APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20250004
OBJECTING PARTY: WORKER
REPRESENTED by: Self
RESPONDENT PARTY: Employer (not participating)
REPRESENTED by: Employer representative
HEARING: VIDEOCONFERENCE – September 27, 2024
HEARD by: S. Waters, appeals resolution officer
DATED: OCTOBER 1, 2024
ISSUE
The worker objects to the Occupational Therapist’s (OT’s) November 7, 2023 decision (and subsequent reconsideration letters) denying reimbursement for an out-of-pocket wheelchair repair.
BACKGROUND
I will only provide a brief summary since prior Appeals Resolution Officer and Workplace Safety and Insurance Appeals Tribunal decisions provide detailed summaries of the worker’s claim. Briefly, on December 2, 2017 while working as a financial controller, the worker participated in snow tubing as part of a work event, hit a bump, and suffered a complete T3 spinal cord injury.
The worker received entitlement for this as well as numerous other physical injuries, obstructive sleep apnea, and a psychotraumatic disability. The worker is approved for full loss of earnings benefits from December 3, 2017 to age 65. The worker is also in receipt of a combined 86% Non-Economic Loss (NEL) benefit for his physical injuries and psychotraumatic disability.
In 2019, the worker was prescribed a power standing wheelchair to increase his wheelchair tolerance, independence with repositioning and standing, greater access to higher objects, and to facilitate eye-to-eye communication. The worker received the wheelchair in early 2020. In September 2023, a vendor submitted a quote for repairs of the worker’s wheelchair. The OT initially approved the repairs on September 29, 2023. However, the vendor then submitted additional quotes on October 26, 2023 with a total repair cost of $16,450.85.
In a letter dated November 7, 2023 the OT denied entitlement for the repairs of the worker’s existing power wheelchair and instead approved entitlement for a replacement device. The OT determined this was the more appropriate option given the age of the current wheelchair, the worker’s heavy use of the wheelchair, the extensive cost to repair the current issues, and the likely short-lived benefits of the quoted repairs. The OT indicated it could take 6-12 weeks to obtain the new wheelchair after assessments and trials.
The worker objected to this decision with an Intent to Object Form dated December 8, 2023. The worker included a receipt indicating he paid $4,375.85 of the total repair cost to repair the standing actuator component. He argued the actuator repair was necessary as the power standing option allowed him to avoid discomfort and increase his tolerance to being in the wheelchair.
In a letter dated January 5, 2024 the OT confirmed the denial of repairs for the existing wheelchair with the exception of a tire replacement for safety during the winter weather. The OT continued to uphold the denial of entitlement for repairs of the current wheelchair in letters dated January 18, 2024, April 19, 2024, and July 29, 2024.
Worker’s Oral Testimony and Position
The worker seeks reimbursement for the out-of-pocket expense he paid to replace the standing actuator component of his old wheelchair. He confirmed that he paid $4,375.85 on November 3, 2023 to repair this component.
The worker stated the standing actuator stopped working in approximately mid-October 2023. He contacted his vendor immediately to let them know and they submitted a quote to the WSIB. The worker heard this repair was approved. But then the vendor indicated there were other parts that might as well get repaired at the same time and submitted a second quote to the WSIB totalling $15,000-20,000. Then the WSIB denied all repairs and approved a replacement wheelchair instead.
The worker indicated the WSIB told him that he would likely get his new wheelchair in about three months. However, the worker knew it would likely take closer to six to nine months to get the new wheelchair based on his prior experience. The worker stated he was willing to wait for the new wheelchair rather than get all of the other repairs done, but it was necessary to get the standing actuator replaced immediately despite the cost.
The worker explained he had to pay for this repair as soon as possible – which he did on November 3, 2023 – because the vendor would not order the part until he paid upfront, and it would take weeks for the part to arrive. The worker confirmed the replacement part did not arrive to complete the repair until late November or early December 2023 despite his payment at the beginning of November 2023.
The worker testified that the standing actuator had to be fixed as soon as possible because the power standing feature of his wheelchair is critical. The worker noted this feature was prescribed as part of his original wheelchair in 2020. The worker stated he noticed increased pain in his left hip as soon as the component broke in mid-October until the component and standing feature was repaired. He explained that he needed the standing feature to “open up his left hip” because he feels pain there despite the T3 spinal injury. The worker also experienced decreased postural control and was not able to sit properly. The worker explained his body always leans to the right, so standing allows him to bear weight equally on both feet whereas he cannot balance out the lean fully on his own while in a seated position.
The worker stated the standing feature is also necessary to have on his wheelchair because he is out and about all the time for medical appointments. He attends physiotherapy six times per week, acupuncture two times per week, massage therapy two times per week, and various specialist appointments. The worker explained he is already in a seated position in the car to and from these appointments, so he uses the standing feature of his wheelchair to change positions and open up his hip in the 10-15 minutes before an appointment when he arrives early. The worker also stands for about one hour after eating meals.
The worker’s wheelchair did also have tilt and recline features, but explained his spine remained curved in these positions which added more pressure. The worker stated it is only standing with his spine straight that really helps with managing his left hip pain. The worker acknowledged he has a standing frame but stated this was not a feasible option for him most of the time. The standing frame is located in his basement and is not mobile, meaning he cannot use it when he is out of the house for his frequent medical appointments. He also requires someone else to help get him in and out of the frame, meaning this is not an option he can use independently. By comparison, the worker demonstrated during the video conference that he could switch from a seated to fully upright standing position in his wheelchair with a button he can control independently. The worker stated having this option helps him build independence in general, and in managing his pain.
