United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

S.Z., Appellant

and

DEPARTMENT OF THE AIR FORCE, HILL 

AIR FORCE BASE, UT, Employer

__________________________________________

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Docket No. 20-0106

Issued: July 9, 2020

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

ALEC J. KOROMILAS, Chief Judge

CHRISTOPHER J. GODFREY, Deputy Chief Judge

PATRICIA H. FITZGERALD, Alternate Judge

JURISDICTION

On October 14, 2019 appellant filed a timely appeal from an April 18, 2019 merit decision 

and an August 21, 2019 nonmerit 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.

ISSUES

The issues are: (1) whether appellant has met his burden of proof to establish a medical

condition causally related to the accepted factor of his federal employment; and (2) whether 

OWCP properly denied appellant’s request for reconsideration of the merits of his claim pursuant 

to 5 U.S.C. § 8128(a).

FACTUAL HISTORY

On April 26, 2018 appellant, then a 54-year-old director of logistics, filed a traumatic injury 

claim (Form CA-1) alleging that on September 6, 2017 he suffered a major heart attack with 

multiple complications while in the performance of duty. On the reverse side of the claim form,

 

1 5 U.S.C. § 8101 et seq.
2

the employing establishment controverted appellant’s claim noting that he was not injured while 

in the performance of duty as he was on leave in Jordan from his deployment in Afghanistan at the 

time of the incident. Appellant stopped work on September 6, 2017 and returned to full-time work 

without restrictions on April 6, 2018.

In support of his claim, appellant submitted a September 27, 2017 report, wherein Dr. Janet 

Lin, a Board-certified specialist in internal medicine, noted that appellant presented with syncope, 

cardiac arrest, and aspiration pneumonia. Dr. Lin reported that, while on vacation in Jordan, he

suffered an episode of syncope and went into cardiac arrest. She reported that appellant’s cardiac 

arrest was thought to be secondary to diabetic ketoacidosis (DKA) related to his untreated diabetes. 

Dr. Lin indicated that he was also treated for acute renal failure, aspiration pneumonia, large sacral 

decubitus ulcer, and methicillin-sensitive staphylococcus aureus(MSSA). She examined appellant 

and diagnosed sepsis, aspiration pneumonia, diabetes mellitus with hyperglycemia, MSSA, cardiac 

arrest secondary to DKA, unstable sacral decubitus ulcer, and hand paresthesia. 

In a September 29, 2017 orthopedic evaluation, Dr. Alan Hibberd, a Board-certified 

orthopedic surgeon, found that appellant had several, non-benign ischemic lesions on the left index 

finger, buttocks, and lateral aspect of the heel. 

In an October 9, 2017 report, Dr. In-Seok Park, a Board-certified specialist in internal 

medicine, noted appellant’s medical history including his hospital stays in Jordan and Texas. He 

examined appellant and diagnosed acute respiratory failure with hypoxia, bilateral healthcareassociated pneumonia, recent cardiac arrest, type 2 diabetes, sacral decubitus ulcer, anemia of 

chronic disease, recent MSSA sepsis, and severe debility.

In an April 26, 2018 timeline, appellant noted that he was deployed to Afghanistan on 

November 4, 2016. He indicated that he traveled to Jordan on April 21, 2017 and suffered a heart 

attack on September 6, 2017. Appellant indicated that he was released from Istishari Hospital in 

Jordan on September 16, 2017. He reported that he was treated in Al Udeid Medical Facility from 

September 16 to 17, 2017, Landstuhl Regional Medical Center, Ramstein Air Base Germany from 

September 18 to 23, 2017, Walter Reed Hospital from September 24 to 25, 2017, San Antonio 

Medical Center from September 25 to 26, 2017, and St. Luke’s Baptist Hospital from 

September 26 to October 9, 2017. Appellant then noted that he spent October 9 through April 4, 

2018 with his family in San Antonio, Texas recovering from open wounds to his sacrum. He 

indicated that he returned to duty at Hill Air Force Base in Utah on April 5, 2018.

In a May 1, 2018 letter, the employing establishment controverted appellant’s traumatic 

injury claim based on performance of duty, noting that appellant was on vacation when the alleged 

employment incident occurred.

