A worker is entitled to benefits when disability/impairment results from a work-related personal injury by accident. Disability/impairment includes both physical and emotional disability/impairment.
The purpose of this policy is to provide entitlement guidelines for claims for psychotraumatic injuries.
If it is evident that a diagnosis of a psychotraumatic disability/impairment is attributable to a work-related injury or a condition resulting from a work-related injury, entitlement is granted providing the psychotraumatic disability/impairment became manifest within 5 years of the injury, or within 5 years of the last surgical procedure.
Psychotraumatic disability/impairment is considered to be a temporary condition. Only in exceptional circumstances is this type of disability/impairment accepted as a permanent condition.
Psychotraumatic disability/impairment resulting from organic brain damage is assessed as a permanent disability/impairment.
Psychotraumatic disability entitlement
Entitlement for psychotraumatic disability may be established when the following circumstances exist or develop
- Organic brain syndrome secondary to
- traumatic head injury
- toxic chemicals including gases
- hypoxic conditions, or
- conditions related to decompression sickness.
- As an indirect result of a physical injury
- emotional reaction to the accident or injury
- severe physical disability/impairment, or
- reaction to the treatment process.
- The psychotraumatic disability is shown to be related to extended disablement and to non-medical, socioeconomic factors, the majority of which can be directly and clearly related to the work-related injury.
The following relevant points are evaluated in assessing the extent of psychotraumatic disability entitlement.
In all cases where history of a prior psychiatric condition is shown to exist, the question of allowance on an aggravation basis is considered, having regard for the emotional effect of the occupational occurrence and a condition resulting from the work-related injury (see 15-02-04, Aggravation Basis).
Unrelated psychiatric disability
In some cases, psychiatric disability/impairment may become apparent in an otherwise uneventful case, and enquiry establishes its origins to other factors (such as family crisis), having no relationship whatsoever to the accident.
The WSIB may pay for the concurrent treatment for a worker if, by doing so, substantial payments under the insurance plan can be avoided. See 17-03-04, Health Care for Non-work-related Conditions.
The decision-maker is responsible to recognize cases where a psychotraumatic condition develops. The WSIB's clinical staff may be consulted to assist in making this determination.
The decision-maker reviews all reports, such as
- Worker's Progress Reports
- Health Professional's Progress Reports
- psycho-vocational assessments
- correspondence, and
- all clinical documentation, watching for the following information
- diagnostic labels or impressions suggestive of psychotraumatic conditions
- personality-related emotional reactions, i.e., the worker's attitudinal response to the accident, and reaction to the treatment process
- "psychogenic" or "functional overlay", while not a diagnostic entity, this term is often used to indicate an exaggeration of, and/or magnification with respect to the residual physical impairment
- prior problems, i.e., a history of pre-existing psychiatric conditions including documentation of previous hospitalization(s) and/or treatment
- prolonged recovery in relation to the physical injury, and
- prescribed drug therapy, pain controlling agents, or psychotropic drugs.
Appropriate clinical management of the organic disability/impairment is essential in the early stages and will aid in the recognition, diagnosis and treatment of a psychotraumatic disability/impairment.
Rating Pre-1990 claims - methods of determining entitlement
The following guidelines relate to Permanent Disability (PD) Benefits (Accidents before 1990). For information on assessing (rating) permanent impairment due to mental and behavioral disorders for accidents occurring on or after January 2, 1990, see 18-05-11, Assessing Permanent Impairment Due to Mental and Behavioural Disorders.
Psychotraumatic and behavioural disorders rating schedule
The following criteria apply to the assessment of permanent disability awards for psychotraumatic disability, chronic pain disability, and fibromyalgia syndrome(see 15-04-04, Chronic Pain Disability Rating Schedule).
Category 1 - minor impairment of total person (10%)
In this category, the injured worker's daily activity is slightly limited and no apparent difficulties are reported in personal adjustment. There is also some loss in personal or social efficacy and the secondary psychogenic aggravations are caused by the emotional impact of the accident.
