10 Red Flag Criteria for FECA Claim Evaluation 

July 9, 2024

Incongruities and unusual circumstances can happen with any claim, but red flags warn that further examination is needed to ensure the legitimacy of a claim.

When assessing FECA workers’ compensation claims, keep an eye out for the following: 

1. Differing Versions: Inconsistencies between the employee’s account and other witnesses’ statements can raise concerns about truthfulness.

2. Time Lag or Delayed Reporting: Claims not reported promptly after the incident may warrant closer scrutiny as there is time for manipulation and interpretation of facts.

3. Lack of Immediate Medical Attention: Delayed seeking of medical can impact claim validity as it can indicate that the incident happened elsewhere.

4. Pre-existing Conditions: Existing health issues may complicate claim assessment and can add symptoms to an otherwise minor incident.

5. Pending Corrective or Disciplinary Action: Claims filed during disciplinary proceedings may be a resentful, retaliatory, or defensive response to the impending action.

6. Near End of Employment or Pending Change: Claims coinciding with employment changes require careful examination as they can result from a subject seeking an alternative source of income option other than what is offered.

7. Disgruntled Employee: Consider the employee’s overall attitude and history to understand the genesis of the claim.

8. Leave Balances and Denied Leave Requests: These factors can influence claim legitimacy.

9. History of Multiple Claims or Injuries: Frequent claims may raise questions as a propensity to seek out reasons to be injured.

10. Concurrent Employment: If the employee has multiple jobs, assess how the injury relates to each role. Look if the employee can still conduct a similar action at one employer for which there is a restriction at the other.   

 

 Basic Elements of a Legitimate Claim 

 Before accepting any claim, ensure the following five conditions are met and there are no ambiguities: 

1. Time (20 CFR 10.115 ( a ) ): 

  • For traumatic injuries, time begins with the date of injury. 
  • For occupational illnesses, it starts when the employee becomes aware of the condition’s relationship to employment. 
  • If exposure to work factors continues after awareness, time begins from the last exposure date. 

 

2. Civilian Employee (20 CFR 10.115 ( b ) ): 

  • The claimant must be a U.S. Federal Government employee. 

 

3. Fact of Injury (20 CFR 10.115 ( c )): 

  • The injury or illness must arise out of employment and occur during the course of employment. 
  • Diagnosis is essential. 

 

4. Performance of Duty (20 CFR 10.115 ( d ) ): 

  • The occurrence must happen while carrying out duties related to the employee’s job. 

 

5. Causal Relationship (20 CFR 10.115 ( e ) ): 

  • Establish the link between the injury/illness and employment. 
  • Medical evidence must include the physician’s professional opinion. Did the workplace incident described by the employee cause the diagnosed medical condition? 

  

Please note that this information serves as a general guide, and specific cases may vary. Always consult official regulations and legal experts for personalized advice regarding OWCP claims. 

 

Frasco Government Services has the required knowledge, skills, and breadth of experience to assist your agency acquire and assemble factual evidence for presentation to the OWCP. 

 

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