United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

C.M., Appellant

and

U.S. COURTS, OFFICE OF THE FEDERAL 

PUBLIC DEFENDER, Little Rock, AR, 

Employer

__________________________________________

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Docket No. 18-1120

Issued: November 26, 2018

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

CHRISTOPHER J. GODFREY, Chief Judge

ALEC J. KOROMILAS, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On May 11, 2018 appellant filed a timely appeal from an April 12, 2018 merit decision of 

the Office of Workers’ Compensation Programs (OWCP). Pursuant to the Federal Employees’

Compensation Act1(FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction over 

the merits of this case.

ISSUE

The issue is whether appellant is entitled to reimbursement of health benefits insurance 

(HBI) premiums for the period February 9, 2014 to May 4, 2015.

 

1 5 U.S.C. § 8101 et seq.
2

FACTUAL HISTORY

This case has previously been before the Board.2 The facts of the case as set forth in the 

prior Board decision are incorporated herein by reference. The relevant facts are as follows.

OWCP accepted that on November 1, 2006 appellant, then a 41-year-old investigator, 

sustained a medial meniscus tear of her left knee. Appellant stopped work on November 6, 2006 

and underwent OWCP-approved anterior cruciate ligament reconstruction and medial/lateral 

meniscus debridement of her left knee on December 12, 2006. She received wage-loss 

compensation for periods of partial and total disability. Appellant was terminated by the

employing establishment on May 22, 2007 because she did not return to available light-duty work 

despite the fact that an attending physician had released her to such work. OWCP accepted her

claim for a recurrence of disability effective May 23, 2007 and paid her disability compensation 

on the periodic rolls. 

On June 10, 2009 appellant underwent OWCP-authorized left knee surgery, including 

meniscectomy and anterior cruciate ligament revision surgery. In September 2009, OWCP 

expanded the acceptance of appellant’s claim to include sprain of the acromioclavicular joint of 

the right shoulder and several additional left knee conditions -- bone contusion, cruciate ligament 

sprain, retear of the medial meniscus, retear of the lateral meniscus, and anterior cruciate ligament 

disruption. 

By decision dated February 25, 2010, OWCP terminated appellant’s wage-loss 

compensation effective March 14, 2010 and, by decisions dated July 26, 2010 and February 28, 

2011, it denied modification of its termination action. 

Appellant appealed to the Board. By decision dated June 6, 2012,3the Board reversed 

OWCP’s February 28, 2011 decision which had terminated her wage-loss compensation effective 

March 14, 2010. The Board found that the medical evidence OWCP relied upon for its termination 

action was insufficiently rationalized to justify the termination of her wage-loss compensation. 

OWCP returned appellant to the periodic rolls.

On a Form EN1032, signed on February 4, 2013, appellant reported that she had been 

employed since April 19, 2012 by the Department of Veterans Affairs as a clinical pastoral 

education resident (student chaplain) at a rate of pay of $13.17 per hour. 

In accordance with the Board’s June 6, 2012 decision, OWCP made supplemental 

payments to appellant to effectively reinstate her wage-loss compensation retroactive to the date 

of the March 14, 2010 termination. Based on her wages as a clinical pastoral education resident 

beginning April 19, 2012 and continuing, it determined her percentage of wage-earning capacity 

under the principles of the Albert C. Shadrick case.

4

 OWCP characterized the pay appellant 

received in this job as a stipend. In making these payments, it deducted HBI premiums for Blue 

 

2 Docket No. 16-1638 (issued October 6, 2017).

3 Docket No. 11-1988 (issued June 6, 2012).

4 See Albert C. Shadrick, 5 ECAB 376 (1953).
3

Cross Blue Shield (BCBS) health insurance coverage for the period March 14, 2010 to 

April 16, 2013. 

In a November 6, 2013 letter to OWCP, appellant noted that her HBI plan through BCBS 

had been terminated after her wage-loss compensation was terminated effective March 14, 2010. 

