F.S. and Department of Agriculture, Forest Service, Cass Lake, MN (Board decision, November 25, 2014)

ECAB final decision. The Board affirmed OWCP’s May 19, 2014 denial of F.S.’s injury claim. Under 20 C.F.R. § 501.6(d), this Board decision becomes final 30 days after issuance unless the Board fixed a different period in it. A party may petition the Board for reconsideration within 30 days unless this decision specifies another period, under 20 C.F.R. § 501.7(a).

Plain-English summary

F.S., a forestry aid, slipped on ice while carrying a box at work and reported left arm and shoulder injuries. OWCP accepted the fall but found the medical evidence insufficient to link a diagnosed condition to it. The Board affirmed. The physician's note gave neither a firm diagnosis nor a causation opinion; other reports came from providers who did not qualify as physicians under FECA or were unsigned.

Decision snapshot

• Authority: Traumatic injury causation under FECA.
• Outcome: May 19, 2014 claim denial affirmed.
• Key point: An accepted fall still required competent medical evidence establishing the resulting injury.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
F.S., Appellant
)
)
and ) Docket No. 14-1751
) Issued: November 25, 2014
DEPARTMENT OF AGRICULTURE,
)
FOREST SERVICE, Cass Lake, MN, Employer
)
__________ )

Appearances: Case Submitted on the Record
Appellant, pro se
Office of Solicitor, for the Director

DECISION AND ORDER

Before:
CHRISTOPHER J. GODFREY, Chief Judge
MICHAEL E. GROOM, Alternate Judge
JAMES A. HAYNES, Alternate Judge

JURISDICTION

On August 11, 2014 appellant filed a timely appeal from a May 19, 2014 merit decision of the Office of Workers’ Compensation Programs 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 over the merits of this case.

ISSUE

The issue is whether appellant met his burden of proof to establish that he sustained left arm and shoulder injuries on March 11, 2014 while in the performance of duty.

FACTUAL HISTORY

On March 11, 2014 appellant, then a 64-year-old forestry aid, filed a traumatic injury claim alleging that he sustained left arm, shoulder and rib injuries that day when he slipped and

1
5 U.S.C. § 8101 et seq. fell on ice on a sidewalk while carrying a box in the performance of duty. He stopped work on the date of injury.

An unsigned medical report dated March 11, 2013 contained the printed name of Katherine Friese, a certified nurse practitioner. The report noted appellant’s chief complaint of left shoulder and elbow pain. It provided a history of the March 11, 2014 incident and appellant’s family and social background. It listed findings on physical and x-ray examination and diagnoses of left upper arm and shoulder contusions. It recommended restricted work duty for appellant through March 18, 2014.

Unsigned x-ray reports dated March 11, 2014 contained the printed name of Dr. Chad J.
St. Germain, a Board-certified radiologist. X-rays of the left elbow, humerus and shoulder revealed subtle irregularity involving the lateral supracondylar region of the distal left humerus that may reflect a nondisplaced fracture. Follow-up radiographs in 10 to 14 days were recommended. The x-rays also revealed mild degenerative changes involving the left shoulder with no evidence of acute fracture or dislocation. A magnetic resonance imaging scan was recommended if there was concern for internal derangement.

On April 15, 2014 appellant accepted the employing establishment’s April 9, 2014 job offer of a light-duty position. He returned to work on March 17, 2014.

By letter dated April 16, 2014, OWCP advised that, when appellant’s claim was received, it appeared to be a minor injury that resulted in minimal or no lost time from work. Because the employing establishment did not controvert continuation of pay or challenge the case, payment of a limited amount of medical expenses was administratively approved. OWCP reopened the claim for adjudication because appellant had not returned to work in a full-time capacity.

Thereafter, OWCP notified appellant of the deficiencies of his claim and afforded him 30 days to submit additional medical evidence. It also requested that the employing establishment submit medical evidence, if appellant had been treated at its medical facility.

In an April 10, 2014 report, Jeffrey Large, a physical therapist, advised that appellant had a left shoulder rotator cuff tear and addressed his treatment.

In an April 17, 2014 report, Dr. John A. Hamilton, a Board-certified orthopedic surgeon, advised that appellant could return to work on that day. He could work as tolerated.

By decision dated May 19, 2014, OWCP accepted that the March 11, 2014 incident occurred as alleged. It denied appellant’s claim, however, finding that the medical evidence failed to establish that his left arm or shoulder conditions were causally related to the accepted employment incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA2 has the burden of proof to establish the essential elements of his or her claim by the weight of the reliable, probative and substantial 2 5 U.S.C. §§ 8101-8193.

