What to do When Injured at Work?

Any local APWU member that needs assistance with work related injuries can contact the Union Hall Monday thru Friday between the hours of 8:00am and 4:30 pm @ (414) 273-7838. You can ask to make an appointment with Bob Wood or leave a message to have Bob call you back. Bob is the local APWU’s specialist in regards to work related injuries and the Office of Workers Compensation Program (OWCP) and takes appointments on a limited basis at the Union Hall.

Note: For access to the appropriate forms referenced in this article and that are necessary to process your injury claim, please contact a union representative or visit the following link:

https://www.dol.gov/owcp/dfec/regs/compliance/forms.htm

Basic information concerning work related injuries and what you need to do are as follows:

 TRAUMATIC INJURY

A Traumatic Injury is defined as a wound or other condition caused by external forces including physical stress and strain. The injury should be identifiable as to time and place of occurrence and member(s) or function of body part affected. Furthermore, it must be caused by a specific event or incident or series of events or incidents within a single work tour.

 To report a traumatic injury the employee or someone acting on his or her behalf must file a Form CA-1, Notice of Traumatic injury.

An employee is entitled to receive Continuation of Pay (COP), for up to 45 calendar days on

account of wages loss due to disability and/or medical treatment after a Traumatic Injury. This will be paid provided you check the box indicating your preference to receive COP on the CA-1. The intent of this provision is to avoid interruption of pay while the case is being adjudicated. COP is not considered compensation and is therefore subject to all regular deductions. Once entitlement to COP ends, you must then apply for compensation by completing Form CA-7 or use your own leave.

The Postal Service does have the right to object to paying COP which is called a “controversion” of your claim. The supervisor may controvert a claim by completing the indicated portion of Form CA-1 and submitting detailed supporting information to OWCP. Even though a claim is controverted, the Postal Service must continue your pay unless at least one of the following conditions apply:

  1. The disability is a result of an occupational disease or illness.
  2. The employee comes within the exclusions of 5 U.S.C. 8101 (1) (B) OR (E) (which refer to persons serving without pay or nominal pay, and to persons appointed to the staff of a former President.
  3. The employee is neither a citizen nor a resident of the United States, Canada, or the territory under the administration of the Panama Canal Commission (i.e., a foreign national employed outside these areas);
  4. The injury occurred off the employing agency’s premises and the and the employee was not engaged in official “off premises” duties;
  5. The employee caused the injury by his or her willful misconduct, or the employee intended to bring about his or her injury or death or that of another person, or the employee’s intoxication was the proximate cause of the injury;
  6. The injury was not reported on a form approved by OWCP (usually Form CA-1) within (30) thirty days of the injury;
  7. Work stoppage first occurred more than (45) forty-five days after the injury;
  8. The employee first reported the injury after employment was terminated;
  9. The employee is enrolled in the Civil Air Patrol, Peace Corps, Job Corps, Youth Conservation Corps work study program, or other group covered by special legislation.

 OCUPATIONAL DISEASE

An Occupational Disease is defined as a condition produced in the work place over a period of time that is longer than one workday or tour. It may result from systemic infection, repeated stress or strain, exposure to toxins, poisons, or fumes, or other continuing conditions of the work environment. Examples of some of the more common injuries that are seen at the Postal Service include, Carpal Tunnel Syndrome, Tendonitis, and back injuries.

If you feel you have an injury that could be work related you should first consult with your doctor and get his/her opinion. There are numerous questions that your doctor must answer before you file.

A report must be obtained from your doctor that includes the following information: 

  1. Dates of examination and treatment.
  2. History of your job duties and your current job description given by you to your doctor.
  3. Detailed description of findings.
  4. Results of all diagnostic tests.
  5. Diagnosis.
  6. The clinical course of treatment.
  7. Physician’s opinion as to whether the disease or illness was caused and/or aggravated by the employment, along with an explanation of the basis for this opinion. (Medical reports that do not explain the basis for the physicians opinion are given very little weight in adjudicating the claim.)

