L.S. and Department of Veterans Affairs, Veterans Health Administration, Denver, CO (Board decision, March 22, 2016)

ECAB remand decision. The Board set aside OWCP’s November 3, 2014 disability denial and remanded for clarification from the impartial medical examiner and a new decision. Whether L.S. was disabled by a work-related condition during the claimed period remains unresolved. 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).

Plain-English summary

L.S., a Veterans Health Administration nurse, injured her wrist when an elevator door closed on her hand. She sought disability compensation for June 2012 through February 2013, including effects of depression that she said followed the injury. The impartial examiner linked her mental health conditions to consequences of the wrist injury in some reports but later emphasized that the conditions were not directly caused by the wrist injury. The Board found his opinion needed clarification on whether the work injury caused or aggravated those conditions and whether they contributed to disability during the claimed period. It returned the case to OWCP for a supplemental report and a new decision.

Decision snapshot

• Authority: 5 U.S.C. § 8123(a); 20 C.F.R. § 10.321.
• Outcome: OWCP's November 3, 2014 disability denial set aside; claim remanded.
• Key point: The impartial examiner needed to address aggravation and consequential effects, not only direct causation.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

)
L.S., Appellant
)
)
and ) Docket No. 15-0470
) Issued: March 22, 2016
DEPARTMENT OF VETERANS AFFAIRS,
)
VETERANS HEALTH ADMINISTRATION,
)
Denver, CO, Employer
)
___________ )

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

DECISION AND ORDER

Before:
PATRICIA H. FITZGERALD, Deputy Chief Judge COLLEEN DUFFY KIKO, Judge
ALEC J. KOROMILAS, Alternate Judge

JURISDICTION

On December 29, 2014 appellant, through counsel, filed a timely appeal from a November 3, 2014 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 appellant’s claim.

ISSUE

The issue is whether appellant met her burden of proof to establish disability for the period June 8, 2012 through February 9, 2013 as a result of employment-related conditions.

FACTUAL HISTORY

This case has previously been before the Board.2 In a September 5, 2013 decision, the Board affirmed a March 7, 2013 OWCP decision, finding that appellant had not established any

1
5 U.S.C. § 8101 et seq.
2
Docket No. 13-1173 (issued September 5, 2013). permanent impairment due to her accepted employment injuries which would entitle her to a schedule award. The facts and history contained in the prior appeal are incorporated herein by reference.

On August 17, 2011 appellant, a nurse, injured her left hand when it was caught in a closing elevator door. She received continuation of pay through October 13, 2011. By letter dated October 12, 2011, OWCP accepted appellant’s claim for contusion of the left wrist.3 On August 18, 2011 appellant was released to return to work by a physician at Health One Occupational Medicine.4 Appellant did not return to work, but received intermittent wage loss for treatment and physical therapy for her wrist condition.5 On March 25, 2012 appellant accepted a modified position, which included duties of typing, computer research, reading, organizing filing cabinets, and filing document. The physical restrictions included intermittent lifting and pushing/pulling up to two pounds. No repetitive work with the left hand was permitted.

OWCP continued to develop the claim.

In a June 8, 2012 treatment note, Dr. John McInroy, a psychologist, indicated that appellant could not return to work due to her medical condition.

Appellant submitted Form CA-7 claims for wage-loss compensation for the period beginning June 8, 2012, and thereafter.6 In a June 25, 2012 report, Dr. Hiep Ritzer, a Board- certified family practitioner, diagnosed a left wrist contusion and reactive depression. She recommended permanent work restrictions. On July 12, 2012 Dr. Ritzer stated that appellant had reached maximum medical improvement.

In a June 26, 2012 report, Dr. McInroy placed appellant on medical leave for her mental/psychological and physical conditions until further notice.7

In a letter dated August 21, 2012, OWCP requested that appellant provide additional documentation with regard to her claim for disability. It noted that her claim had only been accepted for a left wrist contusion. OWCP requested a physician’s opinion supported by a medical explanation as to the relationship between her accepted work-related conditions and any claimed consequential conditions.

