part6-35

6.800.1 
Workers’ Compensation Program

6.800.1.1 
(01-01-2004)
Purpose and Content

  1. This Section explains all general aspects of the workers’ compensation
    program as it applies to the Internal Revenue Service.

  2. It provides the legal basis and administrative oversight of the program.

  3. The Section includes procedures and guidance for managers and other
    interested parties in processing and managing workers’ compensation
    claims.

  4. It includes several helpful exhibits, which can be used as sample guides
    and informational items.

  5. This Section is subject to revision as the Federal Employees Compensation
    Act (FECA) and regulations are amended periodically and as the Internal Revenue
    Service (IRS) and Workers’ Compensation Center (WCC) procedures are
    changed. The electronic filing option for Forms CA-1 and CA-2 was effective
    on October 1, 2001 and these procedures are included.

  6. Other procedures information and forms are available in the Guide to
    Workers’ Compensation Procedures on the ERC website at http://erc.web.irs.gov.
    Just insert
    “workers compensation”
    in the search option.

6.800.1.2 
(01-01-2004)
Legal Basis and IRS Program Oversight

  1. The IRS is fully committed to providing administration of the FECA in
    a manner that will provide employees who are injured while on duty all benefits
    to which they are entitled. Administration of the injury compensation program
    will also reflect sound management and fiscal practices, with emphasis on
    minimizing costs of program benefits and maximizing the value to the function
    of each injured employee and his/her productivity consistent with applicable
    law and regulation. The FECA, under the authority of United States Code (5
    U.S.C. 8101) and the Code of Federal Regulations (20 C.F.R. 10) provides compensation
    benefits to civilian employees of the United States for disability due to
    personal injury or disease sustained while in the performance of duty. The
    FECA also provides for the payment of benefits to dependents if a work-related
    injury or disease causes an employee’s death. The FECA is intended to
    be remedial in nature, and proceedings under it are non-adversarial.

  2. Benefits provided under the FECA constitute the sole remedy against
    the United States for work-related injury or death. A Federal employee or
    surviving dependent is not entitled to sue the United States or recover damages
    for such injury or death under any other statute. The Assistant Secretary
    of Labor for Employment Standards of the Department of Labor (DOL) has delegated
    the responsibility for administration and implementation of Chapter 5 of the
    FECA to the Director, Office of Workers’ Compensation Programs (OWCP).
    Therefore, OWCP of the DOL alone determines whether the employee is entitled
    to benefits and compensation under the FECA.

  3. The FECA mandates that all initial claims, whether via electronic filing
    or on paper forms (CA-1 and CA-2), must be submitted to the DOL no later than
    10 workdays from the agency’s receipt of the claim. The agency’s
    receipt date is the date the manager receives the signed claim summary sheet
    or form from the injured worker. Forms CA-7 for wage loss compensation and/or
    Form CA-2a, Notice of Recurrence, are to be submitted within 5 workdays of
    the agency’s receipt.

  4. The WCC provides all workers’ compensation services for the IRS
    through a variety of state-of-the-art, user-friendly modalities. The program
    uses automation and telecommunications systems to ensure information access
    and services for all employees and managers Servicewide. All personnel responsible
    for administering FECA ensure the protection of claimants’ rights and
    that management exercises appropriate options timely so that workers’
    compensation program costs are effectively controlled.

  5. The WCC is designed to increase the effectiveness of the IRS’s
    workers’ compensation program through program integration and collaboration
    with the Service’s Special Accommodations Program for employees with
    disabilities. Their goal is to ensure equity between employees with disabilities
    and employees who sustain temporary or permanent disabilities from work related
    injuries. All employees, regardless of disabilities, are entitled to job accommodations
    and opportunities for full employment if work is available.

  6. Regulations in 20 C.F.R. 10.16 state that criminal penalties apply for
    wrongfully impeding a FECA claim. See IRM 6.800.1.11,
     Controlling the Claim, paragraph (6).

6.800.1.3 
(01-01-2004)
Responsibilities of Employees

  1. The responsibilities of all employees are as follows:

    1. Report all job-related injuries immediately.

    2. Provide all required information, including medical documentation. Advise
      physician that light duty is available.

    3. Keep management informed of his or her medical status and promptly report
      any changes in medical or physical status.

    4. Return to work as soon as possible when medical documentation indicates
      no longer totally disabled.

    5. Cooperate with management to identify reasonable accommodations to return
      to gainful employment.

    6. Comply with agency regulations to report any criminal act or violation
      of the Code of Ethics.

    7. Ensure that federal health and life insurance premiums are deducted from
      compensation or paid to the carrier when filing claims.

  2. Additional information is available through the ERC web site at http://erc.web.irs.gov
    in the Guide to Workers’ Compensation Procedures.

6.800.1.4 
(01-01-2004)
Responsibilities of Managers

  1. The responsibilities of all managers are as follows:

    1. Ensure that injured employees receive prompt and appropriate medical attention.

    2. Have up-to-date knowledge of workers’ compensation benefits.

    3. Properly complete and timely submit appropriate injury forms.

    4. Maintain a supply of all required forms. Forms can be ordered through
      the servicing CIDS site. Use the catalog numbers that appear in the
      “Other Government Agency Items”
      section of Document 7130, IRS Published Products Catalog. The CIDS toll-free telephone
      number is 1-800-829-2437. Most CA-forms are now available for printing on
      the ERC web site or the Intranet. The address is http://erc.web.irs.gov and
      is available in the Guide to Workers’ Compensation Procedures.

    5. Work with Safety officials and other personnel to determine the cause
      of accidents and maintain a supply of accident reporting forms.

    6. Understand the criteria and procedures for controverting, challenging
      or clarifying claims believed to be questionable or unjustified. FECA regulations
      provide that absent a full reply from the agency, DOL will accept the claimant’s
      statements/allegations as factual and assume that the agency fully concurs
      with these statements.

    7. Inform WCC of any proposed, pending or current adverse actions involving
      the claimant.

    8. Advise the employee of his or her obligation to return to work as soon
      as possible and to keep the manager informed of his or her medical status.

    9. Comply with agency regulations to report any criminal act or violations
      of the Code of Ethics.

    10. Monitor the employee’s medical progress and duty status by obtaining
      periodic medical reports from the employee’s physician. Provide the
      Duty Status Form to the employee for each doctor’s visit and instruct
      him/her to return it within 48 hours.