Upon receiving this medical report if it is your doctor’s opinion that your injury was caused or aggravated by your employment you will than proceed to file a claim with your supervisor.

To report an occupational disease the employee or someone acting on his behalf must file a CA-2 (Notice of Occupational Disease and Claim for Compensation).

If there is time lost from work due to an Occupational injury an employee is NOT entitled to receive Continuation of Pay (COP). If disability is sustained as a result of an occupational disease injury, the employee must forward a completed Form CA-7 to the employing agency. The claim should be filed within 10 days after pay stops or when the employee returns to work, whichever occurs first.

CHOICE OF PHYSICIANS

If a CA-1 was filed: The employee is entitled to select the physician who is to provide treatment. The provider must meet the definition of “physician” under the FECA and must not have been excluded from payment under the program. Physicians employed by or under contract to the agency may examine the employee at the agency’s facility in accordance with OPM regulations. However, the employee’s choice of physician must be honored, and treatment by the employee’s physician must not be delayed for the purpose of obtaining an agency-directed medical examination.

If a CA-2 was filed: The employee will choose the physician.

CA-2a:  Notice of Federal Employee’s Recurrence of Disability and claim for Pay/Compensation.

 There are two (2) instances where you might need to fill out a CA-2a form after a recurrence of disability:

#1. An employee’s inability to work that is caused by the spontaneous change in the employee’s medical condition that is related to a previous injury or illness without intervening injury or new exposure.

#2. Upon returning to work you have an injury that you believe to be the same as your previous injury and you are unable to work. In such cases, you should see your doctor and have him/her make the determination of your medical condition. You will need a report from the doctor that includes the following information:

  1. Dates of examination and treatment.
  2. History of your job duties and current job description given by you to your doctor.
  3. Detailed description of findings.
  4. Results of all diagnostic tests
  5. Diagnosis.
  6. The clinical course of treatment.
  7. Physician’s opinion as to whether the disease or illness was caused and/or aggravated by the employment, along with an explanation of the basis for this opinion. (Medical reports that do not explain the basis for the physicians opinion are given very little weight in adjudicating the claim.

If it is the opinion of the doctor that the injury is a recurrence of your previous condition, you will then fill out the CA-2a form and submit it to your supervisor and submit the medical report to the Health Unit making sure you get a date stamped copy for your records.

If your initial disability was for a Traumatic Injury and you have a Recurrence of that Disability you would be eligible for any balance to the 45 days of entitlement to COP not used during prior periods of disability provide that:

  1. You completed Form CA2-a and elect to receive COP
  2. OWCP did not deny the original claim for disability
  3. The disability recurs and you stop work within the 45 days of the time you first returned to work following the initial periods of disability.
  4. Pay has not been continued for the entire 45 days.

If the 45 days of COP has been reached or your initial injury was an Occupational Disease you can take either Annual Leave, Sick Leave of LWOP.  Once you receive notice that your claim for Recurrence has been approved you will only be able to take LWOP to receive OWCP compensation.

Recurrence of medical condition – a documented need for further medical treatment after release from treatment for the accepted condition or injury when there is no work stoppage.

The same procedures identified above will need to be followed with the exception of the Leave portion.

ENTITLEMENTS and PRIOR AUTHORIZATION REQUIREMENTS

 Once you have an approved claim you are entitled to Medical Reimbursement. Medical re-imbursement is any out of pocket money you used due to your on the job injury. This includes:  Co-Pays, Medical Bills and Prescriptions. Remember to keep your receipts. Use Form OWCP-915 and follow the instructions on the back of the form.

You are also eligible to be reimbursed for all trips made to the doctor’s office, hospital and physical therapy. You must keep an accurate record of each place you traveled, the dates, name and address of the facility and the total number of miles round trip. A log with dates you visited the facility is recommended for verification of your visits.  Use Form OWCP-957 and follow the instructions on the back of the form.

OWCP requires that all procedures are pre authorized unless there is an emergency situation.

