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Does Your Injury Qualify For An OWCP Claim? 5 Key Questions

Sadly, when it comes to having a Worker’s Compensation claim accepted, things are not that black and white. The Office of Workers’ Compensation Programs (OWCP) has a very specific set of rules and standards for making the connection between what happened at work and an injury.

If you are a mail carrier and a dog bites you while delivering the mail, then the connection between the dog bite (the work factor) and the injury (the wound) is pretty clear. This is a case where an OWCP claims examiner can quickly make the decision to accept the OWCP claim based on the clearly visible injury.

But what about the injury you sustained while lifting that box? In that case things aren’t quite as simple. In the case of a musculoskeletal injury, many workers have difficulties getting their claims accepted. And here’s why. The burden of proof for an OWCP claim falls squarely on the shoulders of the injured employee. What does that mean? It is up to the injured worker to get a doctor to explain how the work factors caused the injury. Clearly, finding a doctor who is both DOL certified and experienced with your type of condition can make the difference between whether your OWCP claim is covered, or if getting well will come out of your pocket.

An OWCP Claims examiner is trained to ask the following questions when evaluating the doctor’s evidence to prove this causal relationship.

1. Is the opinion based on a complete, accurate and consistent history covering both medical and factual aspects of the case? It is important for your doctor to understand the details of your work environment and the circumstances surrounding your injury in order to write a medical report that will be acceptable for your OWCP claim. In order to help your doctor, it is important that you note what happened, where, and how, ideally immediately following the event when it is fresh in your mind, in order to provide your doctor with clear information about what happened.
2. Is the opinion well-reasoned and well-rationalized? The medical opinion must be based on objective evidence such as an examination, lab tests, X-rays, MRI etc. The doctor must use this evidence to explain how the work factors and the injury are related. The doctor cannot simply state that your injury occurred on the job, rather how the injury was caused by work factors must be clearly supported by medical evidence. It isn’t enough to document symptoms. The doctor must be able to prove the condition exists through diagnostic testing. For example, the doctor must explain the bio-mechanical forces causing the injury, such as the lifting motion and the position of the back which resulted in a back sprain, in order to prove the causal relationship for the OWCP claim.
3. Does the physician have the expertise and credentials to provide a medical opinion in this case?An injured worker may be examined and treated by the doctor of his or her choice. In the case of the musculoskeletal injuries typically experienced by DOL workers who must lift, carry or conduct repetitive motions at a desk, the opinion of a board-certified chiropractic physician, where subluxation of the spine has been diagnosed by X-ray, will be given more weight and is, therefore, more highly desirable than the opinion of a family practitioner. It is important to note when filing an OWCP claim that OWCP will only accept the opinion of a doctor. There are many urgent care facilities and hospitals staffed by physician’s assistants and nurse practitioners, but their medical reports must be counter-signed by a doctor in order to count as medical evidence.
4. Does the physician have enough knowledge about the employee to have arrived at a sound medical opinion? An injured worker must inform the doctor about any preexisting conditions that could be related to the current injury, as well as provide their medical records for the doctor to review. The doctor will need to include in the OWCP claim report an analysis as to if and how work conditions may cause underlying conditions to worsen. It is important to note that OWCP regulations do allow a claim to be approved if an underlying condition has been aggravated, or worsened, by the work conditions. According to regulations, the OWCP claim may still be compensable.
5. Is the medical opinion speculative or equivocal?According to OCWP standards, reasonable medical certainty is not absolute certainty. This means that if your doctor submits a medical report stating that “to a reasonable degree of medical certainty, specific work factors caused the injury”, this will generally be acceptable for the standards of an OWCP claim. Explaining the cause of an injury to satisfy an OWCP claim, requires avoiding terms like could, may or might, in order to avoid sounding speculative.

Communication with your doctor is the most important thing.

Be sure to review the doctor’s reports and double check that they are referring to the correct side of your body and that your injury date is correct. The accuracy of your claim can avoid problems in the future with claim acceptance.

As soon as you have your accurate medical report for your OWCP claim, be sure to upload it to OWCP.

As a Department of Labor Doctor, Dr. Newman is highly knowledgeable in filing federal work injury claims and ensuring acceptance by the Department of Labor. Our office

specializes in relief of back, neck and disc pain, work and auto related injuries, women’s issues, laser therapy, and spinal decompression.

FECA Procedures Manual: 2-0810