In a May 2, 2018 report, LtCol Gabriel C. Pepper, a Board-certified physician specializing

in occupational medicine, noted that appellant suffered a cardiac arrest in Jordan on September 6, 

2017 after experiencing a syncopal event. He noted that appellant was treated in Jordan and 

Germany before being transferred to St. Luke’s Baptist Hospital in Texas. Dr. Pepper indicated 

that appellant was treated for cardiac arrest, DKA, acute pancreatitis, acute kidney insufficiency, 

MSSA, aspiration pneumonia, decubitus ulcer, multi-focal pneumonia, and bilateral hand 

paresthesia. He reported that appellant’s EKG at St. Luke’s revealed mild tricuspid and mitral 

regurgitation with mild pulmonary pressure. Dr. Pepper further noted that appellant’s EMG 

studies showed median nerve neuropathies bilaterally. He also noted that, following his two-week 
3

stay at St. Luke’s, appellant spent six months recovering and treating his open decubitus ulcer 

before returning to full-duty work without restrictions on April 6, 2018. Dr. Pepper indicated that 

he had been improving, but continued to experience bilateral hand pain. 

A May 4, 2018 development letter from OWCP informed appellant that the evidence of 

record was insufficient to establish his claim. It advised him of the type of factual and medical 

evidence needed and provided a questionnaire for his completion. OWCP afforded appellant 30 

days to submit the necessary evidence.

OWCP subsequently received an October 4, 2017 operative procedure report, Dr. Charles 

Duncan, a Board-certified specialist in internal medicine, which described the details of a flexible 

fiber optic bronchoscopy performed as a result of appellant’s acute respiratory failure with bilateral 

pulmonary infiltrates.2

On May 28, 2018 appellant responded to OWCP’s development questionnaire. He noted 

that, while his normal workweek required 12-hour days, 7 days a week, during the last two months 

of his tour, he worked 18-hour days, 7 days a week. Appellant reported feeling more tired and 

noted that he began to experience weight loss. He alleged that the stress of his job contributed to 

his diabetes and ultimately his cardiac arrest on September 6, 2017. Appellant indicated that he 

had not experienced any cardiac symptoms prior to September 6, 2017 and reported that, prior to 

his deployment to Afghanistan, he had no issues with blood pressure, diabetes, or artery disease. 

He noted that he had never smoked tobacco products and did not drink alcohol.

Appellant submitted reports documenting pulmonary/respiratory evaluations, 

computerized tomography scan results, diagnostic radiology results, magnetic resonance imaging 

scan results, ultrasound results, chemistry testing, coagulation studies, hematology testing, 

microbiology testing, urinalysis testing, and a list of administered medications related to his 

September 26 to October 9, 2017 stay at St. Luke’s Baptist Hospital. Appellant also submitted 

medical reports and diagnostic testing related to a pneumonia diagnosis.

A November 28, 2017 echocardiogram (EKG) report revealed mild mitral regurgitation, 

mild tricuspid regurgitation, and mildly elevated pulmonary artery systolic pressure. 

A December 19, 2017 nuclear stress test revealed normal left ventricular systolic function. 

In a February 14, 2018 report, Dr. Patrick Grogan, a Board-certified neurologist, 

performed a neurological examination and diagnosed hand pain, neuralgia, and meralgia 

paresthetica of the left leg.

In a March 20, 2018 report, Dr. Grogan reviewed the February 21, 2018 EMG study results 

and diagnosed median neuropathies, neuralgia, and meralgia paresthetica of the left leg. He noted 

that appellant was improving.

In April 13, 17, and 26, 2018 work status reports, Dr. Pepper indicated that appellant could 

return to full-duty work.

 

2 A January 26, 2011 letter, wherein Dr. Stephanie Olsen, a Board-certified specialist in internal medicine, reviewed 

a January 21, 2011 myocardial perfusion stress test and reported that appellant had an excellent prognosis and should 

be cleared for service without restrictions.
4

In May 10 and 29, 2018 witness statements, two of appellant’s coworkers noted that 

appellant regularly worked an additional 3 to 4 hours nightly beyond his normal 12-hour, 7 days a

week work schedule. They indicated that he worked this increased schedule because of the 

demands and responsibilities of his work assignment. The witnesses reported that appellant’s 

energy decreased towards the end of his mission and that he looked tired and worn down from the 

extra hours he was working.

By decision dated June 22, 2018, OWCP denied appellant’s traumatic injury claim, finding 

that he was not injured while in the performance of duty as he was on vacation in Jordan on the 

date of injury. 

