Worker v. Employer, 2025 CanLII 111684

APPEALS RESOLUTION OFFICER DECISION

DECISION NUMBER:

20250049

OBJECTING PARTY:

WORKER

RESPONDENT PARTY:

EMPLOYER

HEARING:

VIDEOCONFERENCE

HEARD by:

Kelly Gordon, appeals resolution officer

ADDITIONAL ATTENDEE:

inFORMAL REPRESENTATIVE (observer)

DATED:

March 26, 2025

ISSUES

The worker is objecting to the following decisions:

1. The decision dated June 28, 2024, in which the Occupational Disease (OD) Adjudicator determined the worker fully recovered from the work-related COVID virus as of April 9, 2024.

2. The OD Adjudicator’s decision dated June 28, 2024, that determined the worker recovered from the accepted exacerbation of pre-existing rheumatoid arthritis (RA) as of April 9, 2024.

3. The OD Adjudicator’s decision dated June 28, 2024, and reconsideration decision dated January 14, 2025, that denied entitlement to Chronic Pain Disability (CPD).

4. The OD Adjudicator’s decision dated May 28, 2024, and reconsideration decision dated January 14, 2025, that denied entitlement to psychotraumatic disability.

5. The OD Adjudicator’s decision dated June 28, 2024, that denied entitlement to ongoing loss of earning (LOE) benefits effective July 15, 2024.

BACKGROUND

On March 21, 2022, initial entitlement was accepted in this claim for the worker’s diagnosed COVID infection. Entitlement was allowed for health care, and LOE benefits, as the worker lost time from work starting on March 18, 2022.

The worker underwent an assessment at the COVID Assessment Program (CAP) on April 21, 2022, following which, they attended the recommended treatment. The worker continued to attend follow up assessments at the CAP, and as per the reports submitted, the worker was diagnosed with post-COVID or Long COVID. As per the CAP recommendations, the worker was referred for a psychological assessment. Based on the findings provided in the September 8, 2022, psychological assessment, the Case Manager (CM) issued a decision dated June 27, 2023, allowing entitlement to psychotraumatic disability for the worker’s diagnosed Post Traumatic Stress Disorder (PTSD). In the same decision, the CM denied entitlement to CPD for the worker’s diagnosed Somatic Symptom Disorder (SSD).

On June 29, 2023, entitlement was extended to include an exacerbation of the worker’s pre-existing RA as a secondary condition resulting from the COVID infection.

In the decision dated May 28, 2024, the OD Adjudicator reconsidered entitlement to the worker’s psychological condition, and they determined the criteria to allow psychotraumatic disability was not met. Therefore, they overturned the prior decision that allowed psychotraumatic disability, and they denied entitlement to further psychological treatment.

The OD Adjudicator conducted a claim review on June 11, 2024, and as a result, they issued a correspondence dated June 28, 2024, in which they render multiple decisions. Specifically, the OD Adjudicator determined that as of April 9, 2024, the worker’s RA returned to the level it was prior to the workplace COVID infection. Therefore, they denied ongoing entitlement for the exacerbation of the RA. The OD Adjudicator also determined the worker’s COVID infection fully resolved as of April 9, 2024, with no ongoing impairment. In addition, they found the criteria to allow CPD was not met, and as such, they denied entitlement to CPD. As the OD Adjudicator accepted the worker fully recovered from their work-related conditions, they denied entitlement to ongoing healthcare and LOE benefits in this claim as of July 15, 2024.

The worker submitted the Appeal Readiness Form (ARF) dated December 2, 2024, confirming their objection to the issues noted above. The worker’s objection to the issues noted above form the basis of this appeal.

AUTHORITY

Operational Policy Manual

Published

11-01-05 Determining Permanent Impairment 15-02-03 Pre-existing Conditions 15-04-03 Chronic Pain Disability 15-04-02 Psychotraumatic Disability 18-03-02 Payment and Reviewing LOE Benefits (Prior to Final Review)

November 3, 2014 November 3, 2014 July 20, 2023 September 7, 2018 September 1, 2021

ANALYSIS

In reaching the following decisions, I have carefully considered all the available information on file, the worker’s testimony, and the relevant operational policies.

During the appeal hearing, the worker confirmed that since their date of hire with the employer in 2011, they have worked as an addictions and social service worker. The worker testified that just prior to St. Patrick’s Day in 2022, they came home from work, and they did not feel well. The worker first developed flu like symptoms, and on March 17, 2022, they took a COVID test, that was positive. The worker stayed in their room, and they did not leave the house as they did not want to get anyone else sick. At the time, the worker’s husband was sick, and on April 3, 2022, a community paramedic who came to care for her husband also checked the worker’s lungs. The paramedic told the worker that their left lung was very shallow, and they advised the worker to go to the hospital. At the hospital, the worker was told they had Long COVID, and they were sent home the same day, and told to rest.

