United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

J.Z., Appellant 

and 

DEPARTMENT OF HOMELAND SECURITY, 

CUSTOMS & BORDER PROTECTION, 

Laredo, TX, Employer 

__________________________________________ 

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Docket No. 15-208 

Issued: March 9, 2015 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

COLLEEN DUFFY KIKO, Judge 

PATRICIA HOWARD FITZGERALD, Judge 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On October 27, 2014 appellant filed a timely appeal from a September 22, 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 his burden of proof to establish an employmentrelated injury on August 7, 2014. 

On appeal, appellant generally asserts that his claim should be accepted. 

 1

 5 U.S.C. §§ 8101-8193. 
2

FACTUAL HISTORY 

On August 11, 2014 appellant, then a 54-year-old mission support specialist, filed a 

traumatic injury claim alleging that on August 7, 2014 he suffered a stroke while attending 

training. He started breathing heavily, fainted, and was transported to Laredo Medical Center. 

By letter dated August 20, 2014, OWCP informed appellant of the evidence needed to 

support his claim. This was to include his response to a questionnaire describing the events of 

the claimed injury and a medical report from his physician explaining how the reported work 

incident caused or aggravated a diagnosed condition. 

The employing establishment provided an authorization for examination and/or treatment 

(Form CA-16), signed by Graciela Espinoza on August 7, 2014. On September 5, 2014 

appellant indicated that medical evidence had been submitted. 

Reports from Laredo Medical Center dated August 10, 2014, indicated that appellant was 

an inpatient from August 7 to 10, 2014. The reports include a list of medications and discharge 

recommendations and a discharge diagnosis of syncope. Dr. Maurice A. Click, Board-certified 

in family medicine, appended a note indicating that appellant was medically cleared to return to 

work on August 14, 2014. 

In reports dated August 13 and 27, 2014, Dr. Oscar N. Lightner, also Board-certified in 

family medicine, noted that appellant fainted at work and was transported to Laredo Medical 

Center where he was hospitalized for four days and had a computerized tomography scan and 

other procedures. He reported that appellant complained of headaches, shoulder pain, and 

numbness to his tongue and was somewhat impaired in speech. Dr. Lightner noted no abnormal 

physical examination findings and diagnosed cerebrovascular accident (CVA), weakness of 

muscles, headache, and fatigue. He recommended rest until further studies were done and 

advised that appellant could not return to work. 

In an August 21, 2014 report, Dr. Click noted a history of syncope and checked the box 

“no” as to whether the diagnosed condition was employment related. He advised that appellant 

was totally disabled from August 7 to 14, 2014, could return to work on August 14, 2014, that he 

had been discharged from treatment on August 10, 2014, and that he was being referred to 

Dr. Lightner. 

By decision dated September 22, 2014, OWCP denied the claim finding that appellant 

had not established causal relationship. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA has the burden of proof to establish 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 injury was sustained in the performance of duty as 

alleged and that any disability and/or specific condition for which compensation is claimed are 
3

causally related to the employment injury. Regardless of whether the asserted claim involves 

traumatic injury or occupational disease, an employee must satisfy this burden of proof.2

 OWCP regulations, at 20 C.F.R. § 10.5(ee) 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.3

 To determine whether an employee sustained a traumatic injury in the 

performance of duty, OWCP must determine whether “fact of injury” is established. First, an 

employee has the burden of demonstrating the occurrence of an injury at the time, place, and in 

the manner alleged, by a preponderance of the reliable, probative, and substantial evidence. 

