Understanding the Challenges of Workers’ Compensation Claims for Injuries

Sometimes, the connection between a work-related injury and its cause seems obvious. For instance, if you step on a cracked sidewalk while delivering mail and sprain your ankle, slip on an icy sidewalk and hurt your back, or are involved in a motor vehicle accident while on duty, the cause of the injury is clear to most people. However, when it comes to filing for a federal workers’ compensation claims, things are not always that straightforward.

The Office of Workers’ Compensation Programs (OWCP) has strict guidelines for determining whether a work-related injury is related to your work factors. In cases of clear injuries, like a dog bite that causes a visible wound, OWCP can quickly accept the claim. But many injuries—especially musculoskeletal (bones, joints, ligaments, tendons, and cartilage) —aren’t as easily defined. This makes it harder for federal injured workers to have their claims “accepted”.

The burden of proving that the injury is work-related falls on the injured worker and his medical provider. The employee’s doctor must provide medical evidence showing a clear link between the work-related injury and work factors. Claims Examiners follow specific questions to evaluate the medical evidence and determine causality:

  • Is the medical history complete and consistent?
A doctor’s opinion is more likely to be accepted if the patient provides a thorough account of the injury and the work factors involved. The clearer and more detailed the information, the better the chances of a favorable outcome and the claim be “accepted”.
  • Is the opinion well-supported?
The doctor’s opinion should be backed by medical evidence like physical exams, lab tests, and X-rays. A simple statement that the injury happened at work is not enough. The doctor must explain how specific work factors led to the injury referred to as the causal relationship.
  • Does the doctor have relevant expertise?
For common injuries like musculoskeletal issues, a specialist such as an orthopedic surgeon is more likely to be trusted than a general family doctor. OWCP only accepts medical opinions from qualified professionals. For example, reports from nurse practitioners or physician’s assistants must be signed off by a doctor, and chiropractors are only accepted if they diagnose spinal subluxation through X-rays.
  • Does the doctor understand the worker’s medical history?
OWCP regulations allow claims for injuries that aggravate or accelerate pre-existing conditions. Therefore, workers should inform their doctor about any past health issues related to the injury. The doctor should then assess how these underlying conditions might be affected by work-related factors.
  • Is the opinion clear and definitive?
OWCP requires that the doctor provide an opinion with “reasonable medical certainty.” Phrases like “could,” “may,” or “might” are considered speculative and insufficient to establish causality. The doctor’s opinion should state, for example, that “to a reasonable degree of medical certainty, work-related factors caused the injury.”

Federal Injured Workers must work closely with their medical doctors to ensure that the medical report submitted meets OWCP’s standards or the report can cause delays and maybe a denial. Once the report is accurate, it should be submitted to OWCP as soon as possible, either by mail or online.