T.L. and Department of Veterans Affairs, New Mexico Hospital Center, Albuquerque, NM (Board decision, July 16, 2013)

ECAB final decision. The Board affirmed OWCP’s denial of T.L.’s traumatic injury claim. A party may petition the Board for reconsideration within 30 days of issuance unless this decision specifies another period, under 20 C.F.R. § 501.7(a). FECA compensation decisions are generally not subject to court review under 5 U.S.C. § 8128(b).

Plain-English summary

T.L., a hospital housekeeping aide, slipped on a freshly waxed floor while working in March 2012. OWCP accepted that the fall occurred but found the medical evidence insufficient to link his claimed neck spasms, arm numbness, and headaches to it. The Board agreed that his physicians had not provided a detailed medical explanation of how the fall caused a diagnosed condition. One report relied on symptoms appearing after the fall, while an MRI showed degenerative changes in the cervical spine that also needed explanation. The Board affirmed OWCP’s denial of the injury claim.

Decision snapshot

• Authority: FECA requirement for medical evidence of a diagnosed injury caused by an accepted work incident.
• Outcome: OWCP’s February 13, 2013 denial of the traumatic injury claim affirmed.
• Key point: The timing of symptoms after a fall did not by itself establish medical causation.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
T.L., Appellant
)
)
and ) Docket No. 13-934
) Issued: July 16, 2013
DEPARTMENT OF VETERANS AFFAIRS,
)
NEW MEXICO HOSPITAL CENTER,
)
Albuquerque, NM, Employer
)
__________ )

Appearances: Case Submitted on the Record
Alan J. Shapiro, Esq., for the appellant
Office of Solicitor, for the Director

DECISION AND ORDER

Before:
RICHARD J. DASCHBACH, Chief Judge
ALEC J. KOROMILAS, Alternate Judge
JAMES A. HAYNES, Alternate Judge

JURISDICTION

On March 11, 2013 appellant, through his attorney, filed a timely appeal of a February 13, 2013 Office of Workers’ Compensation Programs’ (OWCP) merit decision denying his traumatic injury claim. Pursuant to the Federal Employees’ Compensation Act1 (FECA) and 20 C.F.R. §§ 501.2(c) and 501.3, the Board has jurisdiction to consider the merits of the case.

ISSUE

The issue is whether appellant has met his burden of proof in establishing that his neck muscle spasm, bilateral arm numbness and headaches are due to his March 6, 2012 employment incident.

1
5 U.S.C. § 8101 et seq.
FACTUAL HISTORY

On March 7, 2012 appellant, then a 40-year-old housekeeping aid, filed a traumatic injury claim alleging that on March 6, 2012 he slipped and fell on a freshly waxed floor in the performance of duty injuring his entire spine, left shoulder, right knee and left ankle. He submitted form reports from his attending physician, Dr. Phillip Wagner, a Board-certified family practitioner, diagnosing strained back and left shoulder beginning March 19, 2012.

In a letter dated May 22, 2012, OWCP requested additional factual and medical evidence in support of appellant’s claim. Appellant underwent a cervical magnetic resonance imaging (MRI) scan on June 15, 2012 which demonstrated multilevel degenerative changes of the cervical spine including severe spinal canal stenosis at C5-6 and C6-7.

By decision dated August 16, 2012, OWCP denied appellant’s claim finding that he failed to submit a detailed narrative medical report. It found that he had established that the employment incident occurred as alleged, but that he failed to submit sufficient medical opinion evidence of a diagnosed condition as a result of his March 6, 2012 employment incident.

On August 21, 2012 counsel requested an oral hearing before an OWCP hearing representative. Dr. John G. Link, a Board-certified family practitioner, completed a form report on August 30, 2012 and diagnosed muscle spasms, back pain, neck pain and headache. He indicated with a checkmark “yes” that appellant’s condition was caused or aggravated by his employment incident noting that appellant “did not have those prior to fall.”

In a narrative report dated August 30, 2012, Dr. Link described appellant’s slip and fall on March 6, 2012 and reviewed his cervical MRI scan. He noted that appellant’s condition was improving and listed findings of soft tissue and paravertebral tenderness, thoracic paravertebral tenderness and lumbar paravertebral tenderness mostly on his left side. Dr. Link also found numbness in appellant’s hands bilaterally presumably from his neck osteophytes and severe spinal stenosis. He stated, “[Appellant] continues having neck muscle spasms and numbness in his bilateral arms that is new since his accident. This has been ongoing since then and has minimally improved. [Appellant] continues having mid back and low back pain which also started with the accident on March 6, 2012. He is also having headaches which started after his accident on March 6, 2012. It is clear that these have resulted from the injuries sustained on March 6, 2012.”

Appellant testified at the oral hearing on December 7, 2012. He noted that he slipped and fell on a waxed floor on March 6, 2012. Appellant stated that he had no physical problems prior to his fall. The fall resulted in pain in his right knee, left ankle, neck, back and left hand.

By decision dated February 13, 2013, an OWCP hearing representative found that appellant had established that his employment incident occurred as alleged on March 6, 2012 and that appellant had submitted medical evidence of diagnosed conditions including neck muscle spasm, bilateral arm numbness and headaches. The hearing representative concluded that appellant had not submitted the necessary medical opinion evidence to establish a causal relationship between his diagnosed conditions and his accepted employment incident on March 6, 2012.

