United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

D.S., Appellant 

and 

DEPARTMENT OF THE NAVY, NAVAL 

FACILITIES ENGINEERING COMMAND 

SOUTHWEST, San Diego, CA, Employer 

__________________________________________ 

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Docket No. 14-466 

Issued: October 10, 2014 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

ALEC J. KOROMILAS, Alternate Judge 

MICHAEL E. GROOM, Alternate Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On December 23, 2013 appellant filed a timely appeal from decisions of the Office of 

Workers’ Compensation Programs (OWCP) dated October 17 and September 19, 2013 denying 

his traumatic injury claim. 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 established that his lumbar condition was causally related 

to the accepted July 24, 2013 employment incident. 

On appeal appellant contends that his back injury was caused by the July 24, 2013 

employment incident. 

 1

 5 U.S.C. § 8101 et seq. 
2

FACTUAL HISTORY 

On July 24, 2013 appellant, then a 59-year-old dispatcher, filed a traumatic injury claim 

alleging that he developed low back and right leg pain on that date when he fell into a chair that 

had its settings changed without his knowledge. He stopped work that day. 

In a July 26, 2013 attending physician’s report (Form CA-20), Dr. Parimal J. Soni, an 

examining physician, diagnosed low back pain. He noted the injury occurred when appellant fell 

back into a chair that had been lowered without his knowledge. Dr. Soni checked “yes” to the 

question of whether the diagnosed condition was caused or aggravated by the identified incident 

with no explanation. 

In a July 26, 2013 progress note, Dr. Mark B. Kerner, a treating Board-certified 

orthopedic surgeon, reported that appellant was status post laminectomy for an employment 

injury sustained in October 2012. He noted that appellant was seen for back pain following 

sitting into a chair at work on Wednesday. Appellant was unaware that the chair had been 

readjusted so that it “caused him to fall and lurch with sudden onset of” right-sided back pain 

radiating into his leg and buttocks. The physical examination revealed equivocal straight leg 

raise, difficulty getting into and out of a chair and standing with a list. Based on appellant’s 

symptoms, Dr. Kerner opined that appellant may have suffered an annular tear, if not a 

significant disc herniation. 

By letter dated August 12, 2013, OWCP informed appellant that the evidence of record 

was insufficient to support his claim. Appellant was advised as to the medical and factual 

evidence required to establish his claim and provided 30 days to provide such information. 

In an August 30, 2013 report, Dr. Kerner noted that appellant fell while getting into his 

chair at work on July 24, 2013 after it had been readjusted. Appellant reported a sudden onset of 

pain in his right buttock, leg and back with a grabbing sensation in his right leg. Dr. Kerner 

reviewed a magnetic resonance imaging (MRI) scan which showed a dramatic aseptic discitis in 

the lumbar spine which he opined was a traumatic inflammatory injury. He related that in 

October 2012 appellant underwent surgery for a laminectomy at L4-5, which was the level of his 

current injury. Dr. Kerner diagnosed lumbar strain and postlaminectomy lumbar syndrome with 

lumbar aseptic discitis. He related that the fall at work injured appellant’s back and exacerbated 

his back and leg pain. Dr. Kerner attributed appellant’s current condition to the July 24, 2013 

work incident. 

By decision dated September 19, 2013, OWCP denied appellant’s claim. It found that he 

failed to establish a diagnosed medical condition causally related to the accepted July 24, 2013 

work incident.2

In a September 23, 2013 report, Dr. Kerner noted that an August 15, 2013 MRI scan 

supported his diagnosis of lumbar spine post-traumatic aseptic discitis. He stated that appellant 

was totally disabled due to severe back and leg pain. 

 2

 The record also contains an identical decision denying appellant’s claim dated September 24, 2013. However, 

the September 24, 2013 decision is unsigned while the September 19, 2013 decision is signed by both, the claims 

examiner and supervisory claims examiner. 
3

In a letter dated September 24, 2013, appellant requested reconsideration. 

By decision dated October 17, 2013, OWCP denied modification.3

LEGAL PRECEDENT 

An employee seeking benefits under FECA4 has the burden of establishing the essential 

elements of his 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.5 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.6

 

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. 