3
In a separate claim, doubled into the present claim, OWCP accepted that on August 2, 2011 appellant had sustained a sprain of the lumbar and sacrum regions of the back. Under that claim, appellant received compensation for intermittent wage loss from October through December 2011. 4 The physician’s signature is illegible.
5
The record reflects that appellant claimed an emotional condition, but the claim was denied and she returned to light-duty work on December 8, 2011 with restrictions related to her accepted wrist condition. The record indicates that appellant sought treatment for an emotional condition that was not accepted as work related and took significant time off from work due to the emotional condition. 6 On June 21, 2012 appellant filed a claim for a recurrence.
7
Appellant was previously seen by Dr. William Boyd, a psychologist, who opined that she had post-traumatic stress disorder (PTSD) due to the August 17, 2011 work injury. On March 16, 2012 Dr. Boyd found that appellant no longer exhibited PTSD symptoms and that her condition had resolved.

2
 In an August 26, 2012 response, Dr. McInroy noted the August 17, 2011 original injury occurred when an elevator door at work closed on appellant’s arm. He advised that her current symptoms included chronic pain and depression. Dr. McInroy explained that appellant was depressed and cried “all the time, is actively suicidal, unable to function at work or home … and can’t go near elevators and had memories associated with the trauma.” He noted that she sought treatment and had been diagnosed by Dr. Boyd with adjustment disorder with depressed mood, severe, and acute PTSD. Dr. McInroy noted results of diagnostic testing that supported appellant’s diagnoses. Under Axis I, he diagnosed major severe depressive disorder; generalized anxiety disorder; and severe PTSD. Dr. McInroy deferred an Axis II diagnosis and diagnosed chronic pain, injury to left arm, intracranial hypertension under Axis III. He opined that the medical/psychological data most strongly supported appellant’s condition and the reason why she was unable to work as a nurse at the employing establishment. Dr. McInroy advised that the other traumas in her life included a serious motor vehicle accident and an intracranial hypertension, also known as a pseudotumor. He explained that appellant’s cerebral spinal fluid was drained periodically to reduce the pressure that caused headaches.

Dr. McInroy also noted appellant’s previous back injury claim. He opined that appellant’s history predisposed her to develop a much more serious mental disorder resulting from the occupational accident with the elevator. He indicated that reactive depression, back injury, and headaches were not due to the August 17, 2001 injury as they were diagnosed prior to the accident. Dr. McInroy indicated, however, that appellant’s severe major depressive disorder, severe PTSD, generalized anxiety disorder, and chronic arm pain were employment related and noted that the PTSD had not been diagnosed before the work injury. He recommended treatment and opined that she was unable to work.

In a September 10, 2012 report, Dr. Samuel Chan, a Board-certified physiatrist, noted seeing appellant and reviewing her history. Appellant related that she did not have range of motion deficits and that her permanent weight restriction should be two pounds as she was “unable to lift even a gallon of milk.” Dr. Chan indicated that as the range of diagnostic testing was negative, there was a rather low probability that appellant had complex regional pain syndrome (CRPS). Regarding permanent work restrictions Dr. Chan noted that her restrictions were based on a functional capacity evaluation (FCE) and clinical evaluations, but clarified that this was not “necessarily a medical recommendation per se,” but that appellant felt that she should “self-limit” herself. Dr. Chan opined that she had reached maximum medical improvement (MMI).

On November 6, 2012 OWCP referred appellant to Dr. Randolph W. Pock, a Board- certified psychiatrist, for a second opinion regarding whether appellant had an emotional condition consequential to her accepted work injuries. In a January 3, 2013 report, Dr. Pock described appellant’s history and provided results on examination. Appellant noted struggling with hardship her entire life and that she had many nonwork stressors.8 Dr. Pock diagnosed severe major depression but found that appellant did not have PTSD. Dr. Pock explained that there were multiple factors affecting her depression that included nonindustrial matters. He indicated that appellant had physical symptoms related to the events involving the elevator door. Dr. Pock did not think that the elevator door incident was a predominant contributing factor to her condition. He advised that, if appellant continued to have symptoms related to the elevator

8
A copy of appellant’s “self-assessment” accompanied his report.

3 door incident, he would consider this to be a contributing factor exacerbating what he believed to be a chronic depression. However, Dr. Pock stated that he saw no evidence to attribute any limitation of function to the elevator incident. In a December 5, 2012 work capacity evaluation, he indicated that appellant was unable to work.

