OWCP stands for the Office of Workers’ Compensation Programs. OWCP is a division of the US Department of Labor which is responsible for administering the FECA (Federal Employees’ Compensation Act) which was created in 1916 to provide monetary compensation, medical care, assistance, vocational rehabilitation and OPM (Office of Personnel Management) retention tights to civilian Federal employees who sustain injuries including occupational disease as a result of their employment with the Federal Government.
FECA is intended to be remedial in nature and proceedings under it are non-adversarial which means everyone should be working together to reach the best resolution for everyone. The Department of Labor, OWCP, Division of Federal Employees’ Compensation (DFEC) administer the FECA and it is responsible for adjudicating new claims for benefits, managing ongoing cases, paying medical expenses and compensation benefits to injured workers and survivors among other things. FECA is financed through the Employees’ Compensation Fund which is appropriated by Congress through a charge back system to the various agencies.
FECA is the sole legal avenue and exclusive remedy by which a Federal employee (or survivors) may recover damages in consideration of an injury or death that is causally related to Federal employment.
Individual cases are protected under the Privacy Act of 1974 and only the employee or representative of the employee may be given routine access to the file which is owned by the Department of Labor and is housed in a district office and may be accessed during appointments that should be requested ahead of time. HIPAA does not apply to OWCP or employing agencies as it relates to information concerning the compensation claim.
Types of OWCP Claims
There are three types of OWCP Claims:
- Traumatic Injury – occurred within one work shift; you can have had multiple incidents in one shift
- Occupational Disease – work factors or injuries over more than one shift
- Death – either at the time of the injury or later resulting from conditions caused by the injury
Elements of a Claim
There are five basic elements to an OWCP claim. They include:
- The claim must be considered timely. In order for a claim to be considered timely filed, it must be filed within three years of date of injury, date of awareness of the injury being work related or the last date of exposure. If a claim is not filed within the three-year limitation, it may still be considered timely if written notice of injury or death was given within 30 days or the Agency had “actual knowledge” of the injury in the first 30 days, and that knowledge was such as to put the Agency on notice that there had been a work-related injury.
- The claimant must be a civil employee. FECA covers all civil employees except for non-appropriated fund employees – there is a NAFI exception for death resulting from injuries incurred in connection with an Armed Force contingency operation. Additionally, temporary employees are covered on the same basis as permanent employees. Furthermore, contract employees, volunteers and loaned employees are covered only under some circumstances.
- Fact of Injury The injury must be factual, meaning the accrual occurrence of the accident, incident or exposure in time, place and manner alleged must be provided. A medical condition diagnosed in connection with that accident, incident or exposure must also be documented. Additionally, an employee’s statement alleging that an incident occurred at a given time, place, and in a given manner is of great probative value and will stand unless refuted by strong or persuasive evidence. In cases involving exposure or specific incidents of employment, the agency may be asked to comment on the injured workers’ statements. It is important to provide accurate and complete responses, even if it is just to say that the Agency agrees with the allegations.
- Performance of Duty The injury needs to have arose in the course of employment. Generally, this means that it happened at work, however, incidental employment is covered which includes: falls in the bathroom, wet floors, coffee burns and falls on stairs. The injury must also have risen out of employment meaning that it is related to actual duties or engaging in activities reasonably associated with the employment, not administrative matters. More information on the criteria of Performance of Duty is described below.
- Causal Relationship There must be a link between work-related exposure or injury and any medical condition found which should be based on medical evidence provided by physicians who have examined and treated the employee (except in death claims and visible injuries). The amount and degree of causal relationship (CR) needed will depend on the type of injury. There are four types of causation. Direct causation is when injury or factors of employment result in the condition claimed through natural and unbroken sequence. Aggravation is when a preexisting condition worsened, either temporarily or permanently by a work-related injury. Acceleration is when a work-related injury or disease may hasten the development of an underlying condition. And finally, precipitation is when a latent condition that would not have manifested itself on this occasion if it had not been for the employment.