If your doctor is recommending surgery for your approved conditional you will need to get the Authorization Request Form – general medical and have your doctor fill this out an fax it to the number on the form.

There are separate Authorization Request Forms one for Physical Therapy / Occupational Therapy and the other for Durable Medical Equipment.

For all the Authorization Forms there is a ACS provider Number that is required which the doctor can obtain by going to http://owcp.dol.acs-inc/portal/main.dol or by calling 1 850 558-1818 prior to submission of this form.

Note: Do not proceed with any procedure without confirming with your doctor that there has been prior authorization. Request a copy of the authorization from your doctor as you will need this to insure your compensation for any lost wages or other cost you may incur. Prior Authorization not only insures your pay but it also insures that the doctor will be compensated for their services.

Form CA-7/20 Claim for Compensation on Account of Traumatic or Occupational Disease/Attending Physicians Report and Compensation by OWCP for Disability (when LWOP is used)

In the case of a Traumatic Injury you would be required to file a Form CA-7 when you are unable to return to work at the end of the 45 Days of COP. If the medical evidence shows that the disability resulting from the Traumatic injury is expected to continue beyond the 45 day period, you must obtain a CA-7 by day 30 of the COP period and submit for OWCP LWOP. You must then fill out the CA-7 and submit it to Injury Compensation Office (making sure to get a date stamped copy for your records). The form and medical is then submitted to OWCP district office by Injury Comp by day 40.

If your disability is a result of an Occupational Disease and is for a short period of time lost a CA-7 is completed and the medical identifying you were unable to work for that period.

In instances of either Traumatic Injury or Occupational Disease or illness, subsequent claims of compensation for periods of disability beyond the initial period of compensation are also made on Form CA-7. It is your responsibility to submit the CA-7. If you don’t fill out the CA-7 there is no way OWCP would have knowledge of your continued lost of wages. Therefore, while your disability continues:

  1. You must submit a claim using Form CA-7 every 2 weeks until OWCP tells you differently.

2.You are also responsible for the submission of medical evidence in support of the claim. This medical can either be on the attached CA-20 which  you give to your doctor or he must write a report that includes dates you were incapacitated.

In instances where the Traumatic Injury or Occupational Disease requires you to take off  intermittently you will also be required to fill out a CA-7a which is a Time Analysis Sheet along with the CA-7.

Waiting Period

 There is a (3) three day waiting period before OWCP compensation begins-unless the disability extends beyond (14) calendar days. (Remember this is calendar days – not work days.)  The (3) day waiting period cannot be satisfied by using sick or annual leave: you must be in a non-pay status.

The waiting applies as follows:

  1. In the case of an Occupational Disease or illness, compensation is not payable for the first (3) days of disability, unless the disability extends beyond (14) days.
  2. In the case of a Traumatic Injury, the (3) day waiting period begins immediately after the end the 45-day COP period, unless the disability continues for more than (14) calendar days after the expiration of the 45-day COP period.

Leave Buy-Back (when Annual or Sick Leave is used)

 If you used Annual leave or Sick leave during the period after COP expired or during a period of disability due to an Occupational injury, you are eligible for buy back the leave with compensation payments. This is done by filling out the CA-7 and checking the leave buy back square. The time you are trying to buy-back must be supported by medical documentation.

  1. The buy-back must be initiated within (1) year of the return to duty, or within (1) year of the date of OWCP approved the claim, whichever is later.
  2. You are not able to buy back leave if you are being separated because of disability or other reasons and you are off the rolls of the Postal Service.

Note:  Once you have an approved claim you can no longer used Sick Leave or Annual Leave and have it compensated by OWCP. Once approved you must use LWOP to receive compensation from OWCP.

SCHEDULED AWARDS

The permanent/partial loss or loss of use of certain members and functions of the body.