On January 31, 2013 OWCP referred appellant to Dr. Howard J. Entin, a Board-certified psychiatrist, for an impartial medical evaluation to resolve the conflict in opinion between Dr. Pock, the second opinion physician, and Dr. McInroy regarding whether the August 17, 2011 injury aggravated appellant’s depression.

In a February 1, 2013 report, Dr. McInroy rebutted Dr. Pock’s report and stated that he spent over 36 hours evaluating appellant and provided objective testing to support his opinion. He noted that Dr. Pock spent 75 minutes evaluating appellant. Dr. McInroy opined that appellant’s work injury contributed to her emotional condition.

In a February 20, 2013 report, Dr. Entin noted appellant’s history, and provided results on examination. Under Axis I, he diagnosed chronic severe major depressive disorder; pain disorder associated with psychological factors and her medical condition; and chronic preexisting dysthymia.9 Dr. Entin determined that appellant clearly had a severe major depressive episode with associated anxiety that was ongoing a few months after her arm injury.10 He noted that her arm was caught in the elevator but it was not life threatening. Dr. Entin noted that appellant had recurrent dreams because she was depressed, angry and overwhelmed by her situation and he believed her avoidance of elevators was primarily due to depression. He believed that she had a pain disorder as her symptoms were out of proportion to objective findings and partly related to psychological issues.11 Dr. Entin advised that, “because of this work injury and the chronic pain, appellant has not been able to work as a registered nurse (RN) on an inpatient unit.” He noted that appellant had been transferred to a light-duty clerical position which in her mind was “humiliating and demeaning.” Afterwards, appellant was given a data entry job, which she found difficult given her left arm problems. She was then placed into a position where she sterilized surgical equipment. He noted that appellant had not been paid for her medical appointments and had significant income loss creating financial hardship.

Appellant became progressively more depressed and was not authorized treatment by OWCP for her depression. She did receive some social security disability benefits but she

9
Dr. Entin indicated there were nonwork diagnoses including intracranial hypertension, chronic headaches, diminished right eye vision, irritable bowel symptoms, bilateral knee pains, chronic fatigue, and insomnia. She had severe stressors along Axis IV including loss of career and financial hardship; chronic severe depression, suicidal ideation, social isolation, and poor home functioning. 10 Dr. Entin explained how appellant met the major depressive episode criteria. He did not diagnose PTSD and noted that most of her PTSD symptoms were directly related to her severe major depression and how “victimized, angry and histrionic she feels.” Dr. Entin stated that if she returned to work, and did not feel so much financial distress and did not feel victimized by the “work comp system,” PTSD symptoms would be less of an issue. 11 Dr. Entin noted that appellant had ongoing physical symptoms and she had physical limitations for her left arm.
He explained that given her profound history of abuse, neglect, and hardship, she has “likely suffered from chronic dysthymia or depression throughout her life and is very prone to feeling abused and victimized.”

4 continued to feel so depressed and victimized that she could barely function.12 Dr. Entin opined that the cause of appellant’s current major depressive symptoms was multifactorial and because of her severe childhood trauma and deprivation, she was vulnerable to depression and decompensation. He advised that within a reasonable degree of medical probability, her injury and her loss of ability to be a floor nurse, or inability to return to work in any capacity as a RN, and the financial stressors from her injury were a temporary aggravating factor that led directly to an aggravation of her chronic depression and development of severe major depression. He opined that appellant would not have her current level of depression, were it not for her work injury.

Dr. Entin clarified that there were several concurrent stressors contributing to her depression, including family matters. He noted appellant had intracranial hypertension since 2008 with severe incapacitating headaches and it was not clear if she could return to RN work because of the headaches. Dr. Entin apportioned 50 percent to her work injury and the fact that she could no longer work as a floor nurse and the other 50 percent to her existing vulnerability and other concurrent emotional, family and physical stressors that were not work related. He found that due to emotional reasons appellant could not work. Dr. Entin believed that she was physically capable of working as an RN and her arm injury did not preclude her from working. He stated that there was no reason that her left arm injury should have caused such severe depression that she could not work. However, Dr. Entin advised that, for other physical issues such as her intracranial hypertension, severe migraines, and effects on her cognition, it was unclear if she could work.

