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May Human Resources Advisor Volume 2, Issue 5

Injury Compensation

What A Federal Employee Should Do When Injured At Work?   Form CA-10

Introduction:  The Federal Employees' Compensation Act (FECA) (5 U.S.C. 8101 et seq.) is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor. It provides compensation benefits to civilian employees of the United States for disability due to personal injury sustained while in the performance of duty or to employment-related disease. The FECA also provides for the payment of benefits to dependents if the injury or disease causes the employee's death. Benefits cannot be paid if the injury or death is caused by the willful misconduct of the employee or by the employee's intention to bring about his or her injury or death or that of another, or if intoxication (by alcohol or drugs) is the proximate cause of the injury or death.

Medical Benefits:  An employee is entitled to medical, surgical and hospital services and supplies needed for treatment of an injury as well as transportation for obtaining care. The injured employee has initial choice of physician and may select any qualified local physician or hospital to provide necessary treatment or may use agency medical facilities if available. Except for referral by the attending physician, any change in treating physician after the initial choice must be authorized by OWCP. Otherwise, OWCP will not be liable for the expenses of treatment.

The term "physician" includes surgeons, osteopathic practitioners, podiatrists, dentists, clinical psychologists, optometrists and chiropractors within the scope of their practice as defined by State law. Payment for chiropractic services is limited to treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by x-ray to exist. If the physician selected has been excluded from participating in the Compensation Program the OWCP District Office will advise the employee of the exclusion and the need to select another physician.

Compensation for Temporary Total Disability:  An employee who sustains a disabling, job-related traumatic injury may request continuation of regular pay for the period of disability not to exceed 45 calendar days or sick or annual leave. If disability continues beyond 45 days or the employee is not entitled to continuation of pay, the employee may use sick or annual leave or enter a leave without pay status and claim compensation from OWCP.

When disability results from an occupational disease, the employing agency is not authorized to continue the employee's pay. The employee may use sick or annual leave or enter a leave without pay status and claim compensation.

Compensation for loss of wages may not be paid until after a three-day waiting period, except when permanent effects result from the injury or where the disability causing wage loss exceeds 14 calendar days. Compensation is generally paid at the rate of 2/3 of the salary if the employee has no dependents and 3/4 of the salary if one or more dependents are claimed.

The term "dependent" includes a husband, wife, unmarried child under 18 years of age, and a wholly dependent parent. An unmarried child may qualify as a dependent after reaching the age of 18 if incapable of self-support by reason of mental or physical disability, or as long as the child continues to be a full-time student at an accredited institution, until he or she reaches the age of 23 or has completed four years of education beyond the high school level.

Compensation for Permanent Effects of Injury:  The Act provides a schedule of benefits for permanent impairment of certain members, functions and organs of the body such as the eye, arm, or kidney and for serious disfigurement of the head, face or neck. For example, an award of 160 weeks of compensation is payable for total loss of vision in one eye.

In addition, compensation for loss of earning capacity may be paid if the employee is unable to resume regular work because of injury-related disability. This compensation is paid on the basis of the difference between the employee's capacity to earn wages after an injury and the wages of the job he or she held when injured.

OWCP may arrange for vocational rehabilitation and provide a maintenance allowance not to exceed $200 per month. A disabled employee participating in an OWCP-approved training or vocational rehabilitation program is paid at the compensation rate for total disability.

If the employee's condition requires a constant attendant, an additional amount not to exceed $1500 per month may be allowed.

Compensation for Death:  If no child is eligible for benefits, the widow or widower's compensation is 50 percent of the employee's pay at the time of death, if death was due to the employment-related injury or disease. If a child or children are eligible for benefits, the widow or widower is entitled to 45 percent of the pay and each child is entitled to 15 percent. If children are the sole survivors, 40 percent is paid for the first child and 15 percent for each additional child, to be shared equally. Other persons such as dependent parents, brothers, sisters, grandparents, and grandchildren may also be entitled to benefits. The total compensation may not exceed 75 percent of the employee's pay or the pay of the highest step for GS-15 of the General Schedule, except when such excess is created by authorized cost-of-living increases.

Compensation to an employee's surviving spouse terminates upon his or her death or remarriage. A widow or widower's benefits continue, however, if the remarriage takes place after the age of 55. Awards to children, brothers, sisters and grandchildren terminate at the age of 18, unless the dependent is incapable of self-support, or continues to be a full-time student at an accredited institution, until he or she reaches the age of 23, or has completed four years of education beyond the high school level.

