United States Department of Labor

Employees’ Compensation Appeals Board

__________________________________________

M.C., Appellant

and

U.S. POSTAL SERVICE, POST OFFICE, 

Milwaukee, WI, Employer

__________________________________________

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Docket No. 23-1031

Issued: December 29, 2023

Appearances: Case Submitted on the Record

Appellant, pro se

Office of Solicitor, for the Director

DECISION AND ORDER

Before:

ALEC J. KOROMILAS, Chief Judge

JANICE B. ASKIN, Judge

JAMES D. McGINLEY, Alternate Judge

JURISDICTION

On July 28, 2023 appellant filed a timely appeal from a June 20, 2023 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 traumatic injury

in the performance of duty on March 18, 2023, as alleged.

1

5 U.S.C. § 8101 et seq.

2 The Board notes that following the June 20, 2023 decision, OWCP received additional 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 April 6, 2023 appellant, then a 54-year-old letter carrier, filed a traumatic injury claim 

(Form CA-1) alleging that on March 18, 2023 he sustained a left rotator cuff injury when reaching 

with a bag on his shoulder while in the performance of duty.3 On the reverse side of the claim 

form, appellant’s supervisor acknowledged that appellant was injured in the performance of duty, 

but indicated by checkmark that their knowledge of the facts about the injury did not agree with 

appellant’s statements. The supervisor further explained that appellant only stated that the alleged 

injury happened over a period of time and never verified that it happened at work. The form 

indicated that appellant stopped work on March 22, 2023. 

A work status note dated March 20, 2023 with an illegible signature was received by 

OWCP and indicated that appellant was seen in an emergency department and was off work until 

March 23, 2023. 

A work status note dated March 22, 2023 and signed by Dr. Jake D. Bauwens, an 

orthopedic surgery specialist, indicated a diagnosis of possible left rotator cuff tear. Dr. Bauwens 

placed appellant off work pending an MRI. 

In a letter received on April 10, 2023, the employing establishment controverted appellant’s 

claim for continuation of pay, contending that there was no proven causal relationship between his 

assigned duties and the alleged injury. It further contended that appellant’s supervisor noted on 

the CA-1 form that appellant stated the injury happened over a period of time and never verified 

it happened at work. 

On April 10, 2023 the employing establishment issued Part A of an authorization for 

examination and/or treatment (Form CA-16). 

In a development letter dated April 17, 2023, OWCP advised appellant of the deficiencies 

in his claim. It indicated that the evidence provided was insufficient to establish that appellant 

actually experienced the employment factors alleged to have caused injury. It also noted that there 

was no diagnosis of any condition, nor a physician’s opinion as to how the alleged injury resulted 

in a medical condition. A questionnaire was provided to appellant to substantiate the factual 

elements of his claim. OWCP afforded appellant 60 days to respond. No response was received.

A duty status report (Form CA-17) dated April 10, 2023 and signed by Dr. Bauwens

indicated a diagnosis of partial left rotator cuff tear and placed appellant on restricted duty. 

In a subsequent development letter dated May 18, 2023, OWCP indicated that it performed 

an interim review of appellant’s case file and found that the evidence remained insufficient to 

support his claim. It further reminded appellant that he was afforded 60 days from the April 17, 

2023 development letter to respond.

3 Appellant has a previously filed traumatic injury claim under OWCP File No. xxxxxx035 for an alleged July 29, 

2015 left shoulder strain.
3

On March 22, 2023 appellant was seen by Dr. Bauwens for severe pain in his left shoulder. 

He noted that on Monday of this week he was carrying an approximately 50-pound bag and doing 

repetitive motions with his left and right arm at work and developed pain in left shoulder. 

Appellant was seen at an urgent care, but his pain had not improved since then. Physical 

examination indicated significant pain and weakness with rotator cuff testing. It also indicated 

previous surgical incisions. Dr. Bauwens diagnosed suspected left shoulder traumatic tear of the 

rotator cuff and ordered an MRI.

