The Role of Medical Evidence in FECA Claims

Medical evidence is required for every FECA (Federal Employees’ Compensation Act) claim.

You can’t win your case without it. Medical evidence may play several roles in establishing and maintaining benefits.

Attorney Daren Sarphie explains medical evidence in FECA claims.

FECA and Medical Evidence

Medical evidence is important in every kind of workers’ compensation claim. It’s especially important in Federal Employees’ Compensation Act claims. According to a former director of the Office of Workers’ Compensation Programs, lack of medical evidence is the top reason that FECA claims are denied.

Having the right medical evidence can help to achieve a positive case outcome. Plus, it can make the claims process faster and easier.

What medical evidence is needed for a FECA claim?

A person claiming FECA benefits must prove:

1. They have an injury or condition.
2. It is related to their federal employment.

Who is responsible for medical evidence for a FECA claim?

20 C.F.R. § 10.501 requires the federal employee to provide medical evidence to justify the payment of compensation sought.

Types of Medical Evidence Needed for FECA Claims

Medical evidence may be used in a FECA claim for these reasons:

• Establishing that an injury or occupational illness occurred
• Showing that employment caused or contributed to the injury
• Expanding a claim to additional injuries or conditions
• Seeking coverage for medical procedures, therapy and devices
• Seeking permanent impairment award for disability
• Holding recurrent review
• Determining whether light duty is appropriate
• Supporting a claim for wage loss
• Appealing or reviewing an unfavorable decision
• Responding to questions about pre-existing conditions

Subjective complaints of pain are not enough to receive FECA benefits. In addition, fear of possible future injury is insufficient, even if the fear results in medical limitations.

Does work have to be the primary cause of injury for FECA claims?

No. Most state work compensation claims require employment to be a leading or aggravating factor in the injury. For FECA claims, employment may be only a contributing factor in causing the injury or illness. Medical evidence must be established to reasonable certainty. However, the medical evidence only needs to show that work contributed to the injury. If it did, the entire claim is compensable.

What does reasonable medical certainty mean for a FECA claim?

Reasonable medical certainty in a FECA claim means more than just a mere possibility. The opinion offered by a treating physician must state that it is to reasonable medical certainty. Words like maybe, could be, possibility, and guess may be problematic for an applicant.

Gathering and Submitting Medical Evidence

A physician’s opinion must be:

• Based on a complete medical history
• To a reasonable degree of medical certainty
• With objective findings to support the conclusion

When gathering and submitting medical evidence, remember that the nature of the harm may inform what kind of medical evidence is needed. For example, an occupational illness may require detailed information about how work contributed to the injury. Injuries from blunt trauma may be obvious and require less detail. One claim may require a general practitioner while another claim requires a specialist.

Medical report requirements for a FECA claim

20 C.F.R. § 10.330 states the requirements for medical reports. Physicians are often more familiar with state workers’ compensation claims and may not understand what needs to be in a FECA medical report.

A medical report from an attending physician for a FECA claim should include:

• Dates of examination and treatment
• Patient history
• Findings, diagnosis
• Prognosis
• Other conditions found that are not related to the claim
• Opinion as to the cause and whether it is related to employment
• Whether the disability impacts the ability to work
• Results of diagnostic tests
• Other material findings

Can the OWCP require you to submit to independent medical testing for a FECA claim?

Yes. The OWCP may require non-invasive testing or a second examination for a FECA claim.

You have a right to have a physician of your choice present for the exam. Also, if you need another person to assist you for a medical reason, like a hearing-impaired person needing an interpreter, they may be present for an independent medical test.

Common Challenges with Medical Evidence in FECA Claims

When the OWCP evaluates medical evidence in a FECA claim, they’ll ask these questions:

• Did the physician have an accurate patient history?
• Is the opinion based on medical tests?
• Are the medical tests and findings sufficient to support the opinion?
• Is the physician qualified for what they are evaluating?
• Is the diagnosis definitive or speculative?

Continuing medical benefits

Medical evidence is important to make your FECA claim. It’s also important to prove your continued right to benefits. If you receive periodic payments, you may be required to submit supplemental medical evidence. Usually, it’s required once a year and with any form CA-1032 submission. However, it may be required whenever OWCP requests it. For long-term conditions or for people who are over 65, OWCP may reduce supplemental medical information to once every three years.

Initial medical benefits

CA-16 is the employer’s authorization for initial medical treatment. Authorization may last up to 60 days. If the case is denied, coverage under CA-16 ends on the date of denial. CA-16 applies for traumatic injury only, not occupational diseases.

The Role of Medical Evidence in Appealing Denied FECA Claims

Because a lack of medical evidence is the leading reason that claims are denied, medical evidence may be the most important factor in a successful appeal.

If the claim was denied for lack of medical evidence, gathering additional information may make your claim a success. A FECA claims lawyer can evaluate your case, help you gather evidence, and create a legal strategy for your appeal.

Contact a FECA Claims Lawyer Today

Medical evidence may be a critical part of any FECA claim. You may have assistance from an experienced FECA claims lawyer. Sarphie Law assists government employees who are hurt on the job and can guide you through all aspects of a claim including making sure that you have compelling medical evidence.

For a consultation and to secure legal help today, contact us now.