United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

K.V., Appellant 

and 

U.S. POSTAL SERVICE, POST OFFICE, 

Little Rock, AR, Employer 

__________________________________________ 

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Docket No. 15-1466 

Issued: September 18, 2015 

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 

JAMES A. HAYNES, Alternate Judge 

JURISDICTION 

On June 29, 2015 appellant filed a timely appeal from a January 28, 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 over the merits of this case. 

ISSUE 

The issue is whether appellant met his burden of proof to establish that he sustained a left 

lower leg injury in the performance of duty on December 7, 2013. 

FACTUAL HISTORY 

On February 19, 2014 appellant, then a 49-year-old letter carrier, filed a traumatic injury 

claim (Form CA-1) alleging that on December 7, 2013 he sustained a left lower leg injury when 

he slipped and fell on some icy steps. He first received medical care on December 10, stopped 

 1

 5 U.S.C. § 8101 et seq.
2

work on December 11, and returned to work on December 16, 2013. Appellant notified his 

supervisor on February 19, 2014 of the alleged injury. Appellant’s supervisor checked the box 

marked “yes” when asked if her knowledge of the facts of injury agreed with appellant’s 

statements. 

By letter dated April 25, 2013, OWCP informed appellant that the evidence of record was 

insufficient to support his claim. Appellant was advised of the factual and medical evidence 

needed and he was asked to respond within 30 days. 

In a detailed statement, appellant reported that at 10:30 a.m. on December 7, 2013, he 

was delivering mail when he turned to go down icy steps. He slipped and fell, landing on his 

lower left leg. An accident report form was also submitted. 

A partially illegible medical note dated December 10, 2013 from Crittenden Regional 

Hospital documented appellant’s treatment and aftercare instructions. 

By decision dated April 2, 2014, OWCP denied appellant’s claim finding that the 

evidence was insufficient to establish that he sustained an injury because he did not submit any 

medical evidence containing a medical diagnosis in connection with the accepted December 7, 

2013 employment incident. It noted that the medical evidence submitted was illegible and that 

did not provide a history of how he was injured. 

On April 22, 2014 appellant requested an oral hearing before the Branch of Hearings and 

Review. He argued that his claim should be accepted as he was off work for four days following 

the incident and could not afford to pay his medical bills. 

In support of his claim, appellant submitted a December 10, 2013 diagnostic report from 

Dr. Jeffrey W. Green, a Board-certified diagnostic radiologist. Dr. Green reported a history of a 

fall and found that an x-ray of the left tibia/fibula revealed no acute bony abnormality. He 

further found that an x-ray of the left ankle revealed no acute bony abnormality. 

A hearing was held on December 10, 2014 where appellant argued that his injury was 

caused by the December 7, 2013 employment incident. Appellant was advised of the medical 

evidence needed to meet his burden of proof and the record was held open for 30 days to allow 

him to submit further evidence. No other evidence was received. 

By decision dated January 28, 2015, the Branch of Hearings and Review affirmed the 

April 2, 2014 decision finding that appellant failed to establish a firm medical diagnosis causally 

related to the accepted December 7, 2013 employment incident. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA 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 or specific condition for which compensation is claimed are causally related to the 
3

employment injury.2 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.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 which is alleged to have occurred.4 The second 

component is whether the employment incident caused a personal injury and generally can be 

established only by medical evidence. 

To establish a causal relationship between the condition, as well as any attendant 

disability claimed and the employment event or incident, the employee must submit rationalized 

medical opinion evidence based on a complete factual and medical background, supporting such 

a causal relationship.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 claimant. This medical opinion 

must include an accurate history of the employee’s employment injury and must explain how the 

condition is related to the injury. The weight of medical evidence is determined by its reliability, 

its probative value, its convincing quality, the care of analysis manifested, and the medical 

rationale expressed in support of the physician’s opinion.6

ANALYSIS 

OWCP accepted that the December 7, 2013 employment incident occurred as appellant 

had alleged. The issue, therefore, is whether the record contains medical evidence that 

establishes the employment incident caused a left leg injury. The Board finds that the medical 

evidence is deficient on two grounds: first, it fails to provide a firm diagnosis; and second, there 

is no narrative, rationalized medical opinion on causal relationship. 

A December 10, 2013 after care instructions note was submitted from Crittenden 

Regional Hospital documenting treatment on that date. The Board notes that the form was 

largely illegible and cannot establish appellant’s traumatic injury claim because neither the 

diagnosis nor the author can be determined. 

The only other medical evidence of record was Dr. Green’s December 10, 2013 

diagnostic report which noted that an x-ray of the left tibia/fibula and left ankle revealed no acute 

 2 Gary J. Watling, 52 ECAB 278 (2001); Elaine Pendleton, 40 ECAB 1143, 1154 (1989). 

3 Michael E. Smith, 50 ECAB 313 (1999). 

4 Elaine Pendleton, supra note 2. 

5 See 20 C.F.R. § 10.110(a); John M. Tornello, 35 ECAB 234 (1983). 

6 James Mack, 43 ECAB 321 (1991). 
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bony abnormality. As the physician reported normal diagnostic findings, his report cannot 

establish a firm medical diagnosis of an injury.7

 This report also offered no opinion on causal 

connection. 

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.8

 An award of compensation may not 

be based on surmise, conjecture, speculation, or on the employee’s own belief of causal relation.9 

To establish a firm medical diagnosis and causal relationship, appellant must submit a 

physician’s report in which the physician reviews those factors of employment alleged to have 

caused his condition and, taking these factors into consideration, as well as findings upon 

examination and his medical history, explain how these employment factors caused or 

aggravated any diagnosed condition, and present medical rationale in support of his opinion.10 

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 that he 

sustained a left lower leg injury in the performance of duty on December 7, 2013. 

 7 J.P., Docket No. 14-87 (issued March 14, 2014). 

8 Daniel O. Vasquez, 57 ECAB 559 (2006). 

9 D.D., 57 ECAB 734 (2006). 

10 Supra note 4. 
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ORDER 

IT IS HEREBY ORDERED THAT the January 28, 2015 decision of the Office of 

Workers’ Compensation Programs is affirmed. 

Issued: September 18, 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