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LEGAL PRECEDENT

An employee seeking benefits under FECA2 has the burden of establishing the essential elements of his or her claim by the weight of the reliable, probative and substantial evidence, including the fact that the individual is an “employee of the United States” within the meaning of FECA and that the claim was timely filed within the applicable time limitation period of FECA, that an injury was sustained in the performance of duty as alleged and that any disability or specific condition for which compensation is claimed is causally related to the employment injury.3 These are the essential elements of each and every compensation claim regardless of whether the claim is predicated upon a traumatic injury or an occupational disease.4

OWCP defines a traumatic injury as, “[A] condition of the body caused by a specific event or incident, or series of events or incidents, within a single workday or shift. Such condition must be caused by external force, including stress or strain which is identifiable as to time and place of occurrence and member or function of the body affected.”5 To determine whether a federal employee has sustained a traumatic injury in the performance of duty, it must first be determined whether a “fact of injury” has been established. First, the employee must submit sufficient evidence to establish that he and she actually experienced the employment incident at the time, place and in the manner alleged.6 Second, the employee must submit sufficient evidence, generally only in the form a medical evidence, to establish that the employment incident caused a personal injury.7 A medical report is of limited probative value on a given medical question if it is unsupported by medical rationale.8 Medical rationale includes a physician’s detailed opinion on the issue of whether these is a causal relationship between the claimant’s diagnosed condition and the implicated employment activity. The opinion of the physician must be based on a complete factual and medical background of the claim, must be one of reasonable medical certainty and must be supported by medical rationale explaining the nature of the relationship between the diagnosed condition and specific employment activity or factors identified by the claimant.9

ANALYSIS

Appellant alleged that he slipped and fell on March 6, 2012 while in the performance of his federal duties. He submitted medical evidence of diagnosed back and left shoulder strains as

2
5 U.S.C. §§ 8101-8193.
3
Kathryn Haggerty, 45 ECAB 383, 388 (1994); Elaine Pendleton, 41 ECAB 1143 (1989).
4
Victor J. Woodhams, 41 ECAB 345 (1989).
5
20 C.F.R. § 10.5(ee).
6
John J. Carlone, 41 ECAB 354 (1989).
7
J.Z., 58 ECAB 529 (2007).
8
T.F., 58 ECAB 128 (2006).
9
A.D., 58 ECAB 149 (2006).

3 well as findings of neck muscle spasms and numbness in his bilateral arms, back pain and headaches. OWCP found that appellant had not submitted the necessary medical opinion evidence to establish a causal relationship between his accepted employment incident and his diagnosed conditions.

The Board finds that appellant has submitted limited medical opinion evidence regarding the causal relationship between his accepted employment incident and a diagnosed condition. Dr. Wagner completed a form report diagnosing strained back and left shoulder on March 19, 2012. This report does not contain detailed findings on physical examination and does not provide any medical opinion evidence explaining how appellant’s accepted slip and fall resulted in the diagnosed condition. Due to the lack of medical opinion evidence, this report is not sufficient to establish that appellant’s slip and fall resulted in the diagnosed conditions.

Appellant also submitted two medical reports from Dr. Link. On August 30, 2012 he completed both a narrative and a form report addressing appellant’s current conditions. In the form report, Dr. Link diagnosed muscle spasms, back pain, neck pain and headache. He indicated with a checkmark “yes” that appellant’s condition was caused or aggravated by his employment incident noting that appellant “did not have those prior to fall.” The Board has held that an opinion on causal relationship which consists only of a physician checking “yes” to a medical form report question on whether the claimant’s disability was related to the history given is of little probative value. Without any explanation or rationale for the conclusion reached, such report is insufficient to establish causal relationship.10 As Dr. Link’s only support for a causal relationship is a temporal connection, the Board finds that this report is not sufficient to meet appellant’s burden of proof. The Board has held that the fact that a condition arises after an injury and was not present before an injury is not sufficient to support causal relationship.11

Dr. Link provided additional findings in his narrative report dated August 30, 2012 including tenderness in the thoracic and lumbar spines. He found numbness in appellant’s hands bilaterally which he attributed to appellant’s neck osteophytes and severe spinal stenosis. Dr. Link described appellant’s ongoing neck muscle spasms, hand numbness mid back and low back pain and headaches. He stated that these issues began after appellant’s accident on March 6, 2012 and concluded, “ It is clear that these have resulted from the injuries sustained March 6, 2012.”

The Board finds that Dr. Link’s August 30, 2012 narrative report does not contain the necessary medical reasoning to establish a diagnosed condition as a result of the March 6, 2012 employment incident. Dr. Link did not provide a clear diagnosis instead listing a series of symptoms including muscle spasms, numbness and pain. He opined that these conditions resulted from appellant’s employment incident, but did not offer a detailed explanation of how appellant’s accepted slip and fall resulted in these conditions. Additional reasoning is necessary as appellant’s cervical MRI scan indicated that his severe spinal canal stenosis at C5-6 and C6-7 was the result of degenerative changes of the cervical spine rather than a traumatic injury. Without a complete and detailed medical report providing a history of injury, findings on

10
Lucrecia M. Nielson, 41 ECAB 583, 594 (1991).
11
Michael S. Mina, 57 ECAB 379, 386 (2006).

4 examination and a diagnosed condition with supportive medical reasoning explaining how and why appellant’s slip and fall resulted in his current medical condition, appellant has failed to establish his traumatic injury claim.

Appellant may submit new evidence or argument with a written request for reconsideration to OWCP within one year of this merit decision, pursuant to 5 U.S.C. § 8128(a) and 20 C.F.R. §§ 10.605 through 10.607.

CONCLUSION

The Board finds that appellant failed to submit the necessary rationalized medical opinion evidence to establish a causal relationship between his claimed conditions and his accepted March 6, 2012 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the February 13, 2013 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: July 16, 2013
Washington, DC

Richard J. Daschbach, Chief Judge
Employees’ Compensation Appeals Board

Alec J. Koromilas, Alternate Judge
Employees’ Compensation Appeals Board

James A. Haynes, Alternate Judge
Employees’ Compensation Appeals Board

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