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THE FEDERAL FEDERAL GOVERNMENT
GOVERNMENT
IS SELF-INSURED
SELF INSURED
The program program is non non-adversarial. non adversarial adversarial. Therefore Therefore, the benefit
benefit
of the doubt ALWAYS goes to the claimant.
N No one may require i an employee l or other h claimant l i
to waive her/his right to claim compensation under
the FECA
Unlike state workers’ compensation programs, our
claimants claimants don don’t t need need an an attorney. attorney
If they do retain an attorney, the claimant is responsible
to pay, but OWCP has to approve the fee.
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THE FEDERAL GOVERNMENT
IS SELF SELF-INSURED
SELF INSURED
Funded through agency chargebacks
When an employee is injured the payments are made form a
compensation fund controlled by the Department of Labor. On a
quarterly basis, those costs are then “charged back” to the
employing agency who must deduct them from their payroll
budget. In effect, OWCP writes a check for these costs that is
drawn on the employer’s account!
Exclusive remedy –a a federal employee
or surviving dependent dependent is is not not entitled entitled to
to
sue the U.S. or recover damages for
injury injury or or death under under any other law
law
2

THE FEDERAL FEDERAL GOVERNMENT
GOVERNMENT
IS SELF-INSURED
SELF INSURED
Once the claimed MEDICAL CONDITION has
been accepted, accepted the the Department Department of of Labor Labor has has the
the
BURDEN OF PROOF to prove that the claimant no
longer has the medical condition, prior to terminating
medical di l b benefits. fi
Once the the claimed claimed DISABILITY has been accepted, accepted the
the
Department of Labor has the BURDEN OF PROOF
of proving that the claimant is no longer disabled, prior
to terminating i i compensation i b benefits.
fi
3

THE NEW YORK DISTRICT
OFFICE COVERS ALL FEDERAL
EMPLOYEES WITHIN:
NEW NEW YORK
NEW NEW NEW JERSEY
PUERTO PUERTO RICO
U.S. U.S. U S VIRGIN ISLANDS
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Benefits Overview
Federal Employees Compensation
Continuation Continuation of Pay (COP)
Medical Medical Benefits
Emergency Emergency Treatment Authorization for Traumatic Injuries
Preventive Preventive care is not authorized
Treatment Treatment Suites
Wage WWage-Loss L LLoss Benefits B fi
2/3 2/3 or 3/4’s (w/dependent or spouse) of weekly salary, tax free.
Survivor S SSurvivor i Benefits B fi
Schedule Schedule Award for Permanent Impairment
6

TRAUMATIC VS. OCCUPATIONAL INJURIES
TRAUMATIC INJURY – FORM CA CA-1
SPECIFIC EVENT OR SEVERAL EVENTS
WHICH OCCUR OVER ONE DUTY SHIFT
EXAMPLES
EXAMPLES:
SLIPPING ON AN ICY SIDEWALK
LIFTING BOXES ALL DAY
HARASSMENT FROM SUPERVISOR - 1 SHIFT
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TRAUMATIC INJURY - Supervisor’s/ICS’ Role
Employee (or someone on her/his behalf,
including supervisor) completes front of Form
CA CA-1
Supervisor completes back
Must be submitted to employing agency within
30 days of date of injury to be eligible for COP
–however however h the h CA CA-1 1 can be b submitted b i d up to
three years after the injury
M Must st be be transmitted transmitted to to OWCP OWCP within ithin 14
14
calendar days from date agency received form –
therefore, do do NOT NOT hold hold the the CA CA-1forwage 1forwage 1 for wage
calculations, supporting documentation, etc.
8

TRAUMATIC INJURY -
Supervisor’s/ICS’ Role
Review CA CA-1 1 for completeness p and assist employee p y in completing p g it
Complete and sign back of CA CA-1 1 (Provide good contact info!!)
If doubt as to whether employee’s condition is related to employment,
note this hi on the h f form
Authorize medical care if needed by completing a Medical Treatment
Form CA CA-16 16 within four hours of request q whenever possible p
May refuse to issue a CA CA-16 16 if more than a week has passed since the
injury since the need for immediate treatment would have become
apparent in that period
Advise employee of the right to elect COP, rather than use leave
Advise employee p y of her/his / responsibility p y to submit medical evidence of
disability within ten calendar days or risk termination of COP
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CONTINUATION OF PAY (COP)
Continuation of regular pay for up to 45 calendar
days of wage loss loss due due to to disability disability and/or and/or medical
medical
treatment after a traumatic injury
Intent is is to to avoid avoid interruption interruption of pay while the
the
claim is being adjudicated
Subject j to usual deductions from pay, p y, such as
income tax, retirement allotment, etc.
10