    11. Work with WCC in monitoring continuation of pay for 45 days.

    12. Provide or develop jobs commensurate with employee’s skills, medical
      limitations and earnings in order to provide reasonable accommodations.

    13. Ensure that injured seasonal employees who are unable to work are carried
      in LWOP-OWCP status.

    14. Carry the injured employee on the employment rolls, where feasible, with
      the goal of returning him or her to duty as soon as possible. This will facilitate
      tracking the employee’s recovery and will simplify the administrative
      process involved in fulfilling the agency’s obligation to restore the
      injured employees to gainful employment.

    15. Provide a copy of the SF-50, Notification of Personnel
      Action      , to the WCC case manager when the employee is terminated for
      any reason from IRS.

  2. Additional information is available through the ERC at http://erc.web.irs.gov
    in the Guide to Workers’ Compensation Procedures.

6.800.1.5 
(01-01-2004)
Responsibilities of WCC

  1. The responsibilities of the WCC are as follows:

    1. Advise managers and employees of their responsibilities.

    2. Properly process and submit initial claims via electronic transmission
      to DOL, when appropriate, and complete other applicable sections of injury
      forms within time limitations.

    3. Work with Safety officials and other personnel to determine the cause
      of an accident.

    4. Monitor claims and work with managers to controvert/challenge claims.

    5. Comply with agency regulations to report any criminal act or violations
      of the Code of Ethics.

    6. Track pending and approved claims, including COP related cases, to ensure
      compliance of FECA rules.

    7. Monitor approved claims and medical evidence to determine earliest practical
      return to duty date.

    8. Work with managers to provide light duty and reasonable accommodations
      for partially disabled employees.

    9. Receive, review, approve and monitor leave buy back requests.

    10. Train managers concerning the workers’ compensation program, adhering
      to budget restraints.

  2. Additional information is available through the ERC at http://erc.web.irs.gov
    in the Guide to Workers’ Compensation Procedures.

6.800.1.6 
(01-01-2004)
Filing Claims

  1. Upon notification of an injury, the manager must take time to listen
    and discuss with the employee the nature of the injury. He or she will ascertain
    how, when and where it took place, along with the names of any witnesses,
    if appropriate. Once these facts are obtained and an investigation of the
    work areas and the
    “type”
    of injury is identified, the
    manager will suggest that the employee e-file the initial claim through the
    Safety and Health Information Management System (SHIMS), mandated August 2002
    for Treasury-wide usage by the Treasury Secretary. If a computer is unavailable,
    the manager may provide the appropriate form(s) to the employee for submission.

    1. Form CA-1, Federal Employee’s Notice of Traumatic
      Injury and Claim for Continuation of Pay/Compensation      . This form is
      for traumatic injury cases only. A traumatic injury is a wound or other condition
      caused by external forces, including physical stress or strain caused by a
      specific event or incident, or series of events within a single work shift.
      The injury is identifiable as to time and place of occurrence and part or
      function of the body affected. This is the criterion that sets a traumatic
      injury apart from an occupational disease. See Forms/Pubs on IRWeb.

    2. Form CA-2, Notice of Occupational Disease and Claim for
      Compensation      . An occupational disease is produced by systemic infections,
      continued or repeated stress or strain, exposure to poison fumes, noise, etc.,
      in the work environment over a longer period of time. To qualify as a disease,
      the injury must be caused by exposure or activities on more than one workday
      or shift. See Forms/Pubs on IRWeb. OWCP has developed checklists (Forms CA-35)
      to assist employees and agency personnel in gathering and submitting material
      required for adjudication of occupational disease claims. See ERC website
      at http://erc.web.irs.gov in the Guide to Workers’ Compensation Procedures
      – Forms CA-35 (Checklists for Occupational Disease Claims).

    3. Form CA-2a, Federal Employee’s Notice of Recurrence
      of Disability and Claim for Continuation of Pay and Compensation.       A
      recurrence of an injury (traumatic or occupational) is defined as a spontaneous
      return or increase of disability due to a previously accepted injury, without
      intervening cause. See Forms/Pubs on IRWeb.

    4. Form CA-7, Claim for Compensation on Account of Traumatic
      Injury or Occupational Disease      . This form is used to claim compensation
      for wages lost due to a work-related traumatic injury after the expiration
      of COP or for occupational disease claims. The CA-1 or CA-2 must be an approved
      claim before the CA-7 can be processed. The CA-7 is submitted biweekly until
      the claimant is notified by OWCP that no additional Forms CA-7 are needed
      or until the claimant returns to duty. It is also used for leave buyback and
      schedule award requests. CA-20, Physician’s Report,
      is attached to the CA-7. See Forms/Pubs on IRWeb.

    5. Form CA-16, Authorization for Examination and/or Treatment
      . This form is used to authorize initial medical treatment in traumatic
      injury cases This form allows initial payment of medical bills to the provider
      of medical services by the DOL office, in accordance with their schedule.
      See the manager who can order this from the local CIDS site.

    6. Form CA-35, Evidence Required in Support of a Claim for Occupational Disease
      or Illness. This form is used in developing an occupational disease claim.
      See ERC website at http://erc.web.irs.gov in the Guide to Workers’ Compensation
      Procedures – Forms CA-35.

    7. Form CA-17 (or the WCC devised form), Duty Status Report
      . The agency can use this form for every doctor’s appointment
      to request information from a physician, particularly regarding the employee’s
      ability to return to work and when restrictions may be involved. See Exhibit 6.800.1-1, Duty Status Report. See also
      http://ciweb/sections/strategy/human_resources/human_resources.htm for a special
      Criminal Investigation form.

    8. OWCP-1500 or HCFA-1500, Health Insurance Claim Form.
      This form is used to request payment for most medical bills. All doctor bills
      not directly related to a hospital stay must be submitted on the OWCP-1500.
      Failure to do so will result in unpaid bills that will be returned to the
      doctor and will become the responsibility of the employee.

    9. UB-52 or UB-92. This form is used by hospitals to request payment for
      services rendered.

    10. Form CA-915, Claimant Medical Reimbursement Form.
      This form, which may be obtained from your DOL (OWCP) district office or via
      the DOL website at www.dol.gov/esa/regs/compliance/owcp/forms.htm is used
      for requesting reimbursement for medical payments on accepted claims when
      the employee has paid the charges.

