United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

M.B., Appellant 

and 

DEPARTMENT OF VETERANS AFFAIRS, 

VETERANS ADMINISTRATION MEDICAL 

CENTER, Pittsburgh, PA, Employer 

__________________________________________ 

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Docket No. 14-152 

Issued: April 21, 2015 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

COLLEEN DUFFY KIKO, Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On October 28, 2013 appellant filed a timely appeal of a June 6, 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 to 

consider the merits of the case. 

ISSUE 

The issue is whether appellant has met his burden of proof to establish a traumatic injury 

on February 12, 2013 in the performance of duty. 

FACTUAL HISTORY 

On February 12, 2013 appellant, then a 64-year-old housekeeping aid supervisor, filed a 

notice of traumatic injury. He alleged that at 2:45 that morning he injured his lower back while 

 1

 5 U.S.C. § 8101 et seq.
2

pulling open a power door when the power was shut off. He sought medical treatment on 

February 12, 2013 from the employing establishment. A Record of Employee Treatment dated 

February 12, 2013 states that appellant pulled a door at work and developed low back pain. 

Appellant was diagnosed with sprain of the lumbosacral area, arthritis by x-rays and history of 

degenerative disc disease and provided work restrictions. 

Dr. Richard Rudman, a Board-certified family practitioner, diagnosed mid or lower back 

strain on February 18, 2013 and prescribed physical therapy on a prescription slip. Appellant 

subsequently received physical therapy. 

In a letter dated May 2, 2013, OWCP noted that appellant’s claim had initially been 

handled as a minor injury, and that payment for a limited amount of medical expenses was 

administratively approved. The letter requested additional factual information from appellant 

regarding the employment incident and medical opinion evidence regarding the relationship 

between the injury and the diagnosed condition. OWCP allowed appellant 30 days for a 

response. 

Appellant submitted a CA-20 form report from Dr. Rudman dated May 10, 2013 

diagnosing acute mid and low back strain. Dr. Rudman determined that forcibly opening the 

nonfunctioning electric door while at work on February 12, 2013 caused or aggravated his 

condition. 

By decision dated June 6, 2013, OWCP denied appellant’s claim finding that he failed to 

submit the necessary factual evidence to establish that he experienced the employment incident 

at the time, place, and in the manner alleged. It also noted that appellant had not submitted any 

narrative medical evidence. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA2 has the burden of establishing the essential 

elements of his or her claim by the weight of the reliable, probative and substantial evidence, 

including the fact that the individual is an “employee of the United States” within the meaning of 

FECA and that the claim was timely filed within the applicable time limitation period of FECA, 

that an injury was sustained in the performance of duty as alleged and that any disability or 

specific condition for which compensation is claimed is 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 upon a traumatic injury or an occupational disease.4

OWCP defines 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 

 2

 5 U.S.C. §§ 8101-8193. 

3 Kathryn Haggerty, 45 ECAB 383, 388 (1994); Elaine Pendleton, 41 ECAB 1143 (1989). 

4 Victor J. Woodhams, 41 ECAB 345 (1989). 
3

time and place of occurrence and member or function of the body affected.”5

 In order to 

determine whether an employee actually sustained an injury in the performance of duty, OWCP 

begins with an analysis of whether fact of injury has been established. Generally, fact of injury 

consists of two components which must be considered in conjunction with one another. The first 

component to be established is that the employee actually experienced the employment incident 

which is alleged to have occurred.6 

With respect to the first component of fact of injury, the employee has the burden of 

establishing the occurrence of an injury at the time, place, and in the manner alleged, by a 

preponderance of the reliable, probative, and substantial evidence. An injury does not have to be 

confirmed by eyewitnesses in order to establish the fact that an employee sustained an injury in 

the performance of duty, but the employee’s statements must be consistent with the surrounding 

facts and circumstances and his subsequent course of action. An employee has not met his or her 

burden of proof of establishing the occurrence of an injury when there are such inconsistencies in 

the evidence as to cast serious doubt upon the validity of the claim. Such circumstances as late 

notification of injury, lack of confirmation of injury, continuing to work without apparent 

difficulty following the alleged injury and failure to obtain medical treatment may, if otherwise 

unexplained, cast sufficient doubt on an employee’s statements in determining whether a prima 

facie case has been established. However, an employee’s statement alleging that an injury 

occurred at a given time and in a given manner is of great probative value and will stand unless 

refuted by strong or persuasive evidence.7

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.8 A 

medical report is of limited probative value on a given medical question if it is unsupported by 

medical rationale.9 Medical rationale includes a physician’s detailed opinion on the issue of 

whether these is a causal relationship between the claimant’s diagnosed condition and the 

implicated employment activity. The opinion of the physician must be based on a complete 

factual and medical background of the claim, must be one of reasonable medical certainty, and 

must be supported by medical reasoning explaining the nature of the relationship between the 

diagnosed condition and specific employment activity or factors identified by the claimant.10

