On the Job Injuries
Get the Best Medical Evidence
Put yourself in this situation: You're a letter carrier who has suffered an on-the-job injury, or maybe you have an illness or disease caused by conditions at work. In either case, you're hurting and feeling low. Then someone tells you that if you want to get your proper benefits, you're going to have to get up, ignore your pain and run a fiendish obstacle course. You must leap hurdles, climb ladders and crawl through tunnels. If you're good enough, you will reach the end and can relax and concentrate on feeling better.
It sounds ridiculous, but unfortunately there really is an obstacle course for ill or injured letter carriers. The hurdles, ladders and tunnels may not have physical reality, but any carrier who has tried to follow the tortuous path to obtaining Office of Workers' Compensation Program [OWCP] benefits can testify that those obstacles create real frustration and pain.
One of the biggest hurdles an injured carrier is obtaining medical evidence with effective medical rationale. This process is equivalent to walking a tightrope over a pool filed with sharks. A misstep can earn you the hostility of your physician, but not walking the tightrope means total failure of your claim.
Medical rationale is a physician's written reasons in support of his or her medical opinion concerning the causal relationship between the medical condition of the carrier—the diagnosis—and what happened on the job that created the medical condition. The rationale basically explains how the doctor arrived at his or her medical opinion, and it must be preceded by key facts and descriptions, including a definitive diagnosis and a definitive opinion with no speculation. The rationale must also reflect the doctors knowledge or the carrier’s on-the-job injury or conditions at work that caused the disability or occupational disease. If medical rationale is not provided, the carrier’s claim for compensation will most likely fail.
You should be aware that the need for strong medical rationale continues as your claim progresses through various stages of the OWCP process. For example, the medical rationale is essential when a carrier first seeks compensation. Later, as the carrier recovers, management may offer a limited duty assignment that the carrier may not be able to perform. Again, the carrier’s doctor must supply medical evidence with medical rationale supporting the carrier’s claim that the assignment is unacceptable.
If a carrier suffers a relapse or additional injury, his or her doctor must provide another medical report with medical rationale linking the new disability with the carrier’s original on-the-job injury or occupational disease. Or a situation may develop in which OWCP obtains second and even third opinions from other doctors that are counter to the opinion of the carrier’s doctor. In such cases, the carrier may still prevail if his or her own doctor can supply convincing medical evidence with medical rationale.
As noted above, doctors can be touchy about criticism, however well-meant. Concerns about the doctor’s medical rationale need to be carefully phrased and diplomatically presented to avoid the risk of alienating the doctor.
Causal relationship. . .
In workers’ compensation, it is necessary to show a causal relationship between the on-the-job injury or conditions at work and the disability, illness or disease. In OWCP lingo, the term causal relationship means “proximately caused.” To prove that the disability, illness or disease was “proximately caused” by the on-the- job injury or conditions at work, you must show that the disability, illness or disease was either “directly caused” by the injury or employment conditions or that the disability, illness or disease was “closely related to,” “as a result of,” or “following” the injury or employment conditions.
The distinction between “direct causation” and the other elements of “proximately caused” conditions can be illustrated by the following examples. Take the case of a letter carrier who is hit by a truck and immediately taken to the hospital. The carrier has a broken leg. Clearly the broken leg was caused by the truck accident that is, there is a direct cause for the injury. A physician reporting this incident to OWCP would not need to provide medical rationale. The cause of the injury and resulting disability is clear.
However, there are many cases in which the cause of the disability is less clearly connected to an on-the-job incident or employment condition. In the above example, the carrier could recover from the broken leg, but three months later come down with symptoms of thrombo-phlebitisn or blood clots forming in the leg. The carrier’s doctor may believe that the phlebitis is a result of the broken leg, but if the carrier is to obtain OWCP benefits, the doctor will have to provide a medical report that would include his or her medical reasons for why the on-the-job accident caused phlebitis.
To go a step further, suppose that six months after the phlebitis developed, the carrier suffers a stroke while sitting quietly in an easy chair at home. The carrier claims additional OWCP benefits for the stroke, believing that the original broken leg led to the phlebitis, which caused the stroke. Again, to obtain these benefits, the carrier's doctor will have to provide a medical report containing medical rationale reflecting the doctor’s opinion that the accident caused the phlebitis and the phlebitis caused the stroke.
What to look for. . .
Medical evidence must provide a positive, definitive answer to the basic question in all OWCP cases: Was the on-the-job injury or conditions at work the cause of the employee's disability, illness or disease that now prevents the employee from working? The physician cannot simply state a belief or a likelihood that the two events are causally related. Rather, the medical evidence must stand up to intense scrutiny by OWCP and possibly the Employees' Compensation Appeals Board [ECAB], which reviews the denial of claims before OWCP.
