United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

J.G., Appellant

and

DEPARTMENT OF HOMELAND SECURITY, 

CUSTOMS & BORDER PROTECTION, 

Fabens, TX, Employer

__________________________________________

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Docket No. 20-0073

Issued: July 6, 2020

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

CHRISTOPHER J. GODFREY, Deputy Chief Judge

PATRICIA H. FITZGERALD, Alternate Judge

VALERIE D. EVANS-HARRELL, Alternate Judge

JURISDICTION

On October 15, 2019 appellant filed a timely appeal from an April 15, 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

 

1 5 U.S.C. § 8101 et seq.

2 The Board notes that appellant submitted additional evidence to OWCP following the April 15, 2019 decision. 

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

ISSUE

The issue is whether appellant has met his burden of proof to establish a diagnosed medical 

condition causally related to the accepted January 30, 2019 employment incident.

FACTUAL HISTORY

On January 30, 2019 appellant, then a 58-year-old customs and border patrol officer, filed 

a traumatic injury claim (Form CA-1) alleging that he sustained swelling and bruising to the right 

eye, lacerations to the nose and right elbow, and right rib pain on that date when he fainted after 

feeling hot and dizzy while in the performance of duty. A supervisor indicated that appellant was 

not injured in the performance of duty, noting that he became dizzy and fainted, striking his head 

on a podium desk. Appellant stopped work on that date and returned on February 1, 2019 with no 

restrictions.

In an emergency room note dated January 30, 2019, Dr. Claudia Kim, an emergency 

medicine specialist, examined appellant for syncope. She noted that he was sitting at work and 

experienced ringing of the ears and feeling dizzy, after which he had a syncopal episode, striking 

his face on a bar. On physical examination, Dr. Kim observed right periorbital ecchymosis and 

swelling and an abrasion to the bridge of the nose. Included with her report were the results of 

computerized tomography (CT) scans of the facial bones and brain and an x-ray of the right elbow, 

taken on January 30, 2019. Dr. Kim diagnosed syncope, periorbital ecchymosis of the right eye, 

and right elbow pain.

In a letter dated February 12, 2019, the employing establishment’s injury compensation 

specialist, noted that appellant had a similar syncopal incident involving light-headedness on 

February 9, 2019 and had filed another claim for traumatic injury. She further noted that, based 

on the medical evidence, it could be an underlying issue and not related to a work injury.

An x-ray of appellant’s right elbow dated January 30, 2019 demonstrated no fracture or 

dislocation, along with olecranon enthesophyte formation and mild subchondral cystic change 

within the humeral capitellum, which was also noted on prior study. 

A CT scan of appellant’s facial bones dated January 30, 2019 demonstrated right-sided 

periorbital hematoma, no facial bone fractures, multilevel upper cervical spine arthritic change, 

and cerumen within both external canals. A CT scan of his brain also dated January 30, 2019 

demonstrated left periorbital tissue swelling and no acute intracranial process.

In a March 11, 2019 development letter, OWCP informed appellant that the factual and 

medical evidence of record was insufficient to establish his claim. It advised him to submit a 

narrative report from a physician, including diagnoses and a rationalized medical opinion on causal 

relationship. OWCP noted that the diagnoses of fainting (syncope) and facial and scalp contusions 

were not substantiated by medical evidence to be caused or aggravated by the incident of 

January 30, 2019. It also requested additional information regarding the alleged January 30, 2019 

employment incident, as well as similar disability or symptoms before the injury. OWCP afforded 

appellant 30 days to submit the necessary evidence.
3

In a discharge summary dated January 30, 2019, Dr. Kim listed diagnoses of fainting 

(syncope) and facial and scalp contusions.

On March 28, 2019 appellant responded to OWCP’s factual development questionnaire. 

He explained that he had hit his head on a desk corner after fainting and falling at work. Appellant 

noted that he did not have a preexisting condition that may have contributed to the injury and that 

the incident had been witnessed and recorded on a security system. 

In a letter dated March 29, 2019, a supervisor at the employing establishment noted that he 

witnessed appellant fall on January 30, 2019. Appellant had been using a pedestrian primary booth 

landline for approximately one minute, then collapsed to the ground, hitting his head and upper 

torso on the pedestrian primary metal inspection counter/station. He laid face down on a ceramic 

floor until coworkers began to administer first aid. 

In a supplemental statement dated March 26, 2019, appellant described the January 30,

2019 incident. He stated that at approximately 3:15 p.m. on that date, he was inspecting vehicles 

coming across the border for 30 minutes, in an environment where he was exposed to exhaust from 

vehicles. Appellant’s next assignment was to process pedestrians inside the facility, which was 

much warmer than the outside. With the temperature change, he felt hot and dizzy, and fainted, 

hitting his face on the edge of a booth/desk and hitting his head on the floor.

