APPEALS RESOLUTION OFFICER DECISION
decision number:
20220021
OBJECTING PARTY:
WORKER
RESPONDENT:
EMPLOYER
HEARING:
HEARING IN WRITING
HEARD by:
kELLY gORDON, appeals resolution officer
DATED: FEBRUARY 14, 2022
ISSUES
The worker is objecting to the Occupational Disease (OD) Adjudicator’s decision dated June 16, 2021.
In this decision, the OD Adjudicator denied secondary entitlement to seronegative rheumatoid arthritis and the resulting loss of earning (LOE) benefits as of June 23, 2021.
BACKGROUND
On December 22, 2020, this personal support worker (PSW) tested positive for COVID 19. The worker was asymptomatic, and isolated as required until January 6, 2021, when the worker returned to work. After returning to work, the worker developed symptoms that include coldness, numbness, and throbbing pain in their right toe and right arm. Although these symptoms resolved within days, the symptoms moved to different parts of the worker’s body. The pain became so severe, that the worker stopped working on January 20, 2021. At the time of the positive COVID 19 test, Public Health declared a
COVID 19 outbreak at the worker’s place of employment. As such, the OD Adjudicator determined it was more probable than not that the worker’s COVID 19 resulted from the workplace exposure. Therefore, in the decision dated March 10, 2021, the OD Adjudicator allowed entitlement to health care and LOE benefits for the worker’s diagnosed COVID 19.
As per the medical information submitted to file, the worker tested negative for COVID 19 on
December 2, 2020, the worker tested positive on December 22, 2020, and negative again on
January 31, 2021. The worker’s family doctor submitted a Health Professional’s Report of Injury, Form 8 dated February 8, 2021. On this form, the doctor states the worker has an inflammatory condition due to COVID 19, and as a result of the severe pain, the worker is unable to walk, or move their hands and arms. The worker underwent assessments with two (2) internal medicine specialists who referred the worker for further testing. These specialists indicate the worker’s COVID 19 could be a possible cause of the worker’s ongoing symptoms, and that the worker may have long haul COVID 19, or reactive arthritis. A referral to a rheumatologist was recommended. The worker underwent a COVID 19 assessment at the WSIB Specialty Program on April 21, and 29, 2021, and May 7, and 13, 2021. As per the assessment report, the worker was diagnosed with post COVID 19 syndrome.
On May 13, 2021, Dr. Florica, Rheumatologist at the WSIB Lower Extremity Specialty Program (LESP) assessed the worker again, and Dr. Florica diagnosed the worker with seronegative rheumatoid arthritis, likely triggered by viral infection COVID 19. Dr. Florica states since COVID 19 is a new entity, there is no clear data on developing inflammatory arthritis. However, Dr. Florica states some reports do support inflammatory arthritis resulting from COVID 19. The OD Adjudicator referred the claim to the Occupational Health Assessment Program (OHAP), and on June 15, 2021, Dr. Markus assessed the worker. Dr. Markus provides the opinion that there is insufficient evidence to causally link the development of the worker’s seronegative rheumatoid arthritis to primary COVID 19 infection at this time.
In the decision dated June 16, 2021, the OD Adjudicator accepts the opinion as provided by Dr. Markus, and states that although the medical assessors determined there may be a possible causal relationship between the worker’s COVID 19 and their ongoing symptoms, the scientific literature does not support a causal relationship. As such, the OD Adjudicator denied entitlement to the diagnosed seronegative rheumatoid arthritis as a secondary condition in this claim. The OD Adjudicator also denied entitlement to LOE benefits as of June 23, 2021, as the worker’s lost time from work was due to the seronegative rheumatoid arthritis, and not COVID 19.
The worker submitted the Appeal Readiness Form (ARF) dated August 10, 2021, confirming their objection to the denial of seronegative rheumatoid arthritis and the resulting LOE benefits.
The worker’s objection to the denial of seronegative rheumatoid arthritis as a secondary condition, and entitlement to ongoing LOE benefits forms the basis of this appeal.
