United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

R.S., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Arlington Heights, IL, Employer 

__________________________________________ 

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Docket No. 15-1364 

Issued: February 22, 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 

PATRICIA H. FITZGERALD, Deputy Chief Judge 

ALEC J. KOROMILAS, Alternate Judge 

JURISDICTION 

On June 4, 2015 appellant filed a timely appeal of an April 29, 2015 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 established that he sustained a diagnosed medical 

condition causally related to the accepted March 12, 2014 incident. 

FACTUAL HISTORY 

On March 24, 2014 appellant, then a 58-year-old laborer custodian, filed a traumatic 

injury claim (Form CA-1) alleging that on March 12, 2014 he became light-headed, dizzy, and 

winded while shoveling snow. 

 1

 5 U.S.C. § 8101 et seq. 
2 

In a March 12, 2014 Northwest Community Hospital form report, Dr. Daniel Reaven, a 

physician specializing in emergency medicine, reported that appellant was seen for chest pain. 

He diagnosed chest pain and near syncope. 

OWCP received additional medical evidence from Northwest Community Hospital 

including a March 12, 2014 admission report by Dr. Michael Magidow, a Board-certified family 

practitioner. Dr. Magidow reported that appellant was admitted to the hospital on March 12, 

2014 for complaints of near-syncope and shortness of breath. Appellant related that he had been 

shoveling snow outside his workplace for more than an hour when he felt dizzy, nauseous, lightheaded, felt a rapid heartbeat in his throat, and his heart beating. A physical examination 

revealed a pulse of 54, blood pressure of 159/88, and normal temperature. Dr. Magidow 

reported normal diagnostic data and diagnosed dyspnea presyncope, hypertension, 

hyperlipidemia, obesity, and implemented gastrointestinal and deep prophylaxis. 

In a March 12, 2014 hospital cardiology consultation report, Dr. Ankit Shah, an 

examining Board-certified cardiologist, noted that appellant was seen for near-syncope and 

dizziness as the result of shoveling snow outside the employing establishment that day. 

Appellant related that he became light-headed with nausea and felt extremely dizzy. Physical 

examination findings were provided and a chest x-ray interpretation showed no active disease. 

Dr. Shah reviewed an electrocardiogram (EKG) which showed normal sinus rhythm and right 

bundle block. Under impression, he diagnosed presyncope with nausea and no evidence of 

ischemia. Dr. Shah opined that appellant’s symptoms might be due to low heart rate, low blood 

pressure, or might be due to appellant having a vasovagal symptoms possibly due to an increased 

dose of verapamil. 

In a letter dated October 2, 2014, OWCP informed appellant that payment of a limited 

amount of medical expenses had been authorized as it appeared that he had sustained a minor 

injury. As the medical bills have exceeded $1,500.00, it had reopened his claim for 

consideration. OWCP informed appellant that the medical evidence was insufficient to establish 

his claim. Appellant was advised as to the medical evidence required to establish his claim and 

afforded him 30 days to provide this evidence. 

In response to OWCP’s request, appellant resubmitted Dr. Shah’s March 12, 2014 report 

and a March 13, 2014 EKG. The EKG report, electronically signed by Dr. Shah on March 13, 

2014, showed left ventricular ejection fraction, mild aortic sclerosis without stenosis, normal 

right ventricular size and systolic function, moderate concentric left ventricular hypertorphy, and 

pesudonormal patter of LV diastolic filling 

By decision dated November 3, 2014, OWCP denied appellant’s claim. It found that he 

had established that the incident occurred as alleged, but failed to submit any medical opinion 

showing how the diagnosed presyncope with nausea was caused or aggravated by the accepted 

incident. 

In a December 8, 2014 letter, Dr. Joseph Gibes, a Board-certified family medicine 

practitioner, noted that he had examined appellant on March 26, 2014 following his 

hospitalization for lightheadness, feeling winded, and dizziness due to overexertion at work. He 

opined that appellant’s symptoms were due to overexertion at work when shoveling snow. 
3 

In a form dated January 9, 2015 and received by OWCP on January 13, 2015, appellant 

requested reconsideration. 

By decision dated April 29, 2015, OWCP denied the claim, finding that appellant failed 

to establish fact of injury. It found that the medical evidence submitted failed to contain a 

diagnosis causally related to the accepted employment incident. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA2 has the burden of establishing 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 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.3 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.4 

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.5 

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.6 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

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

establish causal relationship is rationalized medical opinion evidence.8 Rationalized medical 

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.9 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, 

 2 Id.

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

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

5 B.F., Docket No. 09-60 (issued March 17, 2009); Bonnie A. Contreras, supra note 3. 

6 D.B., 58 ECAB 464 (2007); David Apgar, 57 ECAB 137 (2005). 

7 C.B., Docket No. 08-1583 (issued December 9, 2008); D.G., 59 ECAB 734 (2008); Bonnie A. Contreras, supra

note 3. 

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

642 (2006). 

9 J.J., Docket No. 09-27 (issued February 10, 2009); Michael S. Mina, 57 ECAB 379 (2006). 
4 

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.10 

ANALYSIS 

OWCP accepted that appellant was shoveling snow on March 12, 2014 in the 

performance of duty. It denied his claim, however, finding that he failed to establish that he 

sustained an injury as a result of the accepted incident. The issue before the Board is whether 

appellant submitted sufficient medical evidence to establish that the employment incident caused 

an injury as defined under FECA. The Board finds that the medical evidence of record is 

insufficient to establish a diagnosed medical condition causally related to the accepted March 12, 

2014 incident. 

