United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

C.H., widow of L.H., Appellant 

and 

DEPARTMENT OF THE NAVY, NAVAL 

SHIPYARD, Long Beach, CA, Employer 

__________________________________________ 

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Docket No. 15-240 

Issued: March 26, 2015 

Appearances: Case Submitted on the Record

Sally F. LaMacchia, Esq., for the appellant 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On November 12, 2014 appellant, through counsel, filed a timely appeal from a 

September 4, 2014 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 the employee’s 

death was causally related to his accepted employment injuries. 

FACTUAL HISTORY 

On November 25, 1981 the employee, then a 51-year-old boilermaker, injured his back 

when pulling down on a rope to close a door which had jammed. OWCP accepted the claim for 

 1

 5 U.S.C. § 8101 et seq. 
2

thoracic strain and lumbar muscle spasm with right leg radiculitis. The employee stopped work 

in 1982. 

The employee died on June 9, 2009. On June 15, 2010 appellant filed a (Form CA-5) 

claim for death benefits, alleging that her husband’s death was causally related to employment 

factors. 

This is the third appeal before the Board regarding appellant’s claim for death benefits. 

The relevant facts are as follows. 

In a May 22, 2009 hospital report/discharge summary, received by OWCP on August 17, 

2010, Dr. Kenneth Shapiro, Board-certified in internal medicine, stated that the employee was 

admitted on May 16, 2009, with an admission diagnosis of congestive heart failure. The 

discharge diagnosis was congestive heart failure, with severe ischemic cardiomyopathy, 

anasarca, chronic, and acute renal failure, diabetes, lower extremity ulcers in fact with 

methicillin resistant staphylococcus aureus, and status post coronary artery bypass grafting. 

Appellant submitted the employee’s death certificate which listed his causes of death on 

June 9, 2009 as cardiopulmonary arrest, coronary artery disease, and with diabetes mellitus a 

contributing factor. 

In a June 2, 2010 report, Dr. Kesho N. Hurria, the employee’s attending physician, stated 

that the effects of chronic hypertension were one of the leading risk factors for heart attack, 

stroke, heart failure, and aneurysm. He stated that the employee was a chronic pain sufferer with 

high blood pressure, which caused increased sensitivity to pain and frequently resulted in even 

higher blood pressure. Dr. Hurria stated that the employee’s 1981 work injury led to a chronic 

pain syndrome, which caused a chronic cardiac hypertension, which led to chronic edema to the 

lower extremities, causing decreased circulation to the heart muscle. This caused hypertrophy to 

the heart that eventually led to the employee’s coronary heart attack and coronary bypass surgery 

in 2009. Dr. Hurria stated that the 1981 back injury resulted in chronic hypertension, leading to 

coronary artery disease that led to the employee’s fatal cardiopulmonary arrest on May 23, 2009. 

In a January 6, 2011 report, Dr. Ellen Pichey, an OWCP medical adviser, expressed her 

disagreement with Dr. Hurria’s opinion. She opined that because the employee was 81 years of 

age, had a triple bypass and pacemaker, diabetes, hypertension, and a family history of cardiac 

disease, it was not reasonable to conclude that his death was a consequence of thoracic and 

lumbar sprains and radiculitis from 30 years prior. 

In a decision dated March 29, 2011, OWCP denied appellant’s claim, finding that the 

evidence failed to establish that the employee’s death was due to factors of his federal 

employment. By decision dated November 14, 2011, an OWCP hearing representative affirmed 

the March 29, 2011 decision. In a September 20, 2012 decision,2

 the Board set aside OWCP’s 

decisions. The Board found that there was an unresolved conflict in the medical evidence 

between Dr. Hurria and Dr. Pichey regarding whether the employee’s death was causally related 

to employment factors. The Board remanded the case to OWCP for referral of appellant to an 

 2

 Docket No. 12-861 (issued September 20, 2012). 
3

appropriate impartial medical specialist to resolve the outstanding conflict in the medical 

evidence. 

Appellant was referred to Dr. Ram K. Setty, a Board-certified cardiologist, who 

submitted an impartial medical report dated November 9, 2012. Dr. Setty stated that the risk 

factors for coronary artery disease or hypertension were a family history of coronary artery 

disease, diabetes mellitus, hypertension, cigarette smoking, and dyslipidemia. He asserted that 

the available medical data indicated that acute pain from any reason, including anxiety, could 

raise blood pressure. Dr. Setty advised that because the employee was treated for both back pain 

and hypertension and did not have hypertension before experiencing back pain, it was possible 

that his hypertension might have been caused by his back pain. He also indicated that 

hypertension might have contributed in small part to the employee’s developing coronary artery 

disease. Dr. Setty stated, however, that it was not the sole cause, as he had two major risk 

factors, diabetes, and a family history of coronary artery disease. He expressed doubt as to 

whether the employee’s back pain could cause hypertension, given that he was being treated for 

back pain as well as mild hypertension, and given that his coronary artery disease was associated 

with major, “heavyweight” risk factors like his family history of coronary artery disease and 

diabetes. Dr. Setty stated that mild hypertension was hard to accept as the sole cause of coronary 

artery disease, though it may have played a minor role. 