Burial expenses not to exceed $800 are payable. Transportation of the body to the employee's former residence in the United States is provided where death occurs away from the employee's home station. In addition to any burial expenses or transportation costs, a $200 allowance is paid for the administrative costs of terminating an employee's status with the Federal Government.

Cost-of-Living Increases:  Compensation payments on account of a disability or death which occurred more than one year before March 1 of each year are increased on that date by any percentage change in the Consumer Price Index published for December of the preceding year.

Settlements With Third Parties:  Where an employee's injury or death in the performance of duty occurs under circumstances placing a legal liability on a party other than the United States, a portion of the cost of compensation and other benefits paid by OWCP must be refunded from any settlement obtained. OWCP will assist in obtaining the settlement and the Act guarantees that the employee may retain a certain proportion of the settlement (after any attorney fees and costs are deducted) even when the cost of compensation and other benefits exceeds the amount of the settlement.

Appeal Rights:  An employee or survivor who disagrees with a final determination of OWCP may request an oral hearing or a review of the written record from the Branch of Hearings and Review. Oral and/or written evidence in further support of the claim may be presented. The employee may also request a reconsideration of a decision by submitting a written request to the Compensation District Office which issued the decision. The request must be accompanied by evidence not previously submitted. If reconsideration has been requested, a hearing on the same issue may not be granted. The employee or survivor may also request review by the Employees' Compensation Appeals Board (ECAB). Because the ECAB rules solely on the evidence of record at the time the decision was issued, no additional evidence may be presented.

More Detailed Information:  More detailed information about the requirements for coverage and benefits under the Federal Employees' Compensation Act may be obtained from Federal Personnel Manual Chapter 810, Injury Compensation OWCP Publication CA-810, and booklet CA-550, Questions and Answers About the Federal Employees' Compensation Act, which answers questions commonly asked about compensation benefits.

Continuation of Pay (COP)

An employee who sustains a disabling job-related traumatic injury is entitled to continuation of regular pay (COP) for a period not to exceed 45 calendar days. To qualify for COP, the injured employee must file written notice of injury and claim for COP within 30 days of the injury. COP is not considered compensation and is subject to taxes and other payroll deductions. The employee must make separate claim for monetary compensation if the disability exceeds 45 days or results in any permanent disability.

  • What conditions must be met to receive COP?§10.205
  • May an employee who uses leave after an injury later decide to use COP instead?§10.206
  • May an employee who returns to work, then stops work again due to the effects of the injury, receive COP?§10.207
  • What are the employee's responsibilities in COP cases? §10.210
  • What are the employer's responsibilities in COP cases?§10.211
  • How does OWCP compute the number of days of COP used?§10.215
  • How is the pay rate for COP calculated?§10.216
  • Is COP charged if the employee continues to work, but in a different job that pays less?§10.217
  • When is an employer not required to pay COP?§10.220
  • How is a claim for COP controverted?§10.221
  • When may an employer terminate COP which has already begun?§10.222
  • Are there other circumstances under which OWCP will not authorize payment of COP?§10.223
  • What happens if OWCP finds that the employee is not entitled to COP after it has been paid?§10.224

Recurrence of Disability. If an employee returns to work following a work stoppage without using all 45 days of COP and then suffers a recurrence of disability within 45 days of the first return to duty, he or she should submit a completed Form CA-2a and may elect to use the remaining days of COP. See 20 C.F.R. §10.207.

  • (1) Time lost on the day of injury that is charged to administrative leave is considered a work stoppage, whether the time is used to obtain medical treatment or for disability. If the time away from work is so minimal that no administrative leave is charged, such as a brief visit to the health unit, this is not considered a work stoppage for the purpose of counting time.

 

  • (2) If the 45-day entitlement has been exhausted, or the recurrence begins more than 45 days after the employee first returned to work, the employing agency may not pay COP. Rather, the employee should claim compensation for wage loss on Form CA-7.

 

  • (3) COP is paid for the entire period of any continuous disability which extends beyond the 45-day limit as long as the 45 days have not been used. Any valid period of entitlement to COP for the injury must begin, however, within 45 days of the injury or of the first return to work after the injury.

 

For example, an employee is injured on January 1. The employing agency provides several hours of administrative leave, enabling the employee to obtain medical attention. On January 2, the employee works a full day. The employee is not disabled due to the injury until February 10, but is disabled and off work February 10, 11, and 12 and receives COP for those three days. The employee returns to work on February 13 and does not lose any further time from work due to the injury until March 17. On March 17, 18 and 19, he again loses time from work due to the disability. The 45-day period begins to run when the employee returned to work on January 2, because work stoppage occurred at the time of injury, even though it was covered by administrative leave. The employee is entitled to COP for the time lost in February, but is not entitled to COP for time lost in March, as it is more than 45 days since the first return to work.