In a March 7, 2013 letter to Dr. Entin, OWCP noted that he advised that appellant had intracranial hypertension since 2008 as well as a history of severe abuse, neglect and chaos in her life that were significant contributing factors that made her vulnerable to being abused and victimized. It further noted that Dr. Entin opined that “her worker’s compensation injury, … the loss of her ability to be a floor nurse, the fact that she has not been able to find a level of resilience to return to work in any capacity …, and the financial stressors from her injury, has been a temporary aggravating factor that has led directly to an aggravation of her chronic depression and development of a severe major depression. Were it not for this workers’ compensation injury, I do not believe she would have the level of depression that she currently experiences.” OWCP noted that Dr. Chan’s September 10, 2012 report indicated diagnostic testing for physical conditions was negative. It advised that there were no objective findings for her accepted physical condition. OWCP requested that Dr. Entin provide his medical rationale to support his conclusion that the August 17, 2011 work injury caused her current emotional condition, as opposed to outside factors such as family issues and nonwork related health problems.

In a March 7, 2013 addendum, Dr. Entin agreed that appellant did not have evidence CRPS. He stated that it was his understanding that her permanent physical restrictions on lifting precluded her from floor RN work but she was still capable of working as an RN in another capacity. He noted that the treating psychologist had not released her to work and explained that during the time of the work injury treatment, she was given light-duty restrictions and assigned

12
Dr. Entin indicated that although her medical records revealed preexisting dysthymia and anxiety, she was able to work, obtain her nursing degree, and work for the last 10 years without evidence of difficulty due to her depression.

5 to jobs where she felt demeaned and lost income. Dr. Entin noted that they were all significant psychological stressors related to appellant’s work injury. He explained that the combination of arm pain, work restrictions, and the stressors caused by these events should be considered temporary aggravating factors to her preexisting dysthymia, which contributed to the development of a major depressive episode. Dr. Entin noted that a number of preexisting and concurrent psychological stressors were also aggravating factors. He explained that this was why he apportioned appellant’s major depressive disorder as 50 percent due to the work injury and 50 percent due to other factors. Dr. Entin indicated that treatment for her physical issues was closed as she reached maximum medical improvement on July 12, 2012. He explained that physical symptoms were still present and related to appellant’s work injury, but they were minimally impairing. Dr. Entin explained that she was released to work with some physical restrictions. He opined that appellant’s psychological condition, or major depressive episode, should no longer be considered work compensable. Dr. Entin elaborated that the worker’s compensation injury should no longer be considered an aggravating factor of her mental condition as of July 12, 2012.

In a March 25, 2013 decision, OWCP denied appellant’s claims for compensation finding that her disability during this period of time was not due to her accepted workplace injury.13

In a March 29, 2013 report, Dr. Chan noted that appellant had been treated from October 13, 2011 to September 10, 2012 for a left wrist contusion. He explained that in reviewing her records, she did not fit the criteria for CRPS. Dr. Chan opined that, given the lack of objective findings, there should not be any ongoing issues. He noted that appellant continued with a subjective pain complaint and the pain generator was elusive. Dr. Chan recommended a weight lifting limit up to 15 pounds based on the FCE and prescribed restrictions.

On April 1, 2013 counsel requested a telephonic hearing, which was held on August 15, 2013.14 However, by decision dated December 3, 2013, the hearing representative set aside the March 25, 2013 decision denying her claims for compensation and remanded the case for additional development.15