ANALYSIS 

In its June 6, 2013 decision, OWCP denied appellant’s claim because he had not 

responded to its May 2, 2013 request for additional information. However, the Board finds that 

 5

 20 C.F.R. § 10.5(ee). 

6 Elaine Pendleton, supra note 3. 

7 D.B., 58 ECAB 464, 466-67 (2007). 

8 J.Z., 58 ECAB 529 (2007). 

9 T.F., 58 ECAB 128 (2006). 

10 A.D., 58 ECAB 149 (2006). 
4

appellant has submitted sufficient factual evidence to establish that the employment incident 

occurred as alleged. 

Appellant’s statements on his claim form are consistent with the history provided in the 

employing establishment’s medical report written within hours of the incident. Dr. Rudman’s 

May 10, 2013 report, provided on a CA-20 form, contains a history identical to that provided to 

the employing establishment on the date of the alleged incident. Appellant stated that he injured 

his back on February 12, 2013 while opening a door at work. He sought medical treatment from 

the employing establishment on that date, and later from Dr. Rudman on February 18 and 

May 10, 2013. Appellant provided a timely notification of injury and received work restrictions 

as a result of his treatment. 

The employing establishment has not controverted appellant’s claim and the Board finds 

no evidence in the record to refute appellant’s statements. Appellant’s description of the time, 

place, and manner of his injury has not changed. On appellant’s Form CA-1, Notice of 

Traumatic Injury, dated February 12, 2013, appellant’s supervisor checked a box indicating that 

appellant was injured in the performance of duty, and indicated that his knowledge of the facts 

agreed with appellant’s statement. The supervisor signed his portion of the form with a 

certification that the “the information given above and that furnished by the employee on the 

reverse of the form is true to the best of [his] knowledge, without noting any exceptions.” 

In many opinions, the Board has identified the level of inconsistency which may cause it 

to deny a claim because the incident alleged was not proven. Where an appellant provided four 

distinct accounts of the events surrounding an alleged injury, but failed to provide any witness 

statements or specific evidence of the mechanism of injury, the Board found that appellant had 

failed to prove compensability.11 In a different claim, where appellant alleged a time, place, 

manner, and mechanism of injury, timely sought medical treatment, and where a supervisor 

confirmed that appellant had engaged in the activity alleged, the Board held that appellant had 

proved the incident and remanded the case to OWCP for a decision on the medical issues 

presented.12 The Board finds that appellant has proved that the alleged incident occurred at the 

time, place, and in the manner alleged. 

The Board further finds, however, that appellant has failed to submit rationalized medical 

opinion evidence to establish that the action of opening the door on February 12, 2013 resulted in 

a lumbar strain. While the medical evidence from the employing establishment is sufficient to 

establish the factual aspect of appellant’s claim, neither the employing establishment’s Record of 

Employee Treatment, nor the reports of Dr. Rudman explain how appellant’s actions resulted in 

his diagnosed condition. To be considered rationalized medical evidence, a physician’s opinion 

must be expressed in terms of reasonable medical certainty and must explain the relationship 

between the diagnosed condition and appellant’s specific employment factors.13 There is no 

rationalized medical opinion of record explaining why and how appellant’s attempt to open the 

 11 Paul Foster, 56 ECAB 208 (2004). 

12 Larry D. Dunkin, 56 ECAB 220 (2004). 

13 S.D., 58 ECAB 428 (713 (2007). 
5

automatic door resulted in the diagnosed lumbar sprain. Appellant has, therefore, failed to meet 

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. 

CONCLUSION 

The Board finds that appellant has established that the employment incident occurred on 

February 12, 2013 while opening a door at his place of employment. The Board further finds 

that he has failed to establish that his diagnosed condition of back strain resulted from this 

incident. Appellant, therefore, has failed to establish his traumatic injury claim for back sprain 

on February 12, 2013. 

ORDER 

IT IS HEREBY ORDERED THAT the June 6, 2013 decision of the Office of Workers’ 

Compensation Programs is affirmed, as modified. 

Issued: April 21, 2015 

Washington, DC 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board