The time limit for the use of COP is 45 days from the first return to work following the initial period of disability.

Employee Responsibilities

Per 20 C.F.R §10.205, to be eligible for COP, the injured employee must meet three requirements:

  • Sustain a traumatic injury which is job-related and the cause of the disability and/or the cause of lost time due to the need for medical examination and treatment;
  • Provide timely written notice of such injury on Form CA-1 or other OWCP-approved form; and
  • Begin losing time from work due to the traumatic injury within 45 days of the injury.

In addition to those three requirements, the employee must also present medical evidence in support of any claimed disability. The injured employee is also responsible for advising his or her physician of any available modified duties and for returning to duty upon release to any available work, whether regular or modified.

  • a. Traumatic Injury. A traumatic injury is defined as a condition of the body caused by a specific event or incident, or series of events or incidents, within a single workday or shift. Such condition must be caused by external force, including stress or strain, which is identifiable as to time and place of occurrence and member or function of the body affected. See 20 C.F.R. §10.5(ee). Such an injury is distinguishable from an occupational disease or illness in that the latter is a condition produced by the work environment over a period longer than a single work day or shift. See 20 C.F.R. §10.5(q).

 

  • b. Timely Notice of Injury. The injured employee, or someone acting on his or her behalf, must provide a written report on Form CA-1 (Federal Employee's Notice of Traumatic Injury and Claim for Continuation of Pay/Compensation) to the employing agency within 30 days of the injury. See 20 C.F.R. §10.210(a). Another OWCP-approved form, such as Form CA-2 (Notice of Occupational Disease and Claim for Compensation), CA-2a (Notice of Recurrence), or CA-7 (Claim for Compensation on Account of Traumatic Injury or Occupational Disease), which contains words of claim, can be used to satisfy timely filing requirements.

 

  • c. The employee's first work stoppage must occur within 45 days of the date of injury in order for the employee to be entitled to continued pay. If the employee's work stoppage occurs more than 45 days after the injury, the employee may claim compensation for leave without pay or leave buy back on Form CA-7.

 

  • d. Medical Evidence. The employee must present the employing agency with medical evidence supporting disability resulting from the claimed traumatic injury within 10 calendar days after filing a claim for COP. See 20 C.F.R. §10.210(b). The employing agency may continue the employee's pay absent such evidence if the nature and severity of the injury warrant the continuation. COP may be reinstated retroactively if payment was not initially authorized but supporting medical evidence is received later, as noted in 20 C.F.R. §10.222(a)(1).

 

  • e. Advising the Physician. Where the agency has advised the employee that a specific alternative position exists, the employee must furnish a description of the position to the physician and inquire whether and when he or she will be able to perform such duties. Likewise, where the agency has advised that it is willing to accommodate the employee's work limitations, the employee must so advise the attending physician and ask the physician to specify the limitations imposed by the injury. In both instances, the employee must provide the agency with a copy of the physician's response. See 20 C.F.R. §10.210(e).

 

  • f. Return to Duty. The injured employee must return to work upon notification by the attending physician that the employee is able to perform regular work or light duty, and the agency has advised that work within those restrictions is available. If the employee refuses to do so, the continued absence from work may result in an overpayment. COP may also be terminated if the employee refuses to respond to the agency's offer of work within five work days of receipt of the offer. The agency may make the offer to the employee over the telephone, but must confirm the offer in writing as soon as possible thereafter. The OWCP cannot evaluate the position to determine whether the position meets the claimant's physical restrictions until the position is offered in writing.


Employing Agency Responsibilities

When an employee has suffered an employment-related traumatic injury, the employing agency should take action with respect to the following:

  • a. Authorizing Medical Care. The agency should promptly authorize medical care on Form CA-16 (Authorization for Examination and/or Treatment) and give the form to the claimant (or to someone acting on his or her behalf) to present to initial medical providers. See 20 C.F.R. §10.211(a). If the supervisor is not certain that the injury occurred in the performance of duty, item 6B on Form CA-16 should be checked.

 

  • b. Providing Notice of Injury. The supervisor should furnish Form CA-1 to the employee, or to someone acting on his or her behalf, for completion of the employee's portion of the form. See 20 C.F.R. §10.211(a).

 

  • c. Right of Election. The agency will notify the employee of the right to elect COP or to use annual or sick leave or LWOP if the injury is disabling, and advise the employee that leave used counts against the 45-day COP period, per 20 C.F.R. §10.211(b).

