A denial of compensation and medical benefits is flat-out frustrating, especially since OWCP commonly denies a claim solely because the report from the claimant’s attending physician is inadequate. Medical reports submitted with compensation claims often do not completely set out the facts of and conclusions about work-related conditions.
If a claim is denied, the injured federal employee has the right to appeal by either requesting an oral hearing, requesting reconsideration, or asking for review from the Employees’ Compensation Appeals Board (ECAB). ECAB does not accept new evidence; it makes its decision based on the record. Because the claimant’s initial medical report can be at fault, submitting new evidence is crucial. Therefore, the best way to appeal a denial is usually by hearing or reconsideration.
Reviewing medical reports has been a constant throughout my many years of handling federal workers’ compensation cases. Doctors’ opinions are simply the stuff of which claims are made. If one must appeal a denial of compensation, the key is a supplemental medical report. As I discuss below, OWCP isn’t going to correct a medical report for a claimant.
I commonly write a client’s doctor for an updated, corrected report that is better suited for OWCP’s consideration.
OWCP considers a report adequate when it addresses a number of factors deemed important for determining eligibility for workers’ compensation. After receiving a claim, the claims examiner will send the claimant a development letter asking for additional medical information. Unfortunately, doctors often don’t know about OWCP requirements or don’t discuss the needed factors in a comprehensive and reasoned way. The following are the factors a doctor’s report must include.
- A report must describe in detail the employment incident or circumstance that resulted in the injury, traumatic or occupational.
- A report must provide a firm diagnosis of the injury: a slipped disc, a torn knee ligament, asthma, etc.
- A report must offer an opinion on the causal relationship between the injury and the disability. The definition of disability in this context is a person’s inability to earn the wage—totally or partially—that she was earning at the time of injury.
- A report’s opinions and conclusions on causal relationship must be supported with reasoned analysis and objective findings.
These factors may seem rather straightforward, but they often befuddle a doctor, and the result is a poorly written report and a denied claim. In short, the report should answer why the diagnosed job injury causes the worker to be unable to work. What’s at stake is a worker’s eligibility for wage-loss compensation and for medical benefits to pay for treatment of the work-related condition.
Pursuant to federal regulation, the adjudication of claims is not an adversary process and OWCP has an obligation to assist in the development of the evidence. Thus, claims examiners are given several ways to deal with the problem of inadequate reports—if only they would.
If the report of the attending physician lacks needed details and opinion, the Claims Examiner can write the physician, clearly state what is needed, and request a supplemental report. FECA Procedural Manual, section 2-0810.7.b.
Another approach is for the claims examiner to send the injured employee to another physician for a second opinion consultation. This usually happens where the attending physician has stated a causal connection but with inadequate analysis. However, OWCP often does not follow this step and the claim is simply denied.
Again, as part of appealing a denied compensation claim, a claimant’s attorney can ask the doctor for a better report that includes the above factors and other factors generally determined essential by OWCP. For example, there is a degree to which a doctor must be certain of causal connection, but that degree is by no means 100%. A doctor needs to be told about the degree. Also, there are certain words that suggest speculation that a doctor should avoid. A doctor should be warned from those words. There are certain medical test results that can support a doctor’s conclusions. A doctor should be asked to provide those results.
A better medical report can be submitted to the hearing official along with argument or to the District Office as part of a request for reconsideration. An adequate report may well reverse a denial decision. I’ve seen it happen many times.