By decision dated April 15, 2019, OWCP accepted that the January 30, 2019 employment 

incident occurred as alleged. However, it denied appellant’s traumatic injury claim, finding that 

the evidence of record did not contain a medical diagnosis in connection with the accepted event. 

OWCP concluded, therefore, that the requirements had not been met to establish an injury as 

defined by FECA.

LEGAL PRECEDENT

An employee seeking benefits under FECA3 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 of FECA,4that 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.5 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.6

 

3

Id.

4 S.B., Docket No. 17-1779 (issued February 7, 2018); J.P., 59 ECAB 178 (2007); Joe D. Cameron, 41 ECAB 

153 (1989).

5

J.M., Docket No. 17-0284 (issued February 7, 2018); R.C., 59 ECAB 427 (2008); James E. Chadden, Sr., 40 

ECAB 312 (1988).

6 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).
4

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.7 The second component is whether the 

employment incident caused a personal injury and generally can be established only by medical 

evidence.8

Causal relationship is a medical question that requires rationalized medical opinion 

evidence to resolve the issue.9 A physician’s opinion on whether there is causal relationship 

between the diagnosed condition and the implicated employment factor(s) must be based on a 

complete factual and medical background.10 Additionally, the physician’s opinion must be 

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

rationale that explains the nature of the relationship between the diagnosed condition and 

appellant’s specific employment factor(s).11

Pursuant to OWCP’s procedures, no development of a claim is necessary when there is a 

visible injury, even when time has been lost from work due to disability, following a serious injury 

(motor vehicle accidents, stabbings, shootings, etc.).12 The procedures provide that no 

development is necessary when the employing establishment does not dispute the facts of the case 

and there are no questionable circumstances surrounding the case. No medical report is required 

to establish a minor condition such as a laceration.13 Sound judgment should be employed in these 

cases to provide appropriate and immediate medical care for the injured worker since expeditious 

treatment for these injuries is critical.14

ANALYSIS

The Board finds that appellant has established that he sustained facial and scalp lacerations 

and a periorbital hematoma causally related to the accepted January 30, 2019 employment incident.

 

7 B.P., Docket No. 16-1549 (issued January 18, 2017); Elaine Pendleton, 40 ECAB 1143 (1989).

8 K.L., Docket No. 18-1029 (issued January 9, 2019). See Shirley A. Temple, 48 ECAB 404, 407 (1997); John J. 

Carlone 41 ECAB 354, 356-57 (1989).

9 T.H., 59 ECAB 388, 393 (2008); Robert G. Morris, 48 ECAB 238 (1996).

10 M.V., Docket No. 18-0884 (issued December 28, 2018).

11 Id.; Victor J. Woodhams, 41 ECAB 345 (1989).

12 See Federal (FECA) Procedure Manual, Part 2 -- Claims, Initial Development of Claims, Chapter 2.800.6(a) 

(June 2011).

13 Id.

14 See E.H., Docket No. 19-1282 (issued December 23, 2019); M.C., Docket No. 18-1278 (issued March 7, 2019); 

R.T., Docket No. 08-0408 (issued December 16, 2008); Gregory J. Reser, 57 ECAB 277 (2005).
5

In a discharge summary dated January 30, 2019, Dr. Kim diagnosed facial and scalp 

contusions. In addition, a CT scan of appellant’s facial bones dated January 30, 2019, the results 

of which were included in Dr. Kim’s January 30, 2019 hospital note, demonstrated a right-sided 

periorbital hematoma. As all of these diagnosed conditions were visible and the incident had been 

accepted, no medical reports were required to establish the medical conditions as employment 

related.15 The Board therefore finds that appellant has met his burden of proof to establish facial 

and scalp lacerations and a periorbital hematoma causally related to the accepted employment 

incident. Therefore, upon return of the case file OWCP shall pay all appropriate wage-loss 

compensation and medical benefits. 

CONCLUSION

The Board finds that appellant has established that he sustained facial and scalp lacerations 

and a periorbital hematoma causally related to the accepted January 30, 2019 employment 

incident. 

ORDER

IT IS HEREBY ORDERED THAT the April 15, 2019 decision of the Office of Workers’

Compensation Programs is reversed and the case is remanded for payment of appropriate wageloss compensation and medical benefits consistent with this decision of the Board. .

Issued: July 6, 2020

Washington, DC

Christopher J. Godfrey, Deputy Chief Judge

Employees’ Compensation Appeals Board

Patricia H. Fitzgerald, Alternate Judge

Employees’ Compensation Appeals Board

Valerie D. Evans-Harrell, Alternate Judge

Employees’ Compensation Appeals Board

 

15 Supra note 12.