T.S. and Department of the Navy, Ocean Projects Department, Stennis Space Center, MS (Board decision, July 17, 2015)

ECAB final decision. The Board affirmed OWCP’s January 15, 2015 denial of T.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

T.S., a Navy electronics technician, reported fainting after a shower while aboard a ship for work. OWCP accepted that the incident occurred but denied his claim for lack of medical evidence linking an illness or injury to his employment. The Board found that some medical records were unsigned and that the signed reports did not explain how his duties or the accepted incident caused or aggravated a diagnosed condition. It affirmed the denial. The Board did not dispute that he had been aboard the ship when the incident occurred.

Decision snapshot

• Authority: Federal Employees’ Compensation Act, 5 U.S.C. § 8101 et seq.
• Outcome: January 15, 2015 injury claim denial affirmed.
• Key point: An accepted incident alone did not establish a compensable injury without reasoned medical evidence of causation.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
T.S., Appellant
)
)
and ) Docket No. 15-0890
) Issued: July 17, 2015
DEPARTMENT OF THE NAVY, OCEAN
)
PROJECTS DEPARTMENT,
)
STENNIS SPACE CENTER, MS, Employer
)
__________ )

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

DECISION AND ORDER

Before:
COLLEEN DUFFY KIKO, Judge
ALEC J. KOROMILAS, Alternate Judge
JAMES A. HAYNES, Alternate Judge

JURISDICTION

On March 13, 2015 appellant filed a timely appeal from a January 15, 2015 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.2

ISSUE

The issue is whether appellant established an injury in the performance of duty on November 21, 2014, as alleged.

On appeal, appellant argued that he was feeling fine before he was stationed aboard the Scarlet Isabella in November 2014, that he became sick on the ship with a bad sinus infection, 1 5 U.S.C. § 8101 et seq.
2
Appellant submitted new evidence after the issuance of OWCP’s January 15, 2015 decision. However, the Board may only review evidence that was before OWCP at the time of its final decision. 20 C.F.R. § 501.2(c)(1). and that he passed out after a shower on November 21, 2014. He argued that he was on official government business while on board the ship and sustained a legitimate accident during the course of his federal employment.

FACTUAL HISTORY

On November 22, 2014 appellant, then a 42-year-old electronics technician, filed a traumatic injury claim alleging that on November 21, 2014 he passed out due to dehydration and sinus infection. The employing establishment controverted appellant’s claim, arguing that at the time of the incident, he was in the shower getting ready for his watch. Appellant did not submit any information with his claim.

By letter dated December 11, 2014, OWCP informed appellant that he must submit evidence in support of his claim.

In a statement received by OWCP on December 17, 2014, appellant stated that he was currently seeing a doctor at his home and she was checking him for blood loss that he sustained while working on a ship in the course of his federal employment. He noted that he will have to see a new doctor to do a stomach scan and possible colonoscopy. Appellant further noted that he was having dizzy spells and was very weak. In a December 15, 2014 statement, he reported that he was onboard the Scarlet Isabella vessel when he walked out of the shower and passed out. Appellant noted that after the incident he was very weak and had elevated blood pressure, so he went to the emergency room in Providence, Rhode Island. He further noted that he had not sustained any other injury. In a separate undated and unsigned statement, a coworker noted that on November 21, 2014, while sitting in the galley watching television, appellant came out of the shower and looked extremely pale; that appellant mentioned that while in the shower he was coughing up blood and got dizzy; and that after telling appellant to lie down, the coworker retrieved the captain, who came, examined appellant, and escorted him to his bunk to rest until the ship could get to port and get him to a hospital.

Appellant submitted a November 21, 2014 work release form from Newport Hospital with an illegible signature indicating that he was treated on that date in the emergency department and was released to work with no restrictions. He also submitted his discharge instructions from this visit. The discharge instructions noted that appellant was treated by many clinicians, including Dr. Jeffrey Gaines, a physician Board-certified in emergency medicine, and was diagnosed with syncope, anemia, and dehydration. This document was not signed.

Appellant also submitted largely illegible and unsigned handwritten progress notes from Picayune Family Care Center, dated December 1, 2014, where Dr. Delora A. Denney, a Board- certified family practitioner, and James L. Denney, a family nurse practitioner, maintain a practice.

In a December 8, 2014 report Dr. Warren A. Hiatt, Jr., a Board-certified gastroenterologist and internist, noted that appellant had some episodes of shakiness or dizziness since his event three weeks ago. He listed impressions as: recent episode suggesting upper gastrointestinal bleeding which was very likely nonsteroidal induced with daily use of BC powders containing aspirin and associated anemia; family history of colon cancer; hypertension;

2 and spasm of the right arm secondary to central nervous system injury. In a December 10, 2014 report, Dr. Hiatt noted that he performed an esophagogastroduodenoscopy and noted marked erosive distalesophagitis, apparently from the prior hematemesis. He also performed a screening colonoscopy which was negative for neoplasm.