She indicated that, after the Board reversed the termination of her wage-loss compensation, OWCP 

deducted HBI premiums for BCBS coverage from the wage-loss compensation it paid her for a 

three-year period that she could not use her HBI plan. Appellant asserted that OWCP improperly 

deducted these HBI premiums from her wage-loss compensation and requested that it refund them 

to her. 

As a result of appellant’s inquiry, on December 20, 2013 OWCP paid her $6,830.63 

through an electronic funds transfer (EFT) in order to reimburse her for the HBI premiums for 

BCBS health insurance that were deducted from her compensation payments during the period 

March 14, 2010 to April 16, 2013. In a payment record for this transaction, it noted that her HBI 

plan had been terminated on March 14, 2010, but reinstated as of April 17, 2013. OWCP indicated 

that HBI premium deductions (code 104 for the BCBS plan) were made for the period March 14, 

2010 to April 16, 2013 despite the termination of the HBI plan. It advised that it had been 

confirmed that appellant could not use her HBI plan for this period and that the refund was 

appropriate given her inability to use the HBI plan. 

Appellant telephoned OWCP on January 3, 2014 and advised that, despite being refunded 

the HBI premiums deducted for the period March 14, 2010 to April 16, 2013, she still was unable 

to use her HBI plan. In a January 9, 2014 letter to an OWCP regional director, appellant asserted 

that OWCP had informed her that her HBI coverage would be reinstated effective June 2, 2013,

but noted that she confirmed with BCBS that her HBI coverage had not been reinstated despite the 

fact that OWCP continued to deduct HBI premiums from her wage-loss compensation. 

In a January 14, 2014 letter, OWCP advised appellant that it was enclosing a Health 

Benefits Election Form (Standard Form 2809) that she needed to complete and return with her 

selection of an HBI plan. In making this selection, it requested that she use an effective date of 

January 12, 2014. OWCP informed appellant that her HBI coverage would remain in a cancelled 

status until such time as the Standard Form 2809 was completed and returned. 

In a January 23, 2014 letter, appellant requested that OWCP refund her for the HBI 

premiums from April 17, 2013 to “whatever date in January 2014 the insurance actually become[s] 

effective.” She indicated that she mailed the Standard Form 2809 to OWCP on January 21, 2014 

and noted that she was requesting reinstatement of the same HBI plan she had when her 

compensation benefits were terminated in 2010. Appellant noted that she previously had the 

standard federal plan with BCBS. 

In a January 28, 2014 letter, an OWCP district director responded to appellant’s January 9, 

2014 letter. She indicated that appellant’s wage-loss compensation was terminated effective 

March 14, 2010, but was later reinstated per the Board’s June 6, 2012 decision. The district 

director acknowledged that appellant’s HBI coverage was not reinstated at the same time as her 

wage-loss compensation due to an oversight. She advised that BCBS confirmed that appellant had 

not used her HBI coverage during the period March 14, 2010 to April 16, 2013 and, therefore, 
4

OWCP reimbursed appellant for the HBI premiums that were deducted from her compensation 

payments during that period by issuing her a $6,830.63 check on December 20, 2013. The district 

director noted that, because appellant had not been using the HBI coverage, she had the option of 

reinstating her HBI coverage retroactive to April 17, 2013, or requesting a reimbursement of the 

HBI deductions for the period April 17, 2013 to the present. 

On January 30, 2014 OWCP received the completed Standard Form 2809 in which 

appellant elected to have HBI coverage with the Federal Employees Health Benefits (FEHB) 

Program under BCBS (code 104) effective January 12, 2014. A portion of the form was completed 

by an OWCP official as OWCP was designated as the entity administering the coverage. Also on 

January 30, 2014 OWCP issued appellant a $1,656.84 check in order to reimburse her for the HBI 

premiums for BCBS health insurance that were deducted from her compensation payments during 

the period April 17, 2013 to January 11, 2014. In payment records for this transaction, it noted 

that, for the period April 17, 2013 to January 11, 2014, she had HBI premium deductions (code 

104 for the BCBS plan) taken from her wage-loss compensation despite not having access to HBI 

coverage. Therefore, appellant was entitled to reimbursement for HBI premium deductions for 

this period. It was noted that she chose to have coverage under BCBS (code 104) retroactively 

effective January 12, 2014. 

