R.S. and U.S. Postal Service, Post Office, Arlington Heights, IL (Board decision, February 22, 2016)

ECAB final decision. The Board affirmed OWCP’s April 29, 2015 denial of the claimed injury. OWCP accepted the snow shoveling incident, but the Board found no diagnosed condition medically linked to it. 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

R.S., a postal custodian, became dizzy, light-headed, and short of breath while shoveling snow at work. OWCP accepted that the work incident occurred and paid limited initial medical expenses, but later denied the injury claim. Hospital reports described symptoms and other medical conditions without diagnosing a condition caused by the shoveling. A later physician attributed the symptoms to overexertion but did not give a firm diagnosis or a reasoned explanation. The Board affirmed the denial because the medical evidence did not establish a diagnosed work-related injury.

Decision snapshot

• Authority: FECA traumatic injury and medical causation requirements.
• Outcome: April 29, 2015 injury claim denial affirmed.
• Key point: Symptoms during work did not establish a compensable condition without a diagnosis and medical explanation.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
R.S., Appellant
)
)
and ) Docket No. 15-1364
) Issued: February 22, 2016
U.S. POSTAL SERVICE, POST OFFICE,
)
Arlington Heights, IL, 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
PATRICIA H. FITZGERALD, Deputy Chief Judge ALEC J. KOROMILAS, Alternate Judge

JURISDICTION

On June 4, 2015 appellant filed a timely appeal of an April 29, 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 to consider the merits of the case.

ISSUE

The issue is whether appellant established that he sustained a diagnosed medical condition causally related to the accepted March 12, 2014 incident.

FACTUAL HISTORY

On March 24, 2014 appellant, then a 58-year-old laborer custodian, filed a traumatic injury claim (Form CA-1) alleging that on March 12, 2014 he became light-headed, dizzy, and winded while shoveling snow.

1
5 U.S.C. § 8101 et seq.
 In a March 12, 2014 Northwest Community Hospital form report, Dr. Daniel Reaven, a physician specializing in emergency medicine, reported that appellant was seen for chest pain. He diagnosed chest pain and near syncope.

OWCP received additional medical evidence from Northwest Community Hospital including a March 12, 2014 admission report by Dr. Michael Magidow, a Board-certified family practitioner. Dr. Magidow reported that appellant was admitted to the hospital on March 12, 2014 for complaints of near-syncope and shortness of breath. Appellant related that he had been shoveling snow outside his workplace for more than an hour when he felt dizzy, nauseous, light- headed, felt a rapid heartbeat in his throat, and his heart beating. A physical examination revealed a pulse of 54, blood pressure of 159/88, and normal temperature. Dr. Magidow reported normal diagnostic data and diagnosed dyspnea presyncope, hypertension, hyperlipidemia, obesity, and implemented gastrointestinal and deep prophylaxis.

In a March 12, 2014 hospital cardiology consultation report, Dr. Ankit Shah, an examining Board-certified cardiologist, noted that appellant was seen for near-syncope and dizziness as the result of shoveling snow outside the employing establishment that day. Appellant related that he became light-headed with nausea and felt extremely dizzy. Physical examination findings were provided and a chest x-ray interpretation showed no active disease. Dr. Shah reviewed an electrocardiogram (EKG) which showed normal sinus rhythm and right bundle block. Under impression, he diagnosed presyncope with nausea and no evidence of ischemia. Dr. Shah opined that appellant’s symptoms might be due to low heart rate, low blood pressure, or might be due to appellant having a vasovagal symptoms possibly due to an increased dose of verapamil.

In a letter dated October 2, 2014, OWCP informed appellant that payment of a limited amount of medical expenses had been authorized as it appeared that he had sustained a minor injury. As the medical bills have exceeded $1,500.00, it had reopened his claim for consideration. OWCP informed appellant that the medical evidence was insufficient to establish his claim. Appellant was advised as to the medical evidence required to establish his claim and afforded him 30 days to provide this evidence.

