Policy
In cases where the worker has a pre-accident impairment and suffers a minor work-related injury or illness to the same body part or system, the WSIB considers entitlement to benefits on an aggravation basis.
Generally, entitlement is considered for the acute episode only and benefits continue until the worker returns to the pre-accident state.
Guidelines
Decision-makers should first determine entitlement in the claim (see 15-02-02, Accident in the Course of Employment). Then this policy is used where a relatively minor accident aggravates a significant pre-accident impairment. The intent is to limit entitlement to the injury that is work-related. If a claim is allowed on an aggravation basis, the claim is paid for the acute episode only (temporary period of time) and entitlement ends when the worker's condition returns to the pre-accident state.
Entitlement is not limited in cases where there is no pre-accident impairment, or the severity of the accident/exposure on its own would have resulted in additional impairment. This is the case where the impairment is temporary or permanent despite the presence of the pre-accident impairment.
Definitions
An aggravation is the effect that a work-related injury/illness has on the pre-accident impairment requiring health care and/or leading to a loss of earning capacity.
A loss of earning capacity is the difference between the worker's net average earnings before the work-related injury/illness, and the net average earnings the WSIB determines the worker is capable of earning after the work-related injury.
A minor accident is one that, in the absence of a pre-accident impairment, would be expected to cause a non-disabling or minor disabling injury or illness.
A pre-accident impairment is a condition, which has produced periods of impairment/illness requiring health care and has caused a disruption in employment. (Although the period of time cannot be defined, a decision-maker may use a one to two year timeframe as a guide.)
NOTE
For the purpose of this policy, pre-accident disability refers to a pre-accident impairment plus a loss of earning capacity.
As defined in 14-05-03, Second Injury and Enhancement Fund (SIEF), a pre-accident disability is a condition which has produced periods of disability (impairment/illness/wage loss) in the past requiring treatment and disrupting employment.
A pre-accident state is the worker's level of impairment and work capacity prior to the work-related injury.
Aggravation basis - determining entitlement
Entitlement in a claim is accepted on an aggravation basis when
- a relationship is shown between the pre-accident impairment and the degree of impairment resulting from the accident, and
- an increased degree of impairment occurs, which exceeds the usual, owing to the pre-accident impairment.
Decision-makers are required to evaluate the severity of the accident by the accident history. (For further information, see Second Injury and Enhancement Fund (SIEF), 14-05-03). When a minor accident (see "Definitions" in this policy) aggravates a pre-accident impairment, benefits are paid until the worker's condition returns to the pre-accident state.
Determining pre-accident impairment
Before the allowance on an aggravation basis is considered, decision-makers must determine if a pre-accident impairment exists. Evidence of this includes, but is not limited to, a worker having
- a previously identified and symptomatic medical condition/impairment,
- medical precautions/restrictions and performing modified work prior to the accident,
- receiving regular health care treatments prior to the accident,
- lost time from work prior to the accident.
This information can be obtained by reviewing
- prior health care documentation (e.g., x-rays, hospital records, operative reports)
- prior claim(s)
- statements from the worker, the employer, or co-workers
- employment records.
Example - Pre-accident impairment
Jim suffered a work-related injury on November 1, 2001, when he twisted slightly getting out of his chair. The doctor's diagnosis was soft tissue strain superimposed on severe Degenerative Disc Disease (DDD), and facet joint arthritis. Jim received chiropractic treatment monthly prior to the accident and had medical restrictions requiring permanent modified work. Jim's back improved to the point where he was able to return to the pre-accident employment on March 1, 2002.
Jim aggravated a pre-accident impairment on November 1, 2001. In this case, Jim is entitled to benefits for the acute phase only. Jim's pre-accident impairment returned to its pre-accident state on March 1, 2002. As a result, there is no further entitlement to benefits after March 1, 2002.
Example - No pre-accident impairment
Bob suffered a work-related back injury on March 1, 2002, when he fell 10 feet off a scaffold. He was unable to return to return to his pre-accident employment because of the fall. Bob has a history of back problems and required surgery in 1985. At the time of the accident, Bob was working as a carpenter with no medical restrictions or medical treatment and was only observing proper back care.
Bob sustained a moderately severe back injury on March 1, 2002. He did not have a pre-accident impairment and therefore is entitled to ongoing benefits and services. In this case, there is no limitation of entitlement.
New accident vs. recurrence
If the pre-accident impairment is due to a work-related injury/illness, further entitlement may be allowed as a recurrence. This would occur where it is difficult to identify a specific incident or action that has increased the worker's impairment.
Otherwise, a claim that is allowed on an aggravation basis should have a clearly defined new accident (incident). Decision-makers must establish that the work-related injury/illness would have caused the additional impairment, despite the pre-accident impairment.
When determining whether a worker has suffered a new accident or a recurrence of a prior accident, the decision-maker has to consider the following
- the nature of the subsequent occurrence
- medical evidence/medical compatibility
- evidence of continuity between the two injuries
- the time lapse between the two injuries.
For more information, see 15-03-01, Recurrences.
Ongoing benefits
Decision-makers are responsible for limiting entitlement in claims allowed on an aggravation basis. The worker's clinical status is monitored to determine if the worker has reached the pre-accident state. If a worker remains off work after reaching the pre-accident state, the decision-maker discontinues benefits and advises the worker.
Permanent impairment
In some cases, workers never return to the pre-accident state. If there is a permanent worsening of the pre-accident impairment, the decision-maker may determine that the work-related injury/illness has permanently aggravated the pre-accident impairment. If medical evidence confirms that the work-related injury/illness permanently increased the worker's pre-accident impairment, the worker may be entitled to a non-economic loss benefit. (For more information, see 18-05-03, Determining the Degree of Permanent Impairment).
Once only repair
In some cases, claims are allowed for once only repair, (e.g., strangulated hernia or recurrent shoulder dislocation). The allowance of a claim on this basis recognizes that a work-related injury did occur, but that the required treatment and period of impairment were due, at least in part, to a pre-accident impairment.
Example - Once only repair
Susan dislocates her shoulder in a work-related accident. The medical reports indicate a long history of prior dislocations. The only effective treatment is to surgically repair the shoulder. The decision-maker may approve the repair on a once only basis provided it is the only effective form of treatment and the surgery was not recommended prior to the work-related injury.
Special cases
For some exceptional conditions, there may be some limitations in entitlement.
See 15-03-10, Heart Conditions
See 15-04-08, Hernia
See 15-04-02, Psychotraumatic Disability
See 15-04-12, Fume Toxicity-TD1
See 16-02-03, Skin Diseases
Cost relief
Since the pre-accident impairment significantly contributes to the work-related injury/illness, Schedule 1 claims allowed on an aggravation basis receive immediate SIEF cost relief. (For more information, see14-05-03.)
Application date
This policy applies to all decisions made on or after January 1, 2005, for all claims.
Document history
This document replaces 11-01-15 dated January 5, 2005.
References
Legislative authority
Workplace Safety and Insurance Act
Sections 13(1), 43(1), 46(1), 118
Workers' Compensation Act, R.S.O. 1990, as amended
Section 108(2)
Minute
Administrative
#2, May 26, 2008, Page 460