The worker testified that they continue to have symptoms of Long COVID, and they continue to see their doctor for these symptoms. The worker testified that prior to their COVID infection, they did have medical issues, and they sought medical attention for these issues. However, they were able to continue working, and they did not require light duties. In addition, the worker was independent, they could perform all Activities of Daily Living (ADLs), and they could drive. Since they contracted COVID in March 2022, the worker has had ongoing physical symptoms that they did not have prior to the infection. These include difficulty walking, brain fog, dizziness, shortness of breath (SOB), and severe joint and muscle pain. The worker stated they feel like an 80-year-old woman, and they no longer feel they are capable of working. The worker stated they feel as if their independence has been taken away, and although they have tried all kinds of medication, nothing works.

The worker testified that they need a walker to be mobile, and they need assistance with their ADLs. Specifically, the worker requires assistance with meal preparation, dressing, washing, and cleaning the house. The worker sleeps on the couch every night as they cannot physically get up the stairs to get to their bed. Although the worker had symptoms of urinary incontinence prior to their COVID illness, these symptoms have significantly worsened since they developed COVID, and the worker now regularly wears undergarments. On an average day, the worker gets up after sleeping on the couch, and they brush their teeth. The worker spends the day sitting on the couch, watching TV, or reading a book. The worker has also done a lot of research on COVID. The worker’s sister helps them get washed, and their sister puts their socks on for them. The worker testified they do not go out much. Instead, family and friends come to see them at home.

During the hearing, the worker referred to Dr. Lui’s May 2024, and June 18, 2024, reports that state the worker was seen for pain, and swelling in multiple joints. In addition, Dr. Lui provided an RA score of 40 out of 100 for their functional impairment. The worker testified that a score of 20 is considered normal. Therefore, the worker argues Dr. Lui’s reports confirm an ongoing impairment.

The worker testified that due to their COVID symptoms, they had to stop driving, and now, they rely on family and friends to drive them when they need to go to a medical appointment.

The worker confirmed that in January 2024, they were approved for long term disability, and Canada Pension Plan Disability for their diagnosed Long COVID symptoms.

The worker is requesting ongoing entitlement be allowed for their COVID symptoms, including CPD entitlement as they have never recovered, and they are unable to return to any type of work.

The employer did not participate in the appeal hearing, and no submissions have been provided for my review.

1. Does the evidence support a permanent impairment resulting from the work-related COVID infection?

For the reasons that follow, I find the worker has an ongoing impairment due to their work-related COVID infection.

In addressing this issue, I refer to Policy 11-01-05, that states a work-related impairment is considered permanent when it continues to exist after maximum medical recovery (MMR) has been reached.

A recovery from the work-related injury/disease is considered to have been made if there is no evidence of an ongoing work-related impairment at the time MMR is reached.

In all cases, decision-makers identify when MMR is reached. Decision-makers consider whether

• recent clinical evidence indicates any change in the work-related injury/disease

• the worker is receiving or will receive treatment that is likely to improve the work-related injury/disease, or

• the worker is receiving treatment or using medication to maintain the current level of recovery.

If required, a clinical opinion may be obtained to assist in determining when MMR has been reached.

In my review of the medical evidence, I note the worker tested positive for COVID in March 2022. The worker’s initial symptoms included loss of taste, smell, SOB, joint pain, headaches, fatigue, sneezing, and coughing. The worker was later diagnosed with Long-COVID, and reported additional symptoms of heart palpitations, memory, concentration problems, as well as sleep difficulties.

On April 21, 2022, Dr. Trudel, Medicine and Rehabilitation Specialist assessed the worker at the CAP, and in the report submitted, they provide an occupational diagnosis of Post COVID. Dr. Trudel states the worker’s primary functional limiting symptoms include fatigue, and SOB on exercise. At the time of the assessment, the worker also reported dizziness, and Dr. Trudel diagnosed the worker with possible benign paroxysmal positional vertigo. Dr. Trudel provides a prognosis for full functional recovery in 10 to 12 weeks based on the worker’s history, clinical findings, and typical progression of the diagnosis. However, Dr. Trudel also states recovery may be longer than expected noting the worker’s ongoing symptoms, their pre-existing anxiety and depression, and their perceived disability.

