WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
Decision Number: 20140003 Decision Date: December 16, 2014
Objecting Party: Worker Represented by: Worker Representative
Respondent: Employer Represented by: Employer Representative
Hearing: Hearing in Writing Heard by: C. Marr, Appeals Resolution Officer
ISSUES
The worker is objecting to the following decisions:
- The denial of benefits for Major Depressive Disorder as a psychotraumatic disability.
- The denial of benefits for Chronic Pain Disability (CPD).
- The denial of coverage for a non-professional escort to attend medical appointments subsequent to August 15, 2013.
HOW THE ISSUES ARISE
On May 18, 2012 this peer support worker slipped on a wet spot on the floor, falling on her right side. She sustained injuries to her right hip and low back. She was 53 years of age at the time.
The worker’s compensable low back injury resolved, but after extensive physiotherapy treatment and consultations with multiple specialists she was found to have a permanent impairment as a result of her work-related right hip trochanteric bursitis. She was assessed with a seven percent Non-economic Loss (NEL).
The worker expressed difficulty driving herself to medical appointments due to her right hip injury and requested coverage for a non-professional escort. This was approved for a period, but as outlined in correspondence dated October 16, 2013 the Case Manager (CM) denied coverage for a non-professional escort for medical appointments beyond August 15, 2013. The worker objected to this decision. The decision was reconsidered and upheld on February 20, 2014. It is noted that an escort was approved for the worker’s assessment at the Centre for Addiction and Mental Health (CAMH) in February 2014.
The worker claimed to have developed psychological issues related to her ongoing compensable disability. The CM determined that the worker’s Major Depressive Disorder (depression) is not the result of her compensable accident and injury under this claim. Entitlement to benefits for a psychotraumatic disability was denied as explained in correspondence dated May 16, 2014. The CM also denied benefits for CPD. The worker objected to this decision. The issues in dispute are now before me.
AUTHORITY
Operational Policies
11-01-15 Aggravation Basis dated July 18, 2008 15-04-02 Psychotraumatic Disability 15-04-03 Chronic Pain Disability 17-01-08 Escorts 17-01-09 Travel and Related Expenses
RESOLUTION METHOD AND PROCESS
Hearing in writing.
ASSESSMENT OF THE EVIDENCE
I have carefully considered all of the available information and the relevant operational policies in reaching my decision.
Psychotraumatic Disability
I am unable to establish that the worker’s depression is directly related to the accident and injury under this claim.
The worker had a symptomatic psychological condition in the pre-accident period. The physician’s chart notes from March 25, 2010 to the immediate post-accident period are on file. She was diagnosed with depression and an adjustment disorder in 2010 and 2011. The worker participated in psychological treatment and was also treated with medications. She reported symptoms of anxiety, disrupted sleep, crying and forgetfulness. She related her condition to stress and conflict in the workplace. The worker expressed that she felt her supervisor may be planning to terminate her employment. She was planning to seek a new job. The worker’s last visit to her doctor in the pre-accident period was on February 27, 2012, at which time she continued to report fatigue and a variable mood. The worker saw her family doctor for psychological issues approximately every three months in the two years prior to the workplace accident.
The worker informed the psychologist and psychiatrist at the Centre for Addiction and Mental Health (CAMH) that she was the victim of physical and sexual abuse as a child and young adult. She was later married for ten years to a man who abused her physically and emotionally. As a result she had a psychiatric hospitalization for a week in November 1997 and had weekly therapy sessions for a five-year period beginning in 2004. She reported having chronic intermittent suicidal ideation since she was a child.
The worker did not disclose this history to other treating practitioners. The evaluating physician at the Regional Evaluation Centre (REC) on June 4, 2013 documented that the worker “did not report any emotional problems such as depression or anxiety in her past history.” The worker was treated by a psychologist for approximately six sessions beginning in June 2013. There is no indication on the two reports from this psychologist that the worker disclosed her extensive history of trauma and psychological treatment. This certainly could have influenced the psychologist’s opinion on the etiology of the worker’s psychological condition.
Having a history of psychological trauma or a symptomatic pre-accident psychological condition does not preclude a worker from receiving benefits under the psychotraumatic disability policy if the workplace accident and injury can be shown to have caused the worker’s subsequent psychological disability.
