United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

T.H., Appellant

and

U.S. POSTAL SERVICE, KISSIMMEE 

CARRIER ANNEX, Kissimmee, FL, Employer

__________________________________________

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Docket No. 19-1353

Issued: December 17, 2019

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

CHRISTOPHER J. GODFREY, Chief Judge

JANICE B. ASKIN, Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On June 4, 2019 appellant filed a timely appeal from an April 12, 2019 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 his burden of proof to establish a back condition 

causally related to the accepted December 26, 2018 employment incident.

 

1 5 U.S.C. § 8101 et seq.

2 Following the issuance of OWCP’s April 12, 2019 decision, appellant submitted new evidence. However, the 

Board’s Rules of Procedure provides: “The Board’s review of a case is limited to the evidence in the case record that 

was before OWCP at the time of its final decision. Evidence not before OWCP will not be considered by the Board 

for the first time on appeal. 20 C.F.R. § 501.2(c)(1). Thus, the Board is precluded from reviewing this additional 

evidence for the first time on appeal. Id.
2

FACTUAL HISTORY

On December 26, 2018 appellant, then a 60-year-old laborer custodial, filed a traumatic 

injury claim (Form CA-1) alleging that on that date he sustained a low back injury as he squatted

to clean under a rim while in the performance of duty. On the reverse side of the claim form the 

employing establishment indicated that appellant stopped work on the date of injury.

In a December 26, 2018 narrative statement, appellant noted that on that date he was 

performing his daily duties. He squatted as he started to clean under a toilet rim and felt a strain 

in his back which made it difficult for him to raise up and breathe.

In a letter dated January 29, 2019, the employing establishment challenged appellant’s 

claim, contending that he had not established fact of injury.

OWCP received a January 24, 2019 progress note from Dr. Roxann C. Cook, Boardcertified in family medicine and osteopathic manipulative therapy, who released appellant to return 

to work with no restrictions as of January 30, 2019.

OWCP also received emergency department treatment records, including a report dated 

January 11, 2019 from Dr. Jason Deleon, Board-certified in emergency medicine, and several

nurses, who evaluated appellant for a back injury sustained several weeks prior when he stood up 

quickly. Dr. Deleon diagnosed back pain. A nurse also diagnosed sciatica.

In a March 8, 2019 development letter, OWCP advised appellant that when his claim was 

first submitted it appeared to be a minor injury that resulted in minimal or no lost time from work 

and it, therefore, had administratively approved payment of a limited amount of medical expenses. 

It explained that his claim was being reopened for formal consideration of the merits because the 

employing establishment had challenged his claim. OWCP requested that appellant provide 

additional medical evidence to establish that he sustained a diagnosed condition as a result of the 
3

alleged employment incident and respond to an attached factual development questionnaire. It 

afforded him 30 days to submit the necessary evidence.

In a December 26, 2018 work/school excuse, Dr. Christopher J. Scott, Board-certified in 

emergency medicine, noted that appellant could return to work in two days with no restrictions.

A December 29, 2018 work release form with an illegible signature indicated that appellant 

may return to work with no restrictions on December 31, 2018.

In an additional emergency department report dated December 30, 2018, Dr. Dana 

Kleinman, a Board-certified internist, reviewed appellant’s chart and agreed he had a diagnosis of 

back pain.

An undated and unsigned work/school excuse noted that appellant could return to 

work/school “in two days” with no restrictions.

In a January 11, 2019 work release form, a nurse indicated that appellant could return to 

work on January 15, 2019 with no restrictions.

In a March 2, 2019 letter, Dr. Malcolm J. Heagle, a Board-certified family practitioner, 

placed appellant off work until March 6, 2019 and released him to return to light-duty work with 

restrictions.

In a statement dated March 11, 2019, appellant responded to OWCP’s development 

questionnaire. He reiterated the factual history of injury he provided on the December 26, 2018 

claim form and in the December 26, 2018 narrative statement. Appellant denied having any 

similar injury to his back prior to December 26, 2018. He related that, since his claimed injury,

he continued to experience pain and limitations for which he sought medical treatment.

OWCP, by decision dated April 12, 2019, accepted that the December 26, 2018 

employment incident occurred as alleged. It denied the claim, however, finding that the evidence

of record failed to establish a medical diagnosis in connection with the accepted December 26, 

2018 employment incident. It concluded, therefore, that the requirements had not been met for 

establishing an injury as defined by FECA.

3

LEGAL PRECEDENT

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

 

3 On May 22, 2019 appellant informed OWCP that he had not received the April 12, 2019 denial decision. On 

May 22, 2019 OWCP resent a copy of its April 12, 2019 decision and advised appellant to pursue his appeal rights 

attached to that decision.

4 Supra note 1.
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time limitation period of FECA,5and that 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 determine if an employee sustained a traumatic injury in the performance of duty,

OWCP begins with an analysis of whether fact of injury has been established.8 There are two

components that must be considered in conjunction with one another. The first component is

whether the employee actually experienced the employment incident that allegedly occurred.9 The

second component is whether the employment incident caused a personal injury.10

Causal relationship is a medical question that requires rationalized medical opinion 

evidence to resolve the issue.11 A physician’s opinion on whether there is causal relationship 

between the diagnosed condition and the implicated employment incident must be based on a 

complete factual and medical background.12 Additionally, the physician’s opinion must be 

expressed in terms of a reasonable degree of medical certainty, and must be supported by medical 

rationale, explaining the nature of the relationship between the diagnosed condition, and 

appellant’s specific employment incident.13

ANALYSIS

The Board finds that appellant has not met his burden of proof to establish a back condition 

causally related to the accepted December 26, 2018 employment incident.