AUTHORITY
Operational Policy Manual
Published
15-05-01 Resulting from Work-Related Disability/Impairment
18-03-02 Payment and Reviewing LOE Benefits (Prior to Final Review)
April 9, 2021
April 9, 2021
ANALYSIS
For the reasons that follow, I find the worker does have secondary entitlement to seronegative rheumatoid arthritis. In reaching this decision, I have carefully considered all of the available information on file, the legislation, the worker’s submission, and the relevant operational policies.
On the ARF, the worker refers to their submission dated June 24, 2021. In my review of the information on file, I note no written submissions for this date. However, the worker submitted the Intent to Object (ITO) Form dated July 6, 2021, and on this form, the worker states the supporting evidence supports the worker’s ongoing symptoms are related to the compensable COVID 19. Although scientific research is limited due to COVID 19 being new, the worker states they had no symptoms prior to being diagnosed with COVID 19, and their treating doctors relate the worker’s ongoing symptoms to be a result of
COVID 19. To support this, the worker included a report from Dr. Khalil dated June 24, 2021. For these reasons, the worker is requesting secondary entitlement to seronegative rheumatoid arthritis.
The employer did not return the Respondent Form, and no submissions have been provided for my review.
Entitlement to seronegative rheumatoid arthritis as a secondary condition
Policy 15-05-01 states that workers sustaining secondary conditions that are causally linked to the
work-related injury will derive benefits to compensate for the further aggravation of the work-related impairment, or for new injuries.
As per the medical evidence on file, the worker’s family doctor, Dr. Abdul-Rahman submitted a Health Professional’s Report of Injury, Form 8 dated February 8, 2021. On this form, Dr. Abdul-Rahman refers to the worker’s ongoing symptoms that include headaches, weakness, and pain in their left wrist, hand and bilateral legs. The diagnosis provided is an inflammation condition due to contracting COVID 19. The worker has severe pain in the areas reported, and the worker is unable to walk or move their hands and arms.
Dr. Chiang, internal medicine specialist assessed the worker on February 23, 2021. As per the consultation report, the worker was referred to Dr. Chiang for migratory musculoskeletal pain since being diagnosed with COVID 19 in December 2020. Dr. Chiang notes the worker was asymptomatic and tested positive for COVID 19 on December 24, 2020. The worker self-isolated, and returned to work on
January 6, 2021. Subsequent to the worker’s return to work, the worker felt freezing and throbbing of their various extremities that started with their right toe and then their left arm. Symptoms would take several days to resolve, and would migrate to different parts of their body. The worker also reported extreme fatigue most days and headaches. The worker was seen in the hospital emergency department, and the worker was prescribed Toradol and Tylenol for their symptoms. Dr. Chiang states they do not have a good alternative diagnosis for the worker’s symptoms, and states the worker most likely has COVID long haul symptoms. However, other investigations were requested to rule out autoimmune disorders, and muscular degenerative issues.
Dr. Yan, internal medicine specialist assessed the worker on March 23, 2021. Dr. Yan refers to the same symptoms previously reported, and states the worker has tried three (3) different anti-inflammatories with no relief. The worker has also been prescribed Prednisone with no relief. Dr. Yan notes Dr. Chiang also assessed the worker, and states the investigations as requested by Dr. Chiang have all proven negative. Dr. Yan states they do not have a clear explanation, or etiology to account for the worker’s symptoms, but Dr. Yan provides the opinion the symptoms may be related to complications after the COVID 19 diagnosis given the worker was previously completely healthy. Dr. Yan states that after doing a brief literature search, there are accounts of various seronegative arthropathy following COVID 19, particular reactive arthritis. Dr. Yan then referred the worker to a rheumatologist to see if a further specialist opinion might provide answers. I find it significant to note that Dr. Yan states there is not much scientific literature in terms of long-term complications of COVID 19.