Compensation Schedule: The following table shows the number of weeks payable for each schedule member if the loss or loss of use is total. If the loss is partial, the number of weeks is multiplied by the percentage. For instance, if you have a loss of 10% use of an arm you would take the 312 x .10 = 31.2 weeks of compensation.

MEMBER                                                           WEEKS

Arm                                                                            312

Leg                                                                              288

Hand                                                                          244

Foot                                                                            205

Eye                                                                              160

Thumb                                                                       75

First Finger                                                               46

Great Toe                                                                   38

Second Finger                                                           30

Third Finger                                                              25

Toe other than Great Toe                                        16

Fourth Finger                                                             15

Loss of Hearing – Monaural                                   52

Binaural                                                                       200

Breast                                                                           52

Kidney                                                                          156

Larynx                                                                          160

Lung                                                                              156

Penis                                                                              205

Testicle                                                                          52

Tongue                                                                          160

Ovary (including Fallopian tube)                            52

Uterus/cervix                                                              205

Vulva/vagina                                                               205

 

 

The law does not allow for payments of a scheduled award for impairment to the back, heart or brain.      However if you have a loss of use of one or more of your extremities which is caused by the condition of  the back, heart or brain you may be eligible for a scheduled award.

 

Medical Evidence Required

Before OWCP will consider payment of a scheduled award, the condition of the affected part of the body must have reached maximum medical improvement. Your doctor would to determine that the condition has permanently stabilized. Your doctor would than determine the percentage of loss using the American Medical Association’s Guide to the Evaluation of Permanent Impairment Fifth Edition and the evaluation on which the award is based must conform to the rules set forth there.

 

If you need a copy of the Guide please see a Union Steward and they will assist you.

 

 CLAIM and PAYMENT

 You must file a CA-7 when submitting for a Scheduled Award. Compensation for a schedule awards is computed by multiplying the indicated number of week times (66 2/3 percent without dependents or 75 percent with dependants) of the rate of pay.

Note: You cannot collect a scheduled award at the same time as you are receiving wage –loss compensation for the same injury. Although you can collect a scheduled award at the same time as you are collecting Regular Retirement or Disability Retirement from either OPM or Social Security.

 

Decision

 When issuing a scheduled award, OWCP will notify you as well as the Postal Service of it length (in number of weeks or days), the date it starts (the date of maximum medical improvement), the pay rate on which benefits are computed, and the compensation rate. They will also send you a copy of your appeal right should you disagree with their

 

FORM CA-16 Medical Treatment Authorization

 When injured at work and need immediate medical attention the Postal Service should give you a CA-16 to take with you for the Provider to be paid for his/her services. The following is something you may want to keep and provide to the doctor should you be injured and are not supplied with a CA-16.

 

MEDICAL AUTHORIZATION TIPS FOR PROVIDERS

When an injured worker presents with a Form CA-16

No authorization is needed for:

Office visits and Consultation

Labs

Hospital services (including inpatient)

X-Rays (including MRI and CT scan

Physical therapy

Emergency services (including surgery)

 

Please do not call ACS for authorization if you have a CA-16—The CA-16 is the authorization when an injured worker presents with a Form CA-16.

 

The CA-16 DOES NOT COVER:

Non-Emergency Surgery

Elective Surgery

Home Exercise Equipment, Whirlpools, or Mattresses

Spa/Gym Membership

Work Hardening Programs

 

Authorization request must be submitted for these:

What requires authorization? Whenever treating a DOL employee, use website (hhtp://owcp.dol.acs.com) to determine if the procedure requires authorization.

If you don’t have web access, call 850-558-1818 to speak with the representative or call the Interactive Voice Response (IVR) system at 866-335-8319 to determine if authorization is needed.

Certain procedures require prior authorization. For example surgery, physical therapy, occupational therapy and some Durable Medical Equipment (DME).

 

Authorization Levels

Level 1: Procedures do not require authorization (for example, Office Visit, MRIs, Routine Diagnostic Test)

Level 2: Procedures can be authorized by ACS- often over the phone with ACS

Level 3/4: Procedures require authorization by a Claims Examiner but initiated via fax from Provider to ACS.