Performance of Duty Criteria Explained
Industrial Premises The injury occurred off premises while engaging in work activities which includes preforming assigned duties or engaging in an activity reasonably incidental, to the assignment and no deviation from the assignment for personal reasons may have occurred. Industrial Premises include parking facilities that are owned, controlled or managed by the employer. It is important to note the Proximity Rule which says hazardous condition proximate to the premises may be encompassed (i.e. highway or railroad crossing). Decisions regarding Industrial Premises are made on a case by case basis.
Commuting to/from Work Injuries sustained while commuting to and from work are not covered unless: Employment requires the employee to travel, the employer furnishes transportation to/from work, the employee is subject to emergency duty or the employee is required to travel during curfew
Telework Employees injured in “satellite” offices are treated as if they were at their regular office, but only at the work station. Employees working from home are covered if preforming regular duties of employment at the time of injury or some activity directly related to their employment.
Recreation An employee is considered in the performance of duty while engaged in formal recreation when either the employee is paid for participation or the recreational activity is required and prescribed as a part of the employee’s training or assigned duties.
Fitness Center or Agency Premises Employees who are injured while exercising or participating in recreational activity during break periods on Agency premises are covered whether or not the exercise was part of a structured Physical Fitness Program (PFP). Injuries which occur outside official work hours while using fitness facilities supplied by the Agency are not compensable if the employee was not participating in structured PFP. If the employee’s job requires a certain level of fitness, they may have PFP where work time is not allocated for exercise. Off duty exercise may also be preformed and covered as employees doing authorized PFP exercise are considered to be in the Performance of Duty (POD).
Horseplay An employee is considered to be in the performance of duty (POD) if the horseplay was a character that could reasonably be expected where workers are thrown into personal association for extended periods of time.
Emergencies Coverage may be extended to employees who momentarily step outside of the sphere of their employment to assist an emergency such as to extinguish a fire or help a person who has been hit by a car; each case is decided differently based on the degree to which the employee diverged from duty.
Union Representation Employees performing representational functions which entitle them to official time are in the performance of duty (POD); activities relating to the internal business of the union organization such as soliciting new members or the collecting of dues are not included.
Emotional Reasons An employee who suffers from a medical condition resulting from an emotional reaction to factors or requirements of employment can be considered to be in the performance of duty; an emotional reaction to personnel or administrative actions by the employer is not covered unless there is evidence establishing error or abuse by the employer.
With regards to pre-existing conditions, if a worker’s injury is an aggravation of a pre-existing condition, benefits are the same as for a new injury. However, once the aggravation resolves, benefits are no longer payable. The pre-existing condition can be traumatic or occupational. A physician should be clear what aspects of the patient’s condition were pre-existing and which have been aggravated. History of the patient’s prior conditions and pertinent medical records are required. Finally, the burden to establish the claim is greater as the injured worker has to show that the pre-existing condition has materially worsened.
Where the questions of “fact of injury” and “performance of duty” are decided affirmatively, consideration must also be given to the question of whether the injury or death was caused by the willful misconduct of the employee, the employee’s intention to bring about the injury or death of self or another, or if intoxication of the injured employee was the proximate cause of the injury or death. Each of these is elaborated on individually below.
- Willful Misconduct The question of deliberate willful misconduct arises when at the time of injury the employee was violating a safety rule, regulation or order of law. Because safety rules have been established for the protection of the worker rather than the employer, simple negligent disregard of such rules is not sufficient to deprive an employee or beneficiary of entitlement to compensation. Willful misconduct is a statutory exclusion to compensation benefits and appears in the FECA at 5 U.S.C. 8102 (a) (1).
- Employee’s Intention to Bring About Injury or Death to Self or Another Where it appears that the employee brought about his/her own injury or death, or that of another, the intent must be established. If the factual and medical evidence show that the employee was not in full possession of his/her faculties, the injury may be compensable.
- Intoxication In any case involving intoxication, the record must establish the extent to which the employee was intoxicated at the time of injury and the particular manner in which the intoxication caused the injury. It is not enough to show that the employee was intoxicated; it is the OWCP’s burden to show that the intoxication caused the injury.
Can an Agency challenge a claim?
