        IN THE COMMONWEALTH COURT OF PENNSYLVANIA


City of Lower Burrell,           :
                                 :
                      Petitioner :
                                 :
            v.                   : No. 120 C.D. 2019
                                 : Argued: February 13, 2020
Workers’ Compensation Appeal     :
Board (Babinsack),               :
                                 :
                      Respondent :


BEFORE:      HONORABLE PATRICIA A. McCULLOUGH, Judge
             HONORABLE MICHAEL H. WOJCIK, Judge
             HONORABLE BONNIE BRIGANCE LEADBETTER, Senior Judge


OPINION NOT REPORTED

MEMORANDUM OPINION
BY JUDGE WOJCIK                                       FILED: March 12, 2020

             The City of Lower Burrell (Employer) petitions for review of an order
of the Workers’ Compensation Appeal Board (Board) that affirmed an order of
Workers’ Compensation Judge (WCJ) David Torrey granting Thomas Babinsack
(Claimant) total disability benefits for a psychological injury in the nature of post-
traumatic stress disorder (PTSD). The PTSD resulted from an abnormal work event
that aggravated a preexisting panic disorder and latent trauma. Employer contends
the WCJ erred in concluding that Claimant provided timely and sufficient notice that
his PTSD was work-related. Employer further asserts Claimant’s psychologist’s
testimony regarding the causal relationship between Claimant’s emotional condition
and his employment was equivocal. In addition, Employer argues the WCJ’s finding
that Claimant’s emotional condition was impacted by the death of a fellow officer
was not supported by substantial evidence. Upon review, we affirm.

                                   I. Background
                                     A. Evidence
             In 2003, Claimant began working for Employer as a police officer. In
January 2014, Claimant filed a claim petition alleging work injuries in the nature of
PTSD and heart problems. Claimant sought total disability benefits. Employer filed
a timely answer denying Claimant’s material allegations.
             Thereafter, the WCJ convened hearings. Claimant testified that prior
to his current employment, he had no preexisting problems with his mental or cardiac
health. In 2009, while serving as a volunteer firefighter, Claimant witnessed a
female victim burn to death in a house fire. On January 23, 2011, while attending a
fire as a police officer, Claimant went to the aid of a woman still in the kitchen of a
burning house. During this incident, Claimant experienced an acute onset of angina,
which lasted 10 to 15 minutes. Two days later, while exerting himself in a night-
time search for a suspect, Claimant again suffered an episode of angina.
             In February 2011, while on vacation in Florida, Claimant experienced
repeated episodes of angina. Medical care providers at the scene suggested that he
go to a hospital. The hospital doctors found that Claimant suffered from a massive
occlusion of the left anterior descending (LAD) artery. During his treatment in
Florida, Claimant’s doctors inserted stents into the LAD artery.
             Also while in Florida, Claimant notified Employer in early February
2011 of his angina attack during the house fire on January 23, 2011, and that he
intended to seek compensation benefits under the Act commonly known as the Heart




                                          2
and Lung Act.1 On February 24, 2011, Employer issued a notice of compensation
denial (NCD).
               Claimant was scheduled to return to work on February 16, 2011, but he
suffered a panic attack while attending a grievance hearing. He eventually returned
to work on February 28, 2011.
               However, Claimant continued to have panic attacks triggered by stress.
In response to Claimant’s continued anxiety, his family physician, Dr. Michael J.
Govi (Family Physician), directed him to seek psychological care. Claimant began
seeing Dr. Michael Greenwald (Psychologist).
               In October 2011, Claimant was called to the scene of a shooting where
a fellow officer was shot and killed while approaching a wanted suspect. Claimant
considered the slain officer, Derek Kotecki (Kotecki), to be both a coworker and a
friend. When Claimant arrived at the scene, he witnessed Kotecki’s bloodied body.
Employer gave all of its officers 10 days off following the shooting.
               Thereafter, Claimant tried to continue working, but was forced to retire
on November 8, 2012, after the parties agreed that he suffered from PTSD, which
rendered him unfit for duty as a police officer. At that time, Claimant applied for a
disability pension.
               In support of his claim petition, Claimant presented deposition
testimony from Family Physician. In April 2011, Family Physician began treating
Claimant for insomnia and anxiety. Family Physician stated Claimant developed
anxiety after his hospital procedure in Florida. If Claimant experienced physical
symptoms, he became concerned about a recurrence of his heart problem or coronary




      1
          Act of June 28, 1935, P.L. 477, as amended, 53 P.S. §§637-38.

                                               3
disease. Family Physician tended to think Claimant suffered from PTSD, related to
the death of the fire victim in 2009 and to Kotecki’s death in 2011.
             Claimant also presented the deposition testimony of Psychologist.
Claimant began treating with Psychologist in February 2011 for panic attacks.
Psychologist initially diagnosed Claimant with a panic disorder.         Psychologist
attributed Claimant’s disorder to concerns about his heart after suffering a heart
attack and undergoing surgery. Psychologist testified that Claimant suffered from
anxiety and depression.
             Psychologist further testified that Claimant, over time, developed
PTSD, which was caused by various stressful events during his employment,
including the death of his friend and fellow officer in October 2011. In particular,
Psychologist opined that Claimant’s PTSD became fully evident after Kotecki’s
death. At that time, Claimant began experiencing symptoms of acute stress, chest
pains and signs of avoidance.
             Employer presented the testimony of its police chief, Timothy Weitzel
(Police Chief). He testified regarding Kotecki’s death. The officer was shot three
times while approaching a vehicle. The entire police department responded to the
scene. After the shooting, the entire department received administrative leave.
Police Chief further testified that Kotecki’s shooting was the only time in the city’s
history that a police officer was shot and killed in the line of duty.
             Employer also presented the deposition testimony of Dr. Jeffrey S.
Garrett (IME Physician), who performed an independent medical examination
(IME) of Claimant in April 2012 related to Claimant’s Heart and Lung Act claim.
IME Physician is board certified in cardiovascular diseases and internal medicine.
He diagnosed Claimant with serious, premature coronary artery disease, idiopathic