Level 5: This is covered if total expenditure limits are not exceeded and on closed cases if the date of service is prior to the case closure date.

 

How to submit an Authorization Request 

  1. Online at http://owcp.dol.acs-inc.com
  2. Fax completed Authorization Request Template to 800-215-4901 – faxes in other formats will be returned and not processed.
  3. Mail Authorization Request to:

P.O. Box 8300

London, Kentucky 40742-8300

 

Authorization Request Templates

Available in pdf format at http://owcp.dol.acs-inc.com

Click on Forms and Links

Select FECA

 

Information requires for Authorization Request

Claimant name

Claimant case number

CPT or HCPCS code(s)

Specific body part to be treated

Requested date of service

Appropriate supporting documentation

Provider name and Provider Number/ID

 

Information required for Physical Therapy and Occupational Therapy Authorization Request

Claimant name

Claimant Case number

Requested CPT code(s)

Specific body part to be treated

Prescription from attending physician

Treatment plan

Frequency and Duration of Services

Provider name and Provider Number/ID

 

Information required for DME Authorization Request

Claimant name

Claimant case number

CPT or HCPCS code(s)

Prescription from attending physician

Duration of services

Rental or purchase price for each item

Appropriate supporting documentation

Provider name and Provider Number/ID

 

Authorization Request will be returned if:

The case is closed

The claimant cannot be found

The date of injury is missing for claimant with multiple cases

We are unable to determine what service is being requested

Any of the following are missing:

Prescription when required

Rental or Purchase Price, when required

Frequency and Duration

Timeframes for Completion

Within 3 business days, the authorization will be in the system, forwarded to claims examiner for review, or returned.

All spinal surgery and many other surgery authorizations require District Medical Advisor (DMA) review – anticipate 30 days.

In some instances, additional development of the claim by the Claims Examiner is needed to approve or deny an Authorization Request. Case complexity, claimant responsiveness, Employing Agency responsiveness, provider responsiveness and other factors impact the timeline for authorization.

 

Notification of Authorization Status

If the authorization is approved, the requesting provider receives a letter in the mail.

If the authorization cannot be approved, the requesting provider receives a letter in the mail.

If the authorization cannot be approved at this time because further development by claims examiner is needed, the requesting provider receives a letter in the mail.

If the authorization is formally denied, the injured worker receives a letter in the mail.

Use http://owcp.dol.acs-inc.com to check authorization status.

 

A Final note about Authorizations…

Submitting a request does not guarantee approval.

Bills for authorized services must meet specifications and requirements to be processed and paid.

 

MANAGEMENT’S RESPONSIBILITY WHEN FILING A WORK RELATED CLAIM

 

20 CFR 10.110 – What should the Employer do when an employee files a notice of traumatic injury or occupational disease?

(a) The employer shall complete the agency portion of the CA-1 (for traumatic injury) or CA-2 (for occupational disease) no more than 10 working days after receipt of notice from the employee. THE EMPLOYER SHALL ALSO COMPLETE THE RECEIPT OF NOTICE AND GIVE IT TO THE EMPLOYEE, ALONG WITH COPIES OF BOTH SIDES OF FORM CA-1 or CA-2.

 

ELM 544.12 – CONTROL OFFICE OR CONTROL POINT RESPONSIBILITY

 The control office or control point is responsible for completing Forms CA-16 and CA-17 (see 545.21 and 545.53), Control office and control point supervisors are responsible for reviewing all claims for accuracy and completeness and for forwarding claims and related documents to OWCP within the prescribed FECA time frames. Control points at major postal installations mat be given authority by the control office to manage and submit claims directly to OWCP. The control office or control point must advise the employee whether COP will be controverted and whether ay will be interrupted. THE CONTROL OFFICE MUST PROVIDE THE EMPLOYEE A COPY OF THE COMPLETED CA-1 OR CA-2 AND ALL CORRESPONDENCE BETWEEN THE POSTAL SERVICE AND THE TREATING PHYSICIAN.