The workplace accident was not objectively traumatic. A slip and fall at ground level would not normally be expected to result in an adverse emotional or psychological response. The nature of the worker’s compensable injury would also not be expected to cause an immediate emotional response. Her physical injury was not severe. She did not require surgical intervention and the treatment process was non-invasive and uncomplicated.
Within two weeks of the date of injury the worker reported to the Case Manager (CM) that she was overwhelmed by stress. On June 6, 2012 she contacted the CM in tears to express frustration with the handling of her claim and that she was “giving up”. The employer informed the CM that the worker did not work her shift on June 30, 2012 as she “mentally” and “emotionally” could not perform her duties, even if she physically was capable of sedentary work.
The worker reported that by July 2012 she was suicidal. She created a plan and had initiated the plan before stopping herself. She informed the psychiatrist at CAMH that the combination of her injury and feeling of helplessness served to draw out the feelings she had when she was abused growing up, trigging a recurrence of her suicidal feelings.
This emotional response is not compatible or in line with the severity of the workplace accident and the resulting injury. A slip and fall from ground level resulting in a soft tissue injury to the right hip would not normally trigger an emotional response within weeks of the incident leading to suicidal ideation two months later. The worker’s psychological condition was not due to an emotional response to a severe accident or injury or the treatment process.
While she ultimately was found to have a permanent impairment as a result of her compensable injury, I also cannot determine that the worker’s psychological condition was an emotional response to an extended disablement. The emotional reaction began in the acute phase of the injury when the worker was just beginning physical rehabilitation and medical investigations, long before her disablement could be considered to be extended.
When combined with her significant prior history, her depressive state in the immediate pre-accident period and her concurrent conflict with her employer and her anger about how she feels her WSIB claim was handled, I cannot establish that the worker’s depression is the result of her compensable right hip injury. The worker is not entitled to benefits for a psychological condition under this claim.
Chronic Pain Disability
In order to be eligible for benefits under WSIB Operational Policy 15-04-03 Chronic Pain Disability, all five of the criteria outlined in the policy must be met. In this case, I find that the criterion stipulating that the degree of pain must be inconsistent with the organic findings has not been met.
The worker was determined to have a permanent impairment as a result of her compensable organic condition, diagnosed as right hip trochanteric bursitis. She was assessed as having a seven percent NEL for this condition. As there is evidence of a permanent organic impairment, it is expected that the worker would have a degree of pain and discomfort on a regular and ongoing basis.
The worker’s reported pain levels fluctuated in the post-accident period. When she was first assessed at the REC within four weeks from the date of injury she reported her hip pain as being “ten” on a scale to ten. She perceived her injury as having improved 70 percent by that time. The worker was re-evaluated at the REC on September 5, 2012. At this time her pain levels varied between three and eight out of ten but she felt she had made no improvement since she was first injured. The orthopaedic specialist reported that the worker had “definite improvement” after a cortisone injection administered the day after the REC. Subsequent injections helped a great deal. By November 15, 2012 she told the orthopaedic specialist that she continued to improve and he noted that a lot of her resting pain was gone.
The worker stopped taking medications to manage her pain by September 2012, which is also when she reported increased symptoms at the second REC assessment. She reported that anti-inflammatory medications aggravated her asthma condition so she had to discontinue using these. It does not appear as though other types of medications were used to manage her pain. It was recommended that she see a doctor who specializes in pain management. She did have a good response to the cortisone injections, suggesting that her organic symptoms may be medically manageable to a degree.
The worker was assessed at the WSIB Hip & Knee Specialty Program on several occasions. As part of the initial assessment at this clinic the worker was administered several questionnaires. The worker’s pain score was rated as eight out of ten on one test, which the clinic interpreted as being “consistent with [the] diagnosis and objective findings.”
There are clinical findings to support the degree of impairment from her organic condition. The range of motion of the right hip was decreased in terms of extension, abduction and internal rotation. There was documented evidence of swelling of the hip on clinical examination. The worker reported increased symptoms with certain physical activities. A different orthopaedic surgeon, expressed that the worker continued to have a “soft tissue component” to her pain eleven months post-accident and recommended further physical rehabilitation.