                                           4
(of unknown origin) in nature.             IME Physician rejected the proposition that
Claimant’s coronary artery disease was causally related to his work as a police
officer.
                However, IME Physician testified that Claimant’s episode of angina on
January 23, 2011, when responding to a fire, may have been related to work-related
stress. In other words, Claimant’s angina became symptomatic because of his work
activities on that date.
                IME Physician also testified that Claimant informed him that he
received a diagnosis of PTSD. Because Claimant had a PTSD diagnosis, IME
Physician noted in his report that he would defer to a mental health professional as
to whether Claimant had a psychiatric diagnosis that might influence his ability to
perform his duties as a police officer. Nevertheless, IME Physician did not find
Claimant incapable of performing his full duties as a police officer based on his
cardiac condition.
                Based on IME Physician’s report that Claimant was treating for PTSD,
Employer sent Claimant to its own psychologist, Dr. Samuel K. Schachner, who
evaluated Claimant over a series of appointments. Dr. Schachner ultimately opined
that Claimant suffered from PTSD and was unfit for work. Claimant agreed with
Dr. Schachner’s assessment. After reviewing Dr. Schachner’s reports,2 Employer
advised Claimant at a meeting in October 2012 that he could not continue to work
as a police officer. Employer offered him the option of applying for a disability
pension in lieu of termination.           By letter dated November 8, 2012, Claimant
confirmed his choice to pursue a disability pension.




       2
           Dr. Schachner’s reports were not submitted into evidence.


                                                 5
               With respect to Claimant’s evidence, the WCJ accepted as credible
Claimant’s testimony regarding the effects of the incidents at work, especially
Kotecki’s death. In particular, the WCJ noted Claimant’s unshakeable demeanor
and found all of Claimant’s representations to be believable.
               The WCJ also credited the testimony of Psychologist.         Initially,
Psychologist diagnosed Claimant with a panic disorder caused by his worries about
his heart. However, Psychologist ultimately diagnosed Claimant with PTSD in
addition to the panic disorder. Psychologist further testified that he had no doubt
that Claimant developed PTSD as a result of his work experiences. Although
Claimant had a panic disorder after the stenting procedure in the hospital, he got to
the point of having diagnosable PTSD after Kotecki’s death. Before that event,
Psychologist did not believe that Claimant really met all the criteria for PTSD.


                            B. WCJ’s Findings of Fact
               The WCJ found that on January 23, 2011, Claimant sustained a work
injury in the nature of exertion-induced angina (chest pain). First WCJ Op., 8/21/15,
Finding of Fact (F.F.) No. 26. This episode of angina lasted about 15 minutes. Id.
Claimant experienced another work-induced episode of angina two days later. Id.
These episodes, however, did not cause permanent damage to Claimant’s heart and
resolved when he sat down and rested. Id. In making these findings, the WCJ
credited the testimony of Claimant and IME Physician. Id. Claimant did not sustain
any physical work injuries beyond the two 15-minute episodes of disabling pain. Id.,
F.F. No. 27.
               Because of his continuing angina, the discovery of coronary artery
disease, and his worries over these conditions, Claimant developed a panic disorder.



                                         6
Id., F.F. No. 28. The WCJ based this finding on the testimony of Family Physician
and Psychologist; the WCJ noted they were not contradicted by any other experts. Id.
               In 2009, while working as a volunteer firefighter for the City of
Tarentum Volunteer Fire Company, Claimant witnessed the death of a woman in a
fire. Id., F.F. No. 29. This event highly traumatized Claimant, and he received
counseling.     Id.   However, Claimant began having nightmares, guilt, hyper-
emotionality, behavioral avoidance, recalling images of the event, and feeling guilty
as a result of not being able to save the woman. Id. This not only affected Claimant
at the time, but the distress and its effects became latent. Id. In making this finding,
the WCJ credited the testimony of Claimant and Psychologist. Id.
               The WCJ thus found that Claimant had preexisting conditions of a latent
traumatic episode and a panic disorder brought on by anxiety after the hospital
stenting procedure. Id., F.F. No. 30. Claimant feared he would exert himself at work
and die. Id.
               The WCJ further found the evidence established that Claimant
developed PTSD as a result of these events and Kotecki’s death. Id., F.F. No. 31.
Kotecki’s death, arising in the course of Claimant’s employment, served as a “tipping
point” precipitating Claimant’s PTSD. Id. The WCJ noted Police Chief’s testimony
that Kotecki’s shooting death in the line of duty was the only one in Employer’s
history. Id., F.F. No. 3. Thus, the WCJ found that witnessing Kotecki’s bloodied
body was a highly unusual and singular event for Claimant in the course of his
employment with Employer. Id., F.F. No. 32.
               In finding that Claimant sustained a work injury in the nature of PTSD,
the WCJ specifically found that Claimant suffered an aggravation as a result of the
“tipping point” event of Kotecki’s death, superimposed upon Claimant’s preexisting



                                           7
conditions of a panic attack disorder and the latent trauma of the 2009 fire victim
death. Id., F.F. No. 33. In making this finding, the WCJ credited Psychologist’s
opinion. Id. The WCJ noted Psychologist’s outstanding academic and practice
credentials. Id. Psychologist treated Claimant and analyzed his case for years. Id.
Also, Psychologist explained the basis for his opinion; he was not conclusory. Id.
In sum, the WCJ determined that overall, Psychologist’s testimony constituted an
unequivocal opinion substantiating causation. Id.


                     C. WCJ’s Conclusions of Law & Order
             Based on his findings, the WCJ determined that Claimant met his
burden of proof in his claim petition. First WCJ Op., Conclusion of Law (C.L.) No.
2. With regard to the two episodes of angina in the course of employment in January
2011, the WCJ recognized an injury of work-induced angina. Id., C.L. Nos. 2, 3.
However, Claimant was not entitled to disability or medical benefits for these
injuries. Id., C.L. Nos. 2, 3. The WCJ further concluded that Claimant’s health
worries over the possibility of recurrent episodes of angina or other cardiac problems
on the job did not constitute a work injury. Id., C.L. No. 4.
             Nevertheless, the WCJ determined that Claimant met the burden of
proof required to demonstrate a mental stress/mental disability injury aggravating
his preexisting conditions. First WCJ Op., C.L. No. 5. Claimant’s preexisting
conditions included latent trauma of the 2009 fire victim’s death, and non-work-
related health worry over recurrent episodes of angina and cardiac problems. Id.
However, Claimant demonstrated that his exposure to Kotecki’s bloodied and dead
body on October 12, 2011, constituted a highly unusual and singular event of stress
that acted as a tipping point aggravating his preexisting conditions of panic disorder



