J.C. and Department of Veterans Affairs, Veterans Health Administration, Southern Nevada Healthcare System, North Las Vegas, NV (Board decision, September 15, 2021)

ECAB final decision. The Board affirmed OWCP’s denial of the left knee condition claim. 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.C. reported a left knee injury after a fall at work. The discharge papers described knee pain, but pain alone was a symptom rather than a medical diagnosis. Return to work instructions had an illegible signature, so the Board could not establish that a physician authored them. Without reliable medical evidence diagnosing a condition and linking it to the incident, the Board affirmed the denial.

Decision snapshot

• Authority: 5 U.S.C. § 8101.
• Outcome: November 13, 2019 denial affirmed.
• Key point: Pain alone did not establish a diagnosis, and work instructions with an illegible signature did not establish a physician’s diagnosis.

Full text (ECAB public release)

United States Department of Labor
Employees’ Compensation Appeals Board

________
)
J.C., Appellant
)
)
and ) Docket No. 20-0914
) Issued: September 15, 2021
DEPARTMENT OF VETERANS AFFAIRS,
)
VETERANS HEALTH ADMINISTRATION,
)
SOUTHERN NEVADA HEALTHCARE
)
SYSTEM, North Las Vegas, NV, Employer
)
__________ )

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

DECISION AND ORDER

Before:
JANICE B. ASKIN, Judge
PATRICIA H. FITZGERALD, Alternate Judge
VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On March 20, 2020 appellant filed a timely appeal from a November 13, 2019 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.

ISSUE

The issue is whether appellant has established a left knee condition causally related to the accepted September 29, 2019 employment incident.

FACTUAL HISTORY

On September 29, 2019 appellant, then a 31-year-old police officer, filed a traumatic injury claim (Form CA-1) alleging that on that date he injured his left knee while in the performance of

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5 U.S.C. § 8101 et seq. duty. He explained that he and another officer grabbed a violent mental hold patient with underarm holds, and as the patient was resisting, appellant stepped on a blood pressure cuff, which caused him to slip and fall on his left knee. Appellant also related that his left knee became swollen. On the reverse side of the claim form the employing establishment indicated that he was injured in the performance of duty on September 29, 2019 and that medical reports showed that he was disabled from work. It also related that the injury was caused by a third party, and that appellant had stopped work, but returned to work on September 29, 2019.

In an October 7, 2019 development letter, OWCP informed appellant of the deficiencies in his claim. It advised him of the type of medical evidence necessary to establish his claim and afforded him 30 days to respond.

Appellant submitted September 29, 2019 hospital discharge instructions from the employing establishment’s medical facility indicating that he had been treated by Dr. Elizabeth Harbin-Nelson, Board-certified in family medicine, for knee pain. He also submitted September 29, 2019 return-to-work instructions from the employing establishment’s medical facility, bearing an illegible signature, that indicated he could return to work in five days with the work restrictions of no running and light duty for one week.

By decision dated November 13, 2019, OWCP denied appellant’s traumatic injury claim, finding that the evidence of record was insufficient to establish a diagnosed medical condition in connection with the accepted September 29, 2019 employment incident. It concluded, therefore, that the requirements had not been met to establish an injury as defined by FECA.

LEGAL PRECEDENT

An employee seeking benefits under FECA 2 has the burden of proof to establish the essential elements of his or her claim, including 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 of FECA,3 that an injury was sustained in the performance of duty as alleged, and that any disability or medical condition for which compensation is claimed is causally related to the employment injury.4 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. 5 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. First, the employee must submit sufficient evidence to establish that he or she actually experienced the employment

2
Id.
3
F.H., Docket No. 18-0869 (issued January 29, 2020); J.P., Docket No. 19-0129 (issued April 26, 2019); Joe D. Cameron, 41 ECAB 153 (1989). 4 L.C., Docket No. 19-1301 (issued January 29, 2020); J.H., Docket No. 18-1637 (issued January 29, 2020); James E. Chadden, Sr., 40 ECAB 312 (1988). 5 P.A., Docket No. 18-0559 (issued January 29, 2020); K.M., Docket No. 15-1660 (issued September 16, 2016);
Delores C. Ellyett, 41 ECAB 992 (1990).

2 incident at the time, place, and in the manner alleged. Second, the employee must submit sufficient evidence to establish that the employment incident caused a personal injury. 6

The medical evidence required to establish causal relationship is rationalized medical opinion evidence.7 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, and must be supported by medical rationale explaining the nature of the relationship between the diagnosed condition and specific employment incident identified by the employee. 8

ANALYSIS

The Board finds that appellant has not established a left knee condition causally related to the accepted September 29, 2019 employment incident.

The September 29, 2019 discharge instructions noted a diagnosis of knee pain; however, the Board has held that pain is a description of a symptom, not a diagnosis of a medical condition. 9 It is appellant’s burden of proof to obtain and submit medical documentation containing a firm diagnosis causally related to the accepted employment incident.10 Appellant also submitted September 29, 2019 return-to-work instructions from the employing establishment’s medical facility, bearing an illegible signature, that indicated he could return to work in five days with the work restrictions of no running and light duty for one week. The Board has held that evidence containing an illegible signature has no probative value as it is not established that the author is a physician.11

As appellant has not submitted rationalized medical evidence establishing a diagnosed medical condition causally related to the accepted employment incident, the Board finds that he has not met his burden of proof to establish his claim.

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.

6
T.J., Docket No. 19-0461 (issued August 11, 2020); K.L., Docket No. 18-1029 (issued January 9, 2019); John J. Carlone, 41 ECAB 354 (1989). 7 S.S., Docket No. 19-0688 (issued January 24, 2020); A.M., Docket No. 18-1748 (issued April 24, 2019); Robert G. Morris, 48 ECAB 238 (1996). 8 T.L., Docket No. 18-0778 (issued January 22, 2020); Y.S., Docket No. 18-0366 (issued January 22, 2020);Victor J. Woodhams, 41 ECAB 345, 352 (1989). 9 See K.S., Docket No. 19-1433 (issued April 26, 2021); S.L., Docket No. 19-1536 (issued June 26, 2020); D.Y., Docket No. 20-0112 (issued June 25, 2020). 10 J.P., Docket No. 20-0381 (issued July 28, 2020); R.L., Docket No. 20-0284 (issued June 30, 2020).
11
See Z.G., Docket No. 19-0967 (issued October 21, 2019); Bradford L. Sullivan, 33 ECAB 1568 (1982).

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 CONCLUSION

The Board finds that appellant has not met his burden of proof to establish a diagnosed left knee condition causally related to the accepted employment incident.

ORDER

IT IS HEREBY ORDERED THAT the November 13, 2019 decision of the Office of Workers’ Compensation Programs is affirmed.

Issued: September 15, 2021
Washington, DC

Janice B. Askin, Judge
Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Alternate Judge
Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge Employees’ Compensation Appeals Board

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