By decision dated January 9, 2013, OWCP denied the claim for death benefits. It found 

that Dr. Setty’s impartial medical opinion represented the weight of the medical evidence. 

On May 16, 2013 an OWCP hearing representative affirmed the January 9, 2013 

decision. In a November 6, 2013 decision,3

 the Board set aside the hearing representative’s 

May 16, 2013 decision. The Board, noting that it was not necessary under its case law to provide 

a significant contribution of employment factors for the purpose of establishing causal 

relationship, found that Dr. Setty’s opinion was insufficient to resolve the conflict in medical 

evidence because he opined that hypertension caused by chronic pain might have played at least 

a minor role in the development of coronary artery disease, resulting in the employee’s death. 

The Board therefore found that his opinion required clarification as to whether the employee’s 

death was due, in any part, to his accepted back condition. The Board set aside the May 16, 

2013 decision of the hearing representative and directed OWCP on remand to ask Dr. Setty to 

submit a report clarifying his opinion as to whether the employee’s death was causally related to 

his 1981 work injury. The complete facts of this case are set forth in the Board’s September 20, 

2012 and November 6, 2013 decisions and are herein incorporated by reference. 

In an August 25, 2014 report, Dr. Setty opined that the employee’s death due to coronary 

artery disease and diabetes was not causally related to the 1981 back injury. He stated: 

“The issue, as I understand it is [c]hronic [p]ain -- producing hypertension 

producing [c]oronary [a]rtery [d]isease. If this is true, much of our population 

will have coronary artery disease, as back pain is very common. 

 3

 Docket No. 13-1467 (issued November 6, 2013). 
4

“The blood pressure does go up when there is pain -- a very common combination 

we see always, especially in emergency rooms.... Even during acute heart attack, 

in [emergency rooms] we see blood pressures going sky high and coming down to 

base levels with a shot of morphine. What I am getting [at] here is [that] the 

blood pressures do go up and down in many patients. We call this group as labile 

hypertension or fluctuating blood pressure. [The employee] falls into this group. 

In September 28, 1985, his blood pressure was reported as 130/82. In 

December 6, 1995 it was 160/98. Now we can see a large difference even in 

patients being treated. Obviously, the blood pressure in this patient is not a 

persistent one to produce changes in the body to develop coronary artery disease. 

“The other thing I brought up in my last letter is that [the employee] is under 

constant medical care. We know [patients] treated [for] hypertension do a lot 

better (twice as well) than untreated hypertension. Also [the employee] was on 

many types of painkillers for his back all through. So when somebody has both 

hypertension and back pain and is being treated by continuous medical attention it 

is anybody’s guess that chronic pain has nothing to do in the development of 

hypertension. [The employee] had his back injury in 1981 and open heart surgery 

in 2007. Also, looking at his records, he goes to the hospital with chest pain in 

August 2007 and during the same admission he had open heart surgery, meaning 

he did not have significant coronary artery disease before. If back pain is to 

produce coronary artery disease, [the employee] should have had symptoms of 

coronary artery disease earlier.” 

Dr. Setty further noted that the employee had a family history of diabetes, which, when 

combined with hypertension and the subsequent development of coronary artery disease, 

provided more than enough factors to produce a heart attack. He therefore concluded that there 

was no chance for patients who have controlled pain stemming from a physical injury, like the 

employee, to develop hypertension and coronary artery disease from the injury-related pain. 

By decision dated September 4, 2014, OWCP denied the claim for death benefits. It 

found that Dr. Setty’s impartial medical opinion represented the weight of the medical evidence. 

LEGAL PRECEDENT 

Appellant has the burden of proving by the weight of the reliable, probative, and 

substantial evidence that the employee’s death was causally related to his federal employment. 

This burden includes the necessity of furnishing medical opinion evidence of a cause and effect 

relationship based on a proper factual and medical background.4 

The medical evidence required to establish a causal relationship, generally, is rationalized 

medical opinion evidence.5

 Rationalized medical opinion evidence is medical evidence which 

 4 Kathy Marshall (James Marshall), 45 ECAB 827, 832 (1994); Timothy Forsyth (James Forsyth), 41 ECAB 467, 

470 (1990). 