2 evidence3 including that he or she sustained an injury in the performance of duty and that any specific condition or disability for work for which he or she claims compensation is causally related to that employment injury.4

To determine whether a federal employee has sustained a traumatic injury in the performance of duty, it first must be determined whether fact of injury has been established.5 There are two components involved in establishing the fact of injury. First, the employee must submit sufficient evidence to establish that he or she actually experienced the employment incident at the time, place and in the manner alleged.6

The second component is whether the employment incident caused a personal injury and generally can be established only by medical evidence.7 The evidence required to establish causal relationship is rationalized medical opinion evidence, based upon complete factual and medical background, showing a causal relationship between the claimed condition and the identified factors.8 The belief of the claimant that a condition was caused or aggravated by the employment is insufficient to establish a causal relationship.9

ANALYSIS

OWCP accepted that on March 11, 2014 appellant fell on ice while in the performance of duty. It found that the medical evidence failed to establish that he sustained left arm and shoulder injuries as a result of the accepted incident. The Board finds that appellant failed to provide sufficient medical evidence to establish that he sustained left arm and shoulder injuries causally related to the accepted March 11, 2014 employment incident.

Dr. Hamilton’s April 17, 2014 report released appellant to return to work on that day.
However, he did not provide a firm diagnosis of a particular medical condition,10 provide any history of injury,11 or offer a specific opinion as to whether the accepted March 11, 2014

3
J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 58 (1968).
4
G.T., 59 ECAB 447 (2008); Elaine Pendleton, 40 ECAB 1143, 1145 (1989).
5
S.P., 59 ECAB 184 (2007); Alvin V. Gadd, 57 ECAB 172 (2005).
6
Bonnie A. Contreras, 57 ECAB 364 (2006); Edward C. Lawrence, 19 ECAB 442 (1968).
7
John J. Carlone, 41 ECAB 354 (1989); see 5 U.S.C. § 8101(5) (injury defined); 20 C.F.R. §§ 10.5(ee), 10.5(q) (traumatic injury and occupational disease defined, respectively). 8 Lourdes Harris, 45 ECAB 545 (1994); see Walter D. Morehead, 31 ECAB 188 (1979).
9
Kathryn Haggerty, 45 ECAB 383, 389 (1994).
10
See Deborah L. Beatty, 54 ECAB 340 (2003) (where the Board found that in the absence of a medical report providing a diagnosed condition and a reasoned opinion on causal relationship with the employment incident, appellant did not meet her burden of proof). 11 Frank Luis Rembisz, 52 ECAB 147 (2000) (medical opinions based on an incomplete history have little probative value).

3 employment incident caused or aggravated appellant’s condition.12 Consequently, the Board finds that the report is of limited probative value and does not establish appellant’s traumatic injury claim.

The reports from Ms. Friese, a certified nurse practitioner, and Mr. Large, a physical therapist, are insufficient to establish appellant’s claim. As neither a nurse practitioner nor a physical therapist is a “physician” as defined under FECA, their opinions are of no probative value.13

The unsigned reports which contained the printed name of Dr. St. Germain are insufficient to establish appellant’s claim. A report that is unsigned or bears an illegible signature lacks proper identification and cannot be considered probative medical evidence.14

Therefore, the Board finds that there is insufficient medical evidence to establish that appellant sustained left arm and shoulder injuries causally related to the accepted March 11, 2014 employment incident.

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 has not met his burden of proof to establish that he sustained left arm and shoulder injuries on March 11, 2014 while in the performance of duty.

12
A.D., 58 ECAB 149 (2006) (medical evidence which does not offer any opinion regarding the cause of an employee’s condition is of limited probative value on the issue of causal relationship). 13 The term physician includes surgeons, podiatrists, dentists, clinical psychologists, optometrists, chiropractors and osteopathic practitioners within the scope of their practice as defined by State law. 5 U.S.C. § 8102(2); A.C., Docket No. 08-1453 (issued November 18, 2008) (records from a physical therapist do not constitute competent medical opinion in support of causal relation, as physical therapists are not physicians as defined under FECA); L.D., 59 ECAB 648 (2008) (a nurse practitioner is not a physician as defined under FECA); Roy L. Humphrey, 57 ECAB 238 (2005). 14 Thomas L. Agee, 56 ECAB 465 (2005); Richard F. Williams, 55 ECAB 343 (2004).

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 ORDER

IT IS HEREBY ORDERED THAT the May 19, 2014 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: November 25, 2014
Washington, DC

Christopher J. Godfrey, Chief Judge
Employees’ Compensation Appeals Board

Michael E. Groom, Alternate Judge
Employees’ Compensation Appeals Board

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

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