Doctor’s Narrative and Causal Relationship
Filing a claim with OWCP can be a process that requires patience and understanding from injured employees. Understanding what OWCP requires to develop your claim is just one step toward getting your claim accepted. In order for a claim to be accepted under the Federal Employees' Compensation Act (FECA), the claim must meet 5 basic elements. The claim must:
(1) Be Timely Filed.
(2) Be made by a Federal Civil Employee.
(3) Establish Fact of Injury, which has both a factual and medical component. Factually, the injury, accident or employment factor alleged must have actually occurred. Medically, a medical condition must be diagnosed in connection with the injury or event.
(4) Establish Performance of Duty. The injury and/or medical condition must have arisen during the course of employment and within the scope of compensable work factors.
(5) Establish Causal Relationship, which means the medical evidence establishes that the diagnosed condition is causally related to the injury or event.
One of the main reasons that a claim is either delayed or denied is due to the lack of medical evidence that establishes the fifth element, Causal Relationship. A causal relationship in OWCP is the link between a work-related injury or exposure and a medical condition. In other words, a clear explanation of how the patient's work contributed to their condition, based on medical rationale. To establish a causal relationship, a physician must provide medical evidence that demonstrates a reasonable degree of medical certainty that the work conditions or incident caused the medical condition. We call this medical report the doctor’s narrative and it should include the following:
The patient's history of occupational disease or traumatic event
The patient's employment conditions that may be causing the injury or disease
The patient's medical history, including any similar conditions
The patient's treatment history, including dates of examinations and treatment
The patient's diagnostic test results
The patient's diagnosis
The patient's prognosis for recovery
The patient's disability and how it affects their ability to work
The doctor's opinion on the relationship between the patient's condition and their employment
The CFR § 10.330 states, what are the requirements for medical reports? In all cases reported to OWCP, a medical report from the attending physician is required. This report should include:
(a) Dates of examination and treatment;
(b) History given by the employee;
(c) Physical findings;
(d) Results of diagnostic tests;
(e) Diagnosis;
(f) Course of treatment;
(g) A description of any other conditions found but not due to the claimed injury;
(h) The treatment given or recommended for the claimed injury;
(i) The physician's opinion, with medical reasons, as to causal relationship between the diagnosed condition(s) and the factors or conditions of the employment;
(j) The extent of disability affecting the employee's ability to work due to the injury;
(k) The prognosis for recovery; and
(l) All other material findings
Medical evidence must be submitted by a qualified physician on the physician’s letter head. Nurse practitioners and physician assistants are not considered qualified physicians under the FECA unless the medical report is countersigned by a physician. Also, under the FECA, a "physician" includes chiropractors only if there is a diagnosed spinal subluxation and it is demonstrated by x-ray. Lastly, note that medical evidence must contain a valid medical diagnosis. A definitive diagnosis based on objective medical evidence, such as X-rays, MRIs, or lab tests. A finding of "pain" alone is not sufficient since pain is not a valid diagnosis; rather, it is a symptom.
As part of the doctor’s narrative, you should explain in writing and provide your physician with a detailed description of your work duties that have contributed to your injury. Many doctors do not know what the duties of a letter carrier are so it would be very helpful for you to explain to the doctor what those duties are. Your doctor should state that they have reviewed your description of your job duties and explain how those duties either caused or contributed to the diagnosed condition. It is important to understand that a doctor's statement that there is a causal relationship between the work factors and the injury will not be sufficient for OWCP to accept the claim.
Additionally, OWCP requires that there must be more than just a possibility that the work factors contributed to the diagnosed condition. It requires a degree of certainty or provides sufficient rationale to support causal relationship. An opinion on causal relationship does not have to be 100% conclusive, it also must not, on the other hand, be speculative or equivocal. For example, work factors such as “could have,” “might have, “possibly” or “most likely” caused the disabling condition. If your physician believes that the association between your work and the diagnosed conditions meets this standard, they should indicate that they hold their opinion with "reasonable medical certainty." (Federal Sector Workers’ Compensation Sixth Edition, Eleanor J. Law, Chapter 8 Causal Relationship).
Another fact to remember is that rationalized medical opinion evidence must be based upon “complete factual and medical background, with an accurate history of the injured workers employment injury and must explain how the condition is related to the injury. (Federal Sector Workers’ Compensation Sixth Edition, Eleanor J. Law, Chapter 8 Causal Relationship).
Why is this important? The medical evidence in a doctor's narrative is key to having a claim accepted by OWCP. The narrative should be clear and concise, focusing on the most important aspects of the patient's injury and treatment. The doctor's opinion should be based on a complete medical and factual background of the patient and should be supported by medical evidence. The doctor's opinion should also be stated in definitive terms, without speculation.