OWCP subsequently received a September 22, 2017 patient movement record, wherein

Dr. Daniel Golovko, a Board-certified specialist in internal medicine, noted that on September 6, 

2017 appellant suffered cardiac arrest in Jordan due to DKA from previously undiagnosed diabetes 

mellitus. Dr. Golovko noted that appellant’s diabetes mellitus was now under control. He

diagnosed diabetes and MSSA and recommended that appellant be transferred to Brooke Army 

Medical Center.

In May 2 and June 27, 2018 work status reports, Dr. Pepper indicated that appellant could 

return to full-duty work.

Appellant also submitted a June 12, 2018 medical record which consisted of medical notes 

and diagnostic test results from 75th Medical Group, Brooke Army Medical Center, Landstuhl 

Regional Medical Center, Ramstein Air Base, and Joint Base Andrews dated September 16, 2017 

through May 2, 2018. 

On July 23, 2018 appellant requested reconsideration.

In a July 12, 2018 report, Dr. Pepper diagnosed bilateral median nerve neuropathy of the 

hands as well as diabetes. He found that appellant’s work hours and stress were above average 

and, in combination with the environmental aspects of his deployment, they increased his 

susceptibility to developing DKA. Dr. Pepper opined that, while appellant was on vacation when 

he experienced cardiac arrest, it was caused by DKA which in turn was caused by undiagnosed, 

untreated diabetes that was exacerbated by the physical stressors of appellant’s federal 

employment. He indicated that appellant was intubated and restrained which caused nerve damage 

to his hands. Dr. Pepper opined that appellant’s cardiac arrest was work related to a reasonable 

degree of medical probability.

In an August 24, 2018 development letter, OWCP notified the employing establishment 

that appellant and two of his coworkers had submitted statements that described employment 

factors as the cause or contributing factors of appellant’s medical conditions. It requested that the 

employing establishment review the statements and address what aspects of his job could be 

considered stressful and note any accommodations that were made to reduce stress. OWCP 

afforded the employing establishment 20 days to provide the necessary evidence. No response 

was received.

By decision dated October 15, 2018, OWCP noted that it had converted appellant’s 

traumatic injury claim to an occupational disease claim. It modified the June 22, 2018 decision,

finding that the evidence of record established that appellant worked extra hours on a regular basis, 

which was a compensable factor of employment that occurred in the performance of duty. 
5

However, OWCP further found that the claim remained denied as the medical evidence of record 

was insufficient to establish that appellant’s diagnosed conditions were caused or aggravated by 

his accepted factor of employment. 

On January 18, 2019 appellant requested reconsideration.

In a November 23, 2018 letter, appellant’s supervisor stated that appellant routinely 

worked 80 hours or more each week during his deployment. He noted that there was little that 

could be done to reduce the stress of the job. Appellant’s supervisor also noted that the danger of 

the position also contributed to stress. He reported that the airfield would occasionally come under 

rocket attack, usually late at night. Appellant’s supervisor indicated that the environmental factors 

in Afghanistan made it difficult to work. He stated that temperatures regularly reached 120 degrees 

Fahrenheit and that appellant sometimes needed to wear full body armor and Kevlar helmets in 

these conditions. Appellant’s supervisor also noted that constant dust was a common problem that 

was exacerbated by wind. 

In a January 9, 2019 report, Dr. Pepper noted that heat, cold, wind, dust, increased physical 

activity, working long hours, and working in a war zone were employment factors that could 

contribute to stress. He noted that it was well established that physical and mental stress could 

affect insulin production and unmask the symptoms of underlying diabetes. Dr. Pepper indicated 

that the symptoms of diabetes could go unrecognized which could lead to the development of 

DKA. He noted that the symptoms of DKA could go unrecognized, causing hypoglycemia, 

hypokalemia, and cerebral edema which could lead to a syncopal event and cardiac arrest. 

Dr. Pepper opined that the established employment factors could lead to the unmasking of 

diabetes, which progressed to the point of DKA and then syncope and cardiac arrest. He found 

that this represented a direct causal relationship, despite the fact that the cardiac arrest occurred 

when appellant was on vacation, since the disease process leading to the cardiac arrest occurred 

during his regular deployment duties.

By decision dated April 18, 2019, OWCP denied modification of the October 15, 2018 

decision.