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.7

The claimant has the burden of establishing by the weight of reliable, probative and 

substantial evidence that the condition for which compensation is sought is causally related to a 

specific employment incident or to specific conditions of employment.8 An award of 

compensation may not be based on appellant’s belief of causal relationship. Neither the mere 

fact that a disease or condition manifests itself during a period of employment nor the belief that 

the disease or condition was caused or aggravated by employment factors or incidents is 

sufficient to establish a causal relationship.9 

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

establish causal relationship is rationalized medical opinion evidence.10 Rationalized medical 

 3

 The Board notes that, following the October 17, 2013 decision, OWCP received additional evidence. Appellant 

also submitted new evidence with his appeal to the Board. However, the Board may only review evidence that was 

in the record at the time OWCP issued its final decision. See 20 C.F.R. § 501.2(c)(1); M.B., Docket No. 09-176 

(issued September 23, 2009); J.T., 59 ECAB 293 (2008); G.G., 58 ECAB 389 (2007); Donald R. Gervasi, 57 ECAB 

281 (2005); Rosemary A. Kayes, 54 ECAB 373 (2003). 

4 Supra note 1. 

5 C.S., Docket No. 08-1585 (issued March 3, 2009); Bonnie A. Contreras, 57 ECAB 364 (2006). 

6 S.P., 59 ECAB 184 (2007); Joe D. Cameron, 41 ECAB 153 (1989). 

7 See Elaine Pendleton, 40 ECAB 1143 (1989); K.K., Docket No. 13-1205 (issued December 13, 2013). 

8 Roma A. Mortenson-Kindschi, 57 ECAB 418 (2006); Katherine J. Friday, 47 ECAB 591 (1996). 

9 P.K., Docket No. 08-2551 (issued June 2, 2009); Dennis M. Mascarenas, 49 ECAB 215 (1997). 

10 Y.J., Docket No. 08-1167 (issued October 7, 2008); A.D., 58 ECAB 149 (2006); D’Wayne Avila, 57 ECAB 

642 (2006). 
4

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.11 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.12

ANALYSIS 

Appellant filed a traumatic injury claim attributing his back condition to falling in his 

chair that had its settings changed without his knowledge. OWCP accepted that the incident 

occurred as alleged on July 24, 2013. 

OWCP denied appellant’s claim finding that the medical evidence was insufficient to 

establish that his low back condition was caused or aggravated by his accepted work incident. 

In a July 26, 2013 attending physician’s form Dr. Soni diagnosed low back and checked 

“yes” to the question of whether injury had been caused or aggravated by the identified 

employment activity. The Board has held that when a physician’s opinion on causal relationship 

consists only of checking “yes” to a form question, without explanation or rationale, that opinion 

is of diminished probative value and is insufficient to establish a claim.13 

The Board finds that the medical evidence submitted by Dr. Kerner generally supports 

that he sustained an aggravation of his preexisting lumbar condition causally related to the 

accepted July 24, 2013 incident. 

Dr. Kerner’s reports noted that appellant had a preexisting condition for which he 

underwent a laminectomy L4-5 in October 2012. He reviewed the MRI scan from 2012 with 

that obtained in August 2013. Dr. Kerner noted an increased L4-5 contrast with small disc 

protrusion. He diagnosed postlaminectomy syndrome of the lumbar spine with aseptic discitis 

which he attributed to the July 24, 2013 work incident. 

The Board finds that while Dr. Kerner’s reports are not sufficient to meet appellant’s 

burden of proof to establish his claim with regard to an aggravation of his preexisting lumbar 

condition, they raise a substantial inference between appellant’s claimed lumbar condition and 

the employment injury of July 24, 2013. Dr. Kerner had a history of appellant’s preexisting 

lumbar condition for which he underwent surgery in 2012. He had an accurate history of the 

accepted July 24, 2013 incident accepted in this case. Moreover, Dr. Kerner contrasted the 

diagnostic tests of 2012 with those obtained in 2013 on which he based a diagnosis of 

postlaminectomy syndrome with aseptic discitis, noting a small disc protrusion at L4-5. 

 11 J.J., Docket No. 09-27 (issued February 10, 2009); Michael S. Mina, 57 ECAB 379 (2006). 

12 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345 (1989). 

13 D.D., 57 ECAB 734 (2006); Cecelia M. Corley, 56 ECAB 662 (2005). 
5

Based on Dr. Kerner’s reports, the case will be remanded to OWCP for further 

development of the medical evidence. It should prepare a statement of accepted facts and obtain 

a rationalized medical opinion as to whether the July 24, 2013 incident caused or aggravated 

appellant’s preexisting lumbar condition. Following this and such other development as it deems 

necessary, OWCP shall issue a de novo decision. 

CONCLUSION 

The Board finds that this case is not in posture for a decision. 

ORDER 

IT IS HEREBY ORDERED THAT the decisions of the Office of Workers’ 

Compensation Programs dated October 17 and September 19, 2013 are set aside and the case 

remanded for further proceedings consistent with this decision of the Board. 

Issued: October 10, 2014 

Washington, DC 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 Michael E. Groom, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board