Appellant also submitted a preincident medical report, dated October 28, 2014, wherein Dr. Denney listed her impressions with regard to appellant as: low iron, improving; hypertension which looks excellent; and venous stasis.

By decision dated January 16, 2014, OWCP denied appellant’s claim. It noted that the medical evidence did not demonstrate that appellant’s claimed medical condition was related to the established employment event.

LEGAL PRECEDENT

An employee seeking benefits under FECA has the burden of establishing the essential elements of his or her claim, including the fact that the individual is an employee of the United States within the meaning of FECA, 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 and/or specific condition for which compensation is claimed are causally related to the employment injury. 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.3

In order to determine whether an employee actually sustained an injury in the performance of duty, OWCP begins with an analysis of whether fact of injury has been established. Generally, fact of injury consists of two components, which must be considered in conjunction with one another. The first component to be established is that the employee actually experienced the employment incident or exposure, which is alleged to have occurred.4 In order to meet his or her burden of proof to establish the fact that he or she sustained an injury in the performance of duty, an employee must submit sufficient evidence to establish that he or she actually experienced the employment injury or exposure at the time, place, and in the manner alleged.5 The second component is whether the employment incident caused a personal injury and generally can be established only by medical evidence.6 The medical evidence required to establish causal relationship is usually rationalized medical evidence. Rationalized medical opinion evidence is medical evidence which includes a physician’s rationalized opinion on the issue of whether there is a causal relationship between the claimant’s diagnosed condition and the implicated employment factors. The opinion of the physician must be based on a complete factual and medical background of the claimant, must be one of reasonable medical certainty and

3
Jussara L. Arcanjo, 55 ECAB 281, 283 (2004).
4
See Elaine Pendleton, 40 ECAB 1143 (1989).
5
Linda S. Jackson, 49 ECAB 486 (1998).
6
John J. Carlone, 41 ECAB 354 (1989); Horace Langhorne, 29 ECAB 820 (1978).

3 must be supported by medical rationale explaining the nature of the relationship between the diagnosed condition and the specific employment factors identified by the claimant.7

ANALYSIS

OWCP accepted that the November 21, 2014 incident occurred as alleged, but denied the claim because the medical evidence did not demonstrate that the claimed condition was related to this established work event.

The Board finds that appellant has not established a medical condition causally related to the accepted employment incident. Thus, fact of injury has not been established.

The Board notes that a portion of the medical evidence submitted by appellant is unsigned or contains an illegible signature. The November 21, 2014 work release form contained an illegible signature. The unsigned evidence includes the November 21, 2014 notes from the Newport Hospital emergency department visit with numerous personnel, including Dr. Gaines, and notes from the Picayune Family Care Center dated December 1, 2014. The Board has held that medical reports containing no signature do not constitute probative medical evidence, as the author cannot be identified as a physician.8

The remaining evidence also fails to establish a causal relationship. Although Dr. Hiatt, in his December 8, 2014 report, made a brief reference to appellant’s employment incident when he referred to an episode that had occurred three weeks prior to his report, he failed to indicate that the incident was caused or aggravated by appellant’s employment. In fact, Dr. Hiatt indicated that the incident was very likely nonsteroidal induced with daily use of BC powders containing aspirin and associated anemia.

Dr. Denney’s report, dated October 28, 2014, predates the November 21, 2014 incident, but relates the incident to a preexisting condition of low iron, hypertension, and venous stasis.

Causal relationship must be based on rationalized medical opinion evidence.9 A physician must accurately describe appellant’s work duties and explain the process by which these duties caused or aggravated his condition.10 As appellant did not submit a rationalized medical opinion supporting that he sustained an illness or an injury causally related to the accepted November 21, 2014 employment incident, he did not meet his burden of proof to establish an employment-related traumatic injury.

7
Judith A. Peot, 46 ECAB 1036 (1995); Ruby I. Fish, 46 ECAB 276 (1994).
8
See R.M., 59 ECAB 690, 693 (2008); Merton J. Sills, 39 ECAB 571, 575 (1988).
9
M.E., Docket No. 14-1064 (issued September 29, 2014).
10
Solomon Polen, 51 ECAB 341 (2000) (rationalized medical evidence must relate specific employment factors identified by the claimant to the claimant’s condition, with stated reasons by a physician). See also G.G., Docket No 15-234 (issued April 9, 2015).

4
 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 established an injury in the performance of duty on November 21, 2014, as alleged.

ORDER

IT IS HEREBY ORDERED THAT the decision of the Office of Workers’ Compensation Programs dated January 15, 2015 is affirmed.

Issued: July 17, 2015
Washington, DC

Colleen Duffy Kiko, 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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