A mild anxiety reaction is apparent. The display of symptoms indicate a form of restlessness, some degree of subjective uneasiness and tension caused by anxiety. There are subjective limitations in functioning as a result of the emotional impact of the accident. The disability, from the psychiatric point of view, is not expected to be permanent.
Category 2 - moderate impairment of total person (15% - 25%)
In this category, the worker is still capable of looking after personal needs in the home environment but, with time, confidence diminishes and the worker becomes more dependent on the members of the family in all activities which take place outside the home. The worker demonstrates a moderate, at times episodical, anxiety state, agitation with excessive fear of re-injury, nurturing strong passive dependency tendencies.
The emotional state may be compounded by objective physical discomfort with persistent pain, signs of emotional withdrawal and depressive features, loss of appetite, insomnia, chronic fatigue, low noise tolerance, mild psychomotor retardation and definite limitations in social and personal adjustment within the family. At this stage, there is a clear indication of psychological regression.
Category 3 - major impairment of total person (30% - 50%)
In this category, the worker displays a severe anxiety state, definite deterioration in family adjustment, incipient breakdown of social integration, and longer episodes of depression. The worker tends to withdraw from the family, develops severe noise intolerance and a significant diminished stress tolerance. A phobic pattern or conversion reaction will surface with some bizarre behaviour, a tendency to avoid anxiety-creating situations, with everyday activities restricted to such an extent that the worker may be homebound or even room-bound at frequent intervals.
Category 4 - severe impairment of total person (60% - 80%)
In this category, the worker clearly displays a chronic and severe limitation of adaptation and function in the home and outside environment.
The worker is withdrawn, forgetful, unable to concentrate, and needs continuous emotional support within the family setting. The worker is incapable of self-care and neglects personal hygiene.
There may be an obvious loss of interest in the environment and the worker becomes extremely irritable, showing significant emotional liability, changes of mood and uncontrolled outbursts of temper. The worker may be severely depressed with outstanding features of psychomotor retardation and psychological regression. The worker is usually homebound or even room-bound.
Types of awards
Once entitlement for a psychotraumatic disability is determined, the recommendations may be
- provisional pension for a term with review, or
- PD benefit for the duration of disability which is combined with organic award.
If entitlement is granted for a provisional pension, the decision-maker indicates the quantum, the arrears date to be paid, and refers the claim for organic disability assessment (providing minimum referral time for the organic disability has elapsed). See 18-07-01, Determining the Degree of Disability.
Following the organic disability assessment, the combined pension for the disabilities is processed. As with provisional pensions, the quantum of the pension, and the arrears date to be paid, are indicated.
Review of provisional pensions
Prior to the expiry of a provisional psychotraumatic pension, the decision-maker refers the file to WSIB clinical staff and arranges a psychiatric reassessment of the disability.
If there is no relationship to the accident or a condition resulting from the work-related injury and there is no permanent or physical disability, the decision-maker informs interested parties of benefit closure.
Second injury and enhancement fund relief
In claims for psychotraumatic disability, the WSIB policy regarding the aggravation of pre-existing conditions and application of the Second Injury and Enhancement Fund (SIEF) is applied.
If a permanent disability pension or non-economic loss benefit is made for psychotraumatic disability/impairment following brain damage due to trauma, relief of costs under the SIEF does not usually apply.
This policy applies to all decisions made on or after September 1, 2018, for all accidents.
This document replaces 15-04-02, dated October 14, 2009.
This document was previously published as:
15-04-02 dated November 3, 2008
15-04-02 dated March 15, 2005
15-04-02 dated October 12, 2004
03-03-03 dated October 30, 1990.
Workplace Safety and Insurance Act, 1997, as amended
Sections 2(1)(c), 13(1), 33
Workers' Compensation Act, R.S.O. 1990, as amended
Sections 1(1)(c), 4(1), 24
Workers' Compensation Act, R.S.O. 1980, as amended
Sections 1(1)(a)(iii), 3(1), 23
#2, September 5, 2018, Page 562