Controversion and Challenge Fraud and Abuse

Controversion means disputing the entitlement of COP for a traumatic injury.

Challenge means disputing any aspect of a claim except COP entitlement or disputing the entire claim for either a traumatic injury, occupational disease or illness, or survivor benefits.

Investigating the Claim
Recognizing the Penalty for Conviction of Fraudulent Workers’ Compensation Claim

Investigating the Claim

According to FECA, the USPS does not have the right to participate actively in the claims adjudication process. However, the USPS may investigate the circumstances surrounding an injury to an employee and the extent of the employee’s disability. The submission of the CA-1 or CA-2 can not be delayed pending any such investigation.

The investigation of injury compensation cases involving possible fraud and abuse comes under the jurisdiction of the Inspection Service. The objective of the Inspection Service is to assist ICCO personnel in reducing compensation costs resulting from fraudulent claims and to gather information leading to the removal of dishonest employees from the USPS.

Although the terms fraud and abuse are related, they are not interchangeable.

Fraud is an intentional deceptive act, or series of acts, committed by an individual with the intent to cause the USPS or OWCP to grant benefits that would not normally be provided under FECA, for example, a faked injury or concealment of facts indicating that an injury occurred off duty.

Abuse is excessive, extravagant, or improper use of FECA in a manner contrary to its legal use in order to acquire additional benefits for personal gain, for example, prolonging the length of the recovery period needed for a job-related injury.

The key difference between fraud and abuse is intent. When employees apply for or receive FECA benefits to which they are not entitled, they are abusing FECA. This abuse may occur because the employees are ignorant of the law and its provisions or because they genuinely feel that they are entitled to those benefits. When employees deliberately apply for FECA benefit that they know they are not entitled to, they are committing fraud. Abuse is not always fraud, but fraud is always abuse.

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Recognizing the Penalty for Conviction of Fraudulent Workers’ Compensation Claim

An individual convicted of a violation of 18 USC 1920, as amended, or of any other fraud related to the application for or receipt of benefits under Subchapter I, or III of Chapter 81 of Title 5, forfeits, as of the date of the conviction, all entitlement to any prospective benefits provided by Subchapter I or III for any injury occurring on or before the date of conviction. Such a forfeiture of benefits is in addition to any action the Secretary may take under section 8106 or 8129 of title 5, USC.

In other words, an individual who is convicted of fraud related to the receipt of compensation benefits, can not receive any further compensation benefits for any injury which occurred prior to the date of conviction.

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NRLCA Magazine

Since its inception in 1903, The National Rural Letter Carrier magazine has been providing timely information to members of the NRLCA. The magazine is published on a monthly basis and is mailed to all members as a benefit of union membership... read more