WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20190087
OBJECTING PARTY: Worker
REPRESENTED by: Worker Representative
RESPONDENT: Employer (Not participating)
HEARING: Hearing in Writing
HEARD by: M. Kimevski, Appeals Resolution Officer
DATED: July 12, 2019
ISSUE
The worker objects to the August 22, 2017 decision by the Nurse Consultant denying entitlement to escort fees to attend physiotherapy appointments between July 5, 2016 and November 2, 2016.
BACKGROUND
The claim was established for an accident on March 17, 2016 when the worker, then a 54-year-old Retail Representative tripped over a flatbed cart injuring her right foot. Entitlement was accepted for a right forefoot sprain and right midfoot tarsometatarsal ligamentous injury with mild instability.
The August 22, 2017 decision letter advised that it was a personal preference rather than medical necessity for the worker’s spouse to escort her to physiotherapy appointments, and escort fees would not be reimbursed for visits to the physiotherapist between July 5, 2016 and November 2, 2016.
The case was referred to the Appeals Services Division for consideration of the outlined issue. The worker indicated on her Appeal Readiness Form that she was representing herself in the appeal process and requested a hearing in writing to resolve the appeal. Therefore, the decision was completed based on the information contained in the claim file.
AUTHORITY
Operational Policy
17-01-08 Escorts
17-01-09 Travel and Related Expenses
ANALYSIS
In reaching my conclusion, I considered all of the available information in the context of the relevant operational policy and legislation. For reasons that will be outlined, I do not find in favour of the worker.
The worker submitted that her injury was to the right foot, which was in an air cast and compression stocking and her injury made it impossible for her to drive to appointments. The worker indicated that based on the distance and frequency of appointments, the escort fee is a clinical necessity and practical as it is a cost savings. She argues that the escort fee and mileage reimbursement combined still represent a savings over taxi transportation and due to an unpleasant experience with a taxi, she asked her husband to be available to transport her to her appointments and requests payment for an escort.
The employer did not participate in the appeal; therefore, no information was submitted on their behalf.
Policy 17-01-09 titled Travel and Related Expenses provides over-arching direction by stating the following,
The WSIB pays all reasonable expenses incurred when, on the direction or approval of the WSIB, a worker, or another person designated by the WSIB, must travel in relation to a claim.
Policy 17-01-09 goes on to provide guidelines and indicates,
Travel expenses for an escort are paid when there is a clinical necessity, or for compassionate or practical reasons (see 17-01-08, Escorts).
It there follows that policy 17-01-08 titled Escorts, indicates the following in part,
If a worker must be escorted to health care or WSIB-arranged appointments, the WSIB pays the escort a standard fee and any approved travel and related expenses.
The WSIB pays for
professional qualified escorts (e.g., a registered nurse) if the worker needs assistance to travel to appointments because of serious clinical problems, or
non-professional escorts, if the worker must be accompanied for legal or basic clinical reasons. A non-professional escort can be a parent, friend, or spouse.
In this case, the worker did not seek out or obtain approval for an escort. I note the worker had a conversation with the Case Manager on June 10, 2016, in which she was advised the she would be reimbursed for mileage if she or her husband were driving her to medical appointments related to the claim.
Further, the worker’s injury and inability to drive to physiotherapy appointments was specifically addressed when the worker commenced treatment. I note in a conversation on July 13, 2016, the Nurse Consultant advised the worker that if transportation to physiotherapy was a barrier, WSIB could make arrangements for taxi.
I acknowledge the worker claims she had an unpleasant experience with a taxi and cites clinical necessity and practicality as supporting the payment of an escort; however, the evidence does not establish that the worker required an escort within the meaning of the policy, but rather preferred to have her husband drive her.
I note the worker was again advised in a conversation with the Nurse Consultant on May 24, 2017 that escort fees were based on medical necessity and are not generally paid to attend treatment, as WSIB would provide transportation if requested/needed.
Based on the facts and circumstances of this case, there is no evidence to support that during the claimed time period, the worker had to be escorted to physiotherapy appointments because of serious clinical problems or because of legal or basic clinical reasons.
The information on file also indicates that the worker’s husband was appropriately compensated for driving her through payments for mileage, which is in accordance with what was originally communicated to the worker.
Based on all of the above, it is inappropriate to also grant entitlement for payment of an escort when the evidence does not establish the worker required the services of an escort to attend physiotherapy appointments due to the compensable injury between July 5, 2016 and November 2, 2016. Entitlement to escort feels is not in order.
CONCLUSION
The decision denying entitlement to escort fees to attend physiotherapy appointments between July 5, 2016 and November 2, 2016 is confirmed.
The worker’s objection is denied.
DATED: July 12, 2019
M. Kimevski
Appeals Resolution Officer
Appeals Services Division