Wednesday, February 20, 2013
Under the General Provisions of the Federal Employees Compensation Act, (FECA) part two at 2-0200-2, the definition of an "injury" includes all injuries/diseases proximately caused by the employment as well as damage to or destruction of medical braces, artificial limbs and other prosthetic appliances. Aggravation of a preexisting condition by the employment is also compensable.
You must provide medical evidence that an injury or disease may be related to your employment factors. Types of casual relationship:
1. Direct Causation. This type of relationship is shown when the injury or factors of employment, through a natural and unbroken sequence, result in the condition claimed. A fractured arm sustained in a fall would be considered a direct result of the fall, and a sensor neural hearing loss might likewise be caused directly by occupational noise exposure over a period of time.
In occupational disease claims, however, the medical evidence needed to support the relationship will require greater rationale than in traumatic injury claims. The phrase "proximately caused" is used also to designate this kind of relationship.
2. Aggravation: OWCP defines an Aggravation as a documented physiological process by which a single occupational act or series of acts over a period of time intensified the severity of a physical or mental problem which preexisted the occupational disease.
This kind of relationship occurs if a preexisting condition is worsened, either temporarily or permanently, by an injury arising in the course of employment. For instance, a traumatic back injury may aggravate a claimant's preexisting degenerative disc disease, and compensation would be payable for the duration of the aggravation as medically determined.
Evidence Needed if an Underlying Condition Exists. When the issue of causal relationship involves aggravation, acceleration, or precipitation of a preexisting condition, the CE must ensure that the file reflects a full and accurate history of that condition.
If there is an aggravation to an underlying condition, from the claimant, the CE should obtain:
Full details of the preexisting condition, including the approximate date it first appeared, the names and addresses of all physicians who examined or treated the claimant for this condition, and the approximate dates of such examinations and treatment.
Reports and test results, if any, from all physicians who examined and/or treated the claimant for the preexisting condition.
From the employing agency, the CE should obtain a copy of the pre-employment physical examination, if one was performed.
A claimant should also request a copy of his/her pre-employment physical examination if one exists as this will more than likely show the employee was in good physical and/or mental condition at the date of hire. When compared to the current medical condition, it can help prove your claim.
Copies of any other pertinent medical records held by the employing agency.
A statement from the immediate superior describing the preexisting condition, the nature of any complaints made by the claimant, and any handicap suffered by the claimant in performing his or her duties because of this condition.
Lack of Evidence or Negative Evidence:
When the attending physician negates causal relationship between the condition and the employment and no medical evidence to the contrary appears in the file, the case may properly be disallowed. No other medical opinion is required to support the denial.
When the attending physician is silent with respect to causal relationship in a primary case, the claim may be denied without further development.
Aggravation: A Claimant may sustain an aggravation of a preexisting condition due to an injury arising in the course of employment. This could result from a traumatic event or exposure to hazardous conditions.
Aggravation occurs if a preexisting condition is worsened, either temporarily or permanently, by an injury arising in the course of employment.
In determining whether a preexisting medical condition has been aggravated by an injury or by job duties, causal relationship can only be established by medical evidence. Where medical evidence establishes that a preexisting condition was aggravated, an aggravation will be accepted, not the underlying condition. A permanent aggravation will only be accepted after careful evaluation of the weight of the medical evidence of record, as discussed in FECA PM 2-0805.
Although a CE makes the final decisions in a claim, a CE can neither diagnose nor medically determine the extent and duration of an aggravation or any disability associated with the aggravation. This determination must be made based on the medical evidence. The extent and duration of work-related aggravation is one of the critical areas that should always be developed when an aggravation is diagnosed.
There are two kinds of aggravation:
Temporary Aggravation: The preexisting condition is worsened or made more severe for a period of time with no residual alteration of the underlying condition and without leaving any continuing impairment beyond that time.
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 weight of the medical evidence, and not for any disability caused by the underlying disease. This is true even if the claimant cannot return to the job held at time of injury because the preexisting condition will worsen if he or she does so.
Temporary aggravations may involve either symptoms or short-term worsening of a condition. For instance, a claim may be accepted for angina, which is essentially a symptom, in which case medical treatment and compensation would be limited to the period of work-related angina and would not encompass treatment or disability due to the underlying condition.
Likewise, a claimant with a psychiatric condition may suffer a short-term worsening of the condition which then reverts to its prior state. Both of these situations qualify as temporary aggravation.
Permanent Aggravation: There is continuing and irreversible change in the underlying condition, thus adversely altering the course of the condition or disease process.
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 such that it will not revert to its previous level of severity. For instance, an allergy which would have persisted in any event may be permanently aggravated by exposure to dust and fumes in the workplace such that subsequent episodes are more severe than they otherwise would have been.
In order to establish that permanent aggravation has occurred in a physical disability case, there should be objective evidence of a physiological change in the claimant's preexisting condition.
Federal Employees Compensation Act, (FECA) definitions:
Medical Rationale: A logical explanation for the physician's underlying opinions, fundamental reasons and beliefs concerning causal relationship.
Proximate Cause: That which produces the injury in a natural and continuous sequence, unbroken by an intervening cause and without which the resulting injury would not have occurred.
Acceleration: A documented physiological process by which a single occupational act, or series of acts, can be shown to have increased the expected speed of progression in a preexisting condition documented to be progressive in nature.
An employment-related injury or illness 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. For example, a claimant's diabetes may be accelerated by a work schedule which is so erratic that it prohibits the regular food intake required by persons with this condition. An acceptance for acceleration of a condition carries the same force as an acceptance for direct causation. That is, the condition has been accepted with no limitation on its duration or severity.
Precipitation: Hastening the occurrence of an event or causing to happen or come to crisis suddenly, unexpectedly, or too soon.
A latent condition which would not have become evident but for the employment is said to have been precipitated by factors of the employment. For instance, tuberculosis may be latent for a number of years, and then become manifest due to renewed exposure in the workplace. The claim would be accepted for precipitation, but the acceptance would be limited to the period of work-related tuberculosis and OWCP’s responsibility for the condition would cease once the person recovered.
Any ensuing episode of the disease would be considered work-related only if medical evidence supported such a continued relationship. In this way acceptance for precipitation may resemble acceptance for temporary aggravation. A claim can also be accepted for precipitation of a condition with no limit on the duration of the acceptance.