    11. SF-91, Motor Vehicle Accident Report. This form
      is used to report employee motor vehicle accidents. Obtain it from the local
      Safety Officer.

    12. SF-1199A,Direct Deposit Sign-up. This form is used
      for payment of compensation and may be obtained from local financial institutions.

  2. Additional information is available through the ERC web site at http://erc.web.irs.gov
    in the Guide to Workers’ Compensation Procedures.

6.800.1.7 
(01-01-2004)
Traumatic Injury Claim Procedures (Form CA-1) (Includes Paper Claim
Methods)

  1. The manager should promptly authorize treatment by giving the employee
    a properly executed Form CA-16, Authorization for Examination
    and/or Treatment    , within 7 days of the employee’s injury, shorter
    timeframe if possible. To be valid, a Form CA-16 must give the full name and
    address of the physician or medical facility, must be signed and dated by
    the authorizing official (usually the manager), and must show his or her title
    and local phone number. With emergencies, when there is no time to complete
    a Form CA-16, the manager may authorize treatment by telephone and then forward
    the completed CA-16 to the medical provider within 48 hours. If the employee
    has already been seen by the physician, the Form CA-16 is not issued retroactively.
    Managers are encouraged to use discretion in issuing this form if an employee
    has reported an injury several days after the fact, or did not request medical
    treatment within 24 hours of the injury. The CA-16 obligates the agency to
    pay for medical treatment for a period of 60 days. Therefore, in cases of
    a doubtful nature (for example, injury was not witnessed, injury may not be
    work related, late reporting of injury by employee), Item 6(B) (2) of the
    form should be completed authorizing an initial examination only, and indicating
    the doubt.

  2. Advise the employee that he or she may choose a physician within a 25-mile
    radius of the workplace or the employee’s home, or reimbursement may
    be terminated. Under FECA law, physicians can be extended to include clinical
    psychologists, optometrists and chiropractors (for treatment of manual manipulation
    of the spine to correct subluxation, shown by x-ray to exist). Inform the
    employee that a change of physician is only authorized with prior OWCP approval.

  3. In accordance with the IRS and NTEU national agreement, managers should
    provide Publication CA-550, FECA Questions and Answers about
    the Federal Employees Compensation Act    . The CA-550 is available through
    the ERC at http://erc.web.irs.gov and DOL at www.dol.gov/dol/esa/public/regs/compliance/owcp/feca550q.htm.
    You may also refer the employee to Document 9669, Employee
    Personnel Resource Guide     (Catalog #22761G) or on the ERC website for
    guidance.

  4. Notify WCC by telephone immediately after the injury at 804-771-2900.
    State
    “I am calling to report an injury.”
    Be prepared
    to report all the facts of the injury.

  5. Advise the employee to e-file the claim. See
    IRM 6.800.1.9.    for procedures on E-Filing Methods for CA-1 and CA-2.
    If there is no computer availability for the employee, provide the employee
    with Form CA-1 for reporting the injury. See IRM
    6.800.1.6     for information on Filing Claims.

  6. If electronic filing is not an option, the claim should be submitted
    as a paper claim. After the employee completes the front of the form it should
    be submitted to the manager who is responsible for completing the supervisor’s
    report located on the back of the form. The form should then be submitted
    via fax transmittal to WCC at 804-771-2270 for review.

  7. The manager should make additions/corrections to his/her portion of
    the original form at the advice of the WCC representative. During the contact
    call from the WCC, the manager will be advised to overnight mail Form CA-1
    and all other pertinent information to the WCC within 2 workdays of written
    receipt of the signed Form CA-1. FECA law requires receipt by DOL of the Form
    CA-1 within 10 workdays of the manager’s written receipt of the notice
    of injury. The WCC address is: Internal Revenue Service, Workers’ Compensation
    Center, OS:A:PS:C:W, 11 South 12th Street, #110, Richmond, VA 23219-4035.

  8. The
    “Receipt of Notice of Injury”
    should be completed
    and signed by the supervisor and returned to the employee. A copy should be
    attached to the original CA-1 and sent to the WCC.

  9. The employee should be advised that it is his/her responsibility to
    provide medical evidence as to his/her duty status and it is his/her obligation
    to return to work as soon as possible. The manager should issue the Duty Status
    Report, See Exhibit 6.800.1-1, along with
    the Form CA-16, prior to the initial doctor’s appointment. The employee
    must return the Duty Status Report or other medical evidence immediately after
    examination or at the start of the employee’s next scheduled work shift
    if medically able to do so. (If the employee is unable to work, the form must
    be mailed immediately to the manager.) Upon receipt, the manager should forward
    it to WCC.

  10. Inform the employee that he/she is obligated according to FECA regulations
    to advise the physician of the fact that limited duty is available. If the
    employee cannot yet return to work, the manager should monitor the employee’s
    medical progress and duty status by obtaining periodic medical reports every
    2 weeks. See Exhibit 6.800.1-2, Sample Letter to
    Physician Reporting Work Restrictions.

  11. If applicable, track continuation of pay for up to the 45 days allowed.
    See IRM 6.800.1.10,Continuation of Pay.
    Consult with WCC for advice and send them a leave analysis breakdown for the
    duration of the injury. Do not permit the employee to work overtime, compensatory
    time, credit hours or flexi-tour while on light/limited duty due to medical
    restrictions unless these specialized duty hours are specified in writing
    by the physician.

  12. Carefully review the dates of disability on the Duty Status Report.
    If the employee can return to work, the manager must furnish the employee
    with a written description of the specific duties, physical requirements and
    date of availability of the limited duty assignment.
    See Exhibit 6.800.1-3.    , Sample Job Offer Letter. Have the employee
    sign the letter as accepting or declining the light duty offer and send a
    copy to WCC.

  13. Additional information is available at the ERC web site at http://erc.web.irs.gov
    through the Guide to Workers’ Compensation Procedures.

6.800.1.8 
(01-01-2004)
Occupational Illness Claim Procedures (Form CA-2) (Includes Paper
Claim Methods)

  1. Occupational disease/illness claims are those which occur over a period
    of more than one day. The procedures for submitting the claim are the same
    as those for traumatic injuries with the same 10 workday time limitations
    as for traumatic injuries. See IRM 6.800.1.7, Traumatic
    Injury Claim Procedures (Form CA-1), paragraphs 5-13.