On July 25, 2019 appellant requested reconsideration.3

With his request, appellant submitted an e-mail thread dated June 25 through 27, 2017 

showing that he was unable to receive medical treatment at Kandahar Airfield.

OWCP also received September 6 and 7, 2017 hematology reports.

In September 13 and 16, 2017 reports, Dr. Nayef Habahbeh, an internist, noted that 

appellant was admitted to Istishari Hospital on September 6, 2017. He diagnosed post cardiac 

arrest, severe metabolic acidosis due to DKA, acute pancreatitis, aspiration pneumonia, and sepsis. 

By decision dated August 21, 2019, OWCP denied appellant’s request for reconsideration 

of the merits of his claim pursuant to 5 U.S.C. § 8128(a).

 

3

In an accompanying July 22, 2019 memorandum, appellant noted that he submitted an amendment from

Dr. Pepper dated May 22, 2019 and a memorandum for the record dated July 1, 2019. However, these documents are 

not of record.
6

LEGAL PRECEDENT -- ISSUE 1

An employee seeking benefits under FECA4 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,5that an injury was sustained in the performance of duty as alleged, 

and that any disability or medical condition for which compensation is claimed is causally related 

to the employment injury.6 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.7

To establish that an injury was sustained in the performance of duty in an occupational

disease claim, a claimant must submit the following: (1) a factual statement identifying 

employment factors alleged to have caused or contributed to the presence or occurrence of the 

disease or condition; (2) medical evidence establishing the presence or existence of the disease or 

condition for which compensation is claimed; and (3) medical evidence establishing that the 

diagnosed condition is causally related to the identified employment factors.8

The Board has held that, when working conditions are alleged as factors in causing a 

condition or disability, OWCP, as part of its adjudicatory function, must make findings of fact 

regarding which working conditions are deemed compensable factors of employment and are to 

be considered by a physician when providing an opinion on causal relationship and which working 

conditions are not deemed compensable factors of employment and may not be considered.9 If an 

employee does implicate a factor of employment, OWCP should then determine whether the 

evidence of record substantiates that factor. As a rule, allegations alone by a claimant are 

insufficient to establish a factual basis for an emotional condition claim. The claim must be 

supported by probative evidence.10 If a compensable factor of employment is substantiated, 

OWCP must base its decision on an analysis of the medical evidence which has been submitted.11

Causal relationship is a medical question that requires rationalized medical opinion 

evidence to resolve the issue.12 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 

 

4 Supra note 1.

5 G.L., Docket No. 18-1057 (issued April 14, 2020); J.P., 59 ECAB 178 (2007); Joe D. Cameron, 41 ECAB 

153 (1989).

6 M.G., Docket No. 18-1616 (issued April 9, 2020); R.C., 59 ECAB 427 (2008); James E. Chadden, Sr., 40 ECAB 

312 (1988).

7 20 C.F.R. § 10.115; A.S., Docket No. 19-1955 (issued April 9, 2020); L.M., Docket No. 13-1402 (issued 

February 7, 2014); Delores C. Ellyett, 41 ECAB 992 (1990).

8 R.G., Docket No. 19-0233 (issued July 16, 2019). See also Roy L. Humphrey, 57 ECAB 238, 241 (2005); Victor J. 

Woodhams, 41 ECAB 345 (1989).

9 Y.W., Docket No. 19-1877 (issued April 30, 2020); Dennis J. Balogh, 52 ECAB 232 (2001).

10 L.S., Docket No. 18-1471 (issued February 26, 2020); Charles E. McAndrews, 55 ECAB 711 (2004).

11 M.A., Docket No. 19-1017 (issued December 4, 2019); Norma L. Blank, 43 ECAB 384, 389-90 (1992).

12 L.F., Docket No. 19-1905 (issued April 10, 2020); Jacqueline M. Nixon-Steward, 52 ECAB 140 (2000).
7

be supported by medical rationale explaining the nature of the relationship between the diagnosed 

condition and the specific employment incident identified by the claimant.13

ANALYSIS -- ISSUE 1

The Board finds that this case is not in posture for decision.

