BEST PRACTICES IN FEDERAL WORKERS’ COMPENSATION: SUPERVISOR FECA OVERVIEW FECA OVERVIEW SUPERVISOR TRAINING Kristin Coyle VISN 1 Lead WC Specialist Course Objectives • Overview of the Federal Employees’ Compensation Act (FECA) • Primary Benefits Provided under the FECA • Types of Injuries and Initiating Claims • Conditions of Coverage • COP and Controversion Overview of the FECA • Federal Employees’ Compensation Act (FECA) passed in 1916 • Provides compensation benefits to civilian employees of the US for disability due to personal injury or disease sustained in the performance of duty • Provides benefits to dependents if a work-related injury or disease causes an employee’s death • Coverage is extended to Federal employees regardless of the length of service or position held. Probationary, temporary, term, part-time, are all covered. • Pre-existing diseases and illnesses aggravated, accelerated or precipitated by the employment are also covered. 3 Overview of the FECA (cont) • All kinds of injuries and diseases may be covered if they occur in the performance of duty. However, benefits cannot be paid if injury or death is caused by willful misconduct or intent to injure oneself or another. • Sole (Exclusive) remedy – a Federal employee or surviving dependent is not entitled to sue the US or recover damages for injury or death under any other law • Funded through agency chargebacks • Remedial in nature • Non-adversarial – an attorney is not required Overview of the FECA (cont) • Administered by Department of Labor (DOL), Division of Federal Employees’ Compensation’s (DFEC) Office of Workers’ Compensation Programs (OWCP). (12 District Offices) • OWCP adjudicates claims • Individual case files are protected under the Privacy Act – only the employee, her/his representative (if any), and agency personnel may routinely have access to a file • HIPAA doesn’t apply to OWCP or employing agencies 5 OWCP District Offices The jurisdictions of the 12 OWCP District Offices are as follows: District 1 – Boston, MA (covers claims for CT, ME, MA, NH, RI and VT) District 2 – New York, NY (claims for NJ, NY, PR and the VI) District 3 – Philadelphia, PA (claims for DE, PA,WV and parts of MD) District 6 – Jacksonville, FL (claims for AL, FL, GA, KY, MS, NC, SC and TN) District 9 – Cleveland, OH (claims for IN, MI and OH) District 10 – Chicago, IL (claims for IL, MN and WI) District 11 – Kansas City, MO (claims for AR, IA, KS, MO, NE and DOL employees) District 12 – Denver, CO (claims for NM, CO, MT, ND, SD, UT and WY) District 13 – San Francisco, CA (claims for AZ, CA, HI and NV) District 14 – Seattle, WA (claims for AK, ID, OR and WA) District 16 – Dallas, TX (claims for LA, OK and TX) District 25 – Washington, DC (claims for parts of MD, VA and DC) PROGRAM BENEFITS • • • • Medical Benefits Compensation Benefits Death Benefits Other Benefits Primary Benefits Provided under the FECA • Medical Benefits – Services, appliances, and supplies prescribed or recommended by physicians which in the opinion of OWCP are likely to cure, give relief, reduce the degree or period of disability, or aid in lessening the amount of monthly compensation – Includes examination, treatment, and related services such as medications and hospitalization, as well as transportation needed to secure these services – Preventive care is not authorized 9 Initial Choice of Physician The Agency should advise the employee of the right to his or her initial choice of physician. The Agency must allow the employee to select a qualified physician, after advising him or her of those physicians excluded under subpart I of this part. 20 CFR 10.300 (d) Any qualified physician may provide initial treatment of a work-related injury in an emergency. 20 CFR 10.825(b) CA-16 Issuance • Authorizes medical treatment for a traumatic injury for 60 days from the date of injury, unless terminated sooner by OWCP • This form is not automatic, criteria must be met • Must be provided in traumatic injury claims within 4 hours, but not more than 7 calendar days after an injury • Agency questions the validity of a claim it can be indicated on the CA-16 • The Agency may refuse to issue a CA-16 if more than a week has passed since the injury 20 CFR 10.300(b) – Check with your local WCO to see who issues this at your facility. CA-17 • Duty Status Report – interim medical report about employee’s fitness for duty and work capabilities • May be issued initially with CA-16 • Supervisor/Agency completes agency portion by describing physical requirements of the employee’s job and noting the availability of light or limited duty • Agency can send to physician at any time during life of claim – but not more than once a week • OWCP5 would be another form to use if this is not available. 12 COP/AL/SL/LWOP Once the Agency learns of a traumatic injury sustained by an employee, it shall advise the employee of the right to receive COP, and the need to elect among COP, annual leave, sick leave, or leave without pay, for any period of disability. 