 

HANDBOOK EL 505 3.6 ASSISTING THE EMPLOYEE IN REPORTING AN INJURY AND MAKING A CHOICE OF COP OR LEAVE – SUPERVISOR:

 Upon receiving the completed CA-1 from the employee, do the following:

  • Document on CA-1 THE DATE THE FORM WAS RECEIVED.
  • Complete the receipt attached to the CA-1 and give a copy to the employee or his or her representative.

 

CONTINUATION OF PAY (COP) DEFINED

  • Continuation of regular pay for up to 45 calendar days for wage loss due to disability

and /or medical treatment after a traumatic injury.

  • Intent is to avoid interruption of pay while the claim is adjudicated
  • COP is not considered compensation
  • Employer paid. Employee is in pay status
  • Subject to usual deductions from pay, such as income tax, retirement, allotments etc.
  • Employee’s choice. It is your decision not the Postal Service and they cannot intimidate nor force you not to elect COP. Decision to use leave over COP is not irrevocable. Employee who uses leave can later elect COP within one (1) year of the leave usage or date the case is accepted by OWCP, whichever is later.
  • If OWCP DENIES CLAIM cop MUST BE REPAID. Employee may choose to have time charged to Sick Leave or Annual Leave, or considered an overpayment of pay under 5 USC. 5574
  • The employer must correct any deficiencies in COP as directed by OWCP.

 

CONTINUATION OF PAY – ELIGIBILIT 

  • Must be a traumatic injury (not available for occupational injuries.
  • Must file the CA-1 (or notice of injury) within 30 days of the date of injury.
  • Must begin losing time from work within 45 days of the injury.
  • Must begin using balance of COP within 45 days of first Return to work (RTW) – Not date of injury.
  • COP may be used beyond 45 day RTW time limit provided employee begins using COP balance no later than the 45th day from their RTW and disability continues without interruption.
  • If Disability extends beyond COP period, file for compensation.
  • May use COP for Medical Treatment/Examination Time. Employee is require to RTW TO complete work shift unless disabled.
  • COP is counted by days not hours. Partial days of COP count as a full day of COP.

The employer must continue the pay of an employee who is eligible for COP, and may not require the employee to use his or her own sick or annual leave in almost all circumstances. However, while continuing the employee’s pay, the employer may controvert the employee’s COP entitlement pending a final determination by OWCP. OWCP has the exclusive authority to determine questions of entitlement and all other issues relating to COP.

 

CONTROVERTING A CLAIM WITH COP WITHHELD. AGENCY MAY CONTROVERT ONLY IF ONE OF THE FOLLOWING APPLIES: 

  • Disability is a result of occupational disease or illness.
  • Claimant’s status as an employee is defined by 5 USC 8101 (1)(B) OR (E) (VOLUNTEERS).
  • Employee is neither a citizen nor resident of the US or Canada.
  • Injury occurred off the agency’s premises and the employee was not engaged in official duties.
  • Employee’s willful misconduct, intentional harm or death, or proximate intoxication.
  • Injury not reported on form CA-1 within 30 days following the injury.
  • Work stoppage first occurred more than 45 days after the injury.
  • Employee reported injury after employment was terminated.
  • Employee is enrolled in Civil Air Patrol, Peace Corps, or other group covered by special legislation.

CALCULATING COP 

  • There is a (3) three day waiting period for Postal Employees. The Employee may use Sick / Annual Leave / LWOP for any work days. Non work days also count.
  • If the Disability extends beyond the (14) fourteen calendar days any SL/AL/LWOP will be converted to COP.
  • The pay rate for COP purposes is equal to the employee’s regular weekly pay rate.
  • Excludes overtime pay and Sunday premium, but does include other applicable extra pay such as Night Differential and holidays.
  • Changes in pay which would have otherwise occurred during the 45 day period are to be reflected (i.e. promotion, demotion, step increases).