In support of his claim, appellant submitted July 12, 2018 and January 9, 2019 reports from

Dr. Pepper which discussed causal relationship. Dr. Pepper provided a comprehensive history of 

appellant’s medical conditions and found that heat, cold, wind, dust, increased physical activity, 

working long hours, and working in a war zone were employment factors that could contribute to 

stress. He noted that physical and mental stress could affect insulin production and unmask the 

symptoms of underlying diabetes. Dr. Pepper indicated that the symptoms of diabetes and DKA

could go unrecognized, causing hypoglycemia, hypokalemia, and cerebral edema which could lead 

to a syncopal event and cardiac arrest. He opined that appellant’s employment factors could lead 

to diabetes, which progressed to the point of DKA and then syncope and cardiac arrest. Dr. Pepper

found that this represented a direct causal relationship despite the fact that the cardiac arrest 

occurred when appellant was on vacation in Jordan. Dr. Pepper provided a proper factual and 

medical history in his July 12, 2018 and January 9, 2019 reports. He opined that appellant’s 

cardiac arrest was caused by undiagnosed, untreated diabetes and DKA which was caused by the 

stressors of appellant’s federal employment. Dr. Pepper found that appellant’s cardiac arrest was 

“work-related to a reasonable degree of medical probability” and that there was a “direct causal 

relationship.” His findings were supported by the statement of appellant’s supervisor who noted 

that appellant routinely worked 80 hours or more each week during his deployment, there was little 

that could be done to reduce the stress of the job, and that the danger of the position also contributed 

to stress. The supervisor also indicated that the airfield would occasionally come under rocket 

attack, environmental factors in Afghanistan made it difficult to work, temperatures regularly 

reached 120 degrees Fahrenheit and that appellant sometimes needed to wear full body armor and 

Kevlar helmets in these conditions, constant dust was a common problem that was exacerbated by 

wind, employees were required to manually perform employment duties outside in heat. As these 

conditions were substantiated by a supervisor and were unopposed factually, they are found by the 

Board to also constitute additional compensable factors. 

Proceedings under FECA are not adversarial in nature, and OWCP is not a disinterested 

arbiter. While the claimant has the burden of proof to establish entitlement to compensation, 

OWCP shares responsibility in the development of the evidence to see that justice is done.14 The 

Board finds that while Dr. Pepper’s opinion is not fully rationalized, it is relevant evidence in 

support of appellant’s claim as it explains the physiological process by which his accepted factors 

of federal employment could have affected his insulin production and caused diabetes, progressing 

to DKA and ultimately syncope and cardiac arrest. Furthermore, Dr. Pepper’s opinion is based 

upon a complete factual history and medical background and expresses an unequivocal opinion on 

causal relationship that is supportive of the claim. Although his opinion is insufficiently 

rationalized to meet appellant’s burden of proof, it raises an undisputed inference of causal 

 

13 A.S., supra note 7; Leslie C. Moore, 52 ECAB 132 (2000).

14 R.S., Docket No. 19-1939 (issued May 6, 2020); John J. Carlone, 41 ECAB 354 (1989).
8

relationship sufficient to require further development by OWCP.15 Accordingly, the Board will 

remand the case to OWCP for further development of the medical evidence based upon all 

compensable employment factors.

16

On remand OWCP shall refer appellant, the case record, and a statement of accepted facts

which incorporates all of the compensable employment factors to an appropriate specialist(s) for 

an evaluation to obtain a rationalized medical opinion on whether the compensable employment 

factors caused, contributed to, or aggravated appellant’s diabetic and cardiac conditions. If the 

physician(s) disputes the opinion or findings of Dr. Pepper, the report shall provide a rationalized 

explanation as to the basis for the disagreement. Following this and any other further development 

as deemed necessary, OWCP shall issue a de novo decision.17

CONCLUSION

The Board finds that this case is not in posture for decision. 

 

15 I.S., Docket No. 19-1461 (issued April 30, 2020).

16 On appeal and in his July 22, 2019 request for reconsideration, appellant referenced a May 22, 2019 amendment 

from Dr. Pepper. He noted that OWCP did not address or evaluate the amendment in its August 21, 2019 decision. 

However, the Board finds that this amendment cannot be considered as it is not of record.

17 In light of the Board’s disposition in issue 1, the second issue is rendered moot. 
9

ORDER

IT IS HEREBY ORDERED THAT the August 21 and April 18, 2019 decisions of the 

Office of Workers’ Compensation Programs are set aside and the case is remanded for further 

proceedings consistent with this decision of the Board.

Issued: July 9, 2020

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Christopher J. Godfrey, Deputy Chief Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Alternate Judge

Employees’ Compensation Appeals Board