United States Department of Labor 

Employees’ Compensation Appeals Board 

__________________________________________ 

R.P., Appellant 

and 

U.S. POSTAL SERVICE, PROCESSING & 

DISTRIBUTION CENTER, Orlando, FL, 

Employer 

__________________________________________ 

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Docket No. 15-1509 

Issued: October 28, 2015 

Appearances: Case Submitted on the Record

Lennin V. Perez, for the appellant 

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 July 6, 2015 appellant, through her representative, filed a timely appeal from an 

April 17, 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 her burden of proof to establish a traumatic injury in 

the performance of duty on April 30, 2014. 

FACTUAL HISTORY 

On May 1, 2014 appellant, then a 52-year-old transit mail expediter, filed a traumatic 

injury claim (Form CA-1) alleging that on April 30, 2014 she injured her neck, back, right leg, 

 1

 5 U.S.C. § 8101 et seq. 
2

both feet, shoulders, and arms, after bending, stooping, walking, and standing all day at work. In 

an attached statement, she noted that she had arrived at work that day with pain in her back and 

right leg, which became worse over the course of her shift. Appellant’s supervisor noted on the 

claim form that appellant had stopped work on May 2, 2014. The employing establishment 

controverted continuation of pay, noting that no traumatic injury had been reported and that she 

stated she was in pain before arriving at work. 

An authorization for examination and/or treatment (Form CA-16), was issued by the 

employing establishment on May 1, 2014. The form noted that there was doubt as to whether 

appellant’s condition was caused by a traumatic injury in the performance of duty.2

 

In a duty status report (Form CA-17) dated May 2, 2014, a physician with an illegible 

signature noted that appellant should not work for four weeks. 

By letter dated May 2, 2014, the employing establishment challenged the entire claim. It 

noted that appellant was possibly continuing treatment for a previously denied claim. The 

previous claim, under case number xxxxxx478, involved the same bodily members and was 

denied by OWCP on May 24, 2014. The employing establishment also noted that while a 

supervisor had provided a Form CA-16 to appellant on May 1, 2014 offering to arrange care at 

the closest treatment facility, she declined this offer noting that she already had an appointment 

with another provider that was approximately 122 miles away. 

By letter dated May 8, 2014, OWCP informed appellant of the evidence necessary to 

establish her claim. It noted that she had not submitted sufficient factual evidence to establish 

that her claimed injuries actually occurred, and further noted that she had not submitted 

sufficient medical evidence to establish her claim. OWCP afforded appellant 30 days to submit 

additional evidence and to respond to its inquiries. 

On May 20, 2014 appellant responded to OWCP’s inquiries. She explained that she had 

previous injuries in the performance of duty under other case numbers. Appellant noted that no 

one witnessed her injury, and that she did not have a supervisor to whom she could report the 

injury on April 30, 2014 until the day afterward, which was her day off. She indicated that she 

was in severe pain in her right leg and back, and saw her physician on May 2, 2014. 

The employing establishment responded by letter dated May 22, 2014. It noted that 

while appellant claimed that there was no supervisor to whom she could report her injury on 

April 30, 2014, her work facility was open 24 hours a day and at all times supervisors or 

managers were on site. With regard to April 30, 2014, the employing establishment asserted that 

there were 7 to 10 supervisors on site at the time. 

 2

 When the 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. 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. See 20 C.F.R. § 10.300(c); Tracy P. Spillane, 54 ECAB 

608, 610 (2003). 
3

In a duty status report dated June 3, 2014, Dr. Samy F. Bishai, an orthopedic surgeon, 

noted that appellant should not work for six weeks.3

 He diagnosed her with lumbar disc 

syndrome and cervical disc syndrome. 

By decision dated June 18, 2014, OWCP denied appellant’s claim for compensation. It 

found that she had not submitted sufficient evidence to establish that the events of April 30, 2014 

occurred as she described. OWCP further noted that appellant had not submitted any 

rationalized medical evidence linking Dr. Bishai’s diagnoses to any event on April 30, 2014. 

By letter dated June 30, 2014, appellant requested an oral hearing before an OWCP 

hearing representative. With her request, she submitted another duty status report from 

Dr. Bishai dated July 3, 2014. Dr. Bishai noted that appellant could not work more than three 

hours per day, no bending or stopping, no lifting more than 15 pounds, and no pushing or 

pulling. He included a return to work date of July 7, 2014. 