An MRI report of the left shoulder dated April 6, 2023 and signed by Dr. Deidre Rippl, a 

Board-certified diagnostic radiologist, demonstrated: (1) attenuated insertional supraspinatus 

compatible partial-thickness undersurface tearing, approximately 50 percent; (2) superior and 

posterior labral tears; and (3) subacromial subdeltoid bursitis. 

On April 10, 2023 appellant was seen by Dr. Bauwens for a follow up on his left shoulder 

injury. He related some improvement, and he was now able to “fully range” his shoulder. Physical 

examination showed improvement. Dr. Bauwens diagnosed 50 percent articular-sided 

supraspinatus tear of the left shoulder and noted that this was a workplace injury. He also referred 

appellant to physical therapy and kept him on restricted duty. 

On April 12, 2023 appellant was seen by Leann Harman, a physical therapist. He related 

that on March 18, 2023 he was reaching for a box of mail at work and experienced a sharp and 

stabbing pain to the anterior shoulder. Appellant continued to work for the next two days and by 

the following Monday he was unable to “raise the shoulder into flexion.” He further related he 

underwent a radiograph and an MRI which was conclusive for a tear within the rotator cuff. 

An attending physician’s report (Form CA-20) dated May 19, 2023 by Dr. Bauwens 

reiterated appellant’s diagnosis of 50 percent articular-sided supraspinatus tear of the left shoulder. 

Dr. Bauwens checked a box marked “Yes” to the question of whether he believed appellant’s 

condition was caused or aggravated by an employment activity, and he checked a box marked 

“No” to the question of whether there was history or evidence of concurrent or preexisting injury, 

disease, or physical impairment. Appellant was kept on restricted duty.

Appellant was seen again by Dr. Bauwens on May 24, 2023, he reiterated his opinion that 

appellant had a left shoulder 50 percent partial tear of the rotator cuff, which was a workplace 

injury.

By decision dated June 20, 2023, OWCP denied appellant’s traumatic injury claim, finding 

that the evidence of record was insufficient to establish the occurrence of the alleged March 18, 

2023 employment incident. It concluded, therefore, that the requirements had not been met to 

establish an injury as defined by FECA.

LEGAL PRECEDENT

An employee seeking benefits under FECA4 has the burden of proof to establish the 

essential elements of his or her claim, including that the individual is an employee of the United 

4

Id.
4

States within the meaning of FECA, that the claim was timely filed within the applicable time 

limitation of FECA, 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.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

To determine whether an employee sustained a traumatic injury in the performance of duty, 

it must first be determined whether fact of injury has been established. There are two components 

involved in establishing fact of injury. The first component is whether the employee actually 

experienced the employment incident that allegedly occurred at the time and place and in the 

manner alleged. The second component is whether the employment incident caused a personal 

injury and can be established only by medical evidence.7

An injury does not have to be confirmed by eyewitnesses in order to establish the fact that 

an employee sustained an injury in the performance of duty, but the employee’s statements must 

be consistent with the surrounding facts and circumstances and his or her subsequent course of 

action.8 The employee has not met his or her burden of proof to establish the occurrence of an 

injury when there are inconsistencies in the evidence that cast serious doubt upon the validity of 

the claim. Such circumstances as late notification of injury, lack of confirmation of injury, 

continuing to work without apparent difficulty following the alleged injury, and failure to obtain 

medical treatment may, if otherwise unexplained, cast serious doubt on an employee’s statements 

in determining whether a prima facie case has been established.9 An employee’s statements 

alleging that an injury occurred at a given time and in a given manner is of great probative value 

and will stand unless refuted by strong or persuasive evidence. 10

ANALYSIS

The Board finds that appellant has met his burden of proof to establish a traumatic incident 

on March 18, 2023, as alleged. 

As noted, an employee’s statement alleging that an injury occurred at a given time and 

place, and in a given manner is of great probative value and will stand unless refuted by strong or 

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 B.H., Docket No. 20-0777 (issued October 21, 2020); 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).

