United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

H.L., Appellant 

and 

DEPARTMENT OF HOMELAND SECURITY, 

IMMIGRATION & CUSTOMS 

ENFORCEMENT, Plantation, FL, Employer 

__________________________________________ 

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Docket No. 14-1910 

Issued: February 18, 2015 

Appearances: Case Submitted on the Record

Lenin V. Perez, for the appellant 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

PATRICIA HOWARD FITZGERALD, Judge 

ALEC J. KOROMILAS, Alternate Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On August 29, 2014 appellant, through his representative, filed a timely appeal from an 

April 15, 2014 Office of Workers’ Compensation Programs’ (OWCP) merit decision. 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 met his burden of proof to establish that his medical 

conditions are causally related to an April 12, 2013 employment incident, as alleged. 

On appeal, appellant’s representative contends that the medical evidence of record, 

particularly reports from the attending physician, explained how the work duties that appellant 

performed on the date of injury caused his diagnosed conditions. 

 1

 5 U.S.C. § 8101 et seq. 
2

FACTUAL HISTORY 

On May 2, 2013 appellant, then a 50-year-old special agent, filed a traumatic injury claim 

(Form CA-1) alleging that he injured his neck, back, jaw, testes, shoulders, arms, elbows, wrists, 

hands, legs, knees, ankles, feet, and left big toe on April 12, 2013 as a result of bending, 

reaching, lifting, and stretching to move a total of approximately 850 pounds of ammunition 

while conducting firearms-related duties. He stated that he moved a cart loaded with 35 boxes of 

ammunition weighing approximately 550 pounds, assisted in loading the boxes onto the cart, and 

physically moved the cart from the street up an incline, over a lip into an elevator, back over the 

lip to exit the elevator, and finally into a firearms room. Appellant then assisted in unloading all 

the boxes from the cart, plus an additional 15 boxes. He stopped work on May 8, 2013. 

Appellant submitted a May 15, 2013 physical capacity evaluation and physical therapy 

notes dated May 22 through June 4, 2013. 

In a May 22, 2013 report, Dr. Ramon Berenguer, a family medicine specialist, indicated 

that appellant complained of severe low back pain with radiation down the legs and bilateral hip 

pain. Appellant stated that he had almost constant hip pain when he walked. Dr. Berenguer 

further indicated that the injury, which occurred on April 12, 2013, “also caused multiple other 

complaints.” He diagnosed arthropathy, radiculopathy lower extremities, lumbar spine pain with 

disc bulge at L3-4, L4-5, L5-S1, lumbar facet arthropathy, and internal derangement bilateral 

hips. 

On May 28, 2013 Dr. Samy Bishai, an orthopedic surgeon and appellant’s attending 

physician, indicated that appellant “suffered multiple injuries to different parts of his body in the 

injuries that he suffered on April 12, 2013.” He stated that appellant was a special agent for the 

employing establishment and in the course of his employment he suffered injuries while 

conducting firearms-related duties. Dr. Bishai indicated that appellant was moving a cart loaded 

with 35 boxes of ammunition weighing approximately 550 pounds, assisted in loading the boxes 

onto a cart, moved the cart up an incline, in and out of an elevator, and finally into a firearms 

room. He diagnosed cervical and lumbar disc syndrome with radiculopathy, bunion of the first 

metatarsal bone of the left foot, thoracic disc syndrome with bulging discs, status postoperative 

right shoulder arthroscopic surgery, and internal derangement of bilateral shoulder joints, elbow 

joints, wrist joints, hip joints, knee joints, and ankle joints. 

In a June 28, 2013 letter, OWCP indicated that, when appellant’s claim was received, it 

appeared to be a minor injury that resulted in minimal or no lost time from work and, based on 

these criteria and because the employing establishment did not controvert continuation of pay 

(COP) or challenge the case, payment of a limited amount of medical expenses was 

administratively approved. It stated that it had reopened the claim for consideration because the 

medical bills had exceeded $1,500.00. OWCP requested additional evidence and afforded 

appellant 30 days to respond to its inquiries. 

In a May 8, 2013 report, Dr. Berenguer diagnosed lumbar disc disease, degenerative 

arthritis of the bilateral hip joints, and internal derangement of the right knee, left ankle, and 

bilateral elbows. He opined that appellant was unable to work due to the injury sustained in the 

performance of duty. On June 19, 2013 Dr. Berenguer diagnosed thoracic disc syndrome, 
3

cervical and lumbar disc syndrome with radiculopathy, and internal derangement of the bilateral 

hips and knees. 

On July 11, 2013 Dr. Bishai reiterated his medical diagnoses and opinions. 

By decision dated July 30, 2013, OWCP denied appellant’s claim on the basis that the 

medical evidence was not sufficient to establish a causal relationship between his medical 

conditions and the April 12, 2013 employment incident. 

On August 6, 2013 appellant, through his representative, requested an oral hearing before 

an OWCP hearing representative and submitted reports dated August 28 and September 25, 2013 

from Dr. Bishai who reiterated his medical diagnoses and opinions. 

In an October 30, 2013 report, Dr. Berenguer diagnosed internal derangement of the 

bilateral shoulders, elbows, and wrists. 

A telephonic oral hearing was held before an OWCP hearing representative on 

January 30, 2014. 

On February 19, 2014 Dr. Berenguer reiterated his diagnoses and indicated that appellant 

continued to complain of ongoing pain in the neck, shoulders, wrists, and low back radiating to 

the legs. 

By decision dated April 15, 2014, OWCP hearing representative affirmed the July 30, 

2013 decision. 

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 timely filed within the applicable time 

limitation period of FECA, that an injury3

 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

 

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. 