In a letter from the employing establishment dated July 11, 2014, the employing 

establishment noted that Dr. Bishai changed appellant’s work status from “no work” to “resume 

work with limitations” after denial of the claim. 

The hearing was held on February 11, 2015. At the hearing, appellant testified that she 

had worked for the employing establishment for 16 years, and that she reported to work on 

April 30, 2014 with a pain level of 3 on a scale of 1 to 10. She asserted that, on that date, she 

had to ride trucks in and out, and bend down to seal trailers, for her entire shift. Appellant stated 

that her injury resulted from performing these tasks. The hearing representative noted that the 

diagnoses provided from Dr. Bishai were not the types of diagnoses one would expect from a 

one-time event. Appellant’s representative stated that the events of April 30, 2014 exacerbated 

appellant’s preexisting conditions and quoted from a report from Dr. Bishai, which was not in 

the case record at the time of the hearing. Appellant stated that she had told one of her 

supervisors that she was hurt on the date of injury, April 30, 2014, but that this supervisor 

ignored her and she went home in pain. The hearing representative held the case record open for 

30 days for the submission of additional evidence. 

In a report dated May 2, 2014, Dr. Bishai diagnosed appellant with lumbar disc syndrome 

with radiculopathy; a herniated lumbar disc at the L4-5 level with bilateral neural foraminal 

stenosis; cervical disc syndrome with bilateral radiculopathy; a herniated cervical disc at C3-4 

with neural foraminal narrowing; and internal derangement of the right knee, bilateral shoulders, 

and bilateral ankles and feet. He opined that in the course of her employment on April 30, 2014, 

she suffered these injuries and that “the causal relationship between [appellant’s] injuries and the 

symptoms she is having is quite obvious and the causal relationship is definitely established that 

[appellant’s] symptoms are directly related to the injury of April 30, 2014 while working as a 

transit mail expediter.” Dr. Bishai noted that appellant had suffered previous injuries to her 

neck, back, and lower extremities, as well as radicular pain down her shoulders, arms, and legs, 

due to an incident that occurred on April 22, 2013. He wrote, “The injury that [appellant] 

suffered to her neck and back on April 30, 2014 is an aggravation of these preexisting conditions 

 3

 Dr. Bishai’s Board certification in a medical specialty could not be determined from a search of the databases of 

the American Board of Medical Specialties or the American Osteopathic Association. 
4

that were also work related. [Appellant] did suffer new injuries that she did not have before 

which is the injury to her right knee joint as well as the injury to the shoulders and the painful 

condition of her feet which did not exist prior to this injury of April 30, 2014.” 

Dr. Bishai related her history of present illness, noting that appellant’s pain level in her 

back and her right leg was about a 3 or 4, on a scale of 10, when she arrived at work that day. 

He noted that her job required a lot of bending, stooping, walking, and standing. Dr. Bishai 

explained that when the tractor trailers and trucks came to the dock, appellant had to take the 

seals off which are on the very bottom of the doors and therefore she had to bend and stoop 

down to the bottom of the door. When the trucks left, some of them required a seal which again 

required that she squat down to put the seal on the bottom of the door. Appellant had to work on 

about 18 to 20 trucks on this day and she had to unseal about 6 or 7, affecting her back and 

radiating down her right leg and right foot. Her neck and both shoulders and arms had a lot of 

pain of about 7 to 8 and the pain in her lower back was all the way up to 9 or 10 going down to 

the right leg and both feet. Appellant’s feet started to swell and she had a hard time walking. 

She therefore sought medical attention and she filed a claim because of the injuries that she 

suffered on that day. 

By decision dated April 17, 2015, the hearing representative affirmed OWCP’s June 18, 

2014 decision with modification. She found that appellant had submitted sufficient evidence to 

establish that the events of April 30, 2014 occurred as described, but that she had not submitted 

sufficient evidence to establish a causal relationship between the events of this date and her 

diagnosed conditions. The hearing representative noted that Dr. Bishai’s report of May 2, 2014 

did not contain a medically rationalized explanation of how appellant’s preexisting conditions 

were aggravated by the events of April 30, 2014. 