7 M.H., Docket No. 18-1737 (issued March 13, 2019); John J. Carlone, 41 ECAB 354 (1989); see 5 U.S.C. 

§ 8101(5) (injury defined); 20 C.F.R. §§ 10.5(ee), 10.5(q) (traumatic injury and occupational disease defined, 

respectively).

8 M.F., Docket No. 18-1162 (issued April 9, 2019); Charles B. Ward, 38 ECAB 667, 67-71 (1987).

9 D.M., Docket No. 23-180 (issued August25, 2023); BettyJ. Smith, 54 ECAB 174 (2002); L.D., Docket No. 16-

0199 (issued March 8, 2016).

10 See M.C., Docket No. 18-1278 (issued March 7, 2019); D.B., 58 ECAB 464, 466-67 (2007).
5

persuasive evidence.11 Appellant alleged in his April 6, 2023 Form CA-1 that on March 18, 2023 

he sustained a left rotator cuff injury while reaching with a bag on his shoulder, and that he 

continued to work until March 22, 2023. He sought medical care on March 22, 2023 with

Dr. Bauwens who noted appellant’s history that on Monday of that week appellant experienced

left shoulder pain while carrying a bag on his shoulder and performing repetitive activity with his 

upper extremity. Dr. Bauwens diagnosed a partial left shoulder rotator cuff tear. On April 12, 

2023 appellant was seen by Leann Harman, a physical therapist. Ms. Harman noted a history of 

injury that on March 18, 2023 appellant was reaching for a box of mail at work and experienced a 

sharp and stabbing pain to the anterior shoulder. Appellant continued to work for the next two 

days and by the following Monday he was unable to “raise the shoulder into flexion.12 The injury

he claimed is consistent with the facts and circumstances he set forth, his subsequent course of 

action, and the medical evidence he submitted. The Board thus finds that appellant has met his 

burden of proof to establish the employment incident occurred in the performance of duty on

March 18, 2023 as alleged.

As appellant has established that March 18, 2023 incident factually occurred as alleged, 

the question becomes whether the incident caused an injury.13 As OWCP found that he had not 

established fact of injury, it has not fully evaluated the medical evidence. The case must therefore 

be remanded for consideration of the medical evidence of record. 14 After this, and other such 

further development as deemed necessary, OWCP shall issue a de novo decision regarding causal 

relationship.15

CONCLUSION

The Board finds that appellant has met his burden of proof to establish an employment 

incident in the performance of duty on March 18, 2022, as alleged. The Board further finds that 

the case is not in posture for decision regarding whether the medical evidence of is sufficient to 

establish an injury causally related to the accepted March 18, 2022 employment incident. 

11 See id.

12 While a physical therapist is not a physician, evidence from medical providers who are not physicians can be 

considered in evaluating whether appellant has provided a consistent history of injury. See C.W., Docket No. 18-0754 

(issued October 2, 2019).

13 See M.H., Docket No, 20-0576 (issued August 6, 2020); M.A., Docket No. 19-0616 (issued April 10, 2020);

C.M., Docket No. 19-0009 (issued May 24, 2019).

14 M.H., id.; S.M., Docket No. 16-0875 (issued December 12, 2017).

15 The Board notes that the employing establishment executed a Form CA-16. A completed Form CA-16

authorization may constitute a contract for payment of medical expenses to a medical facility or physician, when 

properly executed. The form 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. See 20 C.F.R. § 10.300(c);

J.G., Docket No. 17-1062 (issued February 13, 2018); Tracy P. Spillane, 54 ECAB 608 (2003).
6

ORDER

IT IS HEREBY ORDERED THAT the June 20, 2023 decision of the Office of Workers’

Compensation Programs is reversed, and the case is remanded for further proceedings consistent 

with this decision of the Board.16

Issued: December 29, 2023

Washington, DC

Alec J. Koromilas, Chief Judge

Employees’ Compensation Appeals Board

Janice B. Askin, Judge

Employees’ Compensation Appeals Board

James D. McGinley, Alternate Judge

Employees’ Compensation Appeals Board

16 On remand OWCP should consider administratively combining OWCP File No. xxxxxx035 with the current 

claim.