5 See Naomi A. Lilly, 10 ECAB 560, 572-73 (1959). 
5

includes a physician’s rationalized opinion on the issue of whether there is a causal relationship 

between the claimant’s diagnosed condition and the implicated employment factors. The 

opinion of the physician must be based on a complete factual and medical background of the 

claimant,6

 must be one of reasonable medical certainty,7 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 claimant.8

 

It is not necessary to provide a significant contribution of employment factors for the 

purpose of establishing causal relationship.9

Section 8123(a) provides that, if there is a disagreement between the physician making 

the examination for the United States and the physician of the employee the Secretary shall 

appoint a third physician who shall make an examination.10 It is well established that, when a 

case is referred to an impartial medical specialist for the purpose of resolving a conflict, the 

opinion of such specialist, if sufficiently well rationalized and based on a proper factual and 

medical background, must be given special weight.11

ANALYSIS 

The Board finds that appellant failed to establish that the employee’s death was causally 

related to his work-related injuries. In his August 25, 2014 report, Dr. Setty stated that the 

employee’s chronic pain resulting from his 1981 back injury did not produce hypertension, 

which resulted in coronary artery disease and caused his fatal heart attack. He advised that back 

pain was common in the general population and resulted in elevated blood pressure in many 

patients; this, however, did not typically result in the patient developing coronary artery disease. 

Dr. Setty advised that blood pressure will fluctuate in patients such as the employee but was not 

sufficiently persistent to produce changes in the body which would develop coronary artery 

disease. He stated that, if back pain had produced the employee’s coronary artery disease, he 

should have manifested symptoms of coronary artery disease earlier. Dr. Setty asserted that 

there was no chance for patients with pain stemming from a physical injury, like the employee, 

to develop hypertension and coronary artery disease from the injury-related pain. He advised 

that the employee’s family history of diabetes, combined with hypertension and the subsequent 

development of coronary artery disease, were sufficient factors to result in his heart attack. 

Based on these reasons, Dr. Setty concluded that the employee’s death due to coronary artery 

disease and diabetes was not causally related to the 1981 back injury. 

 6 William Nimitz, Jr. 30 ECAB 567, 570 (1979). 

7 See Morris Scanlon, 11 ECAB 384, 385 (1960). 

8 See William E. Enright, 31 ECAB 426, 430 (1980). 

9 See Richard E. Simpson, 55 ECAB 490 (2004). 

10 Regina T. Pellecchia, 53 ECAB 155 (2001). 

11 Jacqueline Brasch (Ronald Brasch), 52 ECAB 252 (2001). 
6

OWCP relied on Dr. Setty’s opinion in its September 4, 2014 decision, finding that his 

amended report was a sufficient basis to conclude that the employee’s 2009 death due to 

coronary artery disease and diabetes was not causally related to his accepted 1981 back injury, 

and represented the weight of the medical evidence. The Board finds that Dr. Setty’s impartial 

opinion negates a causal relationship between the employee’s death due to coronary artery 

disease and diabetes was not causally related to the 1981 back injury. Dr. Setty’s opinion is 

sufficiently probative, rationalized, and based upon a proper factual background. Therefore, 

OWCP properly accorded his opinion the special weight of an impartial medical examiner.12 

On appeal, appellant’s counsel reiterates his argument, stated below, that Dr. Pichey’s 

January 6, 2011 report was not sufficient to produce a conflict in the medical evidence. The 

Board has previously addressed this contention and has found that a conflict in the medical 

evidence did exist between the opinions of Dr. Pichey and Dr. Hurria as to whether the 

employee’s death due to coronary artery disease was causally related to his work-related 1981 

back injury. Counsel further argues that Dr. Setty’s August 25, 2014 report was not sufficiently 

rationalized and did not provide a sufficient basis to deny death benefits to appellant; in fact, his 

reports supported a finding of causal relationship. She states that he did not address the reports 

and opinions of Dr. Hurria, who was the employee’s longtime attending physician, treated him 

for years and therefore provided a more credible opinion of whether hypertension, produced by 

chronic back pain, contributed to the development of the employee’s coronary artery disease. 

The Board does not agree. For the reasons stated above, Dr. Setty’s supplemental opinion is 

sufficient to resolve the conflict in medical evidence, as his opinion clarifies that the employee’s 

death was not due, in any part, to his accepted 1981 back injury. OWCP properly found that 

appellant failed to meet her burden of proof to establish that her husband’s death was caused by 

factors of his federal employment.13 The Board therefore affirms the September 4, 2014 decision 

denying compensation for death benefits. 

CONCLUSION 

The Board finds that appellant failed to establish that the employee’s death on May 23, 

2009 was causally related to factors of his federal employment. 

 12 Gary R. Seiber, 46 ECAB 215 (1994). 

13 Victor J. Woodhams, 41 ECAB 345 (1989). 
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ORDER 

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

Compensation Programs dated September 4, 2014 is affirmed. 

Issued: March 26, 2015 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board