13
In a separate March 25, 2013 decision, OWCP denied appellant’s claim for a recurrence. Counsel also requested a hearing with regard to the denial of her claim for a recurrence, which has held on September 11, 2013. In a November 29, 2013 decision, OWCP’s hearing representative affirmed its denial of her claim for a recurrence. 14 On September 30, 2013 OWCP referred appellant to Lawrence Splitter, Board-certified in occupational medicine, to determine if the wrist contusion had resolved. In an October 24, 2013 report, Dr. Splitter noted appellant’s history and determined that she may have had a wrist contusion in the beginning, but he explained that she had a normal MRI scan and inconclusive studies in regard to the development of CRPS and advised that there was nothing to substantiate an ongoing injury currently as the contusion had resolved. On April 18, 2014 OWCP proposed to terminate appellant’s medical and wage-loss benefits based on Dr. Splitter’s opinion. In a May 20, 2014 decision, it terminated her medical and wage-loss benefits. OWCP found that the weight of medical evidence established that she no longer had any residuals or disability due to her accepted condition. 15 The hearing representative instructed OWCP to request that the impartial medical examiner provide a rationalized medical opinion as to whether appellant’s diagnosed emotional conditions were a direct and natural result of the medical effects of her workplace injury independent of noncompensable intervening factors. The hearing representative indicated that if Dr. Entin was of the opinion that appellant’s emotional conditions were work related, he should then be asked whether such conditions prevented her from working or required that she miss time from work for medical treatment for any period beginning June 8, 2012.

6
 In accordance with the remand decision, in a letter dated December 20, 2013, OWCP requested additional information from the impartial medical examiner, Dr. Entin.16

In a January 6, 2014 supplemental report, Dr. Entin opined that the diagnosed major depressive disorder and pain disorder were not due directly to her wrist injury. He opined that they were however “due to the consequences of the wrist injury, as well as a number of other preexisting factors, but these have not been demonstrated as being compensable and related to the work injury.” In response to whether the diagnosed conditions prevented appellant from working for any period beginning June 8, 2012, Dr. Entin responded “[n]o, the diagnosed condition of her wrist injury per se is not a significant problem. [She] had some physical restrictions but was still able to work. Her chronic pain is not a major stressor. Appellant can function with her chronic pain which is bothersome and annoying. I do not believe this chronic pain is causing her current diagnosed psychiatric conditions nor does it interfere with her ability to work within her physical restrictions.” In response to whether intervening factors such as financial hardship, stress related to processing her claim, or dissatisfaction with her light-duty job contributed to the psychological conditions postinjury and prevented her from working rather than any emotional facts of her work injury, the physician responded “yes.” He opined that a number of these other intervening factors including her preexisting susceptibility and vulnerability to depression and anxiety contributed and prevented her from working. Dr. Entin advised that it was not chronic left arm pain that prevented her from working.

In a January 30, 2014 decision, OWCP denied appellant’s claim for wage-loss compensation for the period June 8, 2012 to February 9, 2013.

On February 5, 2014 counsel requested a telephonic hearing, which was held on August 25, 2014.17 He argued that Dr. Entin’s report supported a relationship between the psychiatric condition and the employment injury.

In a report dated June 17, 2014, Dr. McInroy explained that appellant was unable to return to work due to major depression, severe; generalized anxiety disorder, severe; PTSD, severe phobia.18

By decision dated November 3, 2014, the hearing representative affirmed the January 30, 2014 decision.19

16
OWCP requested his opinion with regard to whether the diagnosed conditions were a direct and natural result of the medical effects associated with the work injury independent of appellant’s reaction to financial hardship, processing of her claim, or her dissatisfaction with her light-duty job. It also asked his opinion as to whether the diagnosed conditions related to the effects of the work injury prevented appellant from working for any period beginning June 8, 2012. OWCP also requested that he address whether intervening factors, such as financial hardship, stress related to the processing of her claim, dissatisfaction with her light-duty job contributed to the condition postinjury and prevented her from working rather than any emotional effects of her condition. 17 At the hearing, appellant testified that she had received disability retirement and social security disability for depressive, anxiety and phobia disorders, intracranial hypertension, and vision loss effective June 8, 2012. 18 Dr. McInroy also noted that she had physical disorders such as vision impairment; osteoarthritis; intracranial hypertension; gastroesophageal reflux disease, Crohn’s disease, and a peptic ulcer. 19 The hearing representative found that Dr. Entin clarified his opinion and did not relate appellant’s psychiatric diagnoses to her accepted left wrist injury but to her preexisting conditions and her dissatisfaction with OWCP.