  2. In addition, the employee and the manager should complete an appropriate
    corresponding checklist, Form CA-35. See the ERC website at erc.web.irs.gov
    in the Guide to Workers’ Compensation Procedures. Forms CA-35 have been
    devised for various conditions in order to facilitate submission of evidence.
    The employee completes his/her portion of the checklist and submits it to
    the manager, who then completes the
    “employing agency”
    portion
    of the checklist. All should be sent to WCC, but do not delay submission of
    the CA-2 while awaiting supporting documentation for the checklist.

  3. Because CA-2 claims can be more complex cases, the DOL can take up to
    6 months and occasionally longer to determine acceptance or denial.

  4. Form CA-16 is not issued for occupational disease claims. Obtain medical
    documentation as for CA-1 claims to return the employee to work.

  5. Continuation of pay is not available for occupational disease claims.
    If the claim is accepted, the employee can file a Form CA-7 for wage loss.
    See IRM 6.800.1.14, Claim for Wage Loss
    Compensation (Form CA-7).

  6. Additional information is available at the ERC web Site at http://erc.web.irs.gov
    through the Guide to Workers’ Compensation Procedures.

6.800.1.9 
(01-01-2004)
E-Filing Method for Forms CA-1 and CA-2

  1. It is not necessary to file both electronically and via hard copy, since
    this merely creates a duplicate claim. At the beginning of filing a claim,
    select one method only.

  2. IRS employees may file Forms CA-1 and CA-2 electronically via the Safety
    and Health Information Management System (SHIMS). SHIMS is a web-based application
    owned by Treasury and is accessible through the Treasury Intranet via the
    ERC. SHIMS is also used for filing safety incident reports. The benefits in
    using the e-file method for filing claims include less chance of errors, faster
    claims processing, automatic safety incident completion while filing claims
    and computer access.

  3. SHIMS is designed in a user-friendly question and answer format. By
    answering the questions the system will determine whether the appropriate
    claim form is a CA-1 or CA-2.

  4. To file, access SHIMS. The employee clicks on the ERC web link at http://erc.web.irs.gov
    and accesses the SHIMS link on the left index.

  5. The employee selects from the menu
    “File a claim,”
    after
    which he/she will be given his/her own secure unique claim number (called
    a tracking number) available only to the employee and his/her manager.

  6. The employee collects the summary of information needed for filing and
    continues to file, print and manually sign and certify the printed claim summary
    sheet, following the instructions.

  7. The employee hands the printed summary sheet to the manager who then
    electronically completes his/her portion of the claim and signs and certifies
    it immediately afterwards. The claim is electronically submitted to WCC.

  8. The manager prints a copy of the summary sheets for his/her records
    and ensures the employee maintains the original
    “Receipt of
    Notice of Injury.”

  9. The manager must mail the signed copies of the employee and manager
    summary sheets to the WCC immediately. If any item needs correction, contact
    WCC immediately.

  10. Additional information is available at the ERC web site at http://erc.web.irs.gov
    through the Guide to Workers’ Compensation Procedures.

6.800.1.10 
(01-01-2004)
Continuation of Pay

  1. Continuation of pay (COP), FECA leave, is the continuation of an employee’s
    regular pay by the employing agency when absence is directly related to the
    injury. The manager must advise the employee of the right to elect continuation
    of regular pay or to use annual and/or sick leave if the injury is disabling.
    The employee may not buy back leave during the 45 day entitlement period.
    See IRM 6.800.1.15, Leave Buy Back.

  2. COP is applicable in traumatic injury cases only for a maximum of 45
    calendar days. The days do not have to be used consecutively, but must be
    used within 45 calendar days from the day of the injury or within 45 calendar
    days of the date the employee first returned to work following the initial
    disability, whichever is later.

  3. To qualify for COP, an employee must file a CA-1 within 30 days of the
    date of injury and must submit medical evidence within 10 calendar days of
    claimed COP or date disability begins, whichever is later. The COP selection
    must be selected on the CA-1 initial filing.

  4. Management must first notify the WCC before authorizing COP. If the
    claim is controverted/challenged for any of the reasons listed on the CA-1
    instructions (#36), the agency may refuse to pay COP.
    See IRM 6.800.1.12,     Controversion/Nonconcurrence. The medical must
    also support that the employee is not fit for duty due to his/her workplace
    injury.

  5. COP usually starts the first day of absence following the date of injury
    (the only exception being if the injury occurred before the actual work shift
    began). On the day of the accident, an injured employee’s absence from
    work in order to seek medical attention and take time because medical documentation
    indicated total disability is charged to administrative leave. COP is counted
    in one-day increments, even if the employee worked a portion of the day.

  6. Refer to the Time and Leave Handbook, Document
    11103, Catalog #27297B, Federal Employees’ Compensation Act Section,
    for more details on how to report and count COP days. The website is http://erc.web.irs.gov/DOCS/2002/AWSS/PS/Timekeeping/Timekeepingindex.html

  7. A workers’ compensation case manager at the WCC will assist you
    in closely monitoring the duration of COP. Dates of eligibility for COP should
    be compared with medical reports regarding an employee’s inability to
    work. In cases where the employee has elected sick or annual leave, the employee
    will be placed in a leave status. However, medical documentation is required
    for all absences, regardless of leave type chosen. For every week when an
    employee has an injury related absence, the manager should send to WCC a copy
    of payroll Form 3081.

  8. COP is not authorized for occupational illnesses (Forms CA-2).

  9. Additional information is available at the ERC web site at http://erc.web.irs.gov
    through the Guide to Workers’ Compensation Procedures.

6.800.1.11 
(01-01-2004)
Controlling the Claim

  1. The management of the claim from submission to adjudication by DOL is
    the responsibility of the WCC and IRS management. All claims and allied correspondence
    except medical bills must flow through the WCC before being forwarded to DOL.
    This includes claims filed with no lost time and no medical expense.

  2. Upon receipt of the SHIMS Claimant Report, or the CA-1, CA-2 or CA-2a,
    the manager will prepare a case folder to be maintained in his/her office.
    Also, the WCC will maintain a case file at its site.