In response to OWCP’s request, appellant resubmitted Dr. Shah’s March 12, 2014 report and a March 13, 2014 EKG. The EKG report, electronically signed by Dr. Shah on March 13, 2014, showed left ventricular ejection fraction, mild aortic sclerosis without stenosis, normal right ventricular size and systolic function, moderate concentric left ventricular hypertorphy, and pesudonormal patter of LV diastolic filling

By decision dated November 3, 2014, OWCP denied appellant’s claim. It found that he had established that the incident occurred as alleged, but failed to submit any medical opinion showing how the diagnosed presyncope with nausea was caused or aggravated by the accepted incident.

In a December 8, 2014 letter, Dr. Joseph Gibes, a Board-certified family medicine practitioner, noted that he had examined appellant on March 26, 2014 following his hospitalization for lightheadness, feeling winded, and dizziness due to overexertion at work. He opined that appellant’s symptoms were due to overexertion at work when shoveling snow.

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 In a form dated January 9, 2015 and received by OWCP on January 13, 2015, appellant requested reconsideration.

By decision dated April 29, 2015, OWCP denied the claim, finding that appellant failed to establish fact of injury. It found that the medical evidence submitted failed to contain a diagnosis causally related to the accepted employment incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA2 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 filed within the applicable time limitation; that an injury was sustained while 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.3 These are the essential elements of each and every compensation claim regardless of whether the claim is predicated on a traumatic injury or an occupational disease.4

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.5 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 Second, the employee must submit sufficient evidence, generally only in the form of medical evidence, to establish that the employment incident caused a personal injury.7

Causal relationship is a medical issue and the medical evidence generally required to establish causal relationship is rationalized medical opinion evidence.8 Rationalized medical opinion evidence is medical evidence which includes a physician’s rationalized opinion on whether there is a causal relationship between the employee’s diagnosed condition and the compensable employment factors.9 The opinion of the physician must be based on a complete factual and medical background of the employee, must be one of reasonable medical certainty,

2
Id.
3
C.S., Docket No. 08-1585 (issued March 3, 2009); Bonnie A. Contreras, 57 ECAB 364 (2006).
4
S.P., 59 ECAB 184 (2007); Joe D. Cameron, 41 ECAB 153 (1989).
5
B.F., Docket No. 09-60 (issued March 17, 2009); Bonnie A. Contreras, supra note 3.
6
D.B., 58 ECAB 464 (2007); David Apgar, 57 ECAB 137 (2005).
7
C.B., Docket No. 08-1583 (issued December 9, 2008); D.G., 59 ECAB 734 (2008); Bonnie A. Contreras, supra note 3.
8
Y.J., Docket No. 08-1167 (issued October 7, 2008); A.D., 58 ECAB 149 (2006); D’Wayne Avila, 57 ECAB 642 (2006).
9
J.J., Docket No. 09-27 (issued February 10, 2009); Michael S. Mina, 57 ECAB 379 (2006).

3 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.10

ANALYSIS

OWCP accepted that appellant was shoveling snow on March 12, 2014 in the performance of duty. It denied his claim, however, finding that he failed to establish that he sustained an injury as a result of the accepted incident. The issue before the Board is whether appellant submitted sufficient medical evidence to establish that the employment incident caused an injury as defined under FECA. The Board finds that the medical evidence of record is insufficient to establish a diagnosed medical condition causally related to the accepted March 12, 2014 incident.

A person who claims benefits for a work-related condition has the burden to establish by the weight of the medical evidence a firm diagnosis of the condition claimed and a causal relationship between that condition and factors of federal employment.11 The Board has long held that pain is a symptom, not a compensable medical diagnosis.12 Therefore, since chest pain is a medical symptom, to establish personal injury the medical evidence of record must document a diagnosed condition and must explain how that condition is causally related to the accepted incident of employment.13

In support of his claim, appellant submitted evidence from Northwest Hospital which included a form report from Dr. Reaven, a March 12, 2014 admission report from Dr. Magidow, a cardiology consultation report, and an EKG. OWCP subsequently received a December 8, 2014 report from Dr. Gibes.

