TABLE
OF CONTENTS
Paragraph
and Subject
Date
Trans. No.
Chapter 2-1000 Consequential Injuries
Table of Contents. . .
. . . . . 06/02
02/01
1
Purpose and Scope. . . . . . . .
06/02
02/01
2 Defining a Consequential
Injury
. . . . . . . . . . . . . 06/02
02/01
3 Consequential Injuries of
Metastasized
Cancer . . . . . 06/02
02/01
4 Consequential Injuries Other
Than Metastasized
Cancer . . . . 06/02
02/01
5 Accepting or Denying the
Consequential Injury .
. . . . . 06/02
02/01
6
ECMS Coding . . . . .
. . . . . 06/02 02/01
1. Purpose and Scope. This chapter discusses the Claims
Examiner’s function in developing claims for consequential injuries. It also provides examples of the types
of consequential injuries which may result from illnesses covered under
EEOICPA.
2. Defining a Consequential
Injury. A consequential injury
covered by EEOICPA is an injury or illness that has occurred as
a result of, or was caused by the occupational illness covered under EEOICPA,
unless the consequential injury is shown to be the result of an independent
intervening incident caused or attributed to the employee’s own intentional
conduct. Therefore, any injury or
illness shown by medical evidence to be
a consequence of a covered beryllium disease, silicosis, or covered cancer is
covered for medical benefits.
3. Consequential Injuries of
Metastasized Cancer. Usually,
the claimant will notify the CE of a potential consequential injury. The CE is responsible for investigating
any instance of consequential injury.
a. Assessing and Developing Medical Evidence in Metastasized Cancer Injuries. Where there is a predictable consequential injury of the accepted condition (i.e., secondary cancer has metastasized from the primary site), the CE may accept the consequential injury claim without an extensive investigation. This type of injury will be accepted as a consequential injury if the claimant provides medical evidence that:
(1)
establishes
the diagnosis for the secondary cancer; and
(2)
establishes
the date of diagnosis for the secondary cancer.
The
date of diagnosis for the secondary cancer will be: a) subsequent to the date of
diagnosis for the primary cancer; b) at the same time the primary cancer is
diagnosed; or c) before the date of diagnosis for the primary cancer if the
primary site is not obvious.
If
the medical evidence is inconclusive and the CE
b. Examples of Metastasized Cancer
Injuries. It is widely accepted
amongst cancer specialists in the medical field that certain carcinomas and
sarcomas metastasize from the primary site or lesion to a secondary site or
lesion in a predictable pattern.
For example,
(1) Carcinomas of the lung, breast, kidney,
thyroid, and prostate tend to metastasize to lungs, bone, and brain early during
their course.
(2) Carcinomas of the GI tract, reproductive
system, and abdomen tend to metastasize to the abdominal lymph nodes, liver, and
lungs. Later in their course, they
can metastasize to the brain and other organs.
(3) Sarcomas often first metastasize to the
lungs and the brain.
(4) Primary malignant tumors of the brain
seldom metastasize to other organs, but they can spread to the spinal
cord.
4. Consequential Injuries Other
Than Metastasized Cancer. The
CE is responsible for investigating other types of consequential
injury.
a. Assessing and Developing
Evidence for Other Types of
Consequential Injuries. Where a claim is made for a
consequential injury of the accepted condition other than for a predictable
patterned metastasized cancer, the CE is responsible for investigating the
consequential injury based on the requirements set forth at Sections 30.214 and
30.205 of the EEOICPA regulations. The CE must obtain from the
claimant:
(1) A Personal Statement that
describes the consequential problem and the circumstances that relate it to the
accepted condition. The claimant’s belief alone that the consequential injury is
the result of the accepted condition is insufficient to establish either the
existence of the accepted condition or the causal relationship between the
consequential injury and the accepted condition.
(2) Medical Evidence which establishes
a causal connection between the claimed consequential injury
and the accepted condition. The physician must provide the employee’s medical
history; the diagnostic/physical findings which include supporting documentation
such as pathology reports; and a diagnosis. The physician must also discuss the
causal relationship between the consequential condition and the accepted
condition. The mere fact that an
illness arises subsequent to the acceptance of a medical condition is
insufficient to establish a causal relationship.
b. Assessing the Medical
Evidence. The CE must use reasonable judgement when
assessing the medical evidence required for a claim of consequential
injury. In some instances, the CE
may accept consequential conditions upon receipt of the medical evidence
described above at paragraph 4.a.(2).
In other situations where the relationship is questionable, more medical
evidence (i.e., DMC review, clarification from treating physician, or second
opinion) may be required.
c. Examples of Common Consequential Injuries Resulting from Medical Treatment for Accepted Conditions. As part of a patient’s medical treatment or protocol, a patient may undergo treatment and/or other drug therapy which will produce side effects that can be considered common consequential injuries. Examples of such injuries are:
(1) Extreme fatigue and anemia;
(2) Gastrointestinal conditions such as nausea, vomiting, constipation, diarrhea, weight loss;
(3)
Radiation
pneumonitis;
(4) Skin rashes and radiation burns as a
result of radiation treatment;
(5) Known side effects from prescribed
medications including osteoporosis as a result of steroid treatment which causes
weakening of the bones and injuries such as spontaneous hip
fractures;
(6) Chronic pain;
(7) Pneumonia and pulmonary collapse as a
result of lungs weakened by a covered beryllium disease;
(8) Psychological conditions, including
clinical depression as a result of chronic pain and/or limitations, may result
from a covered cancer or covered beryllium disease.
d. Injury Resulting from Travel. If an employee is seeking medical
treatment for an accepted condition and sustains a new injury while traveling to
obtain medical care, the new injury can be accepted as a consequential
injury. The CE obtains the
following factual and medical evidence.
(1) A Personal Statement that
describes the consequential problem and the circumstances that relate it to the
accepted condition.
(2) Medical Evidence which include a
diagnosis and the diagnostic/physical findings which explain how the diagnosis
was established.
5. Accepting or Denying the
Consequential Injury. The CE is
responsible for taking the appropriate steps in developing any claimed
consequential injury. This includes notifying the claimant of any deficiencies
in the evidence and allowing him or her an opportunity to respond and submit
additional evidence.
a. If the primary covered condition
has been accepted, the claimant can be notified by letter if the
consequential injury will be accepted.
However, if the decision is to deny the consequential injury, the CE is
to advise the claimant of his/her determination by issuing a recommended
decision.
b. When the case is in posture for
the CE to accept a primary covered condition and a potential
consequential injury exists, the CE will proceed with the immediate release of a
recommended decision for the primary condition. A recommended decision accepting a
primary covered condition should not be delayed while developing a consequential
injury; however, if the case is in posture to also accept the secondary cancer,
this acceptance is to be included in the recommended decision. While the case file is at the FAB, the
FAB CE pursues all development regarding consequential injuries. A letter accepting a consequential
injury or a recommended decision denying a consequential injury cannot be issued
until FAB issues a final decision on the primary covered condition. Once the case file is returned to the
DO, the DO CE can continue development on the consequential injury and/or issue
the letter accepting the consequential injury or the recommended decision
denying it.
6. ECMS Coding. Status effective date is the date of
first
manifestation
of the consequential injury.