  3. Investigation of the claim by the immediate manager should start immediately
    upon notification that an injury/illness has occurred. The Safety Officer
    should be a part of this investigation. The investigation should either substantiate
    the claim or raise doubt as to the validity of the claim. Some sources and
    expertise available for the investigation are:

    • Injured employee

    • Witnesses

    • Immediate manager and section chief

    • Treating physician

    • Safety Officer

    • Local law enforcement agency

    • On-site occupational health nurse

  4. A determination will be made whether or not to controvert or question
    the claim. If there is no basis for controversion, the claim and all supportive
    documentation will be immediately forwarded to the WCC. If the investigation
    reveals there are questionable circumstances, the manager will prepare a statement
    outlining the facts that will be forwarded with the claim, if possible, to
    the WCC. This may be forwarded later, so as not to jeopardize the two workday
    claim timeframe. This topic is also discussed in the following subsection.
    See IRM 6.800.1.12, Controversion/Nonconcurrence.

  5. Upon completion of the investigation, the claims package will be prepared
    and forwarded to the WCC within two workdays from the date the supervisor
    is notified of an injury or illness. The package must contain the following
    applicable items and should be sent by overnight service:

    1. Properly completed Claim Form CA-1, CA-2 or CA-2a, OR, if electronically
      filed, signed and dated summary sheets.

    2. Diagram of the accident site to identify its exact location and cause.

    3. Copy of Motor Vehicle Accident Report, Form SF-91, if applicable.

    4. Complete and up-to-date medical report, including dates of the examination
      and treatment, history of injury given by the employee to the physician, detailed
      description of findings, results of all x-ray and laboratory tests, diagnosis,
      clinical course of treatment followed, and the physician’s opinion supported
      by medical rationale as to the causal relationship between the employee’s
      condition or disability claimed and the injury reported; the physician’s
      discussion of the issue of causal relationship is crucial to the claim.

    5. Light duty job offer and duty status report.

    6. Leave audit (breakdown day by day of time worked and leave taken) for
      the previous 12 Months. Contact the WCC case manager for advice.

    7. If applicable, complete OWCP Claim Questionnaire, which is for use in
      cases of suspected fraud and/or abuse. See Exhibit
      6.800.1-4,       OWCP Claim Questionnaire (Key Indicators for Fraud and
      Abuse). See Exhibit 6.800.1-5, OWCP Claim
      Questionnaire. See Exhibit 6.800.1-6, Fraud
      Referral Letter.

    8. Routing slip to indicate any pending disciplinary action, and

    9. Position description.

  6. The submission of the claim should not be unduly delayed. If medical
    reports and supportive information are not readily available, a completed
    e-claim or paper claim form must be sent to the WCC in order for a claim number
    to be assigned and the processing of the claim to be initiated. The regulations
    in 20 C.F.R. 10.16 provide that any person charged with the responsibility
    of making reports in connection with an injury who willfully fails, neglects,
    or refuses to do so; induces, compels, or directs an injured employee to forego
    filing a claim; or willfully retains any notice, report, or paper required
    in connection with an injury; is subject to administrative proceedings (criminal
    penalties).

  7. Additional information is available at the ERC web site at http://erc.web.irs.gov
    through the Guide to Workers’ Compensation Procedures.

6.800.1.12 
(01-01-2004)
Controversion/Nonconcurrence

  1. “Controvert”
    means to dispute COP. An employee can
    file a claim with OWCP and begin collecting COP even though the agency initiates
    the controversion of the COP. Also, If the preliminary review of the CA-1,
    CA-2, CA-2a, witness statement or medical report suggests that the claim is
    unjustified, the agency may controvert/challenge the entire claim or any portion
    of it.

  2. Controversion/challenge of a claim when it is filed is the agency’s
    only opportunity to notify OWCP that it disagrees with the claim being filed.
    If a claim seems unjustified, only the agency can clarify the circumstances
    effectively and immediately. FECA regulations provide that, absent a full
    reply from the agency, DOL can accept the claimant’s statements/allegations
    as factual and can assume that the agency fully concurs with them. The agency
    has no appeal rights in the claim’s adjudication process; therefore,
    it is essential that all pertinent information be provided to DOL prior to
    the adjudication of the claim.

  3. If it is determined that the claim or any portion of it should be controverted/challenged,
    a controversion or nonconcurrence package will be prepared. The package should
    contain, at a minimum, the following:

    1. A statement signed by the manager or authorized official summarizing specific
      factual reason(s) for controversion, and

    2. Exhibits, such as statements of witnesses, investigative reports, photographs,
      official documents, etc.

  4. The controversion package should be submitted to the WCC with the claim
    package, if possible. This will allow DOL to act upon the claim in a timely
    manner. However, even if elements of the controversion package are not readily
    available, the claim form and available documentation must be submitted to
    the WCC within two days of the injury. If you cannot meet the two-day deadline,
    contact WCC to request an extension. The controversion package should also
    include a statement that indicates whether evidence will be submitted upon
    receipt. This evidence should then be forwarded as soon as possible to expedite
    the adjudication of the claim.

  5. Additional information is available at the ERC web site at http://erc.web.irs.gov
    through the Guide to Workers’ Compensation Procedures.

6.800.1.13 
(01-01-2004)
Appeal Rights

  1. The DOL makes formal decisions on whether injured employees are entitled
    to benefits and compensation under the FECA. Negative decisions give a reason
    for denial and include a description of employee appeal rights.

  2. If the employee disagrees with the DOL’s formal decision, he/she
    can appeal it by requesting either a:

    1. hearing,

    2. reconsideration, or

    3. review by the Employee’s Compensation Appeals Board.

  3. Employees may request only one form of appeal at a time and each appeal
    has time limits as prescribed by DOL.

  4. Employees or managers wishing information regarding the appeal process
    may contact WCC for more information.

6.800.1.14 
(01-01-2004)
Claim for Wage Loss Compensation (Form CA-7)

  1. If an employee sustained a traumatic injury and the employee cannot
    return to work at the end of a 45-day period of COP, the employee should be
    placed in LWOP (OWCP) and file a claim for compensation from DOL. The following
    procedures apply to claims for compensation:

    1. At the end of the 45-day period of COP (applicable for Form CA-1) or upon
      acceptance of Form CA-2, forward a Standard Form (SF) 52,
      Personnel Processing Action      , to the servicing personnel office, placing
      the employee in an LWOP-OWCP status. Forward a copy of the SF-52 to the WCC.
      Note that there is a three-day waiting period for which no compensation is
      paid unless the disability lasts more than 14 calendar days.