NINE REASONS FOR
CONTROVERSION
1. Not Traumatic Injury.
2. Not citizen of U.S. or Canada.
3. Claim not filed within 30 days of D.O.I.
4. Injury not reported until after employment terminated.
5Ij 5. Injury occurred d off ff premises, i and d not ti in performance f of fdt duty.
6. Injury caused by employee’s willful misconduct, intent to
injure j or kill his/herself / or other, , or was directly y cause by y
intoxication due to alcohol or illegal drugs.
7. Work did not stop within 45 days of D.O.I.
8. The employee is a volunteer.
9. The employee is enrolled in Civil Air Patrol, Peace Corps,
Youth Conservation Group Group, Work Study Program Program, or other
similar groups.
11

EMERGENCY
TREATMENT
FORM CA CA-16 16
Used for Traumatic Injuries Only Only.
. (Unless authorized by OWCP)
Must be issued within 4 hours of claimed injury.
If verbal approval of medical care is given, CA CA-16 16 may be
issued within 48 hours.
Agency A AAgency i is not required i d to i issue CA CA-16 16 more than h one week k
after date of injury.
Should be issued even even if if you you are are controverting controverting the the claim. claim
12

EMERGENCY
TREATMENT
FORM CA CA-16 16
Form CA-16 CA 16 is effective for 60 days from date of issuance,
unless terminated by OWCP.
Employee has right to choose initial physician.
Designated Physician should be entered on CA CA-16 16
D Designated i d Ph Physician i i may refer f claimant l i for f further f h
examination or medical care.
ONLY ONE CA CA-16 16 TO A CUSTOMER!
13

EMERGENCY
TREATMENT FORM CA CA-16 16
WILL COVER:
Braces, , splints, p , casts, , canes, , etc.
Prescriptions.
Physical therapy
Hospitalization.
WILL NOT NOT COVER: COVER
Surgery
Home exercise exercise equipment, equipment whirlpools whirlpools or or mattresses
mattresses
Spa/gym membership
Work hardening gp programs g and/or / functional capacity p y
evaluations
14

Admin Admin-closures closures
Case Status: C1, C4
OWCP will ill accept without i h review: i
Traumatic Injury Filed within 30 days.
UUn Un-Controverted C CControverted dCl Claim i N No 3 3rd dP Party Issue I
OWCP authorizes:
Up to 45 days of COP
Up to $1500.00 of medical bills
(except (e (except cept where here there there is is a a CA CA-16 CA 16 Medical Medical Authorization).
A thorization)
Medical visits are authorized
PT is authorized for 120 days after injury
15

Admin Admin-closures* closures*
*aka C-closures, Short-form closures
Admin Closures “Flip” Open and require adjudication
when one of the following happens…
Medical bills exceed $1500 where there’s no CA CA-16 16
authorization.
Claimant files a CA-7. CA 7.
OWCP manually flips it open on own initiative or at
employing agency’s request.
16

TRAUMATIC VS. OCCUPATIONAL INJURIES
OCCUPATIONAL INJURY –
FORM CA-2 CA
INJURY OVER A PERIOD OF TIME
EXAMPLES
EXAMPLES:
CARPAL CARPAL TUNNEL FROM DATA DATA-ENTRY ENTRY FOR FOR 5
5
YEARS.
LIFTING LIFTING BOXES OVER SEVERAL DAYS
HARASSMENT FROM SUPERVISOR -LAST LAST 3
MONTHS
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OCCUPATIONAL DISEASE
•COP COP is not provided for occupational diseases
•CA-16 is not issued for occupational diseases
FForm CA CA-22
•Must be transmitted to OWCP within 14 calendar days
ffrom ddate t agency received i df form –do d NOT hhold ld ffor
receipt of supporting documentation
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OCCUPATIONAL DISEASE –
SUPERVISOR’S/ICS’ ROLE
If doubt as to whether employee’s condition is related to
employment, employment employment, note note this this on on the the form
form
Review the employee’s portion of the form and provide
comments comments concerning the the employee employee's s statement
statement
Goal is to have the claim submitted to OWCP within 14
calendar calendar days from date of notification
Prepare a supporting statement to include exposure data,
test results, results, copies copies of of previous previous medical medical reports, reports, and/or
and/or
witness statements –depending depending on the nature of the case
Advise employee p y of the right g to elect sick or annual leave
or LWOP, pending adjudication of the claim
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RECURRENCE OF INJURY
J
What constitutes a recurrence of injury?
Recurrence R RRecurrence of f Disability Di bili
Spontaneous Spontaneous reappearance of disability not
related l d to new work kf factors
Activities Activities of daily living that result in
e exacerbation acerbation of of employment emplo ment condition, condition
resulting in disability.
Consequential Consequential Consequential condition condition arising arising out out of of the
the
employment injury
Recurrence Recurrence of Medical Condition
20

