A while back, I published a blog discussing how the concept of Presumptive Causation applies to certain cancer claims under Part B, based on Special Exposure Cohort guidelines. There is a parallel concept for medical conditions associated with chemical exposures under Part E.
Guidelines for the adjudication of medical conditions due to chemical exposure(s) falls under Part E in the 700-page Federal Procedure Manual for EEOICPA. At a high level, the primary inputs for considering whether chemical exposures could have caused or contributed to a medical condition are as follows:
- Job function
- Length of time in job
- Chemicals associated with a job function (SEM & MSDS)
- Level and frequency of such chemical exposures (Industrial Hygiene assessment)
- Whether there is a supporting medical opinion, and scientific studies, which support a causal relationship between workplace exposure and a medical condition.
There is a section of the Procedure Manual which provides guidance on special considerations for presumptive causation and presumptive exposure. The details can be found in an often overlooked section, Exhibit 15-4. Presumptive causation (and presumptive exposures) for specific medical conditions allows a Claims Examiner to issue claim approval, or bypass normal adjudication processes, if certain criteria are documented.
In context, for chemical causation, “causation” means was likely to have a) directly caused, or b) contributed to (increased risk), or c) aggravated (in the instance of preexisting condition being exacerbated). The EEOICPA standard is “at least as likely as any other source” to have caused, contributed to, or aggravated. Presumptive causation allows a Claims Examiner to accept as a given that chemical exposures, under certain circumstances/criteria as outlined in Exhibit 15-4, did in fact cause or contribute to a medical condition. Additionally, presumptive exposure under Exhibit 15-4 allows a Claims Examiner to bypass an Industrial Hygienist assessment.
There are a lot of details as to how a Claims Examiner organizes input into these processes for any claim. They are instructed to review the Occupational History Interview, utilize SEM (Site Exposure Matrix) by job title and work processes, and refer claims for review by an Industrial Hygienist. The veracity of this process is dependent on the prior experience of the Claims Examiner, knowledge of the worksite in question, and familiarity with alternate ways to use the SEM. There are a LOT of omissions and mistakes which lead to poor outcomes and denied claims.
Exhibit 15-4 was a policy initiated by EEOICPA to streamline this process for specific medical conditions with well-established scientific association for causation. The intention is to be more “claimant friendly”, and to save time and resources where a claim is a “no-brainer”.
EXAMPLES FROM EXHIBIT 15-4:
Presumptive Exposure – Asbestos – All workers, direct employees, contractors, from any job function, are presumed to have had exposure to asbestos. Asbestos was used as a fire retardant in cement, wallboard (think dry wall), paints, and in insulation. Even low-level exposures are considered “significant”, since occasional frequency of exposure can lead to medical issue(s) many years later. The latency or lag time from initial exposure to onset of conditions can be 10-20 years or more.
Presumptive Causation – Mesothelioma – For any job function where a worker had significant exposure for at least 30 days, and a latency to diagnosis of 15 years, a claim is afforded a Presumption of Causation and can be readily approved by a Claims Examiner.
Presumptive Causation – Ovarian Cancer – Any female worker diagnosed with Ovarian Cancer and where they had 1 year on the job, and a latency to diagnosis of 15 years, is afforded the Presumption of Causation and can be readily approved by a Claims Examiner.
Presumptive Causation – Laryngeal Cancer – Any worker diagnosed with Laryngeal Cancer and where they had 1 year on the job, and a latency to diagnosis of 15 years, is afforded the Presumption of Causation and can be readily approved by a Claims Examiner.
Presumptive Causation – Lung Cancer – Any worker diagnosed with Lung Cancer and where they had 1 year on the job, and a latency to diagnosis of 15 years, is afforded the Presumption of Causation and can be readily approved by a Claims Examiner.
There are other Asbestos related conditions identified in Exhibit 15-4.
Here is an interesting section of 15-4 that often goes overlooked for forms of Leukemia(s).
Presumptive Causation – Leukemia – Any worker with all forms of Leukemia (identified by ICD 10 codes), where there was “significant” exposure to Benzene in performing their job function, and with a latency of at least 1 year, is afforded the Presumption of Causation. This is missed all the time by Claim Examiners. The key is to identify the work process the worker was involved with which led to Benzene exposure. Benzene is one of those chemicals that is a frequent ingredient to many, many chemicals, including gun powder, cleaning solutions/chemicals, etc.
Presumptive Causation – Kidney Cancer – Trichlorethylene (TCE) has received a lot of press the past 10 years as being at the root cause of many medical conditions. EEOICPA (and DOE) take the view that TCE was not in use after 1990, which has been proven incorrect at numerous facilities. A worker at most every DOE facility, in job functions/labor categories where there was significant exposure to TCE for 5 or more years prior to 1990, and a latency to diagnosis of 20 years, is afforded the Presumption of Causation and can be readily approved by a Claims Examiner.
There are many additional conditions listed with simple or complex criteria: Asthma, Bladder Cancer, COPD, Hearing Loss, Non-Hodgkins Lymphoma, and Parkinsons.
APPLYING EXHIBIT 15-4 TO YOUR CASE/CLAIM
If the facts of your claim meet the criteria as documented in Exhibit 15-4, then a claim should be approved. If your facts are close, then at least there is a basis/template for pursuing a claim and you may still need a medical opinion from your own doctor or a DOL appointment Contract Medical Consultant. You may want to share with your doctor the framework and details, and when the Claims Examiner requests a medical opinion, you are in a better position to move forward.
If the facts, as you know, are different than what the Claims Examiner developed in your case, you may be able to file an objection and compel them to take another look at the basis for claim. Alternatively, this is when to send AtomicWorkers® an email or call for assistance.
The main point of this blog is that experienced and inexperienced Claims Examiners are routinely not remembering to consider the guidance found in Exhibit 15-4. Some Attorneys and Authorized Representatives miss this as well.
If you have questions about your eligibility for EEOICPA financial and/or medical benefits, please reach out to us. We Can Help.