United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

M.D., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

Melville, NY, Employer

__________________________________________

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Docket No. 18-0709

Issued: September 4, 2018

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 February 15, 2018 appellant filed a timely appeal from an August 23, 2017 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.2

ISSUE

The issue is whether appellant has met her burden of proof to establish a back injury 

causally related to the accepted January 20, 2017 employment incident.

 

1 5 U.S.C. § 8101 et seq.

2 The record provided to the Board includes evidence received after OWCP issued its August 23, 2017 decision. 

The Board’s jurisdiction is limited to evidence that was in the case record at the time of OWCP’s final decision. 

Therefore, the Board is precluded from reviewing this additional evidence for the first time on appeal. 20 C.F.R. 

§ 501.2(c)(1).
2

FACTUAL HISTORY

On January 21, 2017 appellant, then a 52-year-old clerk, filed a traumatic injury claim 

(Form CA-1) alleging that while at work on January 20, 2017 she strained her back when she was 

separating mail. She stopped work on January 22, 2017 and returned on January 24, 2017. On the 

back of the claim form, the employing establishment controverted appellant’s claim contending 

that appellant did not report the injury until five hours after the alleged incident and she could not

recall the equipment she used at the time of the alleged injury.

Appellant was initially treated in urgent care by Sheenz Mendez, a certified physician 

assistant. In a work status note dated January 21, 2017, Ms. Mendez related that appellant was 

treated on that date and could return to work on January 24, 2017. She also completed a duty 

status report (Form CA-17), which indicated that on January 20, 2017 appellant injured her lower 

back when separating mail. Ms. Mendez noted a diagnosis of lower back pain and related that 

appellant could return to work with specified restrictions.

OWCP received a position description for a sales and distribution associate.

On January 28, 2017 OWCP offered appellant a full-time modified-duty job assignment. 

Appellant accepted the job offer on that date.

In a February 3, 2017 development letter, OWCP informed appellant that additional 

evidence was needed in support of her claim. It requested that she complete an attached claim 

development questionnaire and advised appellant of the need for medical evidence to establish her 

claim. OWCP afforded appellant 30 days to submit the requested information. No additional 

information was submitted within the allotted time.

By decision dated March 10, 2017, OWCP denied appellant’s traumatic injury claim. It 

accepted that the January 20, 2017 employment incident occurred as alleged, but denied her claim 

because the medical evidence submitted did not contain a medical diagnosis in connection with 

the accepted incident. OWCP specifically noted that “pain” was a symptom, not a medical 

diagnosis. Consequently, it found that appellant had failed to establish the medical component of 

fact of injury.

OWCP subsequently received several medical reports. In a January 21, 2017 hospital 

record, Ms. Mendez related appellant’s complaints of low back pain “after heavy lifting at work 

yesterday.” Upon physical examination of appellant’s lumbar spine, she observed mild tenderness 

of the bilateral/lateral spine and good range of motion. Ms. Mendez diagnosed low back pain. In 

an amended January 21, 2017 report, signed on March 7, 2017, she added a second diagnosis of 

back muscle spasms.

A January 21, 2017 lumbar spine x-ray scan report showed mild degenerative changes of 

the lumbar spine and bilateral sacroiliac joints.

In a January 21, 2017 doctor’s initial form report, Dr. Melina J. Khwaja, Board-certified in 

emergency medicine, noted a January 20, 2017 date of injury and indicated that appellant was 

processing mail. The form indicated a diagnosis of low back pain.
3

In a January 23, 2017 report, Dr. Khwaja noted a diagnosis of low back pain. She related 

that appellant’s lumbar spine x-ray scan report was normal.

On March 16, 2017 OWCP received appellant’s response to its development letter. In a 

narrative statement, appellant explained that on January 20, 2017 she was emptying a cage and 

then moved on to remove heavy buckets from a bulk mail center (BMC). She indicated that she 

felt a strain in her back when emptying the cage and lifting heavy buckets from the BMC. 

Appellant was able to continue her work, but as time went on, her discomfort progressed to 

excruciating pain. She explained that it was then, approximately four hours after the incident, that 

she notified management. Appellant also noted that she had a previous back injury under OWCP 

File No. xxxxxx845 with a date of injury of May 21, 1998.

On March 29, 2017 appellant requested a hearing before a hearing representative from 

OWCP’s Branch of Hearings and Review. A hearing was held on July 13, 2017.

By decision dated August 23, 2017, OWCP’s hearing representative affirmed the 

March 10, 2017 decision. She found that appellant failed to establish fact of injury as none of the 

medical evidence submitted provided a medical diagnosis in connection with the January 20, 2017 

employment incident.