7
 LEGAL PRECEDENT

The term disability as used in FECA20 means the incapacity because of an employment injury to earn the wages that the employee was receiving at the time of injury.21 Whether a particular injury caused an employee disability for employment is a medical issue which must be resolved by competent medical evidence.22 When the medical evidence establishes that the residuals of an employment injury are such that, from a medical standpoint, they prevent the employee from continuing in the employment held when injured, the employee is entitled to compensation for any loss of wage-earning capacity resulting from such incapacity.23 The Board will not require OWCP to pay compensation for disability in the absence of any medical evidence directly addressing the specific dates of disability for which compensation is claimed. To do so would essentially allow employees to self-certify their disability and entitlement to compensation.24

It is well established that where employment factors cause an aggravation of an underlying physical condition, the employee is entitled to compensation for periods of disability related to the aggravation. Where the medical evidence supports an aggravation or acceleration of an underlying condition precipitated by working conditions or injuries, such disability is compensable. However, the normal progression of untreated disease cannot be said to constitute “aggravation” of a condition merely because the performance of normal work duties reveal the underlying condition. For the conditions of employment to bring about an aggravation of preexisting disease, the employment must cause acceleration of the disease or precipitate disability.25 Where an employee claims that a condition not accepted or approved by OWCP was due to an employment injury, he or she bears the burden of proof to establish that the condition is causally related to the employment injury.26

Section 8123(a) provides that, if there is disagreement between the physician making the examination for the United States and the physician of the employee, the Secretary shall appoint a third physician who shall make an examination.27 The implementing regulation states that, if a conflict exists between the medical opinion of the employee’s physician and the medical opinion of either a second opinion physician or an OWCP medical adviser, OWCP shall appoint a third physician to make an examination. This is called a referee examination and OWCP will select a physician who is qualified in the appropriate specialty and who has no prior connection with the case.28 20 5 U.S.C. §§ 8101-8193; 20 C.F.R. § 10.5(f).
21
Paul E. Thams, 56 ECAB 503 (2005).
22
W.D., Docket No. 09-658 (issued October 22, 2009); id.
23
Id.
24
William A. Archer, 55 ECAB 674 (2004); Fereidoon Kharabi, 52 ECAB 291 (2001).
25
A.C., Docket No. 08-1453 (issued November 18, 2008).
26
Jaja K. Asaramo, 55 ECAB 200 (2004).

27
5 U.S.C. § 8123(a); Barry Neutuch, 54 ECAB 313 (2003).
28
20 C.F.R. § 10.321.

8
 ANALYSIS

The Board finds that this case is not in posture for decision with regard to whether appellant has established that she was disabled for the period June 8, 2012 through February 9, 2013 as a result of her employment-related conditions. OWCP accepted that appellant sustained a contusion of the left wrist.29 A conflict arose between the treating physician, Dr. McInroy and Dr. Pock regarding whether the August 17, 2011 incident aggravated appellant’s depression. OWCP properly selected Dr. Entin, a Board-certified psychiatrist, to resolve the conflict. However, the Board finds that the conflict remains unresolved.

In his February 20, 2013 report, Dr. Entin diagnosed chronic severe major depressive disorder; pain disorder associated with psychological factors and her medical condition; and chronic preexisting dysthymia. He found that appellant had symptoms of a severe major depressive episode with associated anxiety that began a few months after the accepted injury. Dr. Entin opined that the cause of her current major depressive symptoms was multifactorial. He explained that, because of her severe childhood trauma and deprivation, she was vulnerable to depression and decompensation. The physician opined that within a reasonable degree of medical probability, her injury and her loss of ability to be a floor nurse, or inability to return to work in any capacity as a nurse, and the financial stressors from her injury were a temporary aggravating factor that led directly to an aggravation of her chronic depression and development of a severe major depression. Dr. Entin opined that she would not have her current level of depression, were it not for her current injury.30 Dr. Entin apportioned 50 percent to her work injury and the fact that she could no longer work as a floor RN and the other 50 percent to preexisting and concurrent conditions that were not work related.