20 CFR PART 10.211(b) Continuation of Pay (COP) – Continuation of regular pay for up to 45 calendar days of wage loss due to disability and/or medical treatment after a traumatic injury – Intent is to avoid interruption of pay while the claim is being processed for acceptance or denial by OWCP – Subject to usual deductions from pay, such as income tax, retirement, allotment, etc. – Entitlement is not automatic – The Workers’ Compensation Office (WCO) or someone in HR is responsible for the authorization of COP, but check with your local facility – Supervisor responsible for ensuring once authorized by WCO, that timekeeper post COP appropriately – Time lost on the day or shift of the injury does not count towards COP. They should be placed on Administrative leave (AA) 20 CFR 10.215(a) 15 Primary Benefits Provided under the FECA • Wage loss compensation – Temporary Total Disability - continues as long as medical evidence supports total disability – Injured worker who returns to work can receive compensation for time lost due to medical appointments, physical therapy, and/or reduced work hours based on medical restrictions – 66 2/3% of salary without dependents and 75% of salary with dependents 16 Primary Benefits Provided under the FECA • Schedule awards – Compensation for specific periods of time for permanent loss, or loss of use, of certain members and functions of the body – Partial loss or loss of use of members and functions is compensated on a proportional basis – Must have reached maximum medical improvement – Based on pay rate used for compensation purposes – 66 2/3% of salary without dependents and 75% of salary with dependents 17 Primary Benefits Provided under the FECA • Vocational rehabilitation – Main purpose is it provides vocational rehabilitation services to assist disabled employees in returning to gainful employment consistent with physical, emotional, and educational abilities – May be requested by attending physician, employee, or employing agency – Compensation may be reduced or terminated for employee’s failure to participate or to make a good faith effort to obtain employment – Other benefits under this program can also assist in other areas such as medical services and transportation. 18 Release of Records • IMPORTANT TO REMEMBER: The privacy of FECA case files are governed by DOL/GOVT1, they do not fall under the VA System of Records • Absent a court order of competent jurisdiction or written release from the claimant, information may only be used pursuant to DOL’s interpretation of routine use published in DOL/GOVT-1 and in a manner that is compatible with which the record was created. • You cannot use information in the case file for issues such as: EEO’s, disability retirement, reasonable accommodations, etc without the employee written consent to use this information for that purpose. • Files are maintained by DOL, they have the complete file. • DOL/GOVT-1 is available on the DOL website. Benefit Entitlement To claim benefits under the FECA, an employee who has sustained an injury or occupational disease which he or she believes to be work related must give notice of the injury or condition in writing on Form CA1/CA-2 20 CFR 10.100 AND 10.101 Compensation Rights Waiver No employer or other person may require an employee or other claimant to enter into any agreement either before or after an injury or death, to waive his or her right to claim compensation under the FECA. No waiver of compensation rights shall be valid. 20 CFR 10.15 Criminal and Civil Penalties A number of statutory provisions make it a crime to file a false or fraudulent claim or statement with the Government in connection with a claim under the FECA, or to wrongfully impede a FECA claim. 20 CFR PART 10.16 Timeframe for Submitting Claims to OWCP OWCP Must receive the completed CA-1/CA-2 within 10 workdays from the date the employee electronically and wet ink sign the front of the form If a claim is submitted late to OWCP it counts against the Medical Center Directors and the VISN Directors lag time performance CA-1:Traumatic Injury-Definition – Wound or other condition of the body caused by external force, including stress or strain – Caused by specific event or series of events or incidents within a single day or work shift Initiating A Claim for a Traumatic Injury • Notice of Traumatic Injury – CA-1 – Employee (or someone on her/his behalf, including supervisor) completes page 1; Supervisor completes page 2 – Must be submitted to employing agency within 30 days of date of injury to be eligible for COP – however can be submitted up to three years after the injury – Supervisor must have knowledge within 30 days of injury even if filed 3 years later to be timely. – Must be transmitted to OWCP within ten workdays from date injured employee signs the form – WCO cannot hold for wage calculations, supporting documentation, etc. – DOL has 45 days from the date they receive to make a decision on the claim, unless placed in an administrative closure. 25 CA-2: Occupational Disease-Definition – Condition produced over a period longer than one workday or shift (e.g., repetitive motion disorders, asbestosis, stress) – COP is not provided for Occupational Diseases – CA-16 is not issued for Occupational Diseases 29 Supervisor’s Role related to a Occupational Disease Claim • Review pg 1 of CA-2 for completeness and assist employee in correcting any errors or omissions and then complete pg 2 of the CA-2 • Review the employee’s portion of the form and provide comments concerning the employee's statement • Prepare a supporting statement to include exposure data, test results, copies of previous medical reports, and/or witness statements – depending on the nature of the case • Advise employee of the right to elect sick or annual leave or LWOP, pending adjudication of the claim • DOL has 90 days on basic OD claims and 180 on extended OD claims to render a decision. 