For SEC claims where an award has been made for a metastatic bone, metastatic kidney or metastatic lung cancer, the claimant is awarded compensation and full medical benefits for the ongoing treatment and care of that condition, a “covered illness”. “Covered Illness” includes eligibility of claims on impairment, wage loss, in-home care, travel for treatment, and if there are consequential conditions due to surgery or treatment, such conditions are eligible to be “added” for full coverage of those conditions.
If the underlying and primary source of the metastatic bone, kidney or lung cancer is known, medical benefits extend to treatment of the source cancer. If the source cancer is itself an SEC cancer, that cancer is also a “covered illness” as outlined above apply. If the source cancer is NOT an SEC cancer, then medical benefits are limited to treatment only, and the source cancer cannot be considered for claims for impairment, wage loss, in-home care or for consequential conditions related to surgery or treatment of that condition. This is known as a “reverse consequential”, limited coverage for the source cancer.
If the source cancer is evaluated under NIOSH Dose Reconstruction, and is approved under Part B or Part E, then it is re-designated as a “covered illness” in which full medical benefits apply.
SEC Claims – What Benefits Am I Eligible for if Approved for Metastatic Cancer?
Some Key Terms and Definitions for this Chart:
Metastatic/Secondary Cancer – Metastatic Lung, Bone, or Kidney
Primary Cancer – Prostate, Melanoma, or Squamous Cell
PoC – Probability of Causation
NIOSH DR – Dose Reconstruction
CMC – Department of Labor Contract Medical Consultant
|EEOICPA Part for Primary Cancer Adjudication||Part B||Part B||Part E||Part E|
|Causation – NIOSH DR or CMC||PoC >= 50%||PoC < 50%||Likely||Unlikely|
|Benefits for Metastatic/Secondary Cancer||Yes||Yes||Yes||No|
|– Medical Expenses for Treatment related to Secondary||Yes||Yes||Yes||No|
|– Home Care Coverage related to Secondary||Yes||Yes||Yes||No|
|– Impairment Rating related to Secondary||Yes||Yes||Yes||No|
|– Add Consequentials related to Secondary||Yes||Yes||Yes||No|
|Benefits for Primary||Yes||Limited||Yes||No|
|– Medical Expenses for Treatment related to Primary||Yes||Yes||Yes||No|
|– Home Care Coverage related to Primary||Yes||No||Yes||No|
|– Impairment Rating related to Primary||Yes||No||Yes||No|
|– Add Consequentials related to Primary||Yes||No||Yes||No|
Scenario 1 – Metastatic Bone Cancer from Prostate
If worker is eligible under an SEC and claims both conditions, bone cancer is approved as a “covered illness”, and prostate cancer is accepted for treatment only. If NIOSH comes back with a Probability of Causation of 50% or greater (Part B) on the prostate cancer, then source cancer is redesignated as a “covered illness”. If a prostate claim is a “covered illness” under Part B (or Part E), then consequential condition(s) such as urinary incontinence, urge/control or erectile dysfunction can be claimed, and add significantly to an impairment rating and justification on in-home care.
Sometimes a few additional skin cancer claims, along with the original prostate cancer claim can get to the PoC threshold of 50% or greater. Once achieved, the effective date of medical coverage reverts to the original filing date.
Scenario 2 – Metastatic Lung Cancer from Melanoma or Squamous Cell Carcinoma
If a worker is eligible under an SEC for metastatic lung cancer, the same principles as in Scenario 1 apply. Any consequential condition related to treatment (chemotherapy, targeted radiation therapy or surgery) is eligible to be added, and a claim for impairment, wage loss, in-home care or travel considers the metastatic lung cancer and any consequential conditions (e.g., chemo induced neuropathy, radiation fibrosis, osteopenia/osteoporosis). However, if there is subsequent metastasis to brain or metastasis to liver, and this is due to melanoma, these conditions are NOT covered for medical benefits, impairment, wage loss or for in-home care considerations. If a physician can articulate a “chain of causation” to link the original “covered illness”, with subsequent treatment leading to a likely cause, contribution or aggravation (for a pre-existing condition), then it becomes possible to tie all together. This is a multi-step process and takes time and significant support from the worker’s medical team.
More information can be found in the EEOICPA Procedure Manual – Chapter 17, Section 6 (b) – SEC Case with Award.
We know that this is a lot of medical and governmental jargon. If you would like to talk to someone who can help you understand what this all means in your specific situation, please reach out to us. We Can Help.