 

  • d. Need for Medical Evidence. The agency will notify the employee of the need to submit medical evidence of a disabling traumatic injury within 10 calendar days of the date disability begins, or pay may be terminated. The agency should also supply the employee with a Form CA-17 (Duty Status Report) for completion by the physician providing medical care.

 

  • e. Controversion. The agency will inform the employee whether COP will be controverted and, if so, whether pay will be terminated, and the basis for such action. The agency will also explain the basis for controversion (if any) on Form CA-1 or by separate narrative report, per 20 C.F.R. §10.211(c).

 

  • f. Submission of Information. Form CA-1, fully completed by both the employee and employing agency, together with all other pertinent information and documents, must be submitted to the OWCP by the employing agency within 10 working days following the agency's receipt of the completed form from the employee. See 20 C.F.R. §10.211(d). In addition, the official superior shall submit any additional reports which the OWCP requires.

 

  • g. Return to Duty. The agency is responsible for advising the claimant of his or her obligation to return to work as soon as possible in accordance with the medical evidence.

 

  • h. Termination of COP. The agency will terminate COP when disability ends, the 45-day period expires, or the employee returns to work.

 

The Department of Defense Instruction number 1400.25-V810 regarding Injury Compensation provides details of DoD policy and procedures on implementing the agency's injury compensation program under the Federal Employees' Compensation Act.


Adjudicating Your Claim

If you have filed a Form CA-1 for a traumatic injury, and have not lost time from work, limited medical expenses may be paid by OWCP without a formal review of your claim being conducted. In such case, you will not receive a written decision on your claim and may not receive any further correspondence. Your agency representative may be able to advise you in this situation.

A Traumatic Injury is defined as a wound or other condition of the body caused by external force, including stress or strain. The injury must be identifiable as to time and place of occurrence and member or function of the body affected. It must be caused by a specific event or incident or series of events or incidents during a single day or work shift. 20 CFR 10.5 (ee).

The following are examples of a traumatic injury: dog bite, knee strain after a trip and fall, neck strain after an auto accident, or a broken ankle after a slip on ice.

If OWCP makes a formal review of your case, you are responsible for providing enough factual and medical information for OWCP to decide whether you are entitled to benefits. OWCP will help you to meet this responsibility by asking you for the information they need that is not already included in your file. You should send any additional information in writing.

If you are claiming an occupational disease, make sure that you provide all information outlined in the instructions included with Form CA-2, as soon as possible. If OWCP approves your case after formal review and you have lost time from work due to the injury, they will advise you in writing of the acceptance and send you further information about your benefits.

An Occupational Disease is defined as a condition which is produced by continued or repeated exposure to elements of the work environment such as noxious substances or damaging noise levels over a period longer than one work day or shift.

If OWCP denies your case, they will provide you with an explanation of why your claim is denied and advise you fully of your appeal rights, including the time frames for exercising these rights and the offices you should contact.

If a work-related injury results in an employee's death, a claim for survivor's benefits may be filed on Form CA-5 or 5b. The survivor(s), the employing agency on behalf of the survivor(s), or the estate may file the claim for benefits. These sensitive cases are processed expeditiously by an experienced claims examiner.


Medical Care

If you are claiming a traumatic injury, your employing agency may have issued you a Form CA-16 so that you could obtain medical treatment right away. This authorization covers non-surgical treatment and continues for up to 60 calendar days from the date of injury.

If your case is approved, you will remain entitled to medical treatment for your accepted condition. However, if your case is denied, the authorization provided by Form CA-16 will not be valid after the date of denial.

Form CA-16 is not issued for occupational disease cases.

You have the right to select the first doctor who treats you for your injury. If that physician refers you to a specialist, OWCP will honor that referral as long as it is for the work-related condition. If you are first seen by a physician designated by your employer, you still have the right to choose your treating physician. If you wish to change physicians from this initial choice, you must request approval from OWCP. Send a letter stating your reasons for wanting this change, along with the name, address and specialty of the physician to whom you wish to change. OWCP will advise you of their decision in this matter. OWCP will only pay bills from the physician you chose first, until a change in physician is approved.

The FECA recognizes chiropractors as physicians only to the extent that their treatment consists of manual manipulation of the spine and only where the accepted condition is a subluxation of the spine. This subluxation must be shown by x-ray to exist. The x-ray must be taken shortly after the claimed injury. The chiropractor's report must provide an exact diagnosis of your condition based upon this x-ray and explain how the subluxation is related to the claimed injury. Referrals by a chiropractor for other treatment must be approved by OWCP in advance.

