United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

K.T., Appellant 

and 

DEPARTMENT OF LABOR, OFFICE OF 

WORKERS’ COMPENSATION PROGRAMS, 

Chicago, IL, Employer 

__________________________________________ 

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Docket No. 14-218 

Issued: June 11, 2015 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

RICHARD A. DASCHBACH, Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On November 12, 2013 appellant filed a timely appeal from an October 31, 2013 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 met her burden of proof to establish that her dental 

condition is causally related to a November 13, 2012 employment incident. 

On appeal, appellant contends that the Form CA-16 she submitted was sufficient to 

establish causal relationship and even if the denial is upheld, a directive to pay for the costs 

incurred under the coverage of the Form CA-16 medical authorization form is in order. 

 1

 5 U.S.C. § 8101 et seq. 
2

FACTUAL HISTORY 

On November 13, 2012 appellant, then a 58-year-old claims examiner, filed a traumatic 

injury claim (Form CA-1) alleging that on that date she cracked one of her back teeth in the 

lower right portion of her jaw while biting down on a cracker. There is no indication that she 

stopped work as a result of the November 13, 2012 incident. 

The employing establishment issued an OWCP Form CA-16, authorization for 

examination, on November 14, 2012. Appellant was authorized to visit her attending dentist, 

Dr. David Farinacci, in North Canton, Ohio. In a November 15, 2012 report (Form CA-20), 

Dr. Farinacci related that he examined appellant and found that she had broken tooth number 31, 

which resulted in an abscess and required root canal therapy. He checked a box “yes” to indicate 

his support for a causal relationship between appellant’s condition and her employment, noting 

that the injury occurred while she was at her desk and on duty. Dr. Farinacci submitted an 

American Dental Association (ADA) dental claim form stating that he had repaired appellant’s 

molar with root canal therapy on November 15, 2012 for a fee totaling $1,000.00. 

In an August 21, 2013 letter, OWCP notified appellant of the deficiencies of her claim 

and afforded 30 days for the submission of additional evidence. 

Subsequently, appellant submitted an August 28, 2013 narrative statement and a copy of 

the Board’s decision in Margaret F. Tefft.

2

 She argued that the case was similar to her own and, 

therefore, her claim should not be denied. Appellant’s narrative did not provide additional 

factual information but restated and emphasized her belief that on the facts already in the record 

her claim should be found compensable. She also discussed the Form CA-16 and her dental 

costs. 

By decision dated October 31, 2013, OWCP denied the claim finding that the medical 

evidence of record was not sufficient to establish a causal relationship between appellant’s 

broken tooth and the employment incident. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA3

 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 injury4

 was sustained in the performance of duty as alleged, 

 2

 Docket No. 04-745 (issued October 6, 2004). 

3

 5 U.S.C. § 8101 et seq. 

4

 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). 
3

and that any disability or medical condition for which compensation is claimed is causally 

related to the employment injury.5

 

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 

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.6 

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.7

 

ANALYSIS 

OWCP has accepted that the employment incident of November 13, 2012 occurred at the 

time, place, and in the manner alleged. The issue is whether appellant’s tooth condition resulted 

from the November 13, 2012 employment incident. The Board finds that appellant did not meet 

her burden of proof to establish a causal relationship between the condition for which 

compensation is claimed and the employment incident. 

In support of her claim, appellant cited the Board’s decision in Margaret F. Tefft8 and 

argued that the case was similar to her own and, therefore, her claim should not be denied. In the

Tefft case, the employee filed a traumatic injury claim alleging that she sustained a broken tooth 

while eating a sandwich that had a lobster shell in it. In Tefft, the employee had an eyewitness to 

the occurrence. In the instant case, appellant did not submit testimony from or identify any 

eyewitnesses. Thus, the Board finds that the Tefft case is distinguishable from appellant’s case 

and fails to support her claim. 

In D.S.,

9

 the employee working in Iraq claimed that he broke two teeth when a nearby 

explosion from a rocket or tank caused him to bite down on a flashlight. OWCP accepted that 

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

1143 (1989). 

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

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

8 Supra note 2. 

9

 Docket No. 06-1198 (issued October 30, 2006). 
4

the incident occurred as alleged, but denied the claim on the basis that there was no rationalized 

medical opinion evidence to support that the employment incident caused an injury to his teeth. 

Appellant’s dentist reported only that appellant had fractured tooth number 5 and tooth number 

12. The Board affirmed OWCP’s decision finding that the dentist did not provide any history of 

the incident or explain how it caused or contributed to the claimant’s broken teeth. The medical 

evidence proved insufficient to establish the employee’s claim because it failed to explain how 

his dental condition was causally related to the accepted employment incident.10 

In John T. Hanoumis,

11 the employee filed a traumatic injury claim, alleging that he was 

on cart duty when he tripped and hit his chin. He alleged this caused his teeth to snap together 

and broke one tooth in half. The Board found that the employee did not submit any rationalized 

medical evidence to support his claim that the incident caused an injury. The employee’s dentist 

did not attach any report interpreting the three x-rays of record or diagnosing a condition. In 

addition, the dentist did not provide an opinion on the cause of the employee’s alleged injury or 

whether the broken tooth was attributable to his employment. 

In Rachel Brunson,

12 there was no dispute that the employee timely filed her claim for 

compensation benefits and that the incident occurred as alleged, i.e., she fell and hit her chin on a 

cement step while delivering mail. She sought dental treatment promptly after the employment 

incident. Although the claimant promptly reported the incident and sought treatment, the Board 

found that the medical evidence she submitted was insufficient to establish a causal relationship 

between the employment incident and the claimed broken right front tooth. 