For these reasons, the worker testified it was critical to get the standing actuator repaired on his wheelchair at that time while awaiting the new wheelchair. The worker added that it “made a huge difference” in his pain management and independence getting the power standing feature back. The worker testified he needed this feature repaired when it was done since his new wheelchair did not arrive until July 2024, and was not fully adjusted until August 2024.
AUTHORITY
Operational Policy Manual
Published
17-06-03 Independent Living Devices
October 14, 2009
ANALYSIS
I have carefully considered all of the available information, legislation and relevant operational policies in reaching this decision. I find reimbursement is in order for the out-of-pocket expenses paid by the worker on November 3, 2023 to repair the standing actuator component in his wheelchair.
The worker’s appeal is allowed.
Assessment of Entitlement
It is the worker’s position that he is entitled to reimbursement for his out-of-pocket expense to repair the standing actuator component of his wheelchair. Information on file supports this position. When making my decision, I considered the policy that provides guidance regarding entitlement for independent living devices. Policy 17-06-03 (Independent Living Devices) states:
The WSIB pays for maintenance, normal inspection, repair, and replacement of independent living devices (that cost over $250) unless the damage is due to misuse or to not following the warranty or operating instructions. Workers must ensure proper maintenance is carried out.
In September and October 2023, a vendor submitted quotes for repairs to the worker’s wheelchair totalling $16,450.85. However, the worker only paid out-of-pocket and seeks reimbursement for the cost to repair/replace the standing actuator component of his wheelchair. A receipt confirms the worker paid $4,375.85 for this repair on November 3, 2023. I find the worker is entitled to reimbursement of this cost for multiple reasons.
The worker testified that his wheelchair’s power standing feature was not functional from October 2023 until the standing actuator component was replaced. Written statements from the worker, and letters from the treating physiotherapist and assessing OT also confirm this to be the case. There is no evidence on file to indicate that this component stopped working due to damage caused by misuse or the worker not following the warranty and operating instructions. Instead, it appears this component simply deteriorated over time and required replacement.
I understand the OT initially denied reimbursement for wheelchair repairs because they approved entitlement for a replacement wheelchair, which they expected to be available to the worker in 6-12 weeks. In actuality, the worker’s testimony and documentation on file confirms the worker did not receive his replacement wheelchair until nearly nine months later on July 29, 2024. I find this an unreasonable length of time to expect the worker to wait without access to a vital and prescribed power standing feature of his wheelchair. As such, I find it reasonable that the worker paid out-of-pocket to have this specific repair completed to ensure he maintained access to this feature while awaiting his new wheelchair. I also find it reasonable that the worker paid for this expense as early as November 3, 2023 based on his testimony that the vendor would not order the part until he paid upfront.
The worker testified that the power standing feature of his wheelchair was necessary and critical for his independence and symptom management. Medical evidence on file supports the worker’s testimony, and describes the value of the power standing feature of the worker’s wheelchair.
In an initial wheelchair prescription dated August 16, 2019, an OT prescribed the worker a wheelchair with power tilt, recline, and standing features. They stated a wheelchair that does full standing was the worker’s only option for relief of discomfort while remaining in a functional alignment. The OT also argued a wheelchair with these features would increase the worker’s tolerance to being in a wheelchair, would increase the worker’s independence and mobility, would give the worker greater access to higher objects, and facilitate eye-to-eye communication. Similarly, in February 2024 reports, an OT documented that the worker’s replacement wheelchair required power tilt, recline, and standing features for pressure management and to offer the worker access to independent repositioning.
The worker also submitted letters from some of his treating clinicians to support reimbursement of the standing actuator component to regain access to the power standing feature of his wheelchair. The worker’s physiotherapist provided a letter dated November 17, 2023 plus their clinical progress notes. They stated the standing feature of the wheelchair was necessary and required repair as soon as possible to offload the worker’s pelvis and provide pressure relief because other pressure relieving methods did not adequately relieve the worker’s pain. The physiotherapist also documented that the worker’s left glutes pain increased from 6/10 to 8/10 because he did not have access to this feature, which affected his quality of life and ability to participate in physiotherapy treatment.
The OT that originally prescribed the worker’s wheelchair in 2019 also provided a letter on April 5, 2024. They stated the actuator needed repair to re-establish the power standing feature of the worker’s wheelchair until the replacement arrived so that the worker could continue participating in his personal daily activities. The OT explained that a pressure mapping assessment demonstrated that standing was significantly more effective at reducing pressure than the tilt or recline features. The OT also explained the tilt and recline options did not offer the worker a position of comfort to be able to function throughout the day, and a standing frame was not a suitable alternative since it can only be used in one room and forces the worker’s dependence on others for transferring in and out of the frame.
I accepted these medical opinions since both were provided by clinical experts in their field and based on in-person assessments and treatments with the worker. As such, I accepted that the worker was prescribed and required a wheelchair with a power standing feature. Medical records support this feature assisted the worker with pressure/offloading management and helped restore his ability to have eye-to-eye communication as desired, be mobile, and maintain some independence. Considering the nine-month period until the worker’s replacement wheelchair became available, I find it reasonable that the worker paid out-of-pocket for the repair of the standing actuator component to regain the power standing feature while waiting for the replacement. For these reasons, I find the worker is entitled to reimbursement for his out-of-pocket expenses on November 3, 2023 totalling $4,375.85.
CONCLUSION
I find reimbursement is in order for the out-of-pocket expenses paid by the worker on November 3, 2023 to repair the standing actuator component in his wheelchair.
The worker’s appeal is allowed.
DATED October 1, 2024
S. Waters
Appeals Resolution Officer
Appeals Services Division