There is objective clinical evidence to support her pain symptoms. The degree of pain is consistent with the degree of organic impairment, particularly when it is considered that the pain is not being managed with any type of medication. Therefore, the worker is not entitled to benefits under the CPD policy.
Non-medical Escort Fees
According to the Appeal Readiness Form completed by the worker representative on September 8, 2014, the worker is objecting to the February 20, 2014 decision regarding coverage for a non-professional escort (written as simply “escort” below). This decision is a confirmation of the October 16, 2013 CM decision in which escort fees for medical appointments after August 15, 2013 was denied. Escort fees were paid for numerous appointments prior to August 15, 2013 and I note that an escort was approved for the worker to attend assessments at CAMH in February 2014. It appears that some discretion has been applied when considering escort requests subsequent to the decision that is in dispute and currently before me, which is appropriate.
WSIB Operational Policy 17-01-08 Escorts, states in part that non-professional escorts can be approved, “if the worker must be accompanied for legal or basic clinical reasons.” There are no known legal reasons as to why this worker needs to be accompanied to her medical appointments. She requested an escort in part because she wanted her spouse to attend the appointments with her, but she primarily reported wanting one as she has a poor driving tolerance due to her compensable injury.
The worker has a valid driver’s licence. Her licence was not medically suspended. The worker states that her physician chose not to suspend her licence as it is administratively challenging to get the suspension lifted. This suggests that the expectation was that any suspension would be temporary, perhaps during the acute phase of injury and recovery. By August 2013 this acute period had passed and maximum medical recovery (MMR) for the worker’s injury was achieved. That the worker’s licence was not suspended means that it is safe for her to operate a motor vehicle. There is indication in the claim file that the worker does drive.
The specialists who assessed the worker at the WSIB Hip & Knee Specialty Program in April 2013 and at the REC on June 4, 2013 indicated that there were no medical restrictions for the worker’s right hip injury. She had functional tolerance limitations for standing and walking.
WSIB Operational Policy 17-01-09 Travel and Related Expenses, states in part that “practicality, expedience and clinical necessity are considered when determining the mode of transportation.” Travel expenses are payable for travel to medical appointments directed or approved by the WSIB.
It is reasonable to expect that sitting and operating a motor vehicle for an extended period would be problematic given the worker’s right hip impairment. The worker attended physiotherapy and was followed by a specialist in the Cornwall area. She claimed that travel from her residence to Cornwall is 45 kilometres in one direction. Driving this distance is within her physical capabilities as determined by the orthopaedic specialist at the specialty clinic and the physical and rehabilitation specialist at the REC. Escort fees for travel to the Cornwall area are not payable after August 2013, unless there is specific medical intervention being performed (such as a cortisone shot) that would preclude the worker from being able to drive herself back home.
The worker claimed that the psychologist she saw in Grenville, Quebec was located 81 kilometres from her home. An internet search shows that the most direct route is approximately 60 kilometres from her home, in one direction, with an estimated travel time of less than one hour on this route. I also find that this time and distance would be reasonable for the worker to travel without an escort. An escort for these appointments is not approved.
If the worker is approved for travel to medical assessments beyond this geographic area then an escort should be allowed. This is the rationale the CM presumably used in approving the escort for the worker’s assessments at CAMH.
As MMR for her injury was achieved by August 2013 and her symptoms are not being managed with medications, the worker likely did not have much need to see her family doctor for her compensable condition after this period. The worker’s family doctor is located far from her home. The issue of whether coverage for travel expenses to a family doctor outside of her geographic area is appropriate is not before me. If the Operating level determines that travel expenses for visits to the family doctor are in order under this claim, then an escort for these trips should also be approved.
Therefore, subsequent to August 15, 2013, where travel expenses for medical appointments are approved under the claim and the distance travelled is greater than approximately 60 kilometres in one direction, a non-professional escort is approved.
CONCLUSION
- The worker does not have entitlement to benefits for depression or a psychotraumatic disability under this claim.
- The worker does not have entitlement to benefits for Chronic Pain Disability.
- Subsequent to August 15, 2013, a non-professional escort is approved when the worker is travelling to WSIB-approved medical appointments for her compensable injury that are greater than approximately 60 kilometres from her home in one direction.
The objection is allowed in part.
DATED December 16, 2014
C. Marr Appeals Resolution Officer Appeals Services Division