United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

G.Z., Appellant 

and 

DEPARTMENT OF THE ARMY, 

MEDICAL COMMAND, Fort Carson, CO, 

Employer 

__________________________________________ 

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Docket No. 16-0935 

Issued: August 18, 2016 

Appearances: Case Submitted on the Record

Appellant, pro se 

Office of Solicitor, for the Director 

DECISION AND ORDER 

Before: 

CHRISTOPHER J. GODFREY, Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

VALERIE D. EVANS-HARRELL, Alternate Judge 

JURISDICTION 

On March 25, 2016 appellant filed a timely appeal from a March 9, 2016 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 met his burden of proof to establish an employmentrelated injury on February 25, 2015, causally related to the accepted employment incident. 

On appeal, appellant contends that he fell in the parking lot due to the failure of the 

employing establishment to properly remove snow and ice.2

 1

 5 U.S.C. § 8101 et seq. 

2

 The Board notes that appellant submitted additional evidence after OWCP rendered its March 9, 2016 decision. 

The Board’s jurisdiction is limited to reviewing the evidence that was before OWCP at the time of its final decision. 

Therefore, this additional evidence cannot be considered by the Board. 20 C.F.R. § 501.2(c)(1); Dennis E. Maddy, 

47 ECAB 259 (1995); James C. Campbell, 5 ECAB 35, 36 n.2 (1952). 
2

FACTUAL HISTORY 

On December 28, 2015 appellant, then a 78-year-old medical records technician, filed a 

traumatic injury claim (Form CA-1) alleging that on February 25, 2015 he suffered back pain 

after he fell on ice in the employing establishment parking lot. He submitted no evidence with 

his claim. 

By letter dated February 3, 2016, OWCP informed appellant that he must submit 

evidence, including medical evidence in support of his claim. Appellant was afforded 30 days to 

submit this additional evidence. 

In response to this letter, appellant submitted a March 20, 2015 memorandum and 

progress report from Dr. Christopher Rodriguez, an employing establishment health unit 

osteopathic physician. In the progress report, Dr. Rodriguez noted that appellant came in for a 

certificate to return to work. He noted that appellant slipped and fell on the ice on February 25, 

2015, that he was seen at the Emergency Department, that radiographs of the thoracic spine were 

obtained, that they revealed no evidence of acute fracture, and he was released to follow up with 

his physician. Dr. Rodriguez noted that appellant did not return to occupational health until 

March 19, 2015, at which time the staff recommended that he be evaluated by a workers’ 

compensation provider to continue care. He noted that appellant stated that he was feeling 75 

percent better since the injury, but still complained of mild-to-moderate pain and stiffness in his 

upper back and neck. In the memorandum, Dr. Rodriguez noted that appellant filed a claim for a 

diagnosis of contusion. He recommended that appellant return to work on March 23, 2015 

without restrictions. 

By decision dated March 9, 2016, OWCP denied appellant’s claim. It found that he had 

established that the alleged incident occurred as alleged, but that he had not established that he 

sustained a diagnosed medical condition, causally related to the accepted incident. 

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 

causally related to the employment injury. 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.3

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 or exposure, which is alleged to have occurred.4

 

 3 Jussara L. Arcanjo, 55 ECAB 281, 283 (2004). 

4 See Federal (FECA) Procedure Manual, Part 2 -- Claims, Fact of Injury, Chapter 2.803(2)(a) (August 2012). 
3

In order to meet the burden of proof to establish the fact that he or she sustained an injury in the 

performance of duty, an employee must submit sufficient evidence to establish that he or she 

actually experienced the employment injury or exposure at the time, place, and in the manner 

alleged.5

The second component is whether the employment incident caused a personal injury and 

generally can be established only by medical evidence.6

 The medical evidence required to 

establish causal relationship is usually rationalized medical evidence. Rationalized medical 

opinion evidence is medical evidence which 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, 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 claimant.7

ANALYSIS 

OWCP found that appellant had established that the incident occurred as alleged. 

However, it determined that he had failed to submit the necessary medical evidence to establish a 

diagnosed medical condition or that this condition was causally related to the accepted 

employment incident of February 25, 2015. 

The only medical evidence in the record is the report by the employing establishment’s 

physician, Dr. Rodriguez, who did not form any medical diagnosis or reach any conclusion on 

causal relationship. Rather, Dr. Rodriguez mainly addressed appellant’s ability to return to 

work. Although he noted that appellant was in pain, pain is a symptom and not a diagnosis of a 

medical condition.8

 Even if a medical diagnosis had been obtained, appellant still did not 

establish that his medical condition was causally related to the employment incident. As 

previously noted, it is appellant’s burden of proof to submit medical evidence which causally 

related the diagnosed medical condition to the accepted employment incident. The medical 

evidence required to establish causal relationship is usually rationalized medical evidence.9

The Board also notes that, while the record indicates that appellant sought medical 

treatment at a hospital following the accepted incident, he did not submit any records from his 

visit to the hospital to OWCP. 

An award of compensation may not be based on surmise, conjecture, or speculation.10 As 

appellant did not establish that he suffered a medical condition that was causally related to the 

accepted employment incident, OWCP properly denied his claim. 

 5 Linda S. Jackson, 49 ECAB 486 (1998). 

6 John J. Carlone, 41 ECAB 354 (1989); Horace Langhorne, 29 ECAB 820 (1978). 

7 Judith A. Peot, 46 ECAB 1036 (1995); Ruby I. Fish, 46 ECAB 276 (1994). 

8 K.B., Docket No. 16-0122 (issued April 19, 2016). 

9 Supra note 6. 

10 D.I., 59 ECAB 158 (2007); Ruth R. Price, 16 ECAB 688, 691 (1965). 
4

 Appellant may submit additional evidence, together with a written request for 

reconsideration, to OWCP within one year of the Board’s merit decision, pursuant to 5 U.S.C. 

§ 8128(a) and 20 C.F.R. §§ 10.606 and 10.607. 

CONCLUSION 

The Board finds that appellant did not meet his burden of proof to establish an 

employment-related injury on February 25, 2015, causally related to the accepted employment 

incident. 

ORDER 

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

Compensation Programs dated March 9, 2016 is affirmed. 

Issued: August 18, 2016 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board 

 

 Valerie D. Evans-Harrell, Alternate Judge 

 Employees’ Compensation Appeals Board