If your injury requires physical therapy, it is usually authorized for the first 120 days from the date of injury. OWCP will need further medical support for physical therapy beyond 120 days. OWCP must approve in advance any surgery or procedure other than emergency surgery (that is, a procedure which must be performed right away to preserve life or the function of an organ or body part). You (or your medical provider) should contact OWCP for authorization at least 30 days before the intended date of the procedure. OWCP will advise you of the information needed to determine whether they can pay for the requested procedure.


OWCP's Billing and Medical Authorization Process

Automated bill and authorization status is available via OWCP's toll-free Interactive Voice Response (IVR) system at 866-335-8319.

To speak to a customer service representative regarding medical authorizations or bills, call 850-558-1818, which will be a toll call.

Send all bills for Federal workers' compensation cases to:

  • U.S. Department of Labor
    DFEC Central Mailroom
    PO Box 8300
    London, KY 40742-8300

  • Please be sure to include the claim number on every page sent.

 



Information on Bills from Foreign Medical Providers

OWCP handles bills from foreign medical providers differently from U.S. territory and stateside medical providers.

Medical bills from foreign providers are sent directly to the special claims unit in OWCP's Cleveland District Office.

Foreign medical bills should be sent to:

  • ATTN:David T. Woods
  • United States Department of Labor
  • 1240 East Ninth Street Room 851
  • Cleveland, OH 44199

 

(Annotate the outside of the envelope with: DO NOT OPEN IN MAILROOM)

Foreign medical bills may also be faxed to OWCP at (216) 902-5601 or (216) 357-5464

Please be sure to include the claim number on every page sent as well as the claimant's current mailing address.


Medical Care Furnished by a Military Treatment Facility (MTF)

Department of Defense (DoD) appropriated fund employees are not billed for treatment at Military Treatment Facilities for initial or follow-up care for a work-related injury.

Please see HA Policy: 08-002 regarding care furnished by Military Treatment Facilities to Federal employees for on-the-job injuries and for occupational health.


Forms

OWCP's Division of Federal Employees' Compensation (DFEC) has made a variety of forms available online. DFEC's online forms

 

About OWCP Wage Loss Compensation

While compensation is usually claimed in two-week increments to conform to standard Federal pay periods, compensation checks are issued on a weekly or four-weekly basis. Payments of compensation for brief periods of temporary total disability or schedule impairments are issued on a weekly basis, while longer-term payments for disability, schedule award and death are made every four weeks. Payments may be sent to the beneficiary or to a financial institution which he or she designates but they may not be sent in care of the employee's representative unless guardianship or conservatorship is established.

Compensation payments are based on a percentage of the employee's salary (or a statutory pay rate). Payments are computed by multiplying the applicable percentage by the wage rate and increasing the result by any cost-of-living increases to which the beneficiary is entitled.

For both disability and death claims, the pay rate used to compute payments is the one in effect on the date of injury, date of recurrence or date disability began, whichever is higher. Thus, the pay rate for compensation purposes may change over the life of a claim.The salary used to compute compensation is not affected, however, by general increases in the rate paid for the employee's grade and step.Moreover, the pay rate is not affected by any promotion or raise the employee might have received in the future.

Additional Elements of Pay included in the salary are: night shift; Sunday differential; holiday pay; hazard pay; dirty work pay; quarters allowance and post differential for overseas employees and extra pay authorized by the Fair Labor Standards Act (FLSA) for employees who receive annual premium pay for standby duty and who also earn and use leave on the basis of their entire tour of duty, including periods of standby duty. Overtime pay is not included, except for administratively uncontrollable work covered under 5 U.S.C. 5545(c)(2).


Frequently Asked Questions

  • How and when is a claim for wage loss compensation filed?§10.102
  • How and when is a claim for permanent impairment filed?§10.103
  • How and when is a claim for recurrence filed?§10.104
  • What evidence is needed to establish a claim?§10.115
  • What happens if, in any claim, the employer contests any of the facts as stated by the claimant?§10.117
  • How does OWCP determine entitlement to benefits?§10.125
  • After selecting a treating physician, may an employee choose to be treated by another physician instead?§10.316
  • What is total disability?§10.400
  • When and how is compensation for total disability paid?§10.401
  • What are the basic rules governing continuing receipt of compensation benefits and return to work?§10.500
  • What actions must the employer take?§10.505
  • May the employer monitor the employee's medical care?§10.506
  • How should the employer make an offer of suitable work?§10.507
  • What actions must the employee take with respect to returning to work?§10.515