A fact of injury determination is based on two elements. First, the employee must submit 

sufficient evidence to establish that he or she actually experienced the employment incident at 

 2

 5 U.S.C. § 8101 et seq. 

3

 OWCP regulations define a traumatic injury as a condition of the body caused by a specific event or incident, or 

series of events or incidents, within a single workday or shift. Such condition must be caused by external force, 

including stress or strain, which is identifiable as to time and place of occurrence and member or function of the 

body affected. 20 C.F.R. § 10.5(ee). 

4 See T.H., 59 ECAB 388 (2008). See also Steven S. Saleh, 55 ECAB 169 (2003); Elaine Pendleton, 40 ECAB 

1143 (1989). 
4

the time, place, and in the manner alleged. 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. An employee may establish that the employment incident 

occurred as alleged but fail to show that his or her condition relates to the employment incident.5

 

Causal relationship is a medical issue and the medical evidence generally required to 

establish causal relationship is rationalized medical opinion evidence. 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 the specific employment factors 

identified by the employee.6

 

ANALYSIS 

OWCP has accepted that the employment incident of April 12, 2013 occurred at the time, 

place, and in the manner alleged. The issue is whether appellant’s medical conditions resulted 

from the April 12, 2013 employment incident. The Board finds that appellant did not meet his 

burden of proof to establish a causal relationship between the conditions for which compensation 

is claimed and the employment incident. 

In his reports, Dr. Bishai indicated that appellant “suffered multiple injuries to different 

parts of his body in the injuries that he suffered on April 12, 2013.” He stated that appellant was 

a special agent for the employment establishment and in the course of his employment he 

suffered injuries while conducting firearms-related duties. Dr. Bishai indicated that appellant 

was moving a cart loaded with 35 boxes of ammunition weighing approximately 550 pounds, 

assisted in loading the boxes onto a cart, moved the cart up an incline, in and out of an elevator, 

and finally into a firearms room. He diagnosed cervical and lumbar disc syndrome with 

radiculopathy, bunion of the first metatarsal bone of the left foot, thoracic disc syndrome with 

bulging discs, status postoperative right shoulder arthroscopic surgery, and internal derangement 

of bilateral shoulder joints, elbow joints, wrist joints, hip joints, knee joints, and ankle joints. 

Dr. Bishai failed to provide a rationalized opinion explaining how moving ammunition at work 

on April 12, 2013 caused or aggravated his medical conditions. Dr. Bishai noted that appellant’s 

conditions occurred while he was at work. However, such generalized statements do not 

establish causal relationship because they merely repeat appellant’s allegations and are 

unsupported by adequate medical rationale explaining how his physical activity at work actually 

caused or aggravated the diagnosed conditions.7

 Thus, the Board finds that the reports from 

Dr. Bishai are insufficient to establish that appellant sustained an employment-related injury. 

In his reports, Dr. Berenguer diagnosed arthropathy, radiculopathy lower extremities, 

lumbar spine pain with disc bulge at L3-4, L4-5, L5-S1, lumbar facet arthropathy, lumbar disc 

disease, degenerative arthritis of the bilateral hip joints, thoracic disc syndrome, cervical and 

 5 Id. See Shirley A. Temple, 48 ECAB 404 (1997); John J. Carlone, 41 ECAB 354 (1989). 

6 Id. See Gary J. Watling, 52 ECAB 278 (2001). 

7 See K.W., Docket No. 10-98 (issued September 10, 2010). 
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lumbar disc syndrome with radiculopathy, and internal derangement of the bilateral hips, knees, 

shoulders, elbows, wrists, and left ankle. He indicated that appellant sustained an injury on 

April 12, 2013 and opined that appellant was unable to work due to the injury sustained in the 

performance of duty. The Board finds that Dr. Berenguer did not provide sufficient medical 

rationale explaining how appellant’s medical conditions were caused or aggravated by bending, 

reaching, lifting, and stretching to move a total of approximately 850 pounds of ammunition at 

work on April 12, 2013. Thus, appellant failed to meet his burden to establish a claim. 

In support of his claim, appellant submitted a May 15, 2013 physical capacity evaluation 

and physical therapy notes dated May 22 through June 4, 2013. These documents do not 

constitute competent medical evidence as they do not contain rationale by a physician relating 

appellant’s disability to his employment.8

 As such, the Board finds that appellant did not meet 

his burden of proof with these submissions. 

As appellant has not submitted any rationalized medical evidence to support his 

allegation that he sustained an injury causally related to an April 12, 2013 employment incident, 

he has failed to meet his burden of proof to establish a claim for compensation. 

On appeal, appellant’s representative contends that the medical evidence of record, 

particularly reports from the attending physician, explained how the work duties that appellant 

performed on the date of injury caused his diagnosed conditions. Based on the findings and 

reasons stated above, the Board finds the representative’s arguments are not substantiated. 

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 met his burden of proof to establish that his 

medical conditions are causally related to an April 12, 2013 employment incident, as alleged. 

 8 See 5 U.S.C. § 8101(2). Section 8101(2) of FECA provides as follows: “(2) ‘physician’ includes surgeons, 

podiatrists, dentists, clinical psychologists, optometrists, chiropractors, and osteopathic practitioners within the 

scope of their practice as defined by State law.” See also Paul Foster, 56 ECAB 208, 212 n.12 (2004); Joseph N. 

Fassi, 42 ECAB 677 (1991); Barbara J. Williams, 40 ECAB 649 (1989). 
6

ORDER 

IT IS HEREBY ORDERED THAT the April 15, 2014 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: February 18, 2015 

Washington, DC 

 

 Patricia Howard Fitzgerald, Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board