On March 7, 2013 OWCP requested clarification from Dr. Entin.31 In a March 7, 2013 addendum, Dr. Entin noted that appellant’s permanent physical restrictions precluded her from working as a floor RN, but she was capable of working as a nurse in another capacity. He explained that during treatment for the work injury, she was given light duty and assigned to jobs where she felt demeaned and lost income. Dr. Entin noted that there were significant psychological stressors related to her work injury. He explained that the combination of her arm pain, work restrictions, and the stressors caused by these should be considered temporary aggravating factors to her preexisting dysthymia, which contributed to the development of a major depressive episode. Dr. Entin noted that there were a number of preexisting and concurrent psychological stressors that were aggravating factors. He explained that this was the reason that he apportioned her major depressive disorder as 50 percent due to the work injury

29
As noted, infra, OWCP terminated benefits for the accepted wrist contusion on May 20, 2014. Appellant did not appeal this decision.
30
Dr. Entin clarified that there were several concurrent stressors contributing to her depression, including the fact that her daughter no longer lived with her, and her other daughter was in a severe accident. He noted that she had intracranial hypertension with severe incapacitating headaches and it was not clear if she could return to work as an RN because of the headaches. 31 See Roger W. Griffith, 51 ECAB 491(2000) (when OWCP secures an opinion from an impartial medical specialist for the purpose of resolving a conflict in the medical evidence and the opinion from the specialist requires clarification or elaboration, OWCP has the responsibility to secure a supplemental report from the specialist for the purpose of correcting a defect in the original report).

9 and 50 percent due to other factors. Dr. Entin explained that her physical symptoms were still present and related to her work injury, but they were minimally impairing. He explained that her psychological condition, or major depressive episode, should no longer be considered an aggravating factor of her mental condition as of July 12, 2012.

On December 20, 2013 OWCP requested further clarification from Dr. Entin. In a January 6, 2014 supplemental report, Dr. Entin opined that the diagnosed major depressive disorder and pain disorder were not due directly to her wrist injury. However, they were “due to the consequences of the wrist injury, as well as a number of other preexisting factors, but these have not been demonstrated as being compensable and related to the work injury.” Regarding whether the diagnosed conditions prevented appellant from working for any period beginning June 8, 2012, he responded “[n]o, the diagnosed condition of her wrist injury per se is not a significant problem. [She] had some physical restrictions but was still able to work.
[Appellant’s] chronic pain is not a major stressor. [She] can function with her chronic pain which is bothersome and annoying. I do not believe this chronic pain is causing [appellant’s] current diagnosed psychiatric conditions nor does it interfere with her ability to work within her physical restrictions.” In response to whether intervening factors such as financial hardship, stress related to the processing of her claim, or dissatisfaction with her light-duty position contributed to the psychological conditions postinjury and prevented her from working rather than any emotional facts of her work injury, the physician responded “yes.” He reiterated that a number of intervening factors prevented her from working and that it was not chronic left arm pain that prevented her from working.

The Board finds that further development is required. Dr. Entin’s opinion is consistent in stating that the diagnosed conditions of major depressive disorder, and pain disorder, while not being directly related to her wrist injury, were “due to the consequences of the wrist injury.” In his most recent report, Dr. Entin opined that these conditions were not “directly” due to her wrist injury. The Board notes that an employee is not required to prove that occupational factors are the sole cause of her claimed condition. If work-related exposures caused, aggravated or accelerate appellant’s condition, appellant is entitled to compensation.32 Although OWCP concluded that appellant was no longer disabled beginning June 8, 2012 due to an employment- related condition, this is not sufficiently supported by Dr. Entin’s opinion as he appears to be under the impression that an employment factor must be the direct cause of an injury. OWCP must obtain further clarification that resolved the conflict in the medical evidence.33

Upon return of the case record, OWCP shall request a supplemental report from Dr. Entin regarding whether appellant’s work injury caused or aggravated the diagnosed emotional conditions and, if so, whether any work-related condition caused or contributed to disability during the claimed periods. Following this and any other further development as deemed necessary, it shall issue an appropriate merit decision on appellant’s claim.

CONCLUSION

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

32
Beth P. Chaput, 37 ECAB 158 (1985).
33
See supra note 30.

10
 ORDER

IT IS HEREBY ORDERED THAT the November 3, 2014 decision of the Office of Workers’ Compensation Programs is set aside and remanded for further action consistent with this decision.

Issued: March 22, 2016
Washington, DC

Patricia H. Fitzgerald, Deputy Chief Judge Employees’ Compensation Appeals Board

Colleen Duffy Kiko, Judge
Employees’ Compensation Appeals Board

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

11