In a February 4, 2014 letter, appellant advised OWCP that her HBI coverage still had not 

been restarted even though she submitted a Standard Form 2809 making an election of FEHB 

coverage. 

In a May 21, 2015 letter, OWCP advised appellant that she had been reimbursed the HBI 

benefits for the appropriate period. It noted that her HBI enrollment had been transferred back to 

her former employing establishment, U.S. Courts, Office of the Public Defender, and advised her 

that, if any HBI deductions for BCBS were made from February 9, 2014 to the present, then she 

had to address the issue with her former employing establishment. 

On July 9, 2015 OWCP received a FECA Health Benefits Transmittal Sheet which was 

signed by an OWCP health benefits technician on July 9, 2015. The portion of the form to be 

completed by an OWCP claims examiner (Part A) contained the name of a claims examiner, but 

no signature of that claims examiner. In Part A of the form, the HBI code was listed as 104 and 

the “Transfer Effective Date” for HBI coverage was listed as February 9, 2014. OWCP also 

received a Notice of Change in Health Benefits Enrollment (Standard Form 2810) which was 

signed by an OWCP official on July 9, 2015, it was noted that OWCP had accepted transfer of 

appellant’s HBI enrollment with BCBS under code 104. 

OWCP had also been developing the medical evidence as to whether appellant continued 

to be disabled from all work. On January 28, 2014 it terminated appellant’s wage-loss 

compensation effective February 9, 2014. 

Appellant appealed OWCP’s January 28, 2014 decision to the Board. By decision dated

May 5, 2015,5the Board reversed OWCP’s January 28, 2014 termination of her wage-loss 

 

5 Docket No. 14-1302 (issued May 5, 2015). Appellant also appealed from OWCP’s December 19, 2013 decision 

denying her request for authorization for left knee surgery, which the Board affirmed.
5

compensation effective February 9, 2014. The Board found that the medical evidence of record 

was insufficient to justify OWCP’s termination action. 

Following the Board’s reversal of the February 9, 2014 termination of appellant’s wageloss compensation, OWCP made a payment to her on July 10, 2015 which reinstated her total 

wage-loss compensation effective February 9, 2014. The amount of reinstated wage-loss 

compensation beginning February 9, 2014 was reduced by periodic deductions for HBI premiums 

under code 104.6

On August 13, 2015 appellant received a Standard Form 2809 which she completed on 

May 15, 2006 in order to elect HBI coverage with BCBS under code 104. The portion of the form 

to be completed by the relevant employing establishment was initially completed on May 16, 2006 

by an official of her former employing establishment, U.S. Courts, Office of the Federal Public 

Defender. However, an unidentified individual had struck out the “Effective date of action” which 

had been listed as May 16, 2006 and replaced it with the date February 9, 2014. The document 

was submitted in response to a July 9, 2015 letter in which OWCP asked the former employing 

establishment to submit any HBI enrollment forms completed by appellant that it had in its 

possession. OWCP advised the former employing establishment that it was deducting HBI 

premiums from her continuing wage-loss compensation payments and that OWCP would “now be 

the employing office for health insurance purposes.”

In an October 8, 2015 letter, appellant asserted that she should be refunded for the HBI 

premium deductions for the period February 9, 2014 to May 4, 2015 because her HBI coverage 

had been terminated for that period. 

In a December 31, 2015 letter, OWCP advised appellant that HBI premium deductions for 

the period February 9 to May 4, 2015 were correct and were done in accordance with her Standard 

Form 2809 signed on January 12, 2014 and her January 23, 2014 letter requesting reinstatement 

of HBI coverage. It noted that the evidence of record showed that HBI premium refunds issued to 

her were proper and complete and that there was no pending HBI premium refund. OWCP 

informed appellant that if she had evidence showing that she was due an HBI premium refund 

from OWCP, rather than from her employing establishment, she should submit the evidence within 

30 days. It afforded her 30 days to submit the requested information.

