J.T. and Social Security Administration, Region IX, Richmond, CA (Board decision, September 25, 2015)

ECAB final decision. The Board affirmed OWCP’s April 30, 2015 denial of J.T.’s cervical condition 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 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

J.T., a Social Security claims representative, attributed a cervical spine condition to prolonged sitting, typing, reaching, and turning to assist clients. She underwent spine surgery and sought workplace adjustments. The Board accepted the described work duties but found that her physicians’ reports did not explain how those duties caused or aggravated the diagnosed condition. It affirmed OWCP’s denial for lack of medical causation evidence.

Decision snapshot

• Authority: Federal Employees’ Compensation Act, 5 U.S.C. § 8101 et seq.
• Outcome: Cervical condition claim denial affirmed.
• Key point: Medical reports documented the condition and restrictions but did not connect it to the identified work duties.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
J.T., Appellant
)
)
and ) Docket No. 15-1309
) Issued: September 25, 2015
SOCIAL SECURITY ADMINISTRATION,
)
REGION IX, Richmond, CA, 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
COLLEEN DUFFY KIKO, Judge
JAMES A. HAYNES, Alternate Judge

JURISDICTION

On May 22, 2015 appellant filed a timely appeal from an April 30, 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 the case.

ISSUE

The issue is whether appellant met her burden of proof to establish a cervical condition causally related to factors of her federal employment.

FACTUAL HISTORY

On January 28, 2015 appellant, then a 43-year-old claims representative, filed an occupational disease claim (Form CA-2) alleging a shoulder and neck condition, requiring

1
5 U.S.C. § 8101 et seq. surgery, due to repetitive and stressful factors of her federal employment. She stopped work on November 3, 2014 and returned on December 8, 2014.

In an undated statement, received from the employing establishment on February 2, 2015, appellant’s October 17, 2014 cervical spine condition was acknowledged including the surgery of November 4, 2014. It noted that she was on leave from November 3 to December 5, 2014, cleared for limited duty from December 8, 2014 to January 1, 2015, and released for duty without restrictions on January 2, 2015. The employing establishment contended that it had discussed with appellant the availability of ergonomic adjustments for her workstation, but she had failed to submit medical documentation describing what type of ergonomic equipment she needed.

In a January 27, 2015 letter, the employing establishment had conveyed to appellant its willingness to obtain ergonomic equipment, provided that she submit appropriate medical documentation. It further furnished her with an ergonomic video which had information on adjusting a workstation.

Dr. Vedat Deviren, a Board-certified orthopedic surgeon, in a December 1, 2014 work status note (received by OWCP on February 7, 2015) cleared appellant to work with the following restrictions: maintain a six-hour per day schedule, wear a hard cervical collar, and take 15-minute breaks every 90 minutes. In a January 23, 2015 work status note, also received by OWCP on February 7, 2015, Dr. Deviren requested that she be released from work from January 23 to 26, 2015 due to “spine precautions.”

On January 26, 2015 Dr. Deviren completed a form requesting a special needs chair for appellant. He informed the employing establishment that she required a workstation positioned to prevent appellant from bending or twisting her neck. In an attached letter, Dr. Deviren noted that appellant was under his care for a spine condition and advised the employing establishment to provide her with “her own designated desk.”2

In a February 17, 2015 letter, OWCP informed appellant that the evidence of record was insufficient to support her claim. It advised her to provide a medical report containing a physician’s opinion supported by a medical explanation as to how work factors caused or aggravated a diagnosed condition.

OWCP received a December 22, 2014 Family and Medical Leave Act form, in which Dr. Deviren described appellant’s duties as processing claims electronically, interviewing the public, answering telephones, typing, and writing. Dr. Deviren noted October 17, 2014 as the approximate date that her injury commenced and reported that her condition would last from 12 to 18 months. He further advised that appellant necessitated periodic absences from work for postsurgery follow-up examinations and physical therapy rehabilitation.

2
A health summary from appellant’s healthcare provider stated that appellant was diagnosed with cervical spondylosis with myelopathy and cervical disc herniation on October 17, 2014, and cervical stenosis of the spine and cervical myelopathy on October 23, 2014. The summary indicated that appellant underwent a cervical spinal fusion. Accompanying the summary was a listing of blood test values from November 4 to 7, 2014, as well as listings of other testing and treatment provided at other times. The summary was not prepared by a physician.

2
 In a March 11, 2015 statement, appellant attributed her injury to repetitive reaching and typing, long hours of sitting, turning her neck to engage with clients, a lack of ergonomic equipment, and “stressors” from management. She contended that she sat and typed for eight hours per day and reached for documents approximately six hours per day.