LEGAL PRECEDENT 

An employee seeking benefits under FECA4

 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.5

 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.6

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.7

 

First, the employee must submit sufficient evidence to establish that he or she actually 

 4 Supra at note 1. 

5 C.S., Docket No. 08-1585 (issued March 3, 2009); Bonnie A. Contreras, 57 ECAB 364, 366 (2006). 

6 S.P., 59 ECAB 184, 188 (2007); Joe D. Cameron, 41 ECAB 153, 157 (1989). 

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

experienced the employment incident at the time, place, and in the manner alleged.8 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.9

The claimant has the burden of establishing by the weight of reliable, probative, and 

substantial evidence that the condition for which compensation is sought is causally related to a 

specific employment incident or to specific conditions of employment.10 An award of 

compensation may not be based on appellant’s belief of causal relationship. 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 a causal relationship.11

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

establish causal relationship is rationalized medical opinion evidence.12 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 

compensable employment factors.13 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, 

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.14

ANALYSIS 

OWCP has accepted that appellant’s work activities of April 30, 2014 occurred as 

alleged. The Board finds that OWCP correctly denied the claim as the medical evidence 

submitted by appellant is insufficient to establish that her work on April 30, 2014 caused or 

aggravated her diagnosed medical conditions. 

Appellant submitted only one report containing a physician’s opinion as to the cause of 

her diagnosed conditions, that of Dr. Bishai dated May 2, 2014. This report does not contain a 

medically sound explanation of how the April 30, 2014 event caused or aggravated her 

diagnosed conditions. Dr. Bishai offers his understanding of appellant’s explanation of the 

events of April 30, 2014 and noted that “the causal relationship is definitely established that 

 8 D.B., 58 ECAB 464, 466 (2007); David Apgar, 57 ECAB 137, 140 (2005). 

9 C.B., Docket No. 08-1583 (issued December 9, 2008); D.G., 59 ECAB 734, 737 (2008); Bonnie A. Contreras, 

supra note 5. 

10 Roma A. Mortenson-Kindschi, 57 ECAB 418, 428 n.37 (2006); Katherine J. Friday, 47 ECAB 591, 594 (1996). 

11 P.K., Docket No. 08-2551 (issued June 2, 2009); Dennis M. Mascarenas, 49 ECAB 215, 218 (1997). 

12 Y.J., Docket No. 08-1167 (issued October 7, 2008); A.D., 58 ECAB 149, 155-56 (2006); D’Wayne Avila, 

57 ECAB 642, 649 (2006). 

13 J.J., Docket No. 09-27 (issued February 10, 2009); Michael S. Mina, 57 ECAB 379, 384 (2006). 

14 I.J., 59 ECAB 408, 415 (2008); Victor J. Woodhams, 41 ECAB 345, 352 (1989). 
6

[appellant’s] symptoms are directly related to the injury of April 30, 2014 while working as a 

transit mail expediter.” However, he did not explain how his diagnoses of lumbar disc syndrome 

with radiculopathy; a herniated lumbar disc at the L4-5 level with bilateral neural foraminal 

stenosis; cervical disc syndrome with bilateral radiculopathy; a herniated cervical disc at C3-4 

with neural foraminal narrowing; and internal derangement of the right knee, bilateral shoulders, 

and bilateral ankles and feet, were aggravated or caused by the events of April 30, 2014. 

Dr. Bishai provided no medical or pathophysiological explanation regarding how these 

conditions were caused or aggravated by the events on April 30, 2014. He merely asserted that 

they were related and provided appellant’s account of the events on that date. 

Medical evidence submitted 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.15 Lacking such an explanation, Dr. Bishai’s 

May 2, 2014 report is insufficient to establish a causal relationship between the events of 

April 30, 2014 and appellant’s diagnosed conditions. 

As appellant has not submitted any rationalized medical evidence to support her 

allegation that she sustained an injury causally related to an April 30, 2014, employment 

incident, she has not met her burden of proof to establish a claim.16

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 has not met her burden of proof to establish a traumatic 

injury in the performance of duty on April 30, 2014. 

 15 D.D., Docket No. 13-1517 (issued April 14, 2014). 

16 The Board notes that the duty status report containing an illegible signature does not constitute competent 

medical evidence as the author cannot be identified as a physician. Thus, it is of no probative value. See Merton J. 

Sills, 39 ECAB 572, 575 (1988). 
7

ORDER 

IT IS HEREBY ORDERED THAT the April 17, 2015 decision of the Office of 

Workers’ Compensation programs is affirmed. 

Issued: October 28, 2015 

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