By decision dated February 4, 2016, OWCP determined that appellant was not entitled to 

reimbursement of HBI premiums for the period February 9, 2014 through May 4, 2015. It noted 

that, when her FECA benefits were terminated, a transfer of her HBI enrollment package was made 

to her employing establishment. OWCP indicated that, in order for appellant to keep her HBI 

coverage, regardless of whether she was receiving FECA or Office of Personnel Management 

(OPM) benefits, she was required to pay premiums for HBI. It noted that there was no evidence 

explaining why she was entitled to any HBI reimbursement from OWCP for the period February 9, 

2014 to May 4, 2015. OWCP indicated that it advised appellant that all reimbursements regarding 

HBI premiums had been processed. It noted that, in a December 31, 2015 letter, it informed her 

 

6 On July 10, 2015 OWCP paid appellant $52,565.75 in wage-loss compensation for the period February 9, 2014 

to June 27, 2015 through an EFT. Before arriving at this amount, OWCP deducted $3,200.04 for HBI coverage under 

code 104. 
6

that she had 30 days to submit additional evidence regarding the matter. OWCP indicated that no 

new evidence had been submitted by appellant and that, to date, sufficient evidence had not been 

received to establish that she was entitled to a reimbursement of HBI premiums for the period 

February 9, 2014 to May 4, 2015 from OWCP. 

Appellant appealed OWCP’s February 4, 2016 decision to the Board and, by decision dated 

October 6, 2017,7the Board set aside the February 4, 2016 decision and remanded the case to

OWCP for further development. The Board explained that, in its February 4, 2016 decision, and 

prior communications to her, OWCP suggested that her former employing establishment, U.S. 

Courts, Office of the Federal Public Defender, was the only entity responsible for reimbursing her 

HBI premiums for the period beginning February 9, 2014. The Board noted that appellant was 

terminated from her former employing establishment on May 22, 2007 and that OWCP did not 

provide support for its suggestion that her former employing establishment was responsible for 

reimbursing her HBI premiums for the claimed period. The Board further noted that OWCP did 

not cite to relevant statutes, procedures, regulations, or Board precedent to support its

determination. The Board also noted that OWCP had failed to articulate a reason for not 

reimbursing HBI premiums for the period February 9, 2014 to May 4, 2015 (the second period 

appellant’s benefits had been terminated and during which the termination was reversed by the 

Board) for the same reason that it previously reimbursed her for HBI premiums deducted for the 

previous period of termination (March 14, 2010 to January 11, 2014), which was reversed by the 

Board. 

The Board remanded the case to OWCP for further development. 

By decision dated April 12, 2018, OWCP denied appellant’s claim for reimbursement of 

HBI premiums for the period February 9, 2014 to May 4, 2015. It found that she failed to provide 

evidence that she was unable to use her health benefits plan during the period claimed. OWCP

noted that appellant acknowledged receiving an explanation of benefits statements from BCBS,

but did not submit them to OWCP. Moreover, it was unknown whether the explanation of benefits 

statements were for denial of benefits or were intended to advise her about the reduction of fees 

for services rendered. OWCP observed that a medical report for service on March 13, 2014 was 

received on April 23, 2014, which was during the period in question. It indicated that appellant 

might wish to submit a statement from BCBS regarding whether her plan was utilized during the 

period for which she was claiming reimbursement. 

LEGAL PRECEDENT

An employee entitled to disability compensation may continue his or her health benefits 

under the FEHB Program. The regulations of OPM, which administers the FEHB Program, 

provide guidelines for the registration, enrollment, and continuation of enrollment for federal 

employees. In this connection, 5 C.F.R. § 890.502(a) provides that employees and annuitants are 

responsible for paying the enrollee share of the cost of enrollment for every pay period during 

which they are enrolled. An employee or annuitant incurs a debt to the United States in the amount 

of the proper employee or annuitant withholding required for each pay period during which they 

 

7 See supra note 2.
7

are enrolled if the appropriate health benefits withholdings or direct premium payments are not 

made.8

ANALYSIS

The Board finds that the case is not in posture for decision.