    2. The employee is to complete the front of the Form CA-7 and submit the
      form and supporting medical documentation to the manager. For intermittent
      absences, Form CA-7a, Time Analysis, is required. Both
      forms are available on the ERC web site at http://erc.web.irs.gov through
      the Guide to Workers’ Compensation Procedures. The manager is to complete
      the back of the form and then forward the completed CA-7 with all relevant
      medical evidence to the WCC. Because this is the form which sets the compensation
      payment, please ensure that all necessary blanks are completed fully and that
      the claim is filed immediately. Payments are unnecessarily delayed when items
      are incomplete on the form. DOL pays at the rate of 75% of the claimant’s
      salary, for those injured employees with children under 19 (or under qualified
      schooling) and/or a spouse. Those employees without qualifying dependents
      are paid at 66 2/3% of their salaries. Compensation paid by DOL is not subject
      to income tax.

    3. If the disability is expected to continue beyond the period claimed on
      the initial CA-7, have the employee complete subsequent Forms CA-7 every 2
      weeks until he/she returns to work on limited/regular duty, or until otherwise
      directed by the WCC or the servicing DOL office.

    4. Contact the employee’s WCC case manager by telephone immediately
      after the claimant returns to work. Telephone notification is critical to
      prevent a possible overpayment by DOL. Prepare a written job offer denoting
      any changes in the job to fit the employee’s restrictions, using See Exhibit 6.800.1-3,Sample Job Offer Letter.

    5. Additional information is available at the ERC web site at http://erc.web.irs.gov
      through the Guide to Workers’ Compensation Procedures.

6.800.1.15 
(01-01-2004)
Leave Buy Back

  1. A leave buy back or leave restoration is a process by which the sick
    or annual leave the employee used during his/her injury period, including
    any leave bank hours used, is re-purchased and restored to his/her personal
    leave account. Credit and/or compensatory hours may not be repurchased.

  2. These are some of the criteria for acceptance:

    1. A claim must be approved by DOL prior to requesting a leave buy back.
      Medical documentation must be submitted to support all dates claimed.

    2. The leave buy back must be initiated within one year of the date OWCP
      approved the claim or one year from the last date that leave was used for
      a job-related absence, whichever is later.

    3. Employees will have only one opportunity to repurchase leave used for
      each OWCP injury.

    4. The minimum amount of time accepted for a leave buy back is 10 hours.

    5. The employee must be on the active IRS rolls.

    6. Claims must be initiated before third party settlements in order to be
      approved for leave buy backs.

    7. Leave buy backs requesting that a check be sent directly to the claimant
      will not be approved.

    8. Consult WCC for any unusual circumstances.

  3. To apply, the employee must submit Forms CA-7 and CA-7a with supporting
    medical documentation (if not previously furnished) to the WCC. These should
    include specific dates and the amount of leave requested to be repurchased.

  4. In the leave buy back process, the claimant must pay the IRS the difference
    between the total cost of the leave buy back and the DOL contribution (based
    on 2/3 or 3/4 compensation rates). This compensation
    pay rate which is determined by DOL is the salary in effect on the date of
    injury, date of recurrence or date disability began. The WCC caseworkers will
    process the request and will be available for assistance.

  5. From the time the CA-7 and CA-7a are received at the WCC, it takes 6
    or more months until the actual restoration occurs.

  6. Refer to the Time and Leave Handbook, Document
    11103, Catalog #27297B, Federal Employees’ Compensation Act Section,
    for more details on the leave buy-back process. The website is http://erc.web.irs.gov/DOCS/2002/AWSS/PS/Timekeeping/Timekeepingindex.html

  7. It is imperative for managers to adhere to the guidance provided by
    WCC. The DOL will at times issue instructions which are generic to all governmental
    agencies, and are not tailored for the IRS. Because the National Finance Center
    (NFC) maintains IRS payroll accounts, NFC regulations must be followed. The
    employee will not receive the leave restoration until all payback amounts
    are submitted.

  8. Additional information is available at the ERC web site at http://erc.web.irs.gov
    through the Guide to Workers’ Compensation Procedures.

6.800.1.16 
(01-01-2004)
Extended Claim Disabilities

  1. When it is apparent the injured employee will be disabled from work
    for an extended period of time, DOL may take any one or more of several steps
    of action to encourage return to work. Oftentimes, WCC contacts DOL to proactively
    suggest progressive steps. In all cases, DOL informs the employee, generally
    via letter (copy to WCC), of any activity they propose on the case. The following
    are some case management activities DOL may pursue:

    1. Review DOL decisions.

    2. Schedule conference calls with employees and/or managers/WCC case workers
      to discuss claim progress.

    3. Request more medical information from physicians.

    4. Initiate more medical development of the case.

    5. Assign DOL contract nurses to meet, either telephonically or in person,
      with employee and/or manager, physician, and WCC representatives to assist
      in return to work.

    6. Assign contract rehabilitation counselors to explore accommodating limited
      duty at the employee’s job site or to test and train for employment
      elsewhere.

    7. Schedule second and referee medical examinations

6.800.1.17 
(01-01-2004)
Return to Work/Reasonable Accommodations

  1. Title 5 C.F.R. 353 and Subpart C obligates agencies to restore current
    and former employees who have fully or partially recovered from work-related
    injuries. This is based on medical reports provided by the physician. Please
    refer to this code for more detailed information.

  2. Fully recovered within one year – A current or former employee
    who fully recovers within 1 year from the date eligibility for compensation
    began is entitled to be restored immediately and unconditionally to his/her
    former position or an equivalent one in the local commuting area the employee
    left.

  3. Fully recovered after one year – A current or former employee
    whose full recovery takes longer than one year from the date eligibility for
    compensation began, is entitled to priority consideration for restoration
    to his/her former position or an equivalent one as long as his/her application
    is made within 30 days of DOL notification. Regulations on retention rights
    are in 5 C.F.R. 353, 302 and 330.

  4. Partially recovered:

    1. Managers must make every effort to restore, in the local commuting area,
      an individual who has partially recovered and is able to return to work in
      some capacity. This could mean re-engineering his/her former position, if
      feasible, or placing the employee in another position that is within the work
      capabilities.

    2. An employee who is physically disqualified for his/her former position
      or an equivalent position because of a work injury, is entitled to be placed
      in another position that will provide the employee with the same status and
      pay, or the nearest approximation thereof, consistent with the circumstances
      in each case. The DOL will determine if additional benefits will be paid for
      loss of wages.

