The “exception that Proves the Rule” – how One OWCP Claims Examiner Got It Right in A FECA Claim.

Sometimes we have so many problems dealing with  USDOL's Office of Workers' Compensation Programs (OWCP) in Federal Employees' Compensation Act (FECA) claims that we forget it is within their power to do right by these injured workers.  The following case provides a lesson in how these claims can and should be handled by OWCP.

We filed a relatively straightforward carpal tunnel claim for a Postal worker with a history of repetitive motion work for many years. The claim was initially denied because OWCP said the doctor had not addressed the fact that she had worked in a management position, which required less repetitive motion for a period of time.

We then filed a reconsideration request with a new medical report addressing that issue. The Senior Claims Examiner (SCE), a Ms. Sanchez from the New York district office, called and spoke to our paralegal Erika Bauer and then to my partner Dan Goodkin. She said that the new medical report was not clear, because it said that the client's work duties precipitated, aggravated, accelerated and caused the claimant's condition. She felt that was confusing, and wanted to know which it was. While Dan disagreed that these terms were mutually exclusive, the SCE did let us know what evidence she needed in order to approve the claim.

We then wrote to the doctor again, and in his reply he explained that the condition was caused and then aggravated by employment, and provided a more detailed pathophysiological explanation of the process by which those things occurred.

The SCE then called back and said that was good enough on the causation issue, but that she needed some objective test results and a copy of all of the claimant's treatment records since the initial filing. So we provided those, and the claim was approved.

What is the point of this story?  The point is that this SCE engaged in an interactive process with our office about the proof she felt was needed in order for her to make a final decision on the claim. This virtually never happens at OWCP.  Instead, the typical claims examiner would have just denied the reconsideration request, saying that the medical report we submitted was unclear and therefore insufficient. Then we would have filed another reconsideration request based on the doctor's clarification, and the typical claims examiner would have denied the claim again, saying there were no objective tests results provided nor were all the treatment records since the claim filing, and therefore the medical evidence was still insufficient.  Then we would have had to file yet another reconsideration request (request #3) based on that additional information, and perhaps then the claim would have been approved. We have called this frustrating process "piecemeal adjudication".

Questions: In a non-adversarial workers' compensation system, where the evidence is supposed to be viewed liberally in favor of the claimant, why isn't what SCE Sanchez did standard operating procedure?  Wouldn't such a procedure, if instituted across the board in all claims, save tremendous amounts of time, money and effort for all concerned?

NOTE:  After the hearing held on it last month, there has been no further action taken by the Senate on S.2051, the current Postal Reform bill first introduced on 09/17/15 by Sen Carper. Since then, the White House has published its FY2017 budget, which unlike the previous one does not call for cuts in FECA benefits.  WILG is opposed to many of the provisions of S.2051 that affect FECA - benefit cuts, cost-shifting to other programs, etc.  We will keep you advised about this bill.