Occupational disease or illness claims

Note: This article updates and replaces an article in the February 1991 issue.

The Office of Workers’ Compensation Programs defines an “occupational disease or illness” as a medical condition produced in the work environment over a period longer than a single workday or s

Be Doyle by such factors as systemic infection; continued or repeated stress or strain; or

exposure to hazardous elements such as, but not limited to, toxins, poisons, fumes, noise, particulates or radiation, or other continued or repeated conditions or factors of the work environment

A claim based on an occupational disease is filed with OWCP on Form CA-2, “Federal Employee’s Notice of Occupational Disease and Claim for Compensation”—and it must be kept in mind that the employee has the burden of proving that the occupational disease is causally related to the employment (survivors have the same burden in death cases).

The term “causally related,” as used in workers’ compensation, means “proximately caused”—and “proximately caused” is recognized to mean closely related, as a result of or following—in addition to direct cause.

As a general rule, a claim based on an occupational disease is considerably more difficult to prove than a claim based on a traumatic injury; and to be successful in pursuing a claim with OWCP, an employee must provide two basic documents:

Factual statement—A detailed statement, dated and signed by the employee, describing the conditions or factors of employment believed to be the cause of the occupational disease—and the period of time involved. Depending on the specific claim being made, the statement should include such items as the length and description of routes, number of stops, temperature and/or other weather conditions, number of mail bags lifted per day; average weight of mail bags, nature and origin of toxins, etc. A description of the specific duties of the employee making the claim is of more value than a general description of duties.

• Medical report—A detailed narrative medical report from the employee’s attending physician—dated and signed on the physician’s stationery and containing (in addition to dates of examination and treatment, descriptions of tests given, results of x-rays, etc.) the following five key items:

1. A written statement by the physician reflecting knowledge of the employee’s conditions of employment believed to be the cause of the claimed medical condition and resulting disability.  The physician should ideally include or attach a copy of a written statement prepared by the employee describing the conditions of employment, and the physician should reference the employee’s statement with opening remarks such as:

“I have read the statement dated _________ prepared by __________ regarding the conditions of employment at________during the period from to______."

2. Definitive (i.e., conclusive) diagnosis (no impressions).

3. Opinion in definitive (i.e., conclusive) terms (no speculations): Was diagnosis caused, permanently or temporarily aggravated, accelerated (hastened), or precipitated by the conditions of employment described by the employee? If only a temporary aggravation, acceleration or precipitation—then the opinion must specify the length of time involved.

4. Medical reasons for opinion (i.e., how did the physician, from a medical point of view, arrive at the opinion?). This is very important and should include a discussion of the pathological or other medical relationship between the diagnosis and the conditions of employment and an explanation of how any test results formed a basis for the opinion.

5. Period(s) of disability and the extent of disability during the period(s). This should specify whether the disability is total or partial, and if partial (as opposed to total disability for work as a letter carrier), the work limitations involved in working while partially disabled.

Frame of reference: As will be noted from the above, the factual statement and medical report are related. Without the factual statement, the physician does not have a proper “frame of reference” for his or her medical opinion—and many claims fail because a physician has furnished a medical report that does not reflect (see item 1 above) full knowledge of the conditions of employment.

Positive medical opinion: Many claims also fail because the diagnosis and/or medical opinion (items 2 and 3 above) are not provided in positive terms. A speculative diagnosis is worthless, as is a medical opinion couched in wishy-washy language (i.e., terms such as “might be related” or “could very possibly be related” are of no value).

Medical rationale critical: Finally; unless medical rationale is provided by the physician (item 4 above), adjudication of the claim will be delayed until OWCP is satisfied that a full explanation of the basis of the physician’s medical opinion is in the case record—or the claim will in all probability fail.

Further information on causal relationship and medical rationale is provided in Compensation Department articles in the March though June 1996 issues of The Postal Record.

“THE POSTAL RECORD MAY 1998”