On April 10, 2015 appellant was seen in an emergency room by Dr. Emily Harrington, a neurology resident, and Dr. Gary M. Green, Board-certified in emergency medicine, for complaints of arm and leg numbness. A magnetic resonance imaging (MRI) scan revealed a disc bulge. The physicians diagnosed cervical disc herniation. In an accompanying April 10, 2015 report, Dr. Green stated that appellant could return to work the next day.

Appellant, in an April 17, 2015 statement, maintained that her duties included typing, reaching, and turning her neck, on a daily basis. She reported suffering neck and shoulder pain for a “few years” before seeking medical treatment. Appellant related undergoing surgery on November 4, 2014 and returning to work, with restrictions, on December 15, 2014. She expressed interest in attaining ergonomic equipment to avoid further surgery.

On April 30, 2015 OWCP denied appellant’s claim, finding the medical evidence insufficient to demonstrate that appellant’s condition was causally related to the identified employment factors.

LEGAL PRECEDENT

An employee seeking compensation under FECA has the burden of establishing the essential elements of his or her claim by the weight of the reliable, probative and substantial evidence,3 including that he or she is an employee within the meaning of FECA4 and that he or she filed his or her claim within the applicable time limitation.5 The employee must also establish that he or she sustained an injury in the performance of duty as alleged and that his or her disability for work, if any, was causally related to the employment injury.6

To establish that an injury was sustained in the performance of duty in a claim for occupational disease, an employee must submit: (1) a factual statement identifying employment factors alleged to have caused or contributed to the presence or occurrence of the disease or condition; (2) medical evidence establishing the presence or existence of the disease or condition for which compensation is claimed; and (3) medical evidence establishing that the diagnosed condition is causally related to the employment factors identified by the employee.7

3
J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 57 (1968).
4
See M.H., 59 ECAB 461 (2008); see 5 U.S.C. § 8101(1).
5
R.C., 59 ECAB 427 (2008); see 5 U.S.C. § 8122.
6
G.T., 59 ECAB 447 (2008); Elaine Pendleton, 40 ECAB 1143, 1145 (1989).
7
See Roy L. Humphrey, 57 ECAB 238, 241 (2005); Ruby I. Fish, 46 ECAB 276, 279 (1994).

3
 Causal relationship is a medical issue8 and the medical evidence generally required to establish causal relationship is rationalized medical evidence. 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 must be supported by medical rationale explaining the nature of the relationship between the diagnosed condition and the specific employment factors identified by the employee.9

ANALYSIS

There is no dispute that appellant’s work duties included prolonged sitting, repetitive reaching and typing, and engaging with clients. The issue on appeal is whether appellant established a cervical injury as a result of her employment. The Board finds that the medical evidence of record does not establish a causal relationship between appellant’s claimed condition and her employment duties.

On April 10, 2015 Drs. Harrington and Green noted treating appellant for arm and leg numbness and diagnosed cervical disc herniation. The physicians, however, did not provide any opinion as to the cause of appellant’s condition. Medical evidence that does not offer any opinion regarding the cause of an employee’s condition is of limited probative value on the issue of causal relationship.10 Likewise, the reports and status notes from Dr. Deviren do not offer any opinion supporting that appellant’s work duties caused or aggravated her cervical condition.

The record also contains a healthcare summary and listings of medical testing and treatment. See supra note 2. This does not constitute probative medical evidence as there is no indication that the person preparing such documents qualifies as a physician. C.B., Docket No. 09-2027 (issued May 12, 2010); Merton J. Sills, 39 ECAB 572, 575 (1988) (unsigned medical evidence with no adequate indication that it was completed by a physician is not considered probative medical evidence).

On appeal, appellant reiterated that her duties, including sitting, typing, and using a mouse, caused her condition. As noted above, the medical evidence does not establish her claim. Because appellant has not provided such medical opinion evidence, she has failed to meet her burden of proof.

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 did not establish that her cervical condition is causally related to factors of her federal employment.
8
Mary J. Briggs, 37 ECAB 578 (1986).
9
Victor J. Woodhams, 41 ECAB 345 (1989).
10
J.F., Docket No. 09-1061 (issued November 17, 2009).

4
 ORDER

IT IS HEREBY ORDERED THAT the April 30, 2015 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: September 25, 2015
Washington, DC

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

Colleen Duffy Kiko, Judge
Employees’ Compensation Appeals Board

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

5