Dr. Reaven, in a March 12, 2014 Northwest Community Hospital report, diagnosed chest pain and near-syncope; however, these are not firm medical diagnoses. Furthermore, he offered no opinion as to the cause of these symptoms. Similarly, Dr. Magidow noted that appellant had been admitted for complaints of shortness of breath and near-syncope following shoveling snow outside his workplace. He diagnosed several conditions including hyperlipidemia, obesity, dyspnea presyncope, hypertension, and implemented gastrointestinal and deep prophylaxis, but offered no opinion as to the cause of these conditions.

Dr. Shah, an examining Board-certified cardiologist, in a March 12, 2014 hospital cardiology report, identified the employment incident of shoveling snow, and diagnosed presyncope with nausea and no evidence of ischemia. He opined that appellant’s symptoms might be due to low blood pressure, low heart rate, or due to vasovagal symptoms. Again, Dr. Shah did not provide a firm diagnosis of appellant’s condition. Moreover, at no point did he identify shoveling snow as a possible cause of a diagnosed medical condition. The reports from

10
I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345, 352 (1989).
11
See Roy L. Humphrey, 57 ECAB 238 (2005); see Naomi A. Lilly, 10 ECAB 560, 574 (1959).
12
Robert Broome, 55 ECAB 339, 342 (2004).
13
George A. Davis, Docket No. 95-1684 (issued April 3, 1997).

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Dr. Shah, Dr. Magidow, and Dr. Reaven are insufficient to support appellant’s claim as none of the physicians diagnosed a medical condition causally related to the employment incident.14

The record also contains a December 8, 2014 letter from Dr. Gibes who attributed appellant’s symptoms of light-headedness, feeling winded, and dizziness due to shoveling snow at work and overexertion. He did not provide a firm medical diagnosis and offered no supporting rationale explaining his conclusion that the shoveling of snow by appellant was the cause of a diagnosed condition. The Board has held that medical evidence consisting solely of conclusory statements without supporting rationale is of little probative value.15 Thus, these reports are insufficient to support appellant’s claim.

The record also contains a March 13, 2014 EKG report. As it is a diagnostic test, causal relationship was not addressed. The EKG report is insufficient to support appellant’s claim that he sustained a medical condition causally related to the March 12, 2014 incident.16

OWCP advised appellant that it was his responsibility to provide a comprehensive medical report which described his symptoms, test results, diagnosis, treatment, and a physician’s opinion, with medical reasons, on the cause of his condition. Appellant failed to submit appropriate medical documentation in response to OWCP’s request. The Board has held that the mere fact that a condition manifests itself during a period of employment does not raise an inference of causal relation.17 An award of compensation may not be based on surmise, conjecture, speculation, or on the employee’s own belief of causal relation.18 As there is no probative, rationalized medical evidence containing a medical diagnosis and explaining how a diagnosed condition was causally related to the accepted March 12, 2014 incident, he has not met his 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.

14
See T.L., Docket No. 11-1668 (issued February 10, 2012); Ruth C. Borden, 43 ECAB 146 (1991); Val D. Wynn, 40 ECAB 666 (1989).
15
See T.M., Docket No. 08-975 (issued February 6, 2009); Roma A. Mortenson-Kindschi, 57 ECAB 418 (2006);
William C. Thomas, 45 ECAB 591 (1994) (a medical report is of limited probative value on the issue of causal relationship if it contains a conclusion regarding causal relationship which is unsupported by medical rationale). 16 C.B., Docket No. 09-2027 (issued May 12, 2010); S.E., Docket No. 08-2214 (issued May 6, 2009); Jaja K.
Asaramo, 55 ECAB 200 (2004) (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). 17 L.D., Docket No. 09-1503 (issued April 15, 2010); D.I., 59 ECAB 158 (2007); Daniel O. Vasquez, 57 ECAB 559 (2006).
18
S.S., 59 ECAB 315 (2008); J.M., 58 ECAB 3003 (2007); Donald W. Long, 41 ECAB 142 (1989).

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 CONCLUSION

The Board finds that appellant has not met his burden of proof to establish that he sustained a diagnosed medical condition causally related to the accepted March 12, 2014 incident, as alleged.

ORDER

IT IS HEREBY ORDERED THAT the decision of the Office of Workers’ Compensation Programs dated April 29, 2015 is affirmed.

Issued: February 22, 2016
Washington, DC

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

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

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

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