Obtaining Schedule Award Benefits for a Claimant Following Denial of Authorization for Total Knee Replacement Surgery: M.M.

The claimant’s approved treating physician strongly recommended the claimant be authorized to undergo total knee replacement surgery. The request for authorization was denied. On this basis, Mr. Gest requested schedule award benefits for the claimant. The claimant’s physician advised that since the surgery was not authorized, the claimant’s condition had become permanent and stationary and reached a point of maximum medical improvement. The Claims Examiner denied the request for schedule award benefits, stating that the claimant was not authorized to undergo the surgery, but her condition was not considered to be permanent and stationary, since she needed the surgery.

Mr. Gest appealed this decision to the Branch of Hearings and Review. The Hearing Representative stated in the decision as follows:

In conclusion, the Office has not authorized the requested bilateral knee replacements for the claimant. In the absence of such procedures, her physician, Dr. Tauber, submitted impairment ratings of twenty-five per cent to each lower extremity based on the Fifth Edition of the A.M.A. Guides. Therefore, the claimant is entitled to claim her award, despite the possibility of a change in impairment in the future.

Obtaining a Therapeutic Spa for a Claimant Following Total Knee Replacement Surgery: J.H.

The claim was initially denied by the District Office. Following an oral hearing, a Hearing Representative from the Branch of Hearings and Review issued a decision reversing the denial of the claim and ordering that the claim be accepted. Subsequently, authorization was provided for several medical procedures, including total knee replacement surgeries for both knees. Based upon the recommendations of the treating orthopedic surgeon, Mr. Gest was also able to obtain authorization from OWCP for a therapeutic spa for the claimant at a cost of almost $6,000.00.

Obtaining More Than One Schedule Award at a Time and Simultaneously Obtaining OPM Retirement Benefits: I.S.

This claimant had several claims. One of the claims had been accepted for conditions of the arms. Another claim was filed by the claimant for several conditions, including conditions of the lower back. That claim was initially denied. Following appeals, Mr. Gest was successful in obtaining acceptance of that claim. Ultimately, Mr. Gest was able to obtain one schedule award for the client for the conditions of the upper extremities under one claim number while at the same time obtaining another schedule award for the claimant for conditions of the lower extremities under another claim number. In addition, the claimant was able to receive at the same time retirement benefits from the Office of Personnel Management (OPM). It should be noted that a claimant may not receive disability compensation benefits from OWCP and schedule award benefits from OWCP at the same time for the same part of the body under the same claim number. In addition, a claimant may not receive disability compensation benefits from OWCP and regular or disability retirement benefits from OPM at the same time. However, a claimant may receive schedule award benefits from OWCP and regular or disability retirement benefits from OPM at the same time.

Appeal of Decision Terminating Compensation for a Refusal to Accept a Job Offer and Return to Work: A.G.

This claimant was receiving disability compensation benefits from OWCP for an extended period of time. She was provided with a job offer by the employing agency. The Senior Claims Examiner wrote to the claimant, advising her that the job had been found to be suitable and appropriate for her and available. She was provided with a letter which informed her that she had 30 days within which to either accept the job offer without penalty or provide reasons for her rejection of the job offer. The claimant accepted the job offer. The acceptance letter was sent to the Senior Claims Examiner at OWCP. Despite this, 30 days after the initial letter from the Senior Claims Examiner, the claimant was provided with a decision denying her entitlement to disability compensation benefits from OWCP. The decision denying the claimant’s right to disability compensation benefits stated that the claimant’s right to disability compensation benefits had been terminated as a result of her failure to contact the agency to advise them that she was accepting the job offer, and her failure to return to work.

Mr. Gest successfully argued that the simple acceptance of the job offer was sufficient to meet the requirement of the initial letter sent to the claimant. Mr. Gest argued that the basis for the decision terminating the claimant’s right to disability compensation benefits added another requirement, that of notifying the employing agency of the acceptance of the job and returning to work. This was not required by the initial letter. The decision of the Hearing Representative at the Branch of Hearings and Review dated March 16, 2011 stated in pertinent part as follows:

Neither the employing agency, nor the District Office advised the claimant that it would be her responsibility to contact the employing agency to schedule her return to work date. Rather, the agency was to contact the claimant upon acceptance of the job. The Office notified the employing agency on November 2, 2010 that the claimant had accepted the job, but the employing agency did not contact the claimant until after the Office terminated benefits on November 10, 2010. Further, the Office did not provide the claimant with the procedural fifteen-day period to accept the job. I find that the District Office failed to comply with procedural requirements in terminating the claimant’s benefits under section 8106, as there was no legal basis to terminate her benefits because she did not contact the employing agency to secure a return to work date.