long does OWCP have after receiving my CA-7 form to process it.

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  5. Yes, you will need a medical narrative from a physician that connects the new injuries to the original injuries.

    OWCP is supposed to process CA-7's in a timely manner. Except for the case of a schedule award, OWCP is not supposed to delay the processing of a CA-7.

    ReplyDelete