On March 30, 2021, Dr. Medina, at the OHAP COVID Assessment Program (CAP), assessed the worker. During the assessment, the worker reported ongoing fatigue, and described migratory musculoskeletal pain that varies depending on the day. The pain is primarily located around the large and small joints in their extremities. The worker reported the pain usually affects one (1) to two (2) joints at a time, and rarely is widespread. When a joint is flared up, the worker reported the pain could last from one (1) to
five (5) days, and the worker is unable to use the joint while it is symptomatic. The worker also reported occasional and intermittent headaches, overall general weakness, and difficulties with memory and word finding. Following a review of all medical evidence on file and after physically examining the worker,
Dr. Medina states the worker’s current constellation of symptoms and their temporary association with their recent COVID 19 diagnosis are consistent with a post COVID syndrome. Dr. Medina states their symptomatology would fit in the post COVID period (less than 12 weeks following onset of symptoms). Dr. Medina goes on to state that although the worker has ongoing symptoms associated with their COVID diagnosis, it is unlikely the worker remains infectious or that there is any ongoing direct viral damage to their body/organs. Noting the relatively rapid migratory pattern of the worker’s symptoms,
Dr. Medina referred the worker for a rheumatology assessment.
On May 13, 2021, the worker underwent an assessment with Dr. Florica, Rheumatologist at the LESP. Dr. Florica reviewed all prior medical assessments and investigation findings, and examined the worker through virtual assessment. Dr. Florica provides the following clinical impression:
“Possible seronegative rheumatoid arthritis with limited function in the hands, knees and feet. While there is not enough literature to link COVID pneumonia to arthritis, there are however case reports of mono or polyarthritis triggered by COVID 19 pneumonia.”
In the same report, Dr. Florica states:
“In my opinion, their condition is chronic inflammatory arthritis seronegative rheumatoid arthritis, likely triggered by viral infection COVID-19. Since COVID-19 is a new entity, there is no clear data on developing inflammatory arthritis, but only some reports. However, multiple other viral infections are known as triggers for the onset of chronic inflammatory arthritis, specifically autoimmune conditions like rheumatoid arthritis.”
In the report noted above, under occupational diagnosis, Dr. Florica states seronegative rheumatoid arthritis. Under non-occupational diagnosis, Dr. Florica states none. In terms of prognosis, Dr. Florica recommends specific treatment for inflammatory arthritis, respectively, the disease modifying drug, Hydroxychloroquine
The claim file was referred to Dr. Markus at the OHAP, and as per this referral, the OD Adjudicator requested an opinion on whether the diagnosis of seronegative rheumatoid arthritis is causally related to the worker’s COVID 19 infection. In the report dated June 15, 2021, Dr. Markus refers to the medical evidence, and states reactive arthritis is a known phenomenon that can occur in the aftermath of many different infections, both viral and bacterial. Dr. Markus goes on to state the worker developed seronegative arthritis approximately three (3) months after primary infection from COVID 19, and notes that after considering medical literature, there are only four (4) case reports of reactive arthritis. Noting the limited medical literature, Dr. Markus provides the opinion there is insufficient evidence to causally link the development of the worker’s rheumatoid arthritis to their primary COVID 19 infection.
Dr. Khaill, rheumatologist submitted a report dated June 24, 2021, confirming the worker was assessed following a referral from Dr. Abdul-Rahman. Dr. Khaill provides a diagnosis of inflammatory arthritis most likely rheumatoid arthritis. Dr. Khaill refers to the worker’s diagnosed COVID 19 in December 2020, and notes the worker’s symptoms of joint pain, neuropathic pain, fatigue, and headaches lingered on afterwards. Under assessment and plan, Dr. Khaill states the following:
“This is a 42F with symmetric polyarthritis. Symptoms developed after covid 19 infection. We know that viral infections can trigger inflammatory arthritis and connective tissue diseases. There are case reports of RA happening post covid 19. She did not tolerate Hydroxychloroquine due to headaches. Will try sulfasalazine.”
Based on my review of all medical information, I find the evidence supports it is more probable than not that the worker’s seronegative rheumatoid arthritis is a secondary condition that is causally linked to the worker’s work-related COVID 19. In making this determination, I have placed significant weight on the multiple specialist assessment reports on file. Specifically, the worker was assessed by two (2) internal medical specialists, Dr. Medina, infectious disease specialist, and two (2) rheumatologists.
