Click on underlined links for further explanation of element|
Burden of Proof
The employee is responsible for establishing the essential elements of any OWCP claim. Department of Labor will help the employee to meet this responsibility, which is termed burden of proof, by requesting evidence needed to establish these elements if such information is not included with the original submittal.
When information is not submitted in a timely manner, delays in adjudicating cases and paying claims often result. To minimize such delays, the employee and supervisor should submit the required evidence within a specific period, usually within 30 days.
A. Traumatic Injury Cases (Including Recurrence and Death).
(1) The factual evidence required from an employer in a traumatic case often concerns the circumstances of the injury. By anticipating the information that OWCP will need, supervisors should contribute to the efficient handling of the claim. Each submittal of forms should contain a clear description of how the injury occurred, including the time and place, whether it happened during working hours, the presence of witnesses, etc.
If this information is not included in the original submittal, OWCP will request it. If it is not received, OWCP will process the case on the basis of the evidence submitted by the employee, as follows:
(a) If the employee's statement is sufficiently detailed and/or credible, OWCP will accept the statement and adjudicate the case accordingly.
(b) If the employee's statement is not sufficient and/or credible, the case will be denied for the reason that one or more of the five basic elements required to approve a claim has not been established.
(2) Medical evidence in possession of the agency (USPS) may also be requested.
(a) In an unadjudicated case, the supervisor should submit copies of medical records pertaining to the injury and any relevant pre-existing condition at the time of initial submittal to OWCP. OWCP will request this evidence of the agency if it is not sent with the original submittal.
(b) In an accepted case, if the employee receives continuing care from an agency physician (or its contract provider), the supervisor should include supporting medical evidence for disability with claims submitted.
If the file contains prima facie (self evident) medical evidence of disability for the period claimed but additional support is needed, OWCP will authorize payment for a reasonable period and request the evidence from the employer. If another claim is received and the previously requested evidence has not been submitted, OWCP will again authorize payment of compensation for a reasonable period and refer the employee to a medical specialist for examination.
(3) Information needed to make payment will usually include the employee's salary and the days of LWOP claimed. Agencies can speed payment by advising OWCP if the pay rate includes elements of pay such as night and Sunday differential. If so, OWCP will need to know whether the employee has received the increments regularly (in which case the biweekly amount should be stated) or sporadically (in which case the employee's entire earnings in the relevant pay category for the year preceding the injury should be stated).
Where the pay rate is in question, OWCP will begin paying compensation using the lower salary and request clarification from the supervisor. If a second request is necessary, OWCP will advise the employee that documentation is needed to support the higher pay rate and ask for any documentation in his or her possession. If the agency fails to reply and the employee submits adequate documentation (e.g., pay stubs), OWCP will adjust compensation. Until sufficient documentation is received from the supervisor or the employee, compensation will be paid at the lower rate.
Where the days and hours of LWOP are in question, OWCP will request clarification asking for form CA7. Any follow-up request will also advise the employee of the need for documentation and invite him or her to submit a detailed account for the period in question. Form CA7 includes the physician's report form CA20. This must be completed when asking for payment.
B. Occupational Disease Claims (Including Recurrence and Death).
(1) OWCP's requirements for factual information vary according to the type and severity of the medical condition involved. Simple occupational disease claims, for example a claim for poison ivy where the job duties involved exposure to the plant, and the medical evidence confirmed the diagnosis, require less evidence to adjudicate.
The information specified in the instructions on Form CA-2 and on the evidence checklist appropriate to the disease in question should be sent with the initial submittal. If sufficiently detailed descriptions of how the condition developed are not received, OWCP will request the information needed for adjudication.
If the information is not received, OWCP will process the case on the basis of the evidence submitted by the employee. As with traumatic injury cases, if that evidence is sufficient and/or credible, OWCP will accept the employee's statements and adjudicate the case accordingly. If the evidence is not sufficient and/or credible, OWCP will deny the case because one or more of the five basic elements required to approve a case has not been established.
(2) An agency medical facility sometimes provides medical examination and treatment. If additional evidence about such treatment is needed from the agency, OWCP will advise the employee that OWCP is attempting to obtain it, but that the burden of proof still rests upon the employee and that he or she should also try to obtain that evidence.
(3) As with traumatic injury cases, payment information needed from the agency will likely include the employee's pay rate and the days of LWOP claimed, and OWCP will use the procedures described above for obtaining such information in traumatic injury cases. The medical evidence developed for initial adjudication should provide sufficient information about the nature and extent of disability to permit adjudication of the claim for wage loss. If not, OWCP will follow the procedures for developing medical evidence for wage-loss claims in traumatic injury cases.
You have the burden of proof. You must effectively communicate your needs to your physician when asking for documentation.
Remember: You are responsible for your own claim. NOT management; NOT the union. You must insure the accuracy of the information and must provide suitable documentation. Management is responsible for providing and submitting forms. Unfortunately, management's knowledge of worker's compensation issues is severely limited; so do
not expect a lot of help from your supervisor. Keep records and copies of everything.