Second, the employee must submit sufficient evidence, generally only in the form of medical 

evidence, to establish a causal relationship between the employment incident and the alleged 

disability and/or condition for which compensation is claimed. An employee may establish that 

the employment incident occurred as alleged, but fail to show that his or her disability and/or 

condition relates to the employment incident.4

 Causal relationship is a medical issue, and the medical evidence required to establish a 

causal relationship is rationalized medical evidence.5

 The opinion of the physician must be 

based on a complete factual and medical background of the claimant, 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 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 causal relationship.7

ANALYSIS 

Appellant has alleged that he suffered a stroke at work on August 7, 2014. On 

August 20, 2014 OWCP asked him to describe the events of the claimed injury. Appellant did 

not do so. In fact, other than to state on the claim form that he was attending training, it is 

unclear what specific employment factors he maintains caused a diagnosed condition. The 

record establishes that appellant lost consciousness at work on August 7, 2014.8

 The Board 

finds, however, that the medical evidence submitted by appellant is insufficient to establish that 

this incident caused a medical condition because the medical evidence did not offer a consistent 

 2 Gary J. Watling, 52 ECAB 278 (2001). 

3

 20 C.F.R. § 10.5(ee) (1999, 2011); Ellen L. Noble, 55 ECAB 530 (2004). 

4 Supra note 2. 

5 Jacqueline M. Nixon-Steward, 52 ECAB 140 (2000). 

6 Leslie C. Moore, 52 ECAB 132 (2000); Gary L. Fowler, 45 ECAB 365 (1994). 

7 Dennis M. Mascarenas, 49 ECAB 215 (1997). 

8

 The Board notes that, other than the claim form, the record does not contain any evidence from either appellant 

or the employing establishment, such as a witness statement, incident report, or documentation describing the events 

of August 7, 2014. 
4

diagnosed condition and did not relate any diagnosis, including a stroke or CVA, specifically to 

any work factors surrounding the August 7, 2014 employment incident. 

The reports from Laredo Medical Center confirm that appellant was hospitalized from 

August 7 to 10, 2014. These, however, merely included a list of medications, discharge 

instructions, and a discharge diagnosis of syncope. A stroke was not diagnosed. The hospital 

records did not include physician progress notes or consultations, laboratory, or diagnostic study 

reports, or in any way describe appellant’s hospital course. Dr. Click saw appellant in the 

hospital and appended a note that he could return to work on August 14, 2014. In his August 21, 

2014 report, he noted a history of syncope and indicated that the condition was not employment 

related. While he diagnosed a CVA, Dr. Lightner provided no objective findings to support this 

diagnosis and reported no abnormal physical examination findings. Furthermore, he did not 

discuss a cause of the diagnosed condition. 

The record therefore does not contain a detailed medical report describing the 

employment incident in detail or indicate how and why appellant sustained either syncope, a 

CVA, or any other diagnosed condition, due to employment factors on August 7, 2014. Medical 

evidence needed to support a claim for compensation should reflect a correct history, and the 

physician should offer a medically sound explanation of how the claimed work event caused or 

aggravated the claimed condition.9

 Neither physician did so in this case. Appellant did not meet 

his burden of proof to establish that he sustained a traumatic injury on August 7, 2014. 

The Board, however, notes that where, as in this case, an employing establishment 

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

employee’s claim for an employment-related injury, the Form CA-16 creates a contractual 

obligation, which does not involve the employee directly, to pay for the cost of the examination 

or treatment regardless of the action taken on the claim.10 The period for which treatment is 

authorized by a Form CA-16 is limited to 60 days from the date of issuance, unless terminated 

earlier by OWCP.11 The record is silent as to whether OWCP paid for the cost of appellant’s 

examination or treatment for the period noted on the form. 

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 did not establish that he sustained an employment-related 

injury on August 7, 2014. 

 9 Supra note 7. 

10 See Tracy P. Spillane, 54 ECAB 608 (2003). 

11 See 20 C.F.R. § 10.300(c). 
5

ORDER 

IT IS HEREBY ORDERED THAT the September 22, 2014 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: March 9, 2015 

Washington, DC 

 

 Colleen Duffy Kiko, Judge 

 Employees’ Compensation Appeals Board 

 

 Patricia Howard Fitzgerald, Judge 

 Employees’ Compensation Appeals Board 

 

 James A. Haynes, Alternate Judge 

 Employees’ Compensation Appeals Board