RECURRENCE OF INJURY
vs.
NEW NEW INJURY
21

Medical Medical Benefits
Benefits
TYPES OF CAUSAL RELATIONSHIP:
Direct Cause Aggravation
Acceleration Precipitation
Consequential
Unlike State workers’ compensation,
there is no apportionment. Any causal
relationship lti hicreates t a burden b d on the th
government to make the claimant whole.
22

Medical Medical Benefits
Benefits
Treatment Suites
ACS
Central Medical Authorization/
Bill Payment P
23

Federal Employees Compensation
Wage Wage-Loss Loss Compensation Benefits
Temporary Total Disability
Continues Continues as long as medical evidence supports total
disability
Injured Injured worker who returns to work can receive
compensation for time lost due to medical appointments,
physical h i lth therapy, and/or d/ reduced d d work kh hours based b d on
medical restrictions.
LWEC’S
LWEC LWEC LWEC’S S – Loss Loss of of Wage Wage Earning Earning Capacity
Capacity
24

Compensation for Wage
L Loss – Form FrmCA FrmCA7 Form CA CA-7
Supervisor Supervisor provides Form CA CA-7 7 at end of COP or as soon as wage loss
occurs
Employee Employee (or someone on her/his behalf, including supervisor)
completes front
Supervisor Supervisor completes back and submits with any new medical evidence
to OWCP within 7 calendar days days of of receipt receipt –do do NOT hold hold for for receipt
receipt
of documentation
Dates Dates Dates of compensation claimed should represent the period period of of disability
disability
supported by the medical evidence or the interval until the employee’s
next medical appointment
A A new CA CA-7 7 should be submitted every two weeks during periods of
continued disability and wage loss (no prospective claims, please!)
25

Other Functions of
the CA CA-7
An An employee who uses annual or sick leave to avoid
interruption of income may repurchase that that leave, leave
subject to agency concurrence, if the claim is
approved
pp
Schedule Schedule awards for permanent p impairment p
26

Survivor
Benefits
Survivors Survivors of federal employee whose death is work work-related related are
entitled to benefits including compensation payments, funeral
expenses expenses, and and transportation expenses for the the remains
remains
Eligible Eligible survivors
Widow Widow or widower
Unmarried Unmarried child under 18 or over 18 if incapable of self support due to
disability
Child Child 18 –23 23 who has not completed four years of post post-high high school education
and is regularly pursuing full time course of study
Parent, Parent, sibling, grandparent, or grandchild who was wholly or partially
dependent d ddependent d t on deceased
d d
27

SCHEDULE
AWARD
Wh What t i is a S Schedule h d l A Award? d?
Payment Payment of of compensation compensation for for loss loss or or loss loss of of use use of of an an organ organ
or or extremity extremityyy
When is a Schedule Award payable?
Schedule Schedule awards awards are are only only payable payable after after the the claimant’s claimant’s
condition condition dd has has reached reached ddMaximum Maximum Medical Medical dd
Improvement
Improvement --
MMI MMI
A CLAIMANT CANNOT GET REGULAR
COMPENSATION AT THE SAME TIME AS OPM
BENEFITS, BUT CAN GET A SCHEDULE AWARD
AT THE SAME TIME AS OPM BENEFITS.
28

OWCP FORMS
FORMS
CA CA-1 Notice of Traumatic Injury and Claim for Continuation
of Pay/Compensation
CA CA-2 Notice of Occupational Disease and Claim for Compensation
CA CA-2a 2a Notice of Recurrence
CA CA-33 Report p of Termination of Disability s b y and/or d/ Payment y
CA CA-5 Claim for Compensation by Widow, Widower, and/or Children
CA CA-5b 5b Cl Claim i f for C Compensation i b by P Parents, B Brothers, h Si Sisters, G Grandparents, d or
Grandchildren
CA-6 CA Official Supervisor's p Report p of Employee's p y
Death
29