By decision dated October 6, 2017, the Board remanded the case to OWCP for further 

development, including the issuance of a decision that contains adequate facts and findings 

regarding appellant’s claim for reimbursement of HBI premiums for the period February 9, 2014 

to May 4, 2015. By its decision dated April 12, 2018, OWCP denied her claim for reimbursement 

of HBI premiums for the period February 9, 2014 to May 4, 2015. However, it again failed to 

adequately explain the basis for its denial.

In deciding matters pertaining to a given claimant’s entitlement to compensation benefits, 

OWCP is required by statute and regulations to make findings of fact.9 OWCP procedures further 

specify that a final decision of OWCP “should be clear and detailed so that the reader understands 

the reason for the disallowance of the benefit and the evidence necessary to overcome the defect 

of the claim.”

10

 These requirements are supported by Board precedent.11

In its October 6, 2017 decision, the Board explained that, in its February 4, 2016 decision, 

and prior communications to appellant, OWCP suggested that her former employing 

establishment, U.S. Courts, Office of the Federal Public Defender, was the only entity responsible 

for reimbursing her HBI premiums for the period beginning February 9, 2014. The Board 

indicated that she was terminated from her former employing establishment on May 22, 2007 and 

that OWCP did not provide support for its suggestion that her former employing establishment 

was responsible for reimbursing her HBI premiums for the claimed period. The Board further 

noted that OWCP did not cite to relevant statutes, procedures, regulations, or Board precedent to 

support its position. The Board also indicated that OWCP failed to articulate a reason for not 

reimbursing HBI premiums for the period February 9, 2014 to May 4, 2015 (the second period 

appellant’s benefits had been terminated and during which the termination was reversed by the 

Board) for the same reason that it previously reimbursed her for HBI premiums deducted for the 

previous period of termination (March 14, 2010 to January 11, 2014), which was reversed by the 

Board.

As noted, the Board’s October 6, 2017 decision remanded the case to OWCP to resolve 

these above-noted unaddressed concerns. On remand, OWCP issued an April 12, 2018 decision 

 

8 5 C.F.R. § 890.502(a).

9 5 U.S.C. § 8124(a) provides that OWCP “shall determine and make a finding of facts and make an award for or 

against payment of compensation.” 20 C.F.R. § 10.126 provides in pertinent part that the final decision of OWCP 

“shall contain findings of fact and a statement of reasons.”

10 See Federal (FECA) Procedure Manual, Part 2 -- Claims, Disallowances, Chapter 2.1400.5c(3)(e) 

(February 2013).

11 See James D. Boller, Jr., 12 ECAB 45, 46 (1960).
8

denying appellant’s claim for reimbursement of HBI premium deductions, but the decision does 

not address the specific matters of concern denoted by the Board in its October 6, 2017 decision. 

In essence, OWCP’s April 12, 2018 decision does not contain a significantly greater explanation 

of the denial of her claim than did the February 4, 2016 decision which the Board previously found 

to be inadequate. OWCP again failed to cite to relevant statutes, procedures, regulations, or Board 

precedent to support its decision.

For these reasons, OWCP’s February 4, 2016 decision denying reimbursement of HBI 

premium deductions for the period February 9, 2014 to May 4, 2015 would not allow appellant to 

understand the reason for the disallowance and the evidence necessary to overcome the defect of 

her claim. Therefore, the case shall be remanded to OWCP for further consideration of this matter, 

to be followed by the issuance of a de novo decision containing adequate facts and findings.12

CONCLUSION

The Board finds that the case is not in posture for decision.

ORDER

IT IS HEREBY ORDERED THAT the April 12, 2018 decision of the Office of Workers’

Compensation Programs is set aside, and the case is remanded to OWCP for further action 

consistent with this decision.

Issued: November 26, 2018

Washington, DC

Christopher J. Godfrey, Chief Judge

Employees’ Compensation Appeals Board

Alec J. Koromilas, Alternate Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board

 

12 See supra note 10.