LEGAL PRECEDENT

An employee seeking benefits under FECA3 has the burden of proof to establish the 

essential elements of his or her claim by the weight of the reliable, probative, and substantial 

evidence4including that he or she sustained an injury in the performance of duty and that any 

specific condition or disability from work for which compensation is claimed is causally related 

to that employment injury.5

To determine whether a federal employee has sustained a traumatic injury in the 

performance of duty, it first must be determined whether fact of injury has been established.6 There 

are two components involved in establishing fact of injury. 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.7 Second, the employee must submit evidence, generally 

only in the form of probative medical evidence, to establish that the employment incident caused 

a personal injury.8 The employee may establish that the employment incident occurred as alleged, 

 

3 Supra note 1.

4

J.P., 59 ECAB 178 (2007); Joseph M. Whelan, 20 ECAB 55, 58 (1968). 

5 G.T., 59 ECAB 447 (2008); Elaine Pendleton, 40 ECAB 1143, 1145 (1989).

6 S.P., 59 ECAB 184 (2007); Alvin V. Gadd, 57 ECAB 172 (2005).

7 Bonnie A. Contreras, 57 ECAB 364 (2006); Edward C. Lawrence, 19 ECAB 442 (1968).

8 David Apgar, 57 ECAB 137 (2005); John J. Carlone, 41 ECAB 354 (1989). 
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but fail to show that his or her disability or condition for which compensation is being claimed is 

causally related to the employment incident.9

ANALYSIS

Appellant alleged that she strained her back on January 20, 2017 when sorting mail. 

OWCP accepted that the January 20, 2017 employment incident occurred as alleged, but denied 

her claim because the evidence of record did not include a medical diagnosis in connection with 

the accepted incident. The Board finds that appellant has failed to establish her traumatic injury 

claim as the medical evidence submitted is insufficient to establish the medical component of fact 

of injury.

In support of her claim, appellant submitted January 21 and 23, 2017 reports by

Dr. Khwaja. As OWCP noted in its denial decisions, “pain” is a symptom, not a medical 

diagnosis.10 Accordingly, Dr. Khwaja’s finding of back pain is insufficient to satisfy appellant’s 

burden of proof by establishing the medical component of fact of injury.11 

The January 21, 2017 lumbar spine x-ray report also fails to provide a firm diagnosed back 

condition resulting from the January 20, 2017 employment incident.

12

 Without a firm diagnosis 

and rationalized medical opinion regarding causal relationship, this diagnostic report is of limited 

probative value.13 

The several urgent care reports by Ms. Mendez dated January 21, 2017 lack probative 

value and are insufficient to establish appellant’s claim as physician assistants are not considered 

physicians as defined by FECA.14 

There is no evidence of record that establishes a medical diagnosis in connection with the 

accepted employment incident. Accordingly, the Board finds that appellant failed to establish that 

she sustained a back injury causally related to the accepted January 20, 2017 employment incident.

On appeal appellant alleges that she had two coworkers who would attest to the fact that 

she injured herself. She described the January 20, 2017 employment incident and related that she 

continued to suffer from back pain. As explained above, the employment incident has been 

 

9 T.H., 59 ECAB 388 (2008); see also Roma A. Mortenson-Kindschi, 57 ECAB 418 (2006).

10 Findings of pain or discomfort alone do not satisfy the medical aspect of the fact of injury medical determination. 

B.P., Docket No. 12-1345 (issued November 13, 2012); C.F., Docket No. 08-1102 (issued October 2008); Federal 

(FECA) Procedure Manual, Part 2 -- Claims, Fact of Injury, Chapter 2.803.4a(6) (August 2012). 

11 F.U., Docket No. 18-0078 (issued June 6, 2018); see also Deborah L. Beatty, 54 ECAB 340, 341 (2003).

12 T.O., Docket No. 18-0139 (issued May 24, 2018).

13 C.B., Docket No. 09-2027 (issued May 12, 2010); J.F., Docket No. 09-1061 (issued November 17, 2009).

14 5 U.S.C. § 8101(2) provides that a physician includes surgeons, podiatrists, dentists, clinical psychologists, 

optometrists, chiropractors, and osteopathic practitioners within the scope of their practice as defined by state law. 

V.C., Docket No. 16-0642 (issued April 19, 2016); L.C., Docket No. 16-1717 (issued March 2, 2017) (nurses); 

Allen C. Hundley, 53 ECAB 551, 554 (2002) (physician assistant).
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accepted to have occurred as alleged, however, appellant has not submitted sufficient medical 

evidence to establish the medical component of fact of injury of her claim. The medical evidence 

of record fails to support that she sustained a back injury as a result of the accepted employment

incident.

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 back injury 

causally related to the accepted January 20, 2017 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the August 23, 2017 decision of the Office of 

Workers’ Compensation Programs is affirmed.

Issued: September 4, 2018

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