30 Reportable Claims • Medical Charge against OWCP • Disability for work beyond the day or shift of injury • The need for more than two appointments for medical examination within agency and/or treatment leading to loss from work • Future disability • Permanent Impairment • Any claim where treatment is with outside medical provider Reportable Claims (cont) • Payment of Continuation of Pay pursuant 5 U.S.C. 8118 • Any CA2: Notice of Occupational Disease needs to be submitted Note: The employer should not wait for submittal of supporting evidence before sending the form to OWCP Non-Reportable Claims If none of the reportable claim criteria apply, Form CA1 shall be retained as a permanent record in the Employee Medical Folder in accordance with the guidelines established by the Office of Personnel Management (OPM) 20 CFR PART 10.110 (3) (d) Requirements for entitlement FECA does not cover exposure-type cases such as: • Tuberculosis; Sharp exposures; HIV No coverage for the exposure as there has been no medical condition diagnosed yet • These claims must be placed in the employee health folder • If diagnosed later due to the exposure coverage will be afforded retroactively • These cases should be forwarded to OWCP once a condition has been diagnosed. Disputing Claims If an Agency disagrees with any aspect of the injured employee’s claim, it must submit a statement to OWCP that specifically describes the factual allegation or argument with which it disagrees and provide evidence or argument to support its position. The employer may include supporting documents such as witness statement, medical reports or records, or any other relevant information. 20 CFR 10.117 Non-Adversarial NOTE: If the Agency does not submit a written explanation to support the dispute or disagreement, OWCP may accept the injured workers’ claim of injury as established! Also, the Agency cannot delay sending the claim to OWCP because it disagrees with aspects of the claim or to compel the injured employee to change or withdraw the claim. 20 CFR 10.117b Death Benefits • OWCP District Office must be notified immediately via fax or telephone • Supervisor must complete form CA-6 and submit to OWCP within 10 workdays after knowledge by Supervisor of an employee’s work related death • CA-5 form must be completed within 30 days, if possible, but no later than 3 years (widow, widower, children) • CA-5b (Parents, brothers, sisters, grandparents, grandchildren) Evidence Needed to Establish Claim 5 Basic Requirements Time Civil Employee Fact of Injury Performance of Duty Causal Relationship Conditions of Coverage • Time – 3 years from date of injury, first awareness or exposure • Civil Employee – temporary employees covered on the same basis • Fact of Injury – actual occurrence of event – a diagnosed medical condition as a result 45 Conditions of Coverage • Performance of Duty – – – – – – – – ”premises rule” outside working hours/30 minutes official time for representational functions parking facilities agency housing lunch hour travel status recreation • Causal Relationship – connection between injury/medical condition – based on medical evidence 46 Performance of Duty Employees who are injured while exercising or participating in a recreational activity during authorized lunch or break periods in a designated area of the employing establishment premises have the coverage of the Act whether or not the exercise or recreation was part of a structured Physical Fitness Program (PFP). Injuries which occur during the use of fitness and recreational facilities furnished by the employing establishment outside of official work hours, on or off the premises, are not compensable if the employee was not participating in a structured PFP. The mere fact that the employing establishment allows employees to use its facilities on their own time does not create a sufficient connection to the employment to bring any resulting injury within the coverage of the Act. FECA PROCEDURE MANUAL 2-0804-18 OWCP Nurse Purpose • Coordinate Medical Care • Obtain Work Restrictions • Assist Claims Examiner in resolving medical issues that may arise • Visit the worksite • Ensure duties don’t exceed medical limitations • Address any problems the employee may have in adjusting to the work setting (FECA Manual 2-0811-6) Group Injuries When possible, where two or more employees are injured in the same incident, such as an explosion or auto accident, or by the same substance, such as contaminated drinking water, the entire group of cases should be adjudicated by the same Claims Examiner in order to ensure uniformity of action. FECA PM 2-0800-12 Notifying District Office-Group Injuries NOTE: Your Facility Workers’ Compensation Office will notify OWCP District Office that services your Agency to determine their process for submitting group injury information and the information required from the Agency Workers’ Comp and Incarceration If a injured employee is incarcerated in a State or Federal jail, prison, penal institution or other correctional facility due to a State or Federal conviction, he or she forfeits all rights to compensation benefits during the period of incarceration. Entitlement to compensation benefits resumes once incarceration ends, but the benefits suspended during incarceration is not restored retroactively Incarceration (cont) • If the injured worker has eligible dependents, OWCP will pay compensation to them at a reduced rate during the period of his or her incarceration as it relates to 5 U.S.C. 8133(a) (1) through (5) • The employing agency shall provide OWCP any information or documentation they may have concerning such matters. 20 CFR PART 10 (10.18) THE END ANY QUESTIONS????