The December 30, 2018 and January 11, 2019 medical reports from Dr. Kleinman and

Dr. Deleon diagnosed back pain. The Board has long held that a diagnosis of pain does not 

 

5 S.C., Docket No. 18-1242 (issued March 13, 2019); S.B., Docket No. 17-1779 (issued February 7, 2018); J.P., 59 

ECAB 178 (2007); Joe D. Cameron, 41 ECAB 153 (1989).

6 T.H., Docket No. 18-1736 (issued March 13, 2019); J.M., Docket No. 17-0284 (issued February 7, 2018); R.C., 

59 ECAB 427 (2008); James E. Chadden, Sr., 40 ECAB 312 (1988).

7 T.E., Docket No. 18-1595 (issued March 13, 2019); K.M., Docket No. 15-1660 (issued September 16, 2016); L.M., 

Docket No. 13-1402 (issued February 7, 2014); Delores C. Ellyett, 41 ECAB 992 (1990).

8 S.S., Docket No. 18-1488 (issued March 11, 2019); T.H., 59 ECAB 388, 393-94 (2008).

9 E.M., Docket No. 18-1599 (issued March 7, 2019); Elaine Pendleton, 40 ECAB 1143 (1989).

10 E.M., id.; John J. Carlone, 41 ECAB 354 (1989).

11 S.S., supra note 8; Robert G. Morris, 48 ECAB 238 (1996).

12 C.F., Docket No. 18-0791 (issued February 26, 2019); Jacqueline M. Nixon-Steward, 52 ECAB 140 (2000).

13 Id.
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constitute a basis for the payment of compensation under FECA as pain is considered a symptom

rather than a diagnosis.

14

 Therefore, these reports are insufficient to establish appellant’s claim.

The December 26, 2018 work/school excuse from Dr. Scott, January 24, 2019 progress 

note from Dr. Cook, and March 2, 2019 letter from Dr. Heagle addressed appellant’s work 

capacity. None of these physicians provided a history of injury, a firm diagnosis of a particular

medical condition, or a rationalized opinion regarding causal relationship.15 For the stated reasons, 

the Board finds that the reports of Drs. Scott, Cook, and Heagle are insufficient to establish 

appellant’s claim.

Several notes from attending nurses diagnosed back pain and sciatica, and addressed 

appellant’s work capacity. However, these reports are insufficient to establish appellant’s burden 

of proof as a nurse practitioner is not considered a physician as defined under FECA.

16

 Therefore, 

their reports are of no probative value on the issue of casual relationship.

The undated and unsigned work/school excuse and December 29, 2018 work release form 

with an illegible signature addressed appellant’s work capacity. The Board has held that unsigned 

reports and reports that bear illegible signatures cannot be considered probative medical evidence 

because they lack proper identification.17 Similarly, these reports did not offer an opinion on 

causal relationship which also negates its probative value.18 For these reasons, the Board finds 

that this evidence has no probative value to establish appellant’s claim.

As appellant has failed to submit rationalized medical evidence establishing that a 

diagnosed medical condition was causally related to the accepted December 26, 2018 employment 

incident the Board finds that he has not met his burden of proof.19

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 and 20 C.F.R.

§§ 10.605 through 10.607.

 

14 See E.C., Docket No. 19-0736 (issued October 8, 2019); T.T., Docket No. 17-0681 (issued March 13, 2018).

15 See I.C., Docket No. 19-0804 (issued August 23, 2019);see also A.A., Docket No. 18-0031 (issued April 5, 2018).

16 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. 

See also § 8102(2); 20 C.F.R. § 10.5(t); A.A., Docket No. 19-0957 (issued October 22, 2019). Lay individuals such 

as physician assistants, nurses, and physical therapists are not competent to render a medical opinion under FECA. 

See E.O., Docket No. 19-0472 n. 11 (issued August 15, 2019). 

17 See T.H., supra note 6; R.M., 59 ECAB 690 (2008); D.D., 57 ECAB 734 (2006); Richard J. Charot, 43 ECAB 

357 (1991).

18 See C.S., Docket No. 19-0999 (issued October 10, 2019); L.E., Docket No. 19-0470 (issued August 12, 2019).

19 See J.T., Docket No. 18-1755 (issued April 4, 2019); T.O., Docket No. 18-0139 (issued May 24, 2018).
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CONCLUSION

The Board finds that appellant has not met his burden of proof to establish a back condition 

causally related to the accepted December 26, 2018 employment incident.

ORDER

IT IS HEREBY ORDERED THAT the April 12, 2019 decision of the Office of Workers’

Compensation Programs is affirmed.

Issued: December 17, 2019

Washington, DC

Christopher J. Godfrey, Chief Judge

Employees’ Compensation Appeals Board

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board