The worker followed up at the CAP on May 9, 2022, and as per the CAP report, the worker presented with significant joint pain, intense fatigue, SOB, and dizziness with exertion. The worker was not able to walk, and driving and frequent position changes were not recommended until their symptoms improved. In addition to post-COVID, the worker was diagnosed with RA, and they were referred to a rheumatologist for treatment.

Noting the findings provided on the CAP reports, the CM referred the claim to the Occupational Health Assessment Program (OHAP), and they requested a medical claim review. On January 10, 2023, Dr. Markus, Occupational Medical Consultation (OMC) conducted a medical claim review. In response to the CM’s question as to whether the clinical findings support a continued work-related impairment, Dr. Markus, provides the opinion that the worker continues to be totally disabled from symptoms associated with post-COVID syndrome, and they state the medical evidence supports an ongoing work-related impairment.

The worker continued to follow up at the CAP until February 16, 2023, when the worker was discharged. As per the discharge report, Dr. Trudel states the worker completed one block of enhanced functional treatment (EFT) with no significant functional gains. A second block of treatment was put on hold so that the worker could focus on their mental health. The worker underwent Pulmonary Function Tests (PFT), an echocardiogram, a chest x-ray, and a head MRI. All test results were normal. Under relevant non-occupational diagnosis, Dr. Trudel refers to the worker’s PTSD in the context of a significant complex trauma history, SSD, Anxiety and Depression. Dr. Trudel states that although these conditions were stable prior to the COVID infection, these conditions were exacerbated by the worker’s prolonged recovery from COVID. In addition, the worker’s husband was palliating at home which also exacerbated their pre-existing mental health conditions. In terms of prognosis, based on the worker’s history, clinical findings, and the typical progression of the diagnosis, Dr. Trudel states the worker is expected to achieve no further functional recovery.

Following the discharge from the CAP, the worker continued to see Dr. Tanner, their family doctor and Dr. Liu, their rheumatologist. In the report dated April 9, 2024, Dr. Liu states the worker was seen with complaints of pain everywhere, they use a walker to walk, and they continue to have SOB. Dr. Liu notes that these symptoms started after the COVID infection. While I note Dr. Liu states the worker no longer has definite signs to support a continued diagnosis of RA, clinically they state the worker’s ongoing joint symptoms, and body pain is most likely from fibromyalgia, or Long COVID/post-COVID.

Based on my assessment of the evidence, I find the worker does have a permanent impairment for Long COVID. In making this determination, I have placed significant weight on the medical evidence as provided in the CAP reports as well as the opinion provided by Dr. Liu. I have also placed significant weight on the opinion as provided by Dr. Markus.

I first refer to Dr. Markus’s medical claim review dated January 10, 2023. Dr. Markus had the benefit of reviewing all medical evidence including all evidence pertaining to the worker’s pre-existing conditions. After considering all evidence, Dr. Markus states the worker’s diagnosed COVID transitioned into Post-COVID/Long COVID. Dr. Markus refers to the CAP reports, and they note the worker has undergone multiple assessments since April 2022. Dr. Markus states the medical evidence supports the worker continues to have a mix of COVID related symptoms along with a diagnosis of RA. Dr. Markus provides the opinion that the worker continues to be totally disabled from symptoms associated with post-COVID syndrome. Although the worker’s joint pain may be related to RA, Dr. Markus states the worker also has numerous other disabling symptoms that they believe are related to the worker’s post-COVID syndrome. I specifically note that in response to the CM’s question as to whether the pre-existing condition renders the compensable work-related impairment insignificant, Dr. Markus states the following:

“The contribution of the pre-existing condition has not rendered the compensable condition insignificant as there are a host of symptoms reported by the worker that I do not believe can be attributed to RA, namely fatigue, SOB, cough, muscle pain, chest pain, headache, weakness, heart palpitations, memory and concentration problems and trouble sleeping.

I have considered the medical evidence submitted to file after Dr. Markus’s claim review, and I find no evidence to support any of the worker’s Long COVID related symptoms improved.

In terms of the findings provided in the CAP reports, I find it important to note that the worker underwent multiple assessments at the CAP between April 2022 and February 2023. As Dr. Trudel is a specialist in COVID related conditions, and noting they had the benefit of assessing the worker over a significant period, I have placed significant weight on their opinion. In the CAP discharge report, Dr. Trudel refers to the worker’s pre-existing conditions of anxiety and depression, and they state these conditions were stable prior to the worker’s COVID. In addition, Dr. Trudel provides the opinion that these pre-existing conditions have been exacerbated by the worker’s prolonged recovery from COVID. Under prognosis, Dr. Trudel refers to the worker’s ongoing symptoms, and they provide the opinion that based on the worker’s history, clinical findings, and the typical progression of the diagnosis, the worker will have no further functional recovery. Therefore, I find Dr. Trudel’s medical opinion supports the worker’s Long COVID has resulted in a permanent impairment.

