If you have a pre-existing condition, you may qualify to receive Federal Employees’ Compensation Act (FECA) benefits. However, pre-existing conditions may affect your FECA claim.
Attorney Daren Sarphie explains pre-existing injury workers’ compensation for FECA claims.
Can You Get FECA With a Pre-Existing Injury?
You can receive FECA benefits for a pre-existing injury to the extent that the injury or condition is made worse because of employment. A claimant may receive benefits for only the scope of injury or disease that results from work.
Introduction to Pre-Existing Conditions and FECA
A pre-existing condition or injury predates the injury, illness, or medical condition that is the subject of the FECA claim.
FECA defines an injury as an injury by accident or a disease proximately caused by employment. (5 U.S.C. § 8101(5)). To be eligible for FECA benefits, a federal government employee must have sustained the injury in the workplace. (See 5 U.S.C. § 8103 – the law entitles the employee to the services, appliances, and supplies likely to cure, reduce, the period of disability or lessen compensation.)
When a person has pre-existing conditions, they may still be injured on the job. However, it is necessary to separate the portion of the injury or condition that is pre-existing and what is related to employment. The part of the injury that relates to employment will be covered.
Injury or illness involving a pre-existing condition may be:
- Direct causation—A new injury occurs, and it just happens to involve a body part or system already affected by a medical condition.
- Aggravation—A pre-existing condition is made worse because of employment. An aggravation may be temporary or permanent.
- Acceleration—When employment makes an underlying condition or disease manifest faster.
- Precipitation—A latent condition manifests because of employment.
Determining the Impact of Pre-Existing Conditions
A pre-existing condition may impact your claim in two ways:
First, you must prove that your injury is related to employment. As the person claiming benefits, you have the burden to prove your case. Extra attention must be given to necessary proof when a claim involves a pre-existing condition. Medical evidence must differentiate between the pre-existing condition and changes that are work-related. The evidence must link the changes and work exposure.
Second, benefits for a pre-existing condition may be limited to the extent of the worsening of the condition.
Aggravations and work-related conditions
Aggravation of a pre-existing condition may occur from a traumatic event or occupational exposure. FECA benefits are payable for the duration of the aggravation. The aggravation is accepted for FECA benefits. The underlying condition is not accepted.
An acceptance letter must state whether benefits are being awarded for a temporary or permanent aggravation. When aggravation is temporary, benefits cover only the period of disability where there is aggravation. Even if the worker can’t continue in their job, benefits are limited to the period of temporary aggravation.
Proving a Work-Related Aggravation of Pre-Existing Conditions
If a claim involves a pre-existing condition with aggravation or precipitation, there must be a medical opinion to prove and explain the pre-existing condition. Claims examiners need enough information to determine if the acceptance should be temporary or permanent aggravation.
The claims examiner will review information provided by the claimant, including when the condition appeared, treatment, and reports. The employing agency may provide a copy of the pre-employment physical examination, if there is one, and other medical records. A supervisor may provide information regarding complaints made by the employee about the condition and any impact on job duties.
Challenges in FECA Claims with Pre-Existing Conditions
- Medical evidence required—The attending physician must support and state a causal relationship between the condition and employment. If the physician says the condition is not related, and there is no conflicting medical evidence, the case will be denied.
- Explaining the pre-existing condition—The physician’s opinion should differentiate between the work-related effects and those that are pre-existing.
- Future risk—In general, prevention of future injury is not compensable, unless it results from workplace exposure. It is compensable when it results from job-related exposure.
- Previous disability compensation—5 U.S.C. § 8108 says that disability compensation is reduced for an earlier injury if compensation is for the same member and would duplicate compensation for a pre-existing disability.
- Ability to work—A pre-existing condition may be relevant in the context of determining the ability to earn wages.
Recurrence of Medical Conditions under FECA
Another way that a pre-existing condition may be relevant to a FECA claim is the recurrence of a medical condition. This is a situation where a person already has a claim, receives medical care under the claim, and is released from medical care. Then, their condition reoccurs.
How to handle a recurrence of medical care for a FECA claim depends on whether it has been 90 days since the release from medical care.
Within 90 days
If it has been less than 90 days since release from medical care, submit a statement from the attending physician. The statement must affirm the causal relationship between the recurrence and the accepted medical condition. Significant medical evidence is required only if there is an intervening injury, a different diagnosis, or the case was originally based on temporary aggravation.
After 90 days
If release from medical care was more than 90 days ago, submit a physician’s report with current objective findings and a causal relationship between the recurrence and the accepted condition. Medical evidence will likely need to be more detailed. Additional medical explanation is needed for a different diagnosis or a claim based on temporary aggravation.
Doubling Cases
Doubling cases means combining two or more files for the same employee. A worker may have more than one injury. Cases are kept separate but combined into a master file and cross-referenced.
Contact a FECA Claims Lawyer Today
Do you have questions about FECA and pre-existing injury workers’ compensation? Do you need help appealing a denied claim involving a pre-existing condition?
At Sarphie Law, we help injured workers get their benefits. For help, contact us.