    3. If the residuals of the injury will prohibit the employee from returning
      to full duty in the position he/she held at the time of injury, a formal written
      job offer must be issued for a different position . Contact the WCC case manager
      for assistance in this area.

  5. Seasonal employees – Managers should return seasonal employees
    to their positions of record or comparable positions as soon as possible.
    Do not wait until the normal furlough season is over. Contact WCC for advice.

  6. When the claimant returns to work, the manager should immediately notify
    the WCC case manager by telephone. Telephone notification is critical to prevent
    possible overpayment of compensation by DOL.

  7. Additional information is available at the ERC web site at http://erc.web.irs.gov
    through the Guide to Workers’ Compensation Procedures.

  8. See http://ciweb/sections/strategy/human_resources/human_resources.htm
    for special instructions on return to work for Criminal Investigation.

Exhibit 6.800.1-1 
(01-01-2004)
Duty Status Report

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Exhibit 6.800.1-2 
(01-01-2004)
Sample Letter to Physician Requesting Work Restrictions

Sample Letter to Physician
Requesting Work Restrictions
Physician’s Name
Physician’s Address 		   
    Claimant:
Claim #:
SS#:
DOI:
Dear Dr. __________ :
This is regarding the workers’ compensation
claim filed by our employee and your patient, (Employee Name).
We sincerely regret any discomfort or
inconvenience suffered as a result of this occurrence/condition and we are
willing to make reasonable accommodations in accordance with any work restrictions
deemed medically necessary. Light duty assignments are available upon notification
of work restrictions. We need to ensure that the employee can perform the
duties assigned and determine if any changes need to be made to accommodate
any existing medical condition.
For this reason, we would appreciate your
completing the attached Duty Status Report outlining current work restrictions.
To assist you in making your determination, we have enclosed a copy of the
position description. Your response may be faxed to (employee’s manager)
at (fax number).
We appreciate your cooperation in this
matter and look forward to working with you. If you have any questions regarding
the employee’s work requirements, please contact (employee’s manager)
at (telephone #). Questions pertaining to Internal Revenue Service workers’
compensation issues may be directed to our Workers’ Compensation Center
located in Richmond, Virginia, at 1-800-234-8323.
  Sincerely,

Manager
Manager’s Title

 
Enclosures

cc: Workers’
Compensation Center

Exhibit 6.800.1-3 
(01-01-2004)
Sample Job Offer Letter

Employee’s Name
Employee’s
Address
Dear    
We have received medical information from
your physician indicating you can return to work. In accordance with your
medical restrictions, the following position is offered to you:
Title:
Permanent/Seasonal/Temporary
(Job offer must agree with employee’s last appointment):
Series/Grade/Salary:
Organization/Location:
Tour
of Duty/Hours of Work:
Date Job Available:
The following describes the duties and
physical/environmental requirements of this position.

Caution:

The functional requirements of the offered position must be included in narrative
format and must comply with the individual’s physical limitations.

Example:

While sitting in a chair, you input data into a remote
computer terminal. The terminal is at eye level when the operator is in a
sitting position and no reaching or working above shoulder level is required.
You may occasionally be required to move and carry computer listings short
distances. This activity may not exceed a total of 1 hour per day and weight
may not surpass 10 pounds. No stair climbing is involved. You will be working
indoors and will not be exposed to cold or dampness. You will be allowed to
sit or stand at your convenience, for comfort, and you will be permitted to
take frequent walks.] A copy of the official position description is attached.
If you decline this position and OWCP
determines that this is a job that you can perform, your benefits under the
Federal Employees’ Compensation Act may be terminated (except for medical
benefits). If you accept this position, we will provide the necessary information
to the OWCP claims examiner for determination of loss of wage earning capacity,
if any. Your decision as to acceptance or declination of this offer should
be made in writing within 15 days of the date of this letter. The enclosed
Acceptance/Declination Statement is provided for this purpose. Failure to
notify this office of your decision will constitute a rejection of a valid
re-employment offer and may serve as a legal basis for OWCP to terminate benefits.
If you have any questions, contact __________ at (telephone #).
  Sincerely,

Manager
Manager’s Title

 

Enclosure
cc: WCC Claims Specialist
OWCP
Claims Examiner

ACCEPTANCE/DECLINATION
STATEMENT
( ) I, __________,
voluntarily ACCEPT the (permanent, seasonal, temporary) position of (Job Title,
Series/Grade/Step), at an annual salary of $_____.
I make this acceptance voluntarily without pressure or coercion. I understand
that if OWCP benefits are currently being received, this voluntary acceptance
of the position being offered may result in a reduction or termination of
such benefits.
__________
Signature

 _____
Date
( ) I, __________,
DECLINE this offer of placement to the (permanent, seasonal, temporary) position
of (Job Title, Series/Grade/Step), at an annual salary of $_____. I fully understand the consequences that if I decline the
job
offer and OWCP determines that this is a job I can perform, that my compensation
benefits may be terminated (except for medical benefits) under Section 8106
(c) of 5 United States Code.
Give reason for declination:
__________
Signature

 _____
Date
FAILURE TO RESPOND TO THIS
JOB OFFER WILL BE CONSIDERED A DECLINATION
cc: WCC Claims Specialist
OWCP Claims
Examiner

Exhibit 6.800.1-4 
(01-01-2004)
OWCP Claim Questionnaire (Key Indicators for Fraud and Abuse)