These agencies are looking at two elements that should appear in every medical report. First, the evidence in the report must have probative value, defined as “value in serving to prove a particular fact or contention.” Opinions supported by valid medical reasons, such as test results, have more probative value than opinions lacking such medical reasons. OWCP and the ECAB also look at the weight of the evidence. Although many people may interpret this phrase as meaning, “the more evidence, the better,” OWCP is interested in the probative value of the evidence, including whether the physician offering the opinion has performed relevant tests, and whether the doctor is a specialist in the field or is board-certified. Board-certified physicians have passed rigorous tests and have earned high levels of respect within the medical community. An opinion from such a practitioner is given greater weight than opinions from other doctors, as is an opinion from a specialist rather than a general practitioner.
Carriers must ensure that the physician is qualified under the Federal Employees' Compensation Act. The FECA defines the term “physician” to include, in addition to a medical doctor (MD) or osteopath (D.O.), a podiatrist, dentist, clinical psychologist, optometrist or chiropractor within the scope of his or her practice as set forth in state law.
For chiropractors, the FECA limits their reimbursable services to manual manipulation of the spine to correct a subluxation shown by X-ray to exist. (The term, “subluxation,” means an incomplete dislocation, off-centering, misalignment, fixation or abnormal spacing of the vertebrae which must be demonstrable on any X-ray film to individuals trained in the reading of X-rays.)
Problems for carriers . . .
Carriers can find a qualified doctor who tells the carrier that the on-the-job injury or condition of employment has caused the disability, illness or disease. However, persuading such a physician to write a report containing medical rationale that will withstand OWCP and ECAB scrutiny is not always a cut-and-dried proposition. Injured carriers should be aware of a number of options available when they have trouble obtaining proper medical evidence.
First, carriers should be sure to give their doctor a copy of the guidelines for a proper medical report. The guidelines explain the requirements for medical rationale, and ensure that doctors know that these requirements have been set down by OWCP, not by the carrier or the union.
Nevertheless, some physicians may resent being told what to do. They may write a report with an opinion that ignores these guidelines, most often by including speculative language such as the injury “could have,” “might have” or “probably” led to the medical condition or disability. Speculation is unacceptable to OWCP, and the presence of such language in a medical report is sufficient to doom the carrier’s claim. Another problem carriers may encounter when attempting to get this type of medical report from their doctor is the doctor’s refusal to give any medical reasons for their opinion. Such doctors may say, “My opinion is enough. I know what I’m talking about. Why should I have to write out reasons?”
These doctors need to be reminded that OWCP and the ECAB have continually stressed the need for medical reasons. For example, a recent ECAB decision contained this language:
“A physician’s opinion supporting causal relationship between a claimant’s disability and a specific employment incident or factors of employment is not dispositive on the issue of causal relationship simply because it is rendered by a physician. To be probative value to an employee’s claim, the physician must provide rationale for the opinion reached. Where no such medical rationale is present the medical opinion is of diminished probative value.”
Sometimes a physician may tell a carrier that writing a report with medical rationale is simply too time-consuming. One way to avoid this situation would be for carriers to screen doctors by asking before the first visit if the doctor would be willing to handle a federal compensation case and the paperwork involved. Carriers need to explain to the doctor that he/she will be dealing with the federal compensation system, which has different procedures from state systems.
This question should be asked over the phone before the first office visit. If the doctor does not wish to get involved, obviously the carrier should seek another doctor. Note that once a carrier exercises his or her right to the initial choice of a physician, the carrier cannot change physicians without OWPC approval.
Sometimes the doctor may initially be willing to help, but when pressed will protest that providing the required evidence is too time consuming. It is advised that in such cases that the carrier ask if another competent person in the office—a nurse or secretary—could draft a medical report for the doctor's signature.
This person would have access to the carrier's records and should possess the necessary medical knowledge, as well as being more available to the carrier and possibly more willing to review OWCP’s guidelines and take the extra effort to write a report with strong rationale. The doctor would, of course, have final review and must sign the report.
A final option for carriers having problems obtaining proper medical rationales would be to ask the doctor to call the branch compensation specialist directly. In such conversations, the union representative should point out that neither the carrier nor the union is responsible for the rules. The rules exist, however, and must be followed if the carrier is to be helped. The doctor may respond more positively if the compensation specialist talks about how problems with the claims process can be harmful to the carrier's financial welfare, possibly hampering the carrier's recovery or creating additional stress that may complicate the carrier’s condition
Final notes. . .
The importance of obtaining medical evidence with good medical rationale cannot be overstated. More claims fail for lack of this rationale than for any other reason. The medical evidence must meet the guidelines as found in the sidebar below to establish a clear causal relationship between an on-the-job injury or conditions of employment and the disability, disease or illness for which the letter carrier is seeking compensation. And remember that the best medical rationale expresses the medical reasons for the doctor’s opinion in definitive terms.
Although carriers cannot force doctors to write medical reports that follow the guidelines, they should be well-informed about the guidelines and the “rules of the game.” The Branch Compensation Specialist is willing to coach carriers about the best way to approach physicians to obtain their cooperation. It can be very frustrating dealing with OWCP problems but, if carriers do not give up they can safely reach the end of the obstacle course and the benefits and security they deserve.
Adapted from Fall 1998 NALC Activist Article