Get Your Free Initial Consultation
Elements of a Claim
What OWCP Must Find Before a Claim Is Accepted
Filing a claim does not automatically establish entitlement to benefits under the Federal Employees’ Compensation Act (FECA). Before accepting a claim, the Office of Workers’ Compensation Programs (OWCP) must find that the file satisfies five separate requirements. Under 20 C.F.R. § 10.115, OWCP cannot accept a claim that establishes any less. The claimant has the burden of proving each requirement with reliable, probative, and substantial evidence.
Contact Us
Be Responsive
Understanding What’s Missing
If you received a development letter or denial, begin by identifying the exact element OWCP says is missing. A denial based on causal relationship requires a different response from a denial based on fact of injury or performance of duty. The OWCP will be specific about the elements for which they need additional information. Silence or ignoring these requests will not help the filing process.
The Five Elements
The five elements address when the claim was filed, who filed it, what happened, whether it occurred in the performance of duty, and whether the medical evidence connects the diagnosed condition to the accepted work event or employment factors. Filing the right form at the beginning is important. Even if a development letter is sent, it does not shift the burden of proof. The claimant is still responsible for submitting the factual and medical evidence.
Form CA-1
This form is used for traumatic injuries that happened during a one-time incident or from repetitive motion during a single shift.Form CA-2
This form is used for occupational disease claims from exposure to activity over more than one work shift.Form Use
Using the wrong form can complicate claim processing, and result in a denial on a justifiable claim.Timing
There are different timelines for filing forms for traumatic injuries and receiving COP. Be sure to follow the correct procedures.
Elements Checklist
Timely Filing
A FECA claim must be filed within three years of the injury. There are exceptions to this when the employing agency had actual knowledge of the injury within 30 days or when the claim involves a latent occupational disease. A claim for COP requires Form CA-1 to be filed within 30 days of the injury. The latent disease rule may affect when the three-year filing period begins. It can start when the employee became aware of, or reasonably should have become aware of, the relationship between the condition and federal employment. Continued exposure may also affect the relevant date. Employees should report the injury and file promptly rather than rely on an exception.
Federal Civil Employee Status
The claimant must have been a civil employee of the United States within the meaning of 5 U.S.C. § 8101(1) at the time of the injury. This element is often established through federal employment records. The key question is the claimant’s covered employment status when the alleged injury or exposure occurred. FECA generally provides workers’ compensation coverage for civilian federal employees who experience employment-related injuries or occupational diseases.
Fact of Injury
Evidence must establish that the claimed incident, activity, or employment exposure actually occurred. This may require a detailed statement from the employee, witness statements, agency records, incident reports, or other evidence consistent with the circumstances described. The medical evidence must establish a diagnosed condition in connection with the event or employment factors. A description of symptoms alone may not establish the medical portion of fact of injury. Without a diagnosis, OWCP may find that fact of injury has not been established.
Performance of Duty
OWCP considers whether the injury arose in the course of employment, including the relevant time, place, and activity. Assigned duties generally fall within this analysis. Certain activities incidental to employment and some injuries occurring on federal premises may also qualify. Off-duty incidents and injuries occurring while traveling to or from work require a fact-specific review. The physical location of the incident is important, but it is not the only consideration. The file should explain what the employee was doing, why the employee was there, and how the activity related to the employment.
Causal Relationship
Causal relationship is the medical connection between the accepted work event or employment factors and the diagnosed condition. The supporting medical opinion must be rationalized, meaning the physician should identify the accurate work history, provide a diagnosis, and explain medically how the event or exposure caused or contributed to the condition. It may involve direct causation, aggravation, or acceleration of a preexisting injury, or precipitation of a latent condition. A statement that the condition is “work-related” without supporting reasoning may not be enough.
If the employee is claiming wage-loss compensation, the medical evidence must also establish that the accepted condition caused disability for work during the claimed period.
Which Element Usually Fails?
Establishing a causal relationship is a frequent problem because it requires more than an injury report, diagnosis, or a physician’s conclusion. The medical report must explain the connection between the accepted work incident and the diagnosed condition. A physician may have treated the employee appropriately, but provided too little reasoning for OWCP’s claims process, such as omitting the work history, relying on an inaccurate description of the event, or stating that a condition is work-related without describing the medical mechanism.
Responding to a Development Letter
A development letter means OWCP has reviewed the initial submission and determined that the file does not yet contain enough evidence to accept the claim. The letter should identify the missing evidence, and the response should directly address the deficiencies OWCP describes. It might ask for:
A clearer description of the work incident or employment factors
Statements addressing inconsistencies in the record
Witness or agency documentation
A physician’s reasoned causal relationship opinion
A medical diagnosis
Medical evidence addressing disability for wage-loss compensation
When Is a Missing Element Fixable?
Read the development letter or denial closely. It should identify the element OWCP found deficient. Determine whether reliable factual or medical evidence can address the deficiency, such as a supplemental physician report, missing agency records, or a witness statement. After a denial, use the appropriate review procedure and observe its deadlines. Whether a deficiency can be corrected depends on the facts, the available evidence, and the applicable legal requirements.
Evaluating the Missing Element in Your Claim
A denial doesn’t mean that OWCP disagreed with the claim as a whole. It often means that one required element was not established by the evidence in the file. Understanding that element is the starting point for deciding what to do next. If your claim has been denied and you are unsure what to do next, contact Aumiller Lomax for a free telephone consultation. We can discuss the reason for the denial, explain your options, and give you a candid assessment of whether representation would be helpful.
Partner With a Team That Understands the System