An Agency can challenge a claim but they cannot refuse to complete and process any paperwork. The agency only has 14 calendar days to submit CA-1s and CA-2s to DFEC. The Agency has only 7 calendar days to submit CA-7s to DFEC. The claimant and the Agency should keep a copy of everything sent to the DFEC
Withdraw of a Claim
The injured worker has the right to withdraw claims for both traumatic and occupational disease injuries providing that the claim has not been formally adjudicated. The same right and rules are extended to survivors who have filed a claim for benefits. Additionally, all requests for the withdraw of a claim must be in writing.
A traumatic injury is an injury caused by a specific event or series of incidents within a single work day or shift. A traumatic injury is identifiable as to time and place of occurrence and member or function of the body affected. Examples of traumatic injuries include back strains, knee and ankle strains, exposure to fumes, dust or smoke within one shift, acoustic trauma like explosions and noise and finally, traumatic stress which could be caused by an angry customer, co-worker or supervisor.
The traumatic injury form is known as Form CA-1. It must be submitted to the employing agency within 30 days of date of injury to be eligible for continuation of pay (COP). Not all CA-1 forms are submitted from the agency to OWCP. The filing instructions on the back of the form must be followed. If the form should be filed, it must be transmitted to OWCP within 10 work days from the date the agency received notice – this might not necessarily be 10 days from the date the form was actually signed. It is important to not hold the form.
The agency should not wait for the submission of supporting evidence before sending the CA-1 form to OWCP. If an employee requires medical treatment, a CA-16 Form should be issued. It is important that the employee knows of the right to elect continuation of pay (COP) or sick/annual leave if time loss will occur. The attorney should advise the employee as to whether continuation of pay will be converted, and if so, whether pay will be terminated. It is the employee’s responsibility to submit prima facie medical evidence of disability within 10 calendar days or risk termination of continuance of pay.
The OWCP tries to adjudicate traumatic injury claims within 45 days of receipt form the employing agency. If the information submitted with the initial claim form is not sufficient to accept the claim, a letter will be sent to the claimant notifying them of the deficiencies and providing them with an opportunity to submit additional evidence.
Tips for CA-1 Form Completion
The front page of the form should be completed by the employee. However, if the employee is incapacitated, their supervisor can complete it for them. In Block 7, the employee should use their home address NOT the agency address. The employee must put a specific date for the date of injury and date of notice. If the employee puts down a date range for the date of injury, it is likely an occupational claim. Be sure to check that the employee has signed and dated the form prior to submission.
The OWCP Agency Code must be entered and the date of injury in Block 22 should match the date of Block 10 in the employee portion. If you answer “no” to the question regarding your knowledge of the injury in block 35, you must submit evidence to refute the claimed injury. Lack of direct knowledge of the injury does not constitute probative evidence. If you are controverting Continuation of Pay (COP) in Block 36, a reason must be stated. Controverting COP is different than challenging a claim. The supervisor must sign and date the claim and submit it to the OWCP Central Case Facility, NOT the mailroom address in London, KY. The Federal Regulations § 10.110, require a Federal employer to complete and transmit forms CA-1 and CA-2 to OWCP within 10 working days after receipt of notice from the employee.
Short Form Closures
Some Traumatic Injury claims are administratively handled to allow payment of up to $1500 in medical expenses and payment of COP by the agency. These cases are not reviewed or adjudicated by a claims examiner.
Short Form Closures Main Criteria
- Not controverted/challenged by the agency
- Claim created within 6 months of injury
- No claim for wage loss (beyond COP period)
- Claim does not involve excluded source/nature of injury code (i.e. MVA, stress, third party, communicable disease)
- No third party liability
Adjudication of Short Form Closures
If a short form closure (SFC) later requires development of an issue regarding compensation or medical benefits, the claims examiner is required to review and adjudicate the claim. Actions that trigger case adjudication include: receipt of claim for wage loss (CA-7), receipt of surgery request, or receipt of medical bills over $1500. Reopened SFCs do not count against agency timeliness submission goals.
Form CA-16 Authorization for Examination
Form CA-16 is only used in Traumatic Claims (CA-1). It should be issued immediately, but may be issued later and if verbal authorization is given it must be issued within 48 hours. Form CA-16 guarantees payment of all medical expenses for 60 days after the date of injury regardless of when it is issued. Form CA-16 does not cover non-emergency surgery.