While I note the OD Adjudicator states these specialists determined it is only possible the worker’s seronegative rheumatoid arthritis is related to the work-related COVID 19, I do not agree with this opinion. Although I accept the evidence on file supports there is limited literature research on the
long-term affects of COVID, due to COVID being new, I find the opinions provided by the assessing specialists relate the worker’s ongoing symptoms to the work-related COVID condition. In stating this,
I note Dr. Chiang provides the opinion the worker’s ongoing symptoms are likely COVID long haul symptoms. Dr. Yan refers to the worker’s ongoing symptoms and negative investigation findings, and states it is likely the worker’s symptoms are related to complications after the COVID diagnosis given the worker was previously completely healthy.
I specifically place weight on Dr. Medina’s opinion, as Dr. Medina is an infectious disease specialist specializing in COVID infections. Dr. Medina states the worker’s current constellation of symptoms, and their temporary association with their recent COVID 19 diagnosis are consistent with a post COVID syndrome, and notes the worker’s symptomatology would fit in the post COVID period (less than 12 weeks following onset of symptoms). Dr. Florica provides the opinion the worker’s seronegative rheumatoid arthritis was likely triggered by COVID-19, and states that since COVID-19 is a new entity, there is no clear data on developing inflammatory arthritis. However, Dr. Florica also states that multiple other viral infections are known as triggers for the onset of chronic inflammatory arthritis, specifically autoimmune conditions like rheumatoid arthritis. Dr. Khaill, provides the opinion that the most likely diagnosis is rheumatoid arthritis, and states viral infections can trigger inflammatory arthritis and connective tissue diseases. Dr. Khaill states there are case reports of rheumatoid arthritis happening post COVID 19.
While I note Dr. Markus provides the opinion that there is insufficient evidence to causally link the worker’s rheumatoid arthritis to their diagnosed COVID 19, Dr. Markus also states that reactive arthritis is a known phenomenon that can occur in the aftermath of many different infections, both viral and bacterial. I also find it significant that prior to providing their opinion, Dr. Markus states the worker developed seronegative arthritis approximately three (3) months after the primary infection of COVID 19. However, respectfully, I do not find the evidence supports this to be the case. Although the worker was diagnosed with seronegative arthritis three (3) months post COVID 19, the medical evidence on file supports the worker’s symptoms started shortly after being diagnosed with COVID 19, and these symptoms continued until the secondary diagnosis was made.
While I accept there is limited medical research on the long-term effects of COVID 19, I place significant weight on the multiple specialist opinions on file. I find the preponderance of medical evidence supports it is more probable than not that the worker’s diagnosed seronegative rheumatoid arthritis is a secondary condition resulting from the work-related COVID 19.
For the reasons stated above, I accept the evidence supports a causal relationship between the worker’s seronegative rheumatoid arthritis and the work-related COVID 19. As such, I find the worker does have entitlement to seronegative rheumatoid arthritis as a secondary condition in this claim.
Entitlement to LOE benefits
For the reasons that follow, I find the worker does have entitlement to LOE benefits as of June 23, 2021.
In this appeal, I refer to policy 18-03-02 that states in part if the nature or seriousness of the injury/disease completely prevents a worker from returning to any type of work, or if the worker is able to return to some form of work, but the WSIB determines no suitable work is available, the worker is generally entitled to full LOE benefits providing the worker co-operates in health care measures and all aspects of the work reintegration process.
In my review of the OD Adjudicator’s decision dated June 16, 2021, I note entitlement to LOE benefits was terminated as of June 23, 2021, as the worker’s inability to work was related to seronegative rheumatoid arthritis. As noted above, I find the worker does have entitlement to seronegative rheumatoid arthritis. Therefore, I find the worker does have entitlement to LOE benefits as of June 23, 2021.
CONCLUSION
I find the worker does have secondary entitlement to seronegative rheumatoid arthritis. I also find the worker has entitlement to LOE benefits as of June 23, 2021.
Noting I have allowed secondary entitlement to seronegative rheumatoid arthritis, I ask the operating area to determine ongoing entitlement in this claim. This includes ongoing entitlement to LOE benefits as of June 23, 2021.
The worker’s objection is allowed.
DATED February 14, 2022
Appeals Resolution Officer
Appeals Services Division