The Federal Employees’ Compensation Act (FECA) provides essential benefits to federal employees who suffer work-related injuries or illnesses. To maintain the integrity of the system, all parties must ensure that claims meet the required standards. This is where the burden of proof becomes central. Both claimants and the Office of Workers’ Compensation Programs (OWCP) must present and evaluate evidence throughout the claims process.
Below is a clear breakdown of how the burden of proof influences FECA claims.
The Claimant’s Burden of Proof
Under FECA, claimants must prove their case. They need to submit enough evidence to show that their injury or condition deserves compensation. They must meet five essential elements:
1. Timeliness of the Claim:
Claimants must file traumatic injury claims (CA-1) within three years from the date of injury or death. For occupational disease claims (CA-2), you must file within three years. This period starts from the date of your last exposure or when you became aware of the condition.
2. Federal Employee Status:
Claimants must demonstrate they were federal employees at the time of the injury. The act can cover volunteers in some situations. They receive coverage if they complete tasks like regular federal employees.
3. Fact of Injury:
To establish the fact of injury, claimants must prove two parts:
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Factual: They must show the event, accident, or exposure actually occurred.
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Medical: They must provide a medical diagnosis. While we don’t need a detailed definition right now, just saying there is pain is not enough for a diagnosis.
4. Causal Relationship:
Claimants must show that their job caused or aggravated the injury. This may include direct causation, acceleration of an existing condition, or the worsening of underlying issues.
5. Performance of Duty:
An injury is generally said to have occurred in the performance of duty if the injury arose:
- during the course of employment, and
- out of the employment
“Arising during employment means the injury happened while the employee was doing their job.”
“An incident directly linked to work means it arises out of employment.” It does not relate to personal or non-work situations.”
The injury must have occurred while performing duties reasonably related to employment. This includes on-premises injuries, those occurring during mandatory training, or injuries during agency-sponsored events.
The Role of Rationalized Medical Evidence
To establish both the fact of injury and causation, claimants are required to present rationalized medical evidence. This involves:
- Complete Background: Evidence must include a comprehensive factual and medical history.
- Medical Rationale: A physician must clearly explain the connection between the diagnosed condition and the work-related factors.
- Certainty: You must express opinions with reasonable medical certainty and avoid using speculative language such as “might have caused.” The medical opinion must be unequivocal or at least more likely than not.
- 20 CFR 10.330: It outlines the required elements for a complete medical report. Because of this, strong medical documentation plays a crucial role in meeting the burden of proof.
Burden of Proof in Recurrence Claims
When employees experience a worsening or return of symptoms, they must again meet the burden of proof. They must:
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Show the current disability is directly related to the original accepted injury
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Provide reliable medical evidence proving the recurrence
This ensures OWCP distinguishes true recurrences from new injuries or unrelated conditions.
OWCP’s Responsibility in the Evidence Process
The claimant must prove their claim. However, OWCP also helps gather evidence for FECA claims.
Even though the process is not adversarial, OWCP must ensure the claimant gets due process. They should inform the claimant about any issues with the claim. This helps the claimant meet the five elements needed for a claim.
OWCP must act as a neutral party to ensure the case record is complete and all relevant evidence is considered.
Examples include:
- Contact the employing agency to obtain information that may aid in the adjudication of the claim.
- Referring claimants to the District Medical Advisor or to schedule a second opinion examination to resolve medical uncertainties.
Statutory Exclusions Under FECA
FECA does not cover all injuries. The Federal Employees Compensation Act does not cover injuries from three specific situations. People do not see these situations as part of employment. The law clearly states these exclusions.
- Injuries caused by willful misconduct.
- Injuries resulting from intoxication.
- Intentional injuries inflicted on others.
When looking at statutory exclusions, the claims examiner must prove that an exclusion applies. They have the burden of gathering evidence to support their claim. If they succeed, the Act will not cover the injury.
These exclusions underscore the importance of meeting the burden of proof with credible evidence.
Appellate and Shifts in Burden of Proof
Claimants have three options to appeal denied claims or decisions they disagree with. However, the burden of proof shifts to the claimant to support their claim during certain stages:
- Termination of Benefits: The OWCP bears the burden of proving that benefits should be terminated. Once the organization terminates benefits, the claimant must prove their continued eligibility.
- Reconsideration Requests: Claimants must provide new evidence or arguments to support a claim for a merit review. OWCP must receive a request for reconsideration within one year from the date of the last decision.
- Hearing and Review: A request is timely if someone mailed it. This relies on the postmark or date from other carriers. The office must receive it in ECOMP within 30 days of its decision.
- ECAB- the claimant must file application review by the board within 180 days from the date of OWCP decision
Appeals processes, such as oral hearings or reconsiderations, provide opportunities to present additional evidence and clarify issues. When someone appeals a decision to the ECAB, the review will focus only on the evidence in the case record. This evidence is what was available at the time of OWCP’s final decision. The ECAB will not look at any new evidence.
Key Takeaways for Claims Specialists
For claims specialists, understanding the burden of proof is essential to managing FECA claims effectively. Here are some strategies to ensure compliance:
- Review Evidence Carefully: Examine all elements to ensure the claim includes strong, credible, and substantial evidence.
- Communicate with OWCP: Share relevant agency information to help OWCP reach the correct decision, even if OWCP has not explicitly requested it.
- Use Administrative Investigations When Needed: Investigations such as surveillance, medical canvassing, or fact-finding can confirm or clarify information and support claims decisions.
Conclusion
The burden of proof forms the foundation of every FECA claim. By requiring strong, well-supported evidence, the system awards benefits fairly, consistently, and transparently. Claims specialists who understand these requirements can protect program integrity while supporting employees during challenging times.
By understanding the burden of proof, federal agencies can make better decisions. This helps ensure accountability and fairness in workers’ compensation.
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Disclaimer: This blog post is for informational purposes only and should not be considered legal advice. Please consult your general counsel for specific legal guidance. Frasco investigators are licensed, and our operations comply with US industry, federal, state, and local laws.