GOOD CLAIM BAD CLAIM

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GOOD CLAIM? BAD CLAIM?

• Controverting
• and
• Disputing
• FECA Claims

Catherine Cramer VA Madeline Moxley
FBI
2
Controvert or Dispute? What
is the Difference?

• Controversion applies to COP only
• Controversion is the option of the employer to
  oppose the payment of COP
• Very limited application

• Disputing a claim is applicable at many levels
• Merits of the claim
• Payment of bills
• Contest specific medical treatment
• Challenge continuing disability
• Etc.

3
Valid Reasons to Controvert COP

• Disability is caused by an occupational disease
  or condition
• The claim was not filed within 30 days
• Employee is not a US Citizen or resident
• Injury is first reported after an employee is
  terminated by the agency
• Injury is caused by willful misconduct

• Injury occurred off premises and the employee was
  not in the performance of duty
• Work stoppage first occurs 45 days or more
  following the injury
• The employee is excluded by 5 USC 8101 (1)B or E
• The employee is enrolled in the Civil Air Patrol,
  Peace Corps, etc.

4
Termination of COP

• The employer may terminate COP when
• M/E supporting total disability for work is not
  submitted w/in 10 C/days from the date that the
  claim is submitted
• M/E shows that the employee is no longer disabled
  for work
• M/E shows that the employee is not totally
  disabled and the employee refuses a written offer
  of a suitable position
• The employee returns to work with no loss of pay

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more reasons to terminate COP

• Preliminary notice of termination was given
  before the injury and becomes final during the
  COP period.
• OWCP directs the agency to stop COP
• COP has been paid for 45 days

Where an employer stops COP, it must file a
controversion with OWCP stating the basis for
termination , no later than the date of the
termination
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OPPORTUNITIES to DISPUTE a CLAIM

• Initial Submission
• CA1 CA2 CA7 CA-2A
• In response to DOL development letters
• When a hearing transcript is received
• Any time valid evidence comes to your attention
  that there are problems with the case

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THE 5 BASICS THE KEY TO EVERY CLAIM

• TIME
• CIVILIAN EMPLOYEE OF THE FEDERAL GOVERNMENT
• FACT OF INJURY
• PERFORMANCE OF DUTY
• CAUSAL RELATIONSHIP

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TIME

• CLAIMS MUST BE FILED
• For injuries after 9/7/74, claim must be filed
  w/in 3 years of death or injury
• Time begins to run from the date of injury in TI
  cases
• Time begins to run in cases of latent conditions
  when the employee becomes aware of a possible
  relationship between the condition and the job

Claims must be filed w/in 30 days of the injury
for COP entitlement
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Federal Employee

• The claimant must have been a civilian employee
  of the Federal Government at the time of injury
• Peace Corps, Vista Volunteers, Civil Air Patrol,
  
• Non-federal Law Enforcement Officers
• Some students/contract employees

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Fact of Injury Part 1

• THE OCCURRENCE OF THE EVENT!
• Did the employee actually experience the
  accident, event, or employment factor which is
  alleged to have occurred?
• Employees Statement Does the
  Supervisor agree?
• Witness Statement Does it make sense?

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Fact of Injury Part 2

• Existence of Medical Condition !
• Whether the accident or employment factor
• resulted in an injury or disease.
• MEDICAL EVIDENCE
• Does a medical condition exist
• Simple exposure does not constitute an injury
• Medical evidence must give a diagnosis and
  history

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PERFORMANCE OF DUTY

• DID THE INJURY OCCUR
• DURING THE COURSE OF EMPLOYMENT
• While the claimant was carrying out the duties
  for which he was hired

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POD continued

• DID THE INJURY OCCUR
• OUT OF EMPLOYMENT
• Was the incident directly related to some
  aspect or circumstance of the employmentnot
  personal non-work circumstances

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POD RED FLAGS
Premises an employee who is injured on the
agency premises has the protection of the FECA
unless engaged in an activity which removes him
from the scope of employment
Willful Misconduct, Intoxication, or Intention to
Bring about Injury Prohibited Activities
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POD PREMISES

• When the employee has a fixed place of work
  consider the following
• If the building is FEDERALLY owned, areas
  immediately outside the building such as steps or
  sidewalks
• Employee on premises within a reasonable time
  before or after the normal shift

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SPECIAL CONCERNS

• Proximity Rule
• Industrial Premises
• Visit to Premises
• Parking Facilities

• Bunkhouse Rulewhen the employer provides living
  quarters

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OFF PREMISES INJURIESPOD?

• Messengers, letter carriers, and chauffeurs
• Traveling auditors and Inspectors
• Workers sent on errands by the employer
• Workers who perform services at home

• To and from Work
• Employer provides transportation
• Employee is subject to emergency duty
• Employee required to travel in emergency
  situations (public curfew)

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TDY -- Limitations on coverage

• Most activities are covered when an employee is
  on travel
• The actual travel
• Is the employee within the scope of the reason
  for the travel
• Personal activities within a reasonable zone

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HEADS UP!
Review Carefully Recreation or Fitness
Injuries Lunch Hour Idiopathic Falls
Assaults Horseplay Harassment or
Teasing Emergencies Suicide
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CAUSAL RELATIONSHIP THE LAST TEST
A MEDICAL DETERMINATION Causal Relationship
involves establishment of a connection between
the injury and the condition found.
DIRECT AGGRAVATION ACCELERATION PRECIPITATION
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Disputing a Claim
What do you hope to achieve short term or in
the long run?
Prevent a fraudulent claim Save your Agency
Money Build a reputation for fair treatment of
employees for your Agency with OWCP.
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BE FAIR and IMPARTIAL

• WC Benefits are an entitlement
• Not all employees are scamming
• Get all the facts before you reach your
  conclusions
• Do Not give your personal opinions

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BE RESPECTFUL

• OF your injured employee
• Provide him with guidance
• Be responsive to his questions
• Straight Talk

• OF DOL
• Base your dispute on FECA regulations
• Interact with professionalism
• Respect the chain of command

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Building Your Argument
1. The FACTSNothing but the FACTS
2. Witness Statements
3. Agency PolicyIN WRITING!
4. Reinforce your argument with appropriate FECA
regulation and ECAB decisions. Etc.
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DOL LINGO -- USE IT

• Read Decisions
• Know the Rules
• Provide DOL with a logical, analytical Statement
  of objection in a timely manner
• Know the case, the circumstances and the RULES !!!

YOUR BURDEN
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RESOURCES

• DOL WEBSITE
• www.dol.gov/dol/esa/dfec
• FEDERAL EMPLOYEES COMPENSATION ACT
• PUBLICATION CA810

• 20 CFR PARTS