Indicators for Fraud and Abuse Warning
Signals
1. Medical or documented diagnosis is not consistent with nature of
claim
2. Injury was not immediately reported to Supervisor/Manager
3.
If injury occurred:
• After notification/announcement of functional
transfer or redeployment;
• Near date of termination of temporary
employment or was reported after employment was terminated;
• After
leave request has been denied or immediately prior to or following scheduled
leave or holiday;
• When disciplinary action is pending;
•
After repeated disputes with co-workers/supervisor;
• When employee
has a history of leave abuse, personal problems, and/or financial problems;
•
When retirement is approaching.
4. Employee has received compensation for
a lengthy period of time, yet required little or no medical treatment.
5.
Employee changes the description of how the injury occurred or date, time,
and place of injury.
6. Employee was immediately referred for many psychiatric
tests, when reported injury involved physical trauma only.
7. Employee
or family members have a history of compensation claims.
8. Medical treatments
or payments to physicians for injuries that were not diagnosed or do not substantiate
the job-related injury.
9. Evidence of falsification or alteration of
any forms in the claim file (e.g., possibility of forged physician’s
signature).
10. Claimant shows little or no desire to return to duty,
even when light duty is offered.
11. When accidents result by intentionally
ignoring safety standards or requirements.
12. Employee refuses follow-up
visits, changes physicians for unexplained/irrational reasons after initial
selection of physician has been made or repeatedly fails to appear for independent
medical examinations.
13. Employee is receiving compensation while collecting
income from outside employment or performing volunteer work.
14. When
employee fails to provide information of past medical problems and/or injuries.
15.
Conflicting/inconsistent statements made by witnesses (e.g., injury occurred
off premises and employee was not involved in official
“off
premise”
duties).
16. Injuries are soft tissue and are greater than
would be expected from the injury.
17. There are summary medical bills
without itemizations of visits.
18. Employee cannot describe diagnostic
tests or treatments on the bill.
19. Employee can rarely be contacted at
home.
20. Treating physician is located a great distance from the employee,
at a post office address or not available at the regular address shown.
21.
Treating physician or attorney known for handling questionable claims.
22.
When there were no witnesses.
23. Where there are rumors of a disgruntled,
unhappy employee.
24. Early representation by an attorney.
25. Employee
changes jobs frequently.
26. Physical description of employee after lengthy
benefit period is that of well-tanned or muscular appearance or other possible
signs of work.
27. Employees with young children injured soon after re-entering
the work force.

Exhibit 6.800.1-5 
(01-01-2004)
OWCP Claim Questionnaire


OWCP Claim Questionnaire
SECTION I: Complete
the following information
Claimant’s Name: __________ Duty Phone: _____
Position Title: ______ Home Phone: __________
Office Address: ____________________________ Home Address: ____________________________
Claim File #: _____ Claimant’s SSN: _____
Date began Current Employment: _____ Total Leave Balance: _____
Supervisor’s Name: _____ Office Phone: _____
Nature of Injury: __________
Place Injury Occurred: __________
Date Injury Occurred: _____ Date Injury Reported: _____
Physician’s Name: _____ Physician’s Phone: _____
SECTION II:
 Complete with the assistance of claimant only if information is not available from other sources.
Yes__ No__ 1. Does employee regularly participate in physically demanding activities
(sports, military reserve duty, farming, etc.)? If yes, please
explain.
Yes__ No__ 2. Has the employee ever received similar medical treatment or had
a history of similar injuries? If yes, name/phone number of
treating physician(s).
Yes__ No__ 3. Has employee changed physicians since reporting the injury? If yes, name/phone number of the initial treating physician and all
subsequent physicians.
Yes__ No__ 4. Has the employee performed work and received unreported earnings
from any outside employment while receiving compensation?
If yes, explain and, if known, give source.
Yes__ No__ 5. Has the employee performed unremunerated work, such as work performed
in a business run by a spouse, other relative, or friend?
If yes, explain and, if known, give name and address of the business.
Yes__ No__ 6. Has the employee performed volunteer work? If yes,
explain and, if known, give name/address of the organization.
Yes__ No__ 7. Was the injury reported immediately following a weekend, holiday,
or leave period? If yes, explain.
Yes__ No__ 8. Had the employee been notified of a functional transfer or reduction-in-force? If yes, explain.
Yes__ No__ 9. (For Temporary Employees) Was the injury claimed at or
near the end of his/her temporary employment? If yes, give
the date of termination.
SECTION III:
 The supervisor should complete with the assistance co-workers, witness(es),
and (if necessary) the physician.*

*It may be necessary
to obtain a Medical Release from the claimant prior to contacting the physicians
for information.
Yes__ No__ 10. Was leave of any type denied to the employee? If
yes, explain and attach a copy of the SF-71 denying leave.
Yes__ No__ 11. Was disciplinary action pending against the employee at the time
of injury? If yes, explain.
Yes__ No__ 12. Has the supervisor controverted or recommended that this claim
be denied? If yes, attach a copy of statements.
Yes__ No__ 13. Has the employee had a history of leave abuse (for example, frequent
sick leave in conjunction with weekends)? If yes, explain.
Yes__ No__ 14. Has the employee had a history of financial or serious personal
problems prior to injury (for example, family problems, telephone calls from
creditors, arguments/fights with co-workers or supervisor)?
If yes, explain.
Yes__ No__ 15. Has the employee participated in activities which are inconsistent
with the nature of the claimed injury (for example, claims leg injury, but
has been observed jogging)? If yes, explain.
Yes__ No__ 16. Has the employee failed to identify witnesses even though the injury
occurred in an area where it should have been observed? If
yes, explain.
Yes__ No__ 17. Has the employee acted as a witness for other injury claims? If yes, give the name(s) of the other employee(s).
Yes__ No__ 18. Has the same individual who witnessed the employee’s injury
acted as a witness for numerous other claimants? If yes, give
the name(s) of the other claimant(s).
Yes__ No__ 19. Has the employee’s physician established job-related injuries
for other claimants? If yes, give the name(s) of the other
claimant(s).
Yes__ No__ 20. Have there been medical treatments or payments to physicians for
injuries that were not diagnosed as job-related (for example, the employee
injured his/her head, but the physician charged for a back operation)? If yes, explain.
Yes__ No__ 21. Has the employee received compensation for a lengthy period of
time, yet required little or no medical treatment? (Note: This does not apply
to claimants where medical evidence shows that due to age and/or medical condition,
rehabilitation, or reemployment is not feasible.) If yes, explain.
Yes__ No__ 22. Is there evidence of falsification or alteration of any forms in
the claim file (for example, the physician’s signature appears to be
altered or forged)? If yes, attach a copy of the questionable
forms.
Yes__ No__ 23. Has the employee changed the description of how the injury occurred
or made any admissions concerning the injury? If yes, attach
copies of the documentation showing different descriptions.
Yes__ No__ 24. Have any incriminating witness statements been uncovered? If yes, note the name(s) of the witness(es).
Yes__ No__ 25. Does the employee have a history of compensation claims? If yes, provide the claim number(s), type(s) of injury/injuries,
and the time(s) of day.

Exhibit 6.800.1-6 
(01-01-2004)
Fraud Referral Request

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Law Offices of Darrin T. Mish, PA

100 S. Edison Ave. Suite A, PO Box 3414, Tampa, FL 33606 (813) 229-7100
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