A person who claims benefits for a work-related condition has the burden to establish by 

the weight of the medical evidence a firm diagnosis of the condition claimed and a causal 

relationship between that condition and factors of federal employment.11 The Board has long 

held that pain is a symptom, not a compensable medical diagnosis.12 Therefore, since chest pain

is a medical symptom, to establish personal injury the medical evidence of record must 

document a diagnosed condition and must explain how that condition is causally related to the 

accepted incident of employment.13

In support of his claim, appellant submitted evidence from Northwest Hospital which 

included a form report from Dr. Reaven, a March 12, 2014 admission report from Dr. Magidow, 

a cardiology consultation report, and an EKG. OWCP subsequently received a December 8, 

2014 report from Dr. Gibes. 

Dr. Reaven, in a March 12, 2014 Northwest Community Hospital report, diagnosed chest 

pain and near-syncope; however, these are not firm medical diagnoses. Furthermore, he offered 

no opinion as to the cause of these symptoms. Similarly, Dr. Magidow noted that appellant had 

been admitted for complaints of shortness of breath and near-syncope following shoveling snow 

outside his workplace. He diagnosed several conditions including hyperlipidemia, obesity, 

dyspnea presyncope, hypertension, and implemented gastrointestinal and deep prophylaxis, but 

offered no opinion as to the cause of these conditions. 

Dr. Shah, an examining Board-certified cardiologist, in a March 12, 2014 hospital 

cardiology report, identified the employment incident of shoveling snow, and diagnosed 

presyncope with nausea and no evidence of ischemia. He opined that appellant’s symptoms 

might be due to low blood pressure, low heart rate, or due to vasovagal symptoms. Again, 

Dr. Shah did not provide a firm diagnosis of appellant’s condition. Moreover, at no point did he 

identify shoveling snow as a possible cause of a diagnosed medical condition. The reports from 

 10 I.J., 59 ECAB 408 (2008); Victor J. Woodhams, 41 ECAB 345, 352 (1989). 

11 See Roy L. Humphrey, 57 ECAB 238 (2005); see Naomi A. Lilly, 10 ECAB 560, 574 (1959). 

12 Robert Broome, 55 ECAB 339, 342 (2004). 

13 George A. Davis, Docket No. 95-1684 (issued April 3, 1997). 
5 

Dr. Shah, Dr. Magidow, and Dr. Reaven are insufficient to support appellant’s claim as none of 

the physicians diagnosed a medical condition causally related to the employment incident.14 

The record also contains a December 8, 2014 letter from Dr. Gibes who attributed 

appellant’s symptoms of light-headedness, feeling winded, and dizziness due to shoveling snow 

at work and overexertion. He did not provide a firm medical diagnosis and offered no 

supporting rationale explaining his conclusion that the shoveling of snow by appellant was the 

cause of a diagnosed condition. The Board has held that medical evidence consisting solely of 

conclusory statements without supporting rationale is of little probative value.15 Thus, these 

reports are insufficient to support appellant’s claim. 

The record also contains a March 13, 2014 EKG report. As it is a diagnostic test, causal 

relationship was not addressed. The EKG report is insufficient to support appellant’s claim that 

he sustained a medical condition causally related to the March 12, 2014 incident.16 

OWCP advised appellant that it was his responsibility to provide a comprehensive 

medical report which described his symptoms, test results, diagnosis, treatment, and a 

physician’s opinion, with medical reasons, on the cause of his condition. Appellant failed to 

submit appropriate medical documentation in response to OWCP’s request. The Board has held 

that the mere fact that a condition manifests itself during a period of employment does not raise 

an inference of causal relation.17 An award of compensation may not be based on surmise, 

conjecture, speculation, or on the employee’s own belief of causal relation.18 As there is no 

probative, rationalized medical evidence containing a medical diagnosis and explaining how a 

diagnosed condition was causally related to the accepted March 12, 2014 incident, he has not 

met 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. 

 14 See T.L., Docket No. 11-1668 (issued February 10, 2012); Ruth C. Borden, 43 ECAB 146 (1991); Val D. Wynn,

40 ECAB 666 (1989). 

15 See T.M., Docket No. 08-975 (issued February 6, 2009); Roma A. Mortenson-Kindschi, 57 ECAB 418 (2006); 

William C. Thomas, 45 ECAB 591 (1994) (a medical report is of limited probative value on the issue of causal 

relationship if it contains a conclusion regarding causal relationship which is unsupported by medical rationale). 

16 C.B., Docket No. 09-2027 (issued May 12, 2010); S.E., Docket No. 08-2214 (issued May 6, 2009); Jaja K. 

Asaramo, 55 ECAB 200 (2004) (medical evidence that does not offer any opinion regarding the cause of an 

employee’s condition is of limited probative value on the issue of causal relationship). 

17 L.D., Docket No. 09-1503 (issued April 15, 2010); D.I., 59 ECAB 158 (2007); Daniel O. Vasquez, 57 ECAB 

559 (2006). 

18 S.S., 59 ECAB 315 (2008); J.M., 58 ECAB 3003 (2007); Donald W. Long, 41 ECAB 142 (1989). 
6 

CONCLUSION 

The Board finds that appellant has not met his burden of proof to establish that he 

sustained a diagnosed medical condition causally related to the accepted March 12, 2014 

incident, as alleged. 

ORDER 

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

Compensation Programs dated April 29, 2015 is affirmed. 

Issued: February 22, 2016 

Washington, DC 

 

 Christopher J. Godfrey, Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Patricia H. Fitzgerald, Deputy Chief Judge 

 Employees’ Compensation Appeals Board 

 

 Alec J. Koromilas, Alternate Judge 

 Employees’ Compensation Appeals Board