OWCP FORMS
FORMS
CA CA-7 Claim for Compensation
CA CA-7a 7a Time Analysis Analysis Form, Form used used for for claiming
claiming
intermittent compensation, including
repurchase of paid leave
CA-7b CA 7b Leave Buy y Back (LBB) ( )
Worksheet/Certification and Election
30

OWCP FORMS
FORMS
CA CA-16 166 Authorization t o at o for o Examination a at o a and/or d/o
Treatment
CA CA-17 17 Duty Dt Duty Status Stt Report R t
31

Privacy Act – Personally
Identifiable Information
Information
(PII)
Individual case files protected under Privacy Act
Only Only y employee p y and representative p (if ( any) y) may y
routinely have access to a file.
Agency Agency Agency file is also OWCP OWCP’s s – so all all requests for
for
access should be directed to OWCP.
HIPAA HIPAA HIPAA doesn’t doesn t apply apply to to OWCP OWCP or or employing
employing
agencies
32

Federal Employees Compensation
Functions of Claims Examiners
All All Initial Decisions:
Development
Development
Acceptance
Acceptance Acceptance
Denials Denials
Approvals A AApprovals l
Payments Payments
Reconsideration Reconsideration Requests (Sr. Claims Examiners)
Disability Disability y Management g
Fraud Fraud Referrals
33

Federal Employees Compensation
Adjudication Goals
Traumatic Traumatic Injuries – 45 days
Basic Basic Basic Occupational Disease Claims – 90 days
days
Extended Extended Occupational Disease Claims – 180 days
Administratively Administratively Reopened Cases (“Flips”) – 45 days
Recurrences Recurrences – 90 days
Reconsideration Reconsideration Requests – 90 days
Compensation Compensation Compensation Claims Claims – 14 days
days
Hearings Hearings
Remands/Reversals Remands/Reversals before Hearing 93 days
Hearings Hearings 225 days
Reviews Reviews of the Record 105 days
34

Federal Employees p y Compensation p
Medical Benefits
Bill Bill Payment – 30 30 days
Authorization Authorization Requests – 3 days
Treatment Treatment Suites
Communications
Telephone Telephone Responses: 73% same day
92% within 2 work days
Correspondence:
C CCorrespondence: d
Review Review Mail – 3 days
Respond Respond to Priority Inquiries – 14 days
Respond Respond to Correspondence – 30 days
35

PERFORMANCE OF DUTY
Common Law (Larson’s)
Premises Doctrine
Fixed place of employment
Recreation
formal/organized/
sponsored
U Union i D Duties i
not for “internal union
business” business
Horseplay
employees working working side
side
by side
ISSUES
• Emergencies
if step outside of duties for
emergency
• To & From Work
not usually covered
• Idiopathic Falls
•KNOWN KNOWN pathology
•intervening object
• Travel Status
reasonably incidental
• Special Hazard
36

PERFORMANCE OF DUTY
PRINCIPLES
Does the activity y serve the employer? p y
Is the activity a condition of employment?
37

FECA THIRD PARTY REQUIREMENTS
1. Under § 8131, claimants are required to initiate a
suit if the circumstances of their injury or death
created d a legal liability on a person other than the
United States. This requirement in certain limited
circumstances can can be be waived. waived
2. Under § 8132, if there is a recovery, claimants are
required q to reimburse the United States for the
benefits paid. This requirement can never be waived.
38

New York District Office
Contact Information
Customer Service Hotline: (646) ( ) 264 264-3000 3000
New Claims Fax: (646) 264 264-3123 3123
Main Fax: (646) 264 264-3006/Alternate 3006/Alternate Main: 3004
DFEC Website: http://www.dol.gov/owcp/dfec/
-----
ACS Fax Authorization Requests: (800) 215 215-4901 4901
ACS Customer Service Representative Call Center: (800) 558 558-1818 1818
ACS Interactive Voice Response – Medical Auth/Bill Inquiry: (866) 335 335-8319 8319
ACS Website: http://owcp.dol.acs
http://owcp.dol.acs-inc.com/portal/main.do
inc.com/portal/main.do
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