Proving causal relationship—reprise

More than any other reason, claims under the Federal Employees’ Compensation Act are denied because of a lack of rationalized medical evidence based on an accurate history establishing that the disability claimed is causally related to the claimed injury or conditions of employment.

This has been the subject of previous Compensation Department articles, most recently a series of articles in the March through June 1996 issues of The Postal Record—and this article reprises the April 1996 article that stressed the need for obtaining the right kind of medical evidence.

There are five critical items which must be included in the medical evidence supporting all but the most obvious claim filed with the Office of Workers’ Compensation Programs. Because the burden of proof is on the employee, the employee must ensure that these items are provided by his or her attending physician (preferably an appropriate medical specialist).

OWCP forms designed for obtaining medical evidence in instances of a routine traumatic injury, such as OWCP Form CA-20, will not suffice for these claims—the medical evidence must be in the form of a narrative medical report, dated and signed on the physician’s stationery (and including dates of examination and treatment, description of tests given, results of x-rays, etc.) as follows:

1. A written statement by the physician reflecting knowledge of the employee’s injury or 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 injury or conditions of employment, and the physician should reference the employee’s statement with opening remarks such as:

Or (if applicable):

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

3. Opinion in definitive (i.e., conclusive) terms (no speculation): Was diagnosis caused, permanently or temporarily aggravated, accelerated (hastened), or precipitated by the injury of 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 injury or 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 there are five critical items which must be included in the medical evidence supporting all but the most obvious claim filed with OWCP, work as a letter carrier), the work limitations involved in working while partially disabled.

Many claims fall because a physician’s medical report does not contain all of the above items—the first one necessary in order to prove to OWCP that the physician has been provided with an accurate “frame of reference” for his or her opinion.

The second and third items in provided in positive terms—a speculative diagnosis is worthless, and medical opinions containing words such as “might be related” or “could possibly be related” are speculative and of no value.

Finally, and excepting cases where the causal relationship is obvious, unless the fourth item (medical rationale) is provided, 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.

Additional information on medical rationale is provided in the May and June 1996 issues of The Postal Record.

“THE POSTAL RECORD JULY 1998”