                                          8
and latent trauma to PTSD. Id. (citing Payes v. Workers’ Compensation Appeal
Board (Pennsylvania State Police), 79 A.3d 543 (Pa. 2013); PA Liquor Control
Board v. Workers’ Compensation Appeal Board (Kochanowicz), 108 A.3d 922 (Pa.
Cmwlth. 2014)). The WCJ noted that a mental stress causing a mental disability
injury may be awarded when the work-related stressor superimposes itself on non-
work-related, preexisting conditions. Id., C.L. No. 6 (citing RAG (Cyprus) Emerald
Resources, L.P. v. Workers’ Compensation Appeal Board (Hopton), 912 A.2d 1278
(Pa. 2007)).
               Accordingly, the WCJ determined that Claimant was totally disabled
by PTSD from November 12, 2012, to the present. First WCJ Op., C.L. No. 7. The
WCJ noted that under the Workers’ Compensation Act3 (Act), an employer takes an
employee as he comes. Id., C.L. No. 12 (citing RAG). This rule applies in both the
physical injury and mental injury realms. Id. Therefore, workers who suffer from
preexisting mental conditions are not treated differently from workers with
preexisting physical injuries. Id. The WCJ further stated that in a mental stress-
mental disability case, a claimant must show abnormal working conditions. Id., C.L.
No. 15 (citing Payes; PA Liquor Control Bd.) Here, Claimant met this burden by
showing that his exposure to Kotecki’s bloodied and dead body was a highly unusual
and singular event. Id.
               The WCJ also determined that Claimant provided Employer prompt
and effective notice of injury. First WCJ Op., C.L. No. 10. The WCJ noted that
Employer never denied that Claimant provided notice or raised a notice defense. Id.
               In his order, the WCJ granted Claimant’s claim petition and awarded
Claimant total disability benefits for aggravation by mental stress of preexisting non-


      3
          Act of June 2, 1915, P.L. 736, as amended, 77 P.S. §§1-1041.4, 2501-2710.


                                               9
work-related conditions, manifesting in PTSD. First WCJ Op., Order, 8/21/15. The
WCJ directed Employer to pay Claimant total disability benefits from November 18,
2012, to the present and continuing until Employer establishes Claimant’s condition
changed. Id. The WCJ also awarded Claimant payment for his mental health
treatment commencing on October 12, 2011, the date of Kotecki’s death. Id.


                  D. Board’s Decision to Remand on Notice Issue
               In November 2016, the Board issued an opinion remanding the case to
the WCJ. In its decision, the Board determined that the WCJ failed to adequately
address the issue of notice. Consequently, the Board directed the WCJ to make
additional findings based on the existing record and to reconsider whether Claimant
provided Employer timely notice of his work injury. The Board did not address
Employer’s appeal of the merits of the claim petition.


                          E. WCJ’s Decision on Remand
               In November 2017, the WCJ issued a decision on remand. In his
decision, the WCJ noted that the parties agreed to compromise and settle the case.
Second WCJ Op., 11/6/17, F.F. No. 8. At a June 2017 hearing, Claimant accepted
the sum of $105,000 in exchange for a final release. Id. Nevertheless, the parties
requested that the WCJ decide the remand. Id. Ultimately, the WCJ found that
Employer had notice of injury as of February 24, 2011, the date it issued an NCD to
Claimant relative to Claimant’s complaint of angina occurring in January 2011. Id.,
F.F. No. 10.




                                         10
             Accordingly, the WCJ determined that Claimant met his burden of
proof required under Section 311 of the Act, 77 P.S. §631, to communicate sufficient
notice of a work injury to Employer. Second WCJ Op., C.L. No. 2. The WCJ again
noted that Employer issued an NCD relative to Claimant’s episode of work-induced
angina, which occurred on January 23, 2011. Id. In explaining his determination,
the WCJ noted that notice of the original occurrence of the injury is effective to
cover all compensable consequences which are a natural and probable result of the
original trauma.    Id., C.L. No. 3 (citing Crown Services, Inc. v. Workmen’s
Compensation Appeal Board (Beck), 682 A.2d 1333 (Pa. Cmwlth. 1996), aff’d, 701
A.2d 221 (Pa. 1997)). In particular, the WCJ reasoned that although Claimant’s
initial injury was a physical injury, Employer observed Claimant struggling with
mental problems thereafter. Id., C.L. No. 4. In short, Employer knew of the genesis
of Claimant’s injury and had every opportunity to investigate it. Id. In support of
his finding, the WCJ cited Katz v. Evening Bulletin, 403 A.2d 518 (Pa. 1979). There,
our Supreme Court, in interpreting the notice provisions in the Act, recognized that
the issue of whether notice was given is a question of fact. As such, the facts found
by a fact-finder (now a WCJ), are binding on reviewing courts. Katz, 403 A.2d at
520. Moreover, the Supreme Court reasoned that a meritorious claim should not, if
possible, be defeated based on technicalities in less than “letter perfect” notice. Id.
The WCJ also noted that the Act, including the notice provisions, must be liberally
construed in furtherance of its humanitarian purposes. Second WCJ Op., C.L. No.
5 (citing Zwick v. Workers’ Compensation Appeal Board (Popchocoj), 106 A.3d 251
(Pa. Cmwlth. 2014)).
             After reconsidering the notice issue, studying the existing record and
reviewing the law, the WCJ once again determined that Claimant provided effective



                                          11
notice to Employer. Second WCJ Op., C.L. No. 6. Therefore, the WCJ reconfirmed
the August 2015 award of benefits. Id., Order, 11/6/17.


                             F. Board’s Final Decision
             Employer again appealed. In January 2019, the Board issued a decision
affirming the WCJ’s order granting Claimant’s claim petition. With respect to
timely notice, the Board observed that the issue of whether a claimant provided
proper notice of injury under Section 311 of the Act is a question of fact for the WCJ.
See Gentex Corp. v. Workers’ Compensation Appeal Board (Morack), 23 A.3d 528,
534 (Pa. 2011).
             Here, the Board recognized that Employer did not dispute that, in
February 2011, Claimant provided timely notice of a physical injury occurring the
month before.     However, Employer did dispute whether the notice covered
Claimant’s subsequent psychological injury that occurred in October 2011. Citing
Crown Services, the Board agreed with the WCJ’s determination that Claimant’s
PTSD was reasonably associated with his original episode of work-induced angina
and later medical conditions stemming from that injury. See Bd. Op., 1/9/19, at 6.
To that end, Employer observed Claimant’s struggle with mental problems
following the initial work incident and culminating with Claimant witnessing
Kotecki’s dead body in October 2011. Id. Consequently, the Board determined
Claimant’s February 2011 notice was sufficient to cover Claimant’s medical
problems arising in October 2011. Id.
             With respect to the merits of Claimant’s claim petition, the Board
agreed with the WCJ’s determination that Claimant’s psychological injury should
be classified as a “mental-mental” injury requiring proof that it was caused by



                                          12
abnormal working conditions. See Gulick v. Workers’ Compensation Appeal Board
(Pepsi Cola Operating Co.), 711 A.2d 585, 589 (Pa. Cmwlth. 1998) (an examination
of abnormal working conditions must focus on a particular incident to determine
whether that incident was a highly unusual and singular event).
               Citing Payes, the Board noted that this standard applies even where the
claimant is employed in a stressful or dangerous position such as a police officer. In
Payes, a state police officer struck and killed a woman who ran in front of his patrol
car. The Supreme Court determined that the incident was so extraordinarily unusual
and distressing as to constitute an abnormal working condition, even considering the
general expectation that a police officer would experience stressful events.
               Here, the Board noted, Claimant observed the bloodied and dead body
of a friend and fellow officer who was shot and killed in the line of duty. No police
officer had been shot and killed in the line of duty in the city’s history. Noting these
facts, the Board agreed with the WCJ that these events were so extraordinarily
unusual and distressing as to constitute an abnormal working condition under Payes.
Accordingly, the Board affirmed the WCJ’s award. Employer petitions for review.4

                                       II. Discussion
                                      A. Timely Notice
                                       1. Contentions
               Employer first contends that the WCJ erred in determining that
Claimant provided timely and effective notice of his psychological injury. In order
for a claimant to be eligible for compensation, he must provide notice of injury to
his employer within 120 days of the injury. Section 311 of the Act, 77 P.S. §631;

       4
         Our review is limited to determining whether the WCJ’s findings of fact were supported by
substantial evidence, whether an error of law was committed or whether constitutional rights were
violated. Phoenixville Hospital v. Workers’ Compensation Appeal Board (Shoap), 81 A.3d 830 (Pa.
2013).

                                               13
Gentex, 23 A.3d at 534. In cases where the connection between an employee’s injury
and his employment is not clear, the notice period does not begin to run until the
employee knows or should have known, by the exercise of due diligence, of the
existence of his injury and its possible relationship to his employment. Section 311
of the Act, 77 P.S. §631; Borough of Norwood v. Workmen’s Compensation Appeal
Board (Wiker), 538 A.2d 143 (Pa. Cmwlth. 1988).
             Here, Employer asserts, Claimant notified it by a February 2011 letter
that he suffered injuries to his heart during the course of his employment in January
2011. Claimant’s letter made no reference to any mental condition or disability as a
result of these incidents. Employer maintains it did not become aware that Claimant
suffered from PTSD until it received IME Physician’s April 2012 report. Also, IME
Physician’s report only mentioned that Claimant was being treated for PTSD; the
report did not indicate causation.
             Employer further contends Claimant never testified as to when he
provided notice that his psychological disability was work-related.        Employer
maintains that the earliest it could have inferred that Claimant’s disability was
related to his employment was a meeting on October 19, 2012. Claimant testified
that, at the meeting, Employer offered him the option of applying for a pension based
on an occupational disability in lieu of being terminated. Employer claims that no
earlier date is supported by the evidence. Thus, Employer argues that any notice it
received regarding Claimant’s PTSD occurred well after the October 2011 date that
Claimant allegedly developed PTSD after witnessing Kotecki’s bloodied body.
             Essentially, Employer challenges the WCJ’s “cascade of events” theory
(see Second WCJ Op., C.L. No. 2), on several grounds. In particular, Employer
contests the WCJ’s determination that Claimant’s notice of his cardiac condition in



                                         14
February 2011, coupled with Employer’s knowledge of Claimant’s psychological
issues immediately thereafter, put Employer on notice that Claimant had a serious
condition. First, Employer disputes the WCJ’s reliance on the fact that a witness for
Employer saw Claimant have a panic attack and collapse at a grievance hearing in
February 2011. See Second WCJ Op., C.L. No. 4. Employer asserts the mere fact
that a supervisor watched a subordinate collapse at his desk and then be transported
to a hospital by paramedics does not, by any reasonable means, charge the supervisor
with notice of the medical diagnosis or whether the diagnosis was work-related.
             In support of its position, Employer cites State Workmen’s Insurance
Fund v. Workmen’s Compensation Appeal Board (Wagner), 677 A.2d 892 (Pa.
Cmwlth. 1996), where we reasoned that although notice under the Act does not require
an exact diagnosis, the notice must include a reasonably precise description of the
injury and indicate that it was work-related. Employer asserts that under the WCJ’s
reasoning, an employer is put on notice merely by a supervisor’s observations.
Employer argues that the WCJ’s conclusion is contrary to the law.
             Second, Employer contends the union grievance episode, which
occurred in February 2011, cannot support a determination that Employer had notice
of Claimant’s PTSD, which occurred eight months later when Kotecki died.
Therefore, Employer asserts, the WCJ imputed knowledge of a disabling injury
before it occurred.
             Employer also emphasizes that the WCJ did not cite any legal authority
for his cascade of events theory. Rather, the WCJ justified his notice determination
by trying to connect emotional residuals related to Claimant’s transient angina
episodes to an emotional disability occurring 10 months later. Employer points out
that Claimant never challenged the denial of his claim for benefits based on his



                                         15
cardiac condition. Employer also noted the WCJ’s determinations that Claimant’s
angina episodes and associated health worries were not compensable. Based on
those determinations, Employer argues that the WCJ’s cascade of events theory is
illogical and unreasonable.
             Further, Employer contends our decision in Crown Services, upon
which the WCJ relied, is factually distinguishable from the unique situation in the
present case. In Crown Services, the claimant sustained a work injury when a
machine injured her three fingers. Thereafter, the claimant filed a claim petition
alleging a lower back injury as a result of the work injury. The WCJ in Crown
Services determined that the back injury resulted from the work injury and
determined that notice of the injury to the claimant’s fingers was sufficient to cover
all manifestations of the injury. 682 A.2d at 1339.
             Here, Employer asserts, the WCJ found two injuries: a physical injury
diagnosed as cardiac in nature, and a mental injury diagnosed as PTSD. Claimant’s
cardiac injuries occurred in January 2011.       Claimant’s PTSD developed after
Kotecki’s death in October 2011. Employer therefore argues this case, unlike Crown
Services, involves separate injuries with separate natures occurring on separate
dates. Thus, Employer maintains that Crown Services cannot possibly be stretched
to impute notice to an employer aware of a physical injury that a mental injury
manifesting 10 months later was caused by a specific incident. Consequently,
Employer contends the WCJ erred in holding that Claimant provided timely notice
of his mental injury manifesting in October 2011.




                                         16
                                          2. Analysis
               Under the Act, notice is a prerequisite to receiving workers’
compensation benefits. Gentex, 23 A.3d at 534. The claimant has the burden of
demonstrating he gave proper notice to his employer. Id. Section 311 of the Act
requires an employee to provide notice to his employer within 120 days from the
date of the injury, or from the date the employee learns the injury is work-related.
77 P.S. §631. Section 312 of the Act requires that the notice inform the employer
that a certain employee received an injury, described in ordinary language, during
the course of his employment, on or about a specified time, and at or near a specified
place. 77 P.S. §632. However, “the parameters of what constitutes adequate notice
in a given case has been developed through [case law].” Gentex, 23 A.3d at 534.
               Further, the question of whether an employee provided adequate notice
of his work injury is a mixed question of law and fact. Gentex, 23 A.3d at 534. The
more fact-intensive the inquiry, the more deference a reviewing court should give to
the findings of fact. Id. The Supreme Court also noted that in construing the Act,
a reviewing court must be mindful that “the Act was intended to benefit the injured
employee, and, therefore, must be construed liberally in the employee’s favor in
order to effectuate its humanitarian objectives.” Id. at 534. “As such, borderline
interpretations are to be decided in favor of the claimant.” Id.
             As we recognized in Crown Services, the term “injury”5 as defined in
Section 301(c)(1) of the Act, 77 P.S. §411(1), “includes any medical malady
reasonably associated with the work place incident or injury, as well as any


       5
         Section 301(c)(1) of the Act defines an “injury” in part as “an injury to an employe[e],
regardless of his previous physical condition … arising in the course of his employment and related
thereto, and such disease or infection as naturally results from the injury or is aggravated,
reactivated or accelerated by the injury ….” 77 P.S. §411(1).


                                                17
subsequent causally related medical problems stemming from that injury.” Crown
Services, 682 A.2d at 1339. Here, the WCJ determined Claimant sustained a work-
related injury in the nature of work-induced angina (chest pain) on January 23, 2011.
First WCJ Op., F.F. No. 26. Claimant suffered another episode of work-induced
angina on January 25, 2011. Id. In his remand decision, the WCJ determined that
these angina episodes “set in play a cascade of events” culminating in Claimant’s
development of PTSD on or about October 12, 2011. Second WCJ Op., C.L. No. 2.
             In light of the particular circumstances, our decision in Gulick is
instructive here. In Gulick, the claimant sustained a “lumbar strain” injury while
working as a delivery driver, and the employer issued a notice of compensation
payable. Thereafter, the employer filed a termination petition alleging the claimant
fully recovered and could return to work without restriction. 711 A.2d at 586. The
claimant, who suffered from preexisting schizophrenia, was hospitalized with
anxiety over the fear his benefits would be terminated. Id. Although the claimant’s
employment did not cause his schizophrenia, his medical expert testified that the
instability and uncertainty brought on by the termination action significantly
worsened his mental disorder.      Id. at 586-87.   Therefore, we determined the
claimant’s disability needed to be established under the mental-mental standard of
an abnormal working condition. Id. at 589.
             In making this determination in Gulick, we applied our Supreme
Court’s rationale in Ryan v. Workman’s [sic] Compensation Appeal Board
(Community Health Services), 707 A.2d 1130 (Pa. 1998). In Ryan, the claimant, a
visiting nurse who sustained physical injuries in a work-related automobile accident,
suffered a psychological injury when the other driver sued her. The Supreme Court
noted that, without the accident, there would not have been the lawsuit to trigger or



                                         18
stimulate the psychological injury. Id. at 1135. Ultimately, the Court reasoned that
the psychological stimulus of learning that she was being sued as a result of the
work-related accident, rather than the physical injuries sustained in the accident,
caused the claimant’s psychological injury. Id. The Court determined the claimant’s
injury should have been classified as mental-mental for workers’ compensation
purposes. Id.
            Similar to the accident in Ryan, Claimant’s work-related angina
episodes began the series of events culminating in his psychological injury in the
nature of PTSD. As the WCJ noted, Claimant developed a panic attack disorder
related to his health worries over his cardiac condition. First WCJ Op., F.F. Nos.
19, 33. On February 1, 2011, Claimant first notified Employer of his episodes of
angina and his cardiac condition. See Notes of Testimony (N.T.), 5/16/14, at 23;
Reproduced Record (R.R.) at 40a. Also, on February 16, 2011, Claimant suffered a
panic attack in the presence of his supervisor and coworkers at a union grievance
meeting. N.T. at 24; R.R. at 41a. An ambulance transported Claimant from work
to a hospital. Id. Claimant remained hospitalized for two days. Id.
            Psychologist testified that he started treating Claimant for anxiety and
panic attacks in February 2011. First WCJ Op., F.F. No. 19; Dep. of Michael
Greenwald, Ph.D. (Greenwald Dep.), 8/22/14, at 7; R.R. at 215a. Psychologist stated
that as a result of Claimant’s work incidents, combined with the 2009 fire where he
witnessed a woman burn to death, Claimant developed an increasing vulnerability
to the onset of PTSD. First WCJ Op., F.F. No. 19; Greenwald Dep. at 14-17; R.R.
at 222a-25a. Following Kotecki’s death in October 2011, Claimant not only had
similar chest pain, he also had symptoms of acute stress and began to show signs of
avoidance. First WCJ Op., F.F. No. 19; Greenwald Dep. at 17; R.R. at 225a.



                                        19
Claimant described memories of nightmares of coming into harm and memories of
the woman burning. First WCJ Op., F.F. No. 19; Greenwald Dep. At 15; R.R. at
223a. At this point, Claimant met the criteria for PTSD. First WCJ Op., F.F. No.
19; Greenwald Dep. at 17; R.R. at 225a.
            The WCJ found Psychologist credibly testified that Claimant suffered
an aggravation of preexisting conditions when his PTSD manifested as a result of
Kotecki’s death. First WCJ Op., F.F. No. 33. Psychologist explained that Kotecki’s
death, superimposed upon Claimant’s preexisting conditions, including a panic
attack disorder and the latent trauma of the 2009 death of a fire victim, acted as a
“tipping point” in causing Claimant’s PTSD. Id.
            Consequently, following Claimant’s written notice of his cardiac
condition, and his panic attack at a grievance hearing, which resulted in an
ambulance transporting Claimant from work to a hospital, Employer had sufficient
notice in 2011 that Claimant was struggling with mental problems following the
work incidents in January and February 2011. Second WCJ Op., C.L. Nos. 2, 4. As
we noted above, the term “injury” as defined by the Act includes not only any
medical condition reasonably associated with the work incident or injury, but also
“any subsequent causally related medical problems stemming from that injury.”
Crown Services, 682 A.2d at 1339 (emphasis added).
            Thus, in light of Psychologist’s testimony and the WCJ’s findings, we
reject Employer’s contention that Claimant’s onset of work-related PTSD in October
2011 arose from a separate and distinct cause unrelated to his cardiac and panic
attack episodes in January and February 2011. Rather, as the WCJ determined, the
work-induced angina episodes and Claimant’s panic attack at a union grievance
hearing put Employer on notice that Claimant suffered from a serious condition.



                                          20
Second WCJ Op., C.L. No. 4. Therefore, Employer had effective notice of the
genesis of Claimant’s work injury and sufficient opportunity to investigate
Claimant’s deteriorating mental condition related to the onset of his cardiac
problems. See Crown Services; Borough of Norwood.
             As to the details of Claimant’s notice letter, this Court recognizes that
PTSD “is not an obvious or common place injury apparent to the ordinary claimant.”
Borough of Norwood, 538 A.2d at 145. Symptoms of PTSD are also symptoms of a
large number of other disorders. Id. Thus, in Borough of Norwood, we reasoned that
we cannot attribute psychiatric expertise to a layman who knows only that something
is wrong with him. Id.
             As discussed above, where a notice inquiry is heavily weighted toward
issues of fact rather than issues of law, the WCJ’s determinations regarding adequate
notice must be afforded significant deference. Gentex, 23 A.3d at 534. Moreover,
as our Supreme Court instructed, borderline interpretations of the required notice are
to be decided in favor of the claimant. Id. at 533. In accord with our decision in
Crown Services, wherein we reasoned that a work injury includes all subsequently
diagnosed conditions causally related to it, we discern no error in the WCJ’s
determination. Claimant’s initial notice and panic attack in February 2011 provided
Employer with sufficient notice of injury to cover his later psychological injury
stemming from his original work injury.

                 B. Competency of Claimant’s Expert Evidence
                               1. Contentions
             Employer next contends that Psychologist’s causation opinion was
equivocal as to the cause of Claimant’s PTSD. Employer points out that the WCJ
framed the central issue in the case as whether Kotecki’s death was a material


                                          21
contributing factor in aggravating Claimant’s preexisting conditions resulting in a
diagnosis of PTSD in October 2011. First WCJ Op., F.F. No. 8. The WCJ found
Claimant suffered a traumatizing episode when Employer summoned him to the
scene of Kotecki’s fatal shooting, where he witnessed his colleague’s bloodied body
on the ground. Id. Citing the Supreme Court’s decision in RAG, the WCJ stated that
in a mental-mental case, work stress that aggravates a preexisting condition can be
an injury under the Act. Id. The WCJ also observed that all parties in the case
acknowledge that Claimant has PTSD. Id. Indeed, the WCJ found that Employer
terminated Claimant’s employment because he suffered from PTSD. Id.
             Employer also cites Finding of Fact No. 31, wherein the WCJ found that
Claimant developed a PTSD reaction to the fire victim’s death in 2009 only after he
experienced adverse threatening events at work and his cardiac illness. The WCJ
specifically found that a “material factor, that is the ‘tipping point’ was reached when
Claimant experienced [Kotecki’s death], an event arising in the course of [Claimant’s]
employment and related thereto.” First WCJ Op., F.F. No. 31. The WCJ also
specifically credited Claimant’s statement that “the episode with [Kotecki] was
particularly aggravating to him, as he was already in an anxiety-ridden and panicked
condition for nine months.” Id.
             Employer raises two challenges to these determinations. First, Employer
contends Psychologist’s testimony was equivocal and does not support the WCJ’s
“tipping point” analysis. Second, Employer asserts Claimant never testified that the
Kotecki incident was particularly aggravating to him, and that Psychologist’s notes
do not suggest that Claimant’s emotional health was impacted by that incident.
             Regarding Psychologist’s testimony, Employer cites Finding of Fact
No. 33, where the WCJ acknowledges that Psychologist appeared to be equivocal as



                                          22
to when Claimant’s PTSD actually manifested. Nonetheless, the WCJ further found
that overall, Psychologist’s testimony unequivocally established substantiating work
causation for Claimant’s PTSD. First WCJ Op., F.F. No. 33. Employer, however,
maintains that Psychologist’s opinion as to causation was just as equivocal as his
opinion as to when Claimant’s PTSD developed.
             Psychologist originally diagnosed Claimant with a panic attack disorder
in February 2011.      Sometime between February 2011 and November 2012,
Psychologist’s diagnosis evolved to PTSD. Employer further asserts Psychologist
referenced multiple traumatic and upsetting experiences, several of which did not
occur in the course of Claimant’s employment.           However, Employer claims
Psychologist did not specifically state an opinion that Kotecki’s death triggered
Claimant’s PTSD.
             Employer argues the WCJ erred in relying on Halaski v. Hilton Hotel,
409 A.2d 367 (Pa. 1979), for the proposition that when causation is unequivocally
established, the fact that the expert cannot pinpoint the pathology or date thereof
should not defeat a worker’s claim. In Halaski, the medical testimony established
that the disability flowed from one of two compensable injuries. In other words,
either injury would be compensable.
             Here, Employer contends that Psychologist failed to specifically link
Claimant’s development of PTSD to one specific event. Rather, Psychologist
identified multiple events that contributed to the PTSD, including events that did not
occur in the course of Claimant’s employment. Employer therefore argues that
Psychologist’s failure to unequivocally link Claimant’s PTSD to only work-related
compensable injuries effectively nullifies causation.




                                         23
             Summarizing, Employer asserts that the mere possibility that a work-
related incident contributed to the development of Claimant’s PTSD fails to establish
the required nexus between a work-related injury and a resulting disability necessary
for an award of compensation. Therefore, in light of Psychologist’s allegedly
equivocal testimony regarding causation, and the lack of psychological notes
evidencing a direct correlation between any one event and Claimant’s PTSD,
Employer argues that the WCJ’s determination regarding causation lacks the
necessary evidentiary support. Employer thus maintains that the WCJ’s award of
benefits must be reversed.


                                    2. Analysis
             The WCJ credited Psychologist’s opinions. First WCJ Op., F.F. Nos.
29, 33. In particular, the WCJ noted Psychologist’s outstanding academic and
practice credentials. Id., F.F. No. 33. Psychologist treated and analyzed Claimant’s
case for years. Id. The WCJ found that Psychologist explained the basis for his
opinions and was not merely conclusory. Id. As the sole fact-finder in workers’
compensation cases, the WCJ has exclusive province over issues of credibility and
evidentiary weight. A & J Builders, Inc. v. Workers’ Compensation Appeal Board
(Verdi), 78 A.3d 1233 (Pa. Cmwlth. 2013). The WCJ may accept or reject the
testimony of any witness, including an expert witness, in whole or in part. Id. In
addition, we are bound by the WCJ’s credibility determinations. Id.
             Further, it is irrelevant whether the record contains evidence to support
findings other than those made by the WCJ; the critical inquiry is whether there is
evidence to support the findings actually made. Id. Moreover, we must view the




                                         24
evidence in a light most favorable to the prevailing party and give it the benefit of
all inferences reasonably deduced from the evidence. Id.
             Turning to the issue of causation, we recognize that in cases where the
causal connection between a claimant’s work and his injury is not obvious, the
connection must be established by unequivocal medical testimony. Bemis v. Workers’
Compensation Appeal Board (Perkiomen Grille Corp.), 35 A.3d 69 (Pa. Cmwlth.
2011). Whether an expert’s testimony is unequivocal is a question of law fully
reviewable on appeal. Id. In reaching that determination, we must review the
testimony of a witness as a whole and not take words or phrases out of context. Id.
An expert’s testimony is unequivocal if, after providing a foundation, he states that he
believes or thinks the facts exist. Id. In short, the expert must state not that the injury
or condition may have possibly come from the assigned cause, but rather that in his
professional opinion, the injury or condition did come from the assigned cause. Id.
Nonetheless, the law does not require that every utterance from an expert on a medical
subject be certain, positive, and without reservation or exception. Id. An expert’s use
of words such as “probably,” “likely,” and “somewhat” will not render the opinion
equivocal as long as the expert does not recant his opinion as to causation. Id. at 72.
             Here, Psychologist testified that Claimant did not have PTSD when he
first began treating him in February 2011. First WCJ Op., F.F. No. 19; Greenwald
Dep. at 14; R.R. at 222a. Psychologist further testified that Claimant did not have a
PTSD reaction to the fire victim’s death in 2009 until after Kotecki’s death in
October 2011. First WCJ Op., F.F. No. 19; Greenwald Dep. at 17; R.R. at 225a.
Specifically, Psychologist testified as follows on direct examination:

             Q. [Claimant’s Counsel] At what point in time in the
             timeline do you believe [Claimant] developed [PTSD]?



                                            25
            A. I’ve got that in the second row to the bottom where
            following the death, he not only had similar chest pain and
            he had some symptoms of acute stress, but he began to
            show lots of avoidance. He showed memories of
            nightmares of coming to harm, he had memories of the
            [woman] burning, his emotions were very labile. He had
            symptoms of depression, and so he met criteria for PTSD
            disorder at that time.

            Q. [Employer’s Counsel] Excuse me doctor, when is that
            time?

            A. Immediately following the death of his friend,
            [Kotecki].

Greenwald Dep. at 17-18; R.R. at 225a-26a (emphasis added).
            Further, when questioned by Employer’s counsel on interim cross-
examination as to whether Claimant manifested signs of PTSD prior to Kotecki’s
death and what event was the “tipping point,” Psychologist replied: “I think that he
manifested – according [to] my records and my opinion, he didn’t really meet all the
criteria for PTSD until his friend got killed.” Greenwald Dep. at 34-35; R.R. at
242a-43a (emphasis added). Psychologist explained that Claimant may have had
some of the symptoms of PTSD prior to Kotecki’s death, but he did not have
symptoms in each of the four domains necessary to call it PTSD. Greenwald Dep.
at 37-38; R.R. at 245a-46a. Psychologist added at the end of direct examination that
his opinions were made “within a reasonable degree of psychological certainty.”
Greenwald Dep. at 36; R.R. at 244a.
            However, Employer asserts that on cross-examination, Psychologist
testified that although he was sure that Claimant had PTSD, he could not be certain
as to what exactly was the precipitating cause of Claimant’s PTSD symptoms. See
Greenwald Dep. at 64; R.R. at 272a. In Cerro Metal Products Co. v. Workers’
Compensation Appeal Board (Plewa), 855 A.2d 932 (Pa. Cmwlth. 2004), we


                                        26
reasoned that even if a witness admits to some uncertainty, reservation, doubt or lack
of information with respect to precise details, the witness’s opinion will not be
rendered equivocal if the witness does not recant the opinion first expressed.
             Such is the case here. In particular, the WCJ found: “Importantly,
[Psychologist] was not shaken of his opinions despite meticulous, exacting and expert
cross-examination.” First WCJ Op., F.F. No. 33. At no point did Psychologist recant
his opinion that Claimant did not meet the criteria for PTSD until the shooting death
of Kotecki. Consequently, we reject Employer’s contention that Psychologist’s
opinions were equivocal as to the work-related causation of Claimant’s PTSD. See
Bemis; Cerro Metal Products.

                             C. Substantial Evidence
                                 1. Contentions
             In its final argument, Employer contends that Claimant’s testimony
regarding the effect of Kotecki’s death does not support the WCJ’s finding that the
officer’s death materially aggravated Claimant’s preexisting condition. See First
WCJ Op., F.F. No. 31. To the contrary, Employer maintains that this finding is
unsupported by the record and contrary to Psychologist’s treatment notes.
             More specifically, Employer asserts Claimant did not reference
Kotecki’s death in his claim petition. Also, most of Claimant’s testimony dealt with
how his emotional condition was impacted by his heart health, and his perceptions
as to how badly Employer treated him. What is missing from Claimant’s testimony,
Employer argues, is any explanation of how Kotecki’s death affected Claimant’s
preexisting emotional issues, including his panic attack disorder and depression in
the days and weeks following the incident.         Employer emphasizes that after




                                         27
receiving a 10-day leave, Claimant returned to his regular duties and worked for
months.
             In addition, Employer contends that Psychologist’s treatment notes do
not support the WCJ’s finding that Kotecki’s death materially aggravated Claimant’s
preexisting condition. In particular, Employer asserts: Psychologist’s October 25,
2011 notes, R.R. at 288a, indicate that Claimant was doing well; Psychologist’s
November 15, 2011 notes, R.R. at 287a, make no reference to Kotecki; and
Psychologist’s November 30, 2011 notes, R.R. at 286a, confirm that Claimant was
not experiencing any symptoms of PTSD.
             Summarizing, Employer argues the WCJ’s award was premised on the
fact that Kotecki’s death served as a material contributing factor in producing
Claimant’s PTSD. However, the factual predicates for this determination are simply
not contained in the record. Accordingly, Employer asserts this finding must be
stricken and the WCJ’s award of benefits reversed.


                                    2. Analysis
             As discussed above, Psychologist’s testimony unequivocally established
that Kotecki’s death aggravated Claimant’s preexisting psychological conditions,
which resulted in Claimant’s development of PTSD. As for Claimant’s testimony,
this Court will not attribute professional expertise to a layman who knows only that
something is wrong with him. Borough of Norwood. To that end, PTSD is not an
obvious or common injury apparent to the ordinary claimant. Id.
             Nonetheless, when asked whether he could recall any specific instance,
other than his cardiac incidents and panic attacks, which contributed to his mental
condition, Claimant testified:



                                        28
              There’s been numerous events and suicides and accidents.
              But I guess the biggest one that sticks out in my mind is
              when a coworker was murdered in October 2011 at work.
              I was called out to the scene and helping the other officers
              that were there deal with it. I mean, at that time, I was in
              treatment for anxiety and depression for nine months at
              least.

N.T., 5/6/14, at 31; R.R. at 48a.


              Consequently, the record contains substantial, competent evidence
supporting the WCJ’s findings that Kotecki’s death constituted a tipping point in
Claimant’s development of PTSD. As noted above, prior to that incident, Claimant
had some, but not all of the symptoms needed to meet the criteria for PTSD.
Greenwald Dep. at 37-38; R.R. at 245a-46a. Following Kotecki’s death, Claimant
met all the criteria for a PTSD diagnosis. Greenwald Dep. at 34-35; R.R. at 242a-
43a. As such, the WCJ’s determination that Kotecki’s death was a substantial
contributing factor in Claimant’s development of PTSD is adequately supported by
the record.
              For the same reason, we reject Employer’s contention that
Psychologist’s treatment notes regarding the time frame immediately after Kotecki’s
death indicate that the incident did not cause Claimant’s PTSD. When questioned
about his notes, Psychologist clarified that he knew Claimant was upset about
Kotecki’s death even if his October 2011 notes did not accurately reflect that fact.
Greenwald Dep. at 39; R.R. at 247a. Psychologist explained that he documents
symptoms in his treatment notes, but not necessarily specific diagnostic changes.
Greenwald Dep. at 41; R.R. at 249a.
              Regardless, an expert’s testimony is unequivocal if, after providing a
foundation, he states that he believes or thinks the facts exist. Bemis. Even if an


                                          29
expert admits to uncertainty, reservation or lack of information with respect to details,
an expert’s testimony remains unequivocal so long as the expert expresses a belief
that, in his or her professional opinion, a fact exists. Bemis. Here, Psychologist
testified that he treated Claimant since February 2011, and in his professional opinion,
Claimant showed symptoms meeting the necessary criteria for PTSD following
Kotecki’s death in October 2011.        Thus, we reject Employer’s contention that
inconsistencies in Psychologist’s treatment notes render his opinion equivocal.


                                   III. Conclusion
             For the above reasons, we discern no error in the WCJ’s decision
granting Claimant’s claim petition. Accordingly, we affirm the Board’s order.




                                           ______________________________
                                           MICHAEL H. WOJCIK, Judge




                                           30
        IN THE COMMONWEALTH COURT OF PENNSYLVANIA


City of Lower Burrell,            :
                                  :
                       Petitioner :
                                  :
            v.                    : No. 120 C.D. 2019
                                  :
Workers' Compensation Appeal      :
Board (Babinsack),                :
                                  :
                       Respondent :



                                ORDER
            AND NOW, this 12th day of March 2020, the order of the Workers’
Compensation Appeal Board, dated January 9, 2019, is AFFIRMED.




                                     ______________________________
                                     MICHAEL H. WOJCIK, Judge