In R.C.,

13 the employee filed a traumatic injury claim alleging that he broke tooth number 

13 when he bit a popcorn kernel at work. There was no eyewitness testimony. OWCP accepted 

that the incident occurred as alleged, but denied the claim on the grounds that the medical 

evidence submitted was insufficiently rationalized to establish that the accepted incident caused 

the broken tooth. The claimant submitted a Form CA-20 report from his dentist, who merely 

checked a box “yes” indicating causal relationship, and noted that the injury had occurred while 

the employee was on duty. The Board affirmed OWCP’s decision on the basis that the medical 

evidence was not sufficient to establish a claim.14 

 10 Cf. Patrick M. Mooney, Docket No. 97-428 (issued December 22, 1998) (where the Board found that the 

employee’s fractured tooth occurred in the performance of duty as he was on temporary travel duty as a customs 

pilot and was under the 24-hour coverage of FECA at the time of injury). 

11 Docket No. 00-1377 (issued January 2, 2001). 

12 Docket No. 94-2586 (issued August 26, 1996). 

13 Docket No. 08-520 (issued June 13, 2008). 

14 Cf. Diana M. St. Julian, Docket No. 97-168 (issued October 7, 1998) (where OWCP accepted the claim for a 

broken tooth and the employee filed a notice of recurrence alleging that she lost her dental filling while eating 

dinner, the Board found that appellant submitted sufficient evidence to make a prima facie showing that the dental 

procedures performed by her dentist were causally related to the accepted condition and remanded the case for 

further development). 
5

In the instant case, there is no eyewitness testimony corroborating appellant’s biting 

down on a cracker on November 13, 2012. There is no indication that she stopped work as a 

result of the November 13, 2012 incident. Dr. Farinacci, appellant’s attending dentist, submitted 

a Form CA-20 report dated November 15, 2012 indicating that he examined appellant and found 

that she had broken tooth number 31, which resulted in an abscess and required root canal 

therapy. He checked a box “yes” indicating causal relationship. The Board has held that a 

physician’s opinion which is expressed only by checking a box on a form report is of diminished 

probative value in establishing causal relationship.15 No rationale or explanation was provided 

by Dr. Farinacci on the issue of causal relationship.16 

The Board finds that Dr. Farinacci failed to provide a rationalized opinion explaining 

how factors of appellant’s federal employment, such as biting down on a cracker at work, caused 

or aggravated her tooth condition. Dr. Farinacci noted that appellant’s condition occurred while 

she was at work. Such generalized statements do not establish causal relationship because they 

merely repeat appellant’s allegations. Further, he failed to provide a narrative setting forth a full 

and accurate history of appellant’s condition, including a comparison of any diagnostic testing 

obtained after November 13, 2012 with prior tests.17 The Board finds that the reports from 

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

While appellant contends that her work contributed to her tooth condition, the record 

contains insufficient medical opinion explaining how the claimed work factors caused or 

aggravated her claimed condition. The Board has held that the mere fact that a condition 

manifests itself during a period of employment does not raise an inference that there is a causal 

relationship between the two.18 Neither the fact that the condition became apparent during a 

period of employment, nor appellant’s belief that the employment caused or aggravated her 

condition is sufficient to establish causal relationship.19 Causal relationship must be 

substantiated by reasoned medical opinion evidence which is appellant’s responsibility to submit. 

There is insufficient probative, rationalized medical evidence explaining why appellant’s 

claimed tooth condition was caused or aggravated by her employment activities. 

On appeal, appellant contends that the Form CA-16 she submitted was sufficient to 

establish causal relationship and that even if the denial is upheld, a directive to pay for the costs 

incurred under the coverage of the Form CA-16 medical authorization form is in order. The 

Board notes that the employing establishment issued appellant a Form CA-16 on November 14, 

2012 authorizing medical treatment. The Board has held that where an employing establishment 

properly executes a Form CA-16, which authorizes medical treatment as a result of an 

 15 See Calvin E. King, 51 ECAB 394 (2000). 

16 See Sedi L. Graham, 57 ECAB 494 (2006). 

17 Cf. V.M., Docket No. 08-2304 (issued May 21, 2009) (where the Board found that appellant, who alleged a 

broken molar after the left arm of his office chair dropped about six to eight inches, submitted contemporaneous 

medical evidence containing a generally consistent history of injury and remanded the case for further 

development). 

18 See supra note 9. 

19 Id. 
6

employee’s claim for an employment-related injury, it creates a contractual obligation, which 

does not involve the employee directly, to pay the cost of the examination or treatment regardless 

of the action taken on the claim.20 Although OWCP denied appellant’s claim for an injury, it did 

not address whether she is entitled to reimbursement of medical expenses pursuant to the Form 

CA-16.21 Upon return of the case record, OWCP should further address this issue. 

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 her burden of proof to establish that her tooth 

condition is causally related to a November 13, 2012 employment incident as alleged. On return 

of the record, OWCP should consider the Form CA-16 issued in this case. 

ORDER 

IT IS HEREBY ORDERED THAT the October 31, 2013 decision of the Office of 

Workers’ Compensation Programs is affirmed.22 

Issued: June 11, 2015 

Washington, DC 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board 

 20 See D.M., Docket No. 13-535 (issued June 6, 2013). See also 20 C.F.R. §§ 10.300, 10.304. 

21 Cf. Beverly J. Stokes, Docket No. 96-2110 (issued June 25, 1998) (where the claimant alleged a broken tooth 

after being kicked in the face by a patient, the Board found that the medical evidence was insufficient to establish 

fact of injury and the employee would not return the Form CA-16 issued by the employing establishment and would 

not continue treatment with her dentist, who advised that x-rays showed preexisting dental conditions). 

22 Richard J. Daschbach, Chief Judge, participated in the preparation of this decision but is no longer a member of 

the Board effective May 16, 2014.