Doctor’s Opinion doesn’t Meet ‘Sufficiently Rationalized’ Standard to Terminate SSA Rep’s Benefits

Federal Focus

Just because a doctor says someone's condition has resolved doesn't mean it brings sufficient medical rationale to satisfy federal workers' compensation law. Simply Research subscribers have access to the full text of the decision.

Case

M.P. and Social Security Administration, No. 25-0200 (ECAB 01/29/25)

What Happened

A claims representative for the Social Security Administration filed an occupational disease claim (CA-2), alleging that she developed Parvo Virus due to factors of her federal employment. Specifically, she alleged that she was exposed to the virus by her coworker, who sat across from her and shared her desk and telephone while her computer was being repaired.

The Office of Workers' Compensation Programs developed and accepted the claim.

Later, OWCP referred the representative to a board-certified orthopedic surgeon, who opined that the Parvo Virus was clinically resolved and that the representative could return to work with no restrictions.

The representative's doctor reported to OWCP that the representative continued to experience symptom's consistent with persistent Parvo Virus and opined that she was not fit to work.

OWCP terminated the representative's wage-loss compensation. The representative submitted additional evidence, including laboratory specimens testing positive Parvo Virus.

After OWCP denied modification, the representative sought review from the Employees' Compensation Appeals Board.

Rule of Law

Once OWCP accepts a claim and pays compensation, it has the burden of proof to justify termination or modification of compensation benefits. After it has determined that, an employee has disability causally related to her federal employment, it may not terminate compensation without establishing either that the disability has ceased or that it is no longer related to the employment.

OWCP’s burden of proof includes the necessity of furnishing rationalized medical opinion evidence based on a proper factual and medical background. The right to medical benefits for an accepted condition is not limited to the period of entitlement for disability compensation. To terminate authorization for medical treatment, OWCP must establish that appellant no longer has residuals of an employment-related condition, which require further medical treatment.

What ECAB Said

ECAB found that OWCP did not meet its burden of proof to terminate the representative's wage-loss compensation and medical benefits. In particular, ECAB highlighted that the doctor who indicated that the Parvo Virus had resolved did not obtain or review any diagnostic tests. Instead, the doctor "offered a conclusory opinion and did not explain, with any supporting medical rationale, why he concluded that [the representative's] accepted condition was self-limited and had resolved."

Takeaway

To justify the termination of a federal worker's wage-loss and medical benefits, the medical evidence must be sufficiently rationalized.

Share This Article: