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Note: This is not a policy; it is a supplementary document to illustrate how the WSIB will administer the Workplace Safety and Insurance Act, 1997 (WSIA) and Policy 11-01-05, Determining Permanent Impairment in practice. If there is a conflict between this Administrative Practice Document and the WSIA and/or WSIB policy, the decision-maker will rely on the WSIA and/or WSIB policy.
Key principles
- Decision-makers gather relevant information and weigh evidence to make adjudicative decisions, including a likely permanent impairment.
- When assessing and weighing medical evidence, decision-makers are guided by the administrative practice document on weighing of medical evidence.
- Workers are entitled to receive benefits for injuries and illnesses that result from accidents that arise out of and in the course of employment.
- Work-relatedness is established when determining initial entitlement. Decision-makers continue to evaluate the work-relatedness of a worker’s ongoing impairment and treatment throughout the life of a claim.
- Return to work is part of the recovery process and acting early can assist in achieving full recovery and minimizes the likelihood or degree of a permanent impairment.
- Workers are entitled to a non-economic loss (NEL) benefit for permanent impairments resulting from work-related injuries or illnesses.
- The American Medical Association’s Guide to the Evaluation of Permanent Impairment (AMA Guides), clearly distinguishes between impairment (what is wrong with a body part or organ system and its functioning) and disability (alteration of the ability to meet personal, social, or employment demands).
- The WSIB makes its decisions based on the merits and justice of each case.
Definitions
Maximum medical recovery (MMR) occurs when there is a plateau in recovery and it is not likely that there will be any further significant improvement in the work-related injury or illness.
Significant improvement refers to a marked degree of improvement in the work-related impairment that is demonstrated by a measurable change in objective clinical findings.
Impairment means a physical or functional abnormality or loss, including disfigurement, which results from an injury and any psychological sequelae arising from the abnormality or loss.
Permanent impairment is evident when the impairment continues to exist after MMR is reached.
Pre-existing condition is any condition that existed prior to a work-related injury, and may include injuries, illnesses, degenerative conditions and psychiatric conditions. The existence of the condition must be confirmed by pre-injury or post-injury clinical evidence and may have been evident prior to the work-related injury or it may become evident afterward. See more information on pre-existing conditions.
Impairment
As noted in Policy 11-01-05, Determining Permanent Impairment, impairment is defined as a physical or functional abnormality or loss, including disfigurement, which results from an injury and any psychological damage arising from the abnormality or loss. WSIB considers a:
- physical abnormality: a change to or damage to a body part or organ system
- physical loss: a loss of some or all of a body or organ system
- functional abnormality: a malfunction of a body part or organ system
- functional loss: a loss of some or all of the functioning of a body part or organ system,
- disfigurement: an altered or abnormal appearance such as an alteration of colour, shape, structure, or a combination of these
- psychological damage: a mental condition resulting in a decline in psychological or cognitive functioning arising from the workplace injury, abnormality or loss
Introduction
Decision-makers at the WSIB must decide a worker’s entitlement to benefits and services under the Workplace Safety and Insurance Act, 1997 (WSIA). Decision-makers collect information and weigh evidence to make adjudicative decisions at the initial entitlement stage and throughout the life of the claim.
The WSIB has adopted the evidence-based principle of “Better at Work” to guide our approach in case management. This approach recognizes the importance of timely access to health care, integrated with return to suitable and safe work to realize optimal recovery. The goal of case management is to help worker’s achieve full recovery and return to work from the work-related injury or illness and reduce the likelihood or degree of a work-related permanent impairment.
A key adjudicative decision is the determination of when MMR of a work-related injury or illness is achieved. When MMR is achieved, decision-makers must then determine if the worker has made a full recovery or if there is evidence of a work-related permanent impairment. In some cases, such as an amputation, evidence of permanent impairment may be known before MMR is achieved.
This document focuses on the approach for determining MMR and a work-related permanent impairment. In making these determinations, decision-makers are guided by Policy 11-01-05, Determining Permanent Impairment.
Maximum medical recovery
MMR is an adjudicative decision made by decision-makers based on the information contained in the claim file.
Decision-makers:
- Must gather all relevant information that is available with respect to a case to make entitlement and case management decisions.
- Review and assess the clinical information to monitor the worker’s recovery.
- While monitoring recovery consider whether MMR is reached, as it is not always clearly specified in medical reports.
MMR decisions are made on a case-by-case basis because even for the same injury or illness, there is variability in recovery and recovery times.
Considerations for determining maximum medical recovery
The MMR date must be supported by clinical information on file. Decision-makers must assess and weigh all the information on file, satisfied that further significant improvement in the work-related injury or illness is not likely to occur after the selected date.
A significant improvement is one that is noticeable as evidenced by a measurable change in objective clinical findings.
When determining MMR, the WSIB considers if:
- the worker is receiving, or further active treatment is recommended with clear expectations of significant improvement in their function, mobility, stability and/or strength relative to the work-related injury or illness
- the worker received adequate treatment for the nature and severity of the injury or illness
- further diagnostic or investigative studies are being recommended to clarify the extent or severity of the injury or illness
- surgery is scheduled, being considered or proposed by a treating health practitioner
- there is a pre-existing or other non-work related condition that, if treated, would allow additional improvement in the work-related injury or illness
A worker may reach MMR while still receiving treatment, when the likelihood of significant improvement is low.
Information that indicates MMR has been achieved includes, but is not limited to:
- Return to work with no further active medical interventions
- Specialist report indicating the worker has been discharged with no further treatment, surgery or diagnostics required or contemplated
- Treatment discharge report recommending no further treatment, a home maintenance program, no medical intervention, or follow-up
- Treatment of the pre-existing or other non-work-related condition, which posed a barrier to recovery from the work-related injury or illness, is unlikely to cause significant improvement in the work-related injury or illness
- Recommendation for additional treatment but with no clear expectation of functional improvement and/or medication reduction
- Clinical progress reports do not reveal any significant change over time
- When the worker is no longer in treatment as they self-discharged
Where the clinical information on file does not provide sufficient details or is unclear, decision-makers can request the assistance of the Nurse Consultant. The Nurse Consultant can assist the decision-maker in understanding the medical information that is on file and/or identifying outstanding information that the decision-maker may need to obtain to make a decision on MMR. In complex cases, Nurse Consultants or decision-makers may also request the assistance of an Occupational Health Assessment Program (OHAP) case consultation physician. When assessing and weighing medical evidence, decision-makers are guided by the administrative practice document on weighing of medical evidence.
In most cases, where the workplace accident resulted in multiple injuries or illnesses, MMR is reached when further improvement is not likely to occur in any of the work-related injuries or illnesses.
When there is evidence of a pre-existing or other condition(s), work-related and non-work related, that may be contributing to or enhancing the impairment to the area of the work-related injury or illness, all conditions should generally have reached MMR.
Determining permanent impairment
Decisions on permanent impairment should generally not be made until it’s determined the worker has reached MMR. Decision-makers must determine whether a permanent impairment after MMR is likely, and whether the continuing impairment is due to the work-related injury or illness.
The existence of impairment should be established based on clinical findings found in the medical records. An objective clinical finding is a sign that can be seen, heard, felt by touch, and/or measured by a health care professional. Objective clinical findings of impairment may include:
- objective clinical findings of physical loss or abnormality
- objective clinical findings of functional loss or abnormality
- evidence of complication of healing
- abnormal neurological findings
- abnormal range of motion
- abnormal radiological findings
In the absence of objective clinical findings of impairment, factors such as pain complaints and the duration or perceived severity of the condition are not considered indicators of impairment. For example, surgery is a therapeutic intervention intended to improve or fully restore function; however, it is not the sole indicator of permanent impairment. The post-operative outcome of the surgery, specifically the functional recovery and associated objective clinical findings must be assessed to determine if there is an ongoing impairment.
In psychological injuries, subjective reporting is important information that is included in decision making, along with more objective and observable markers. This may include:
- Impairments in psychological or cognitive functioning related to the work-related injury
- Residual psychological symptoms related to the work-related injury
- Psychological vulnerability in terms of relapse and resurgence of psychological symptoms related to the psychological injury
Where the accident resulted in more than one area of injury or illness, decision-makers must assess the objective clinical findings for each injury or illness to determine whether ongoing impairment after MMR is likely. As the injury or illness reaches a different level of recovery, decision-makers may conclude there is no evidence of ongoing impairment, or ongoing impairment is evident for some or all of the injuries or illnesses. Decision-makers must clearly specify the area(s) of injury or illness with clinical evidence of ongoing impairment.
A worker is recovered if there is no evidence of ongoing impairment due to the work-related injury or illness when MMR is reached.
Determining work-relatedness
If there is evidence of ongoing impairment when MMR is reached, decision-makers must determine if it is a result of the work-related injury or illness. Decision-makers must consider:
- whether the current diagnosis is the same as or compatible with the initial work-related injury or illness diagnosis,
- whether the clinical evidence of impairment is related to the current diagnosis, and
- whether a pre-existing condition or other non-work-related factor is causing or contributing to the ongoing impairment.
Where the clinical evidence of impairment is related to the current work-related diagnosis, and there is no evidence of a pre-existing condition or other non-work-related factor causing or contributing to the ongoing impairment, the ongoing impairment is considered work related.
When information is received, indicating the worker has a pre-existing or other condition(s) that may be causing or contributing to their ongoing impairment, decision-makers will collect all relevant information, including the relevant medical reports and clinical records, about the pre-existing or other condition(s). The clinical information is of particular importance when determining the impact of the pre-existing or other condition(s) on the ongoing impairment resulting from the work-related injury or illness and the worker’s entitlement to continuing benefits. Decision-makers can refer to 15-02-03, Pre-existing Conditions and 15-06-08, Adjusting Benefits Due to Post-accident, Non-work related Change in Circumstances.
Decision-makers must carefully review the clinical evidence relating to the work-related injury or illness and the pre-existing or other condition(s) to differentiate the objective clinical findings. There must be evidence of objective clinical findings compatible with the work-related injury or illness to consider the ongoing impairment.
When the clinical evidence indicates the work-related injury or illness and a pre-existing condition or non-work related condition are contributing to the total impairment to the area, the impairment resulting from the work-related injury or illness must be delineated from the impairment resulting from the pre-existing or non-work-related condition(s). At MMR, the decision-maker must decide which of the conditions contributing to the same area of impairment are considered work-related vs. non-work related. Workers are only compensated for the permanent impairment resulting from the work-related injury or illness. See 18-05-03, Determining the Degree of Permanent Impairment for more information. If the pre-existing condition or non-work-related condition was exacerbated or aggravated by the work-related injury or illness, and persists at MMR, the decision-maker must delineate entitlement for a permanent exacerbation or aggravation of the condition.
If the ongoing impairment is caused solely by a pre-existing condition and/or non-work-related factor, there is no work-related permanent impairment.
Conclusion
As outlined in Policy 11-01-05, Determining Permanent Impairment, decision-makers must confirm that:
- MMR is reached,
- evidence of ongoing impairment exists, and
- the ongoing impairment is a result of the work-related injury or illness.
When decision-makers determine MMR is reached and is likely a work-related permanent impairment, the worker’s entitlement to non-economic loss benefits is determined.
Document history:
April 2023 – Reviewed
August 2015 – replaces Adjudicative Advice, Determining Maximum Medical Recovery, February 2006.