Finally, I refer to Dr. Liu’s April 9, 2024, report. While I note Dr. Liu states the worker no longer has definite signs of RA, they do not provide any indication that the worker has recovered. Instead, they relate the worker’s ongoing symptoms to either fibromyalgia or Long COVID.

While I do not question the medical evidence supports the worker had significant physical and psychological conditions prior to contracting COVID, I accept the medical opinions on file support the worker’s pre-existing conditions do not render the symptoms from the COVID infection insignificant. I also find the medical evidence supports the worker never recovered from their Long COVID.

In summary, I find Dr. Markus’s opinion is consistent with the opinions as provided by Dr. Trudel and Dr. Liu. I accept the opinions as provided, and I find all opinions support a permanent impairment for the worker’s Long COVID. Therefore, I find the worker’s COVID infection did not fully recover. Instead, I find the worker has entitlement to a permanent impairment for their Long COVID.

2. Does the evidence support the worker fully recovered from the exacerbation of pre-existing RA?

For the reasons that follow, I find the worker does not have ongoing entitlement to the exacerbation of the pre-existing RA. Instead, I accept the evidence supports the exacerbation ceased as of April 9, 2024.

As the worker has a pre-existing condition for RA, I refer to Policy 15-02-03 that states when a pre-existing condition is evident, or becomes evident, the work-relatedness of the ongoing impairment must be monitored. If the pre-existing condition is not impacting the worker’s impairment, there is no effect on the worker’s benefits. If the pre-existing condition is impacting the worker’s impairment, benefits will generally continue as long as the work-related injury/disease continues to significantly contribute to the worker’s impairment.

Once the existence of a pre-existing condition has been established, ongoing work-relatedness is determined by considering the relationship, if any, between the pre-existing condition, the work-related injury/disease, and the worker’s impairment, based on the clinical evidence.

The decision-maker determines whether the pre-existing condition is impacting the worker’s ongoing impairment by considering factors such as whether

• the impairment affects the same body part or system as the pre-existing condition

• the impairment continues beyond the expected recovery period, given the work-related injury/disease

• the impairment is unexpectedly severe given the work-related accident

• there is a change in the worker’s ability to perform the pre-accident work, beyond what was expected given the work-related injury/disease.

When assessing the impact of the pre-existing condition on the worker’s ongoing impairment, the decision-maker determines whether the work-related injury/disease continues to be a significant contributing factor. To make this determination, the decision-maker considers the significance of the work-related injury/disease and the pre-existing condition, relative to each other.

In this case, the medical evidence supports the worker had a 10-year history of RA prior to contracting the COVID virus. However, following the COVID infection, the worker’s blood test showed a high rheumatoid factor, and the worker developed multiple symptoms consistent with an exacerbation of their RA. Therefore, in the decision dated June 29, 2023, the CM granted entitlement to an exacerbation of the worker’s pre-existing RA resulting from the COVID infection.

As this issue addresses the worker’s exacerbation of the pre-existing RA, I have focused my review on the medical evidence as provided by Dr. Liu, the worker’s Rheumatologist. Dr. Liu had the benefit of assessing and treating the worker for their RA condition from August 17, 2022 to April 9, 2024, and they submitted multiple medical reports confirming the worker’s ongoing symptoms related to RA.

I note Dr. Liu discharged the worker from treatment on April 9, 2024. As per their discharge report, Dr. Liu states the worker no longer shows clinical signs of RA, and they confirm the worker is no longer taking medication for RA. Dr. Liu provides the opinion that the worker’s ongoing symptoms are likely from fibromyalgia or Long COVID.

Based on my review of the relevant medical evidence, I find the exacerbation of the pre-existing RA fully resolved as of April 9, 2024. In coming to this conclusion, I have placed significant weight on Dr. Liu’s April 9, 2024, discharge report. Specifically, in this report, Dr. Liu confirms the worker no longer shows definite signs to support a diagnosis of RA, and they recommend no further follow up assessments. In addition, Dr. Liu confirms the worker is no longer taking medication for RA. While I do not question, Dr. Liu provides findings to support the worker continues to have ongoing symptoms, I accept Dr. Liu’s opinion that the worker’s ongoing symptoms are not related to the RA exacerbation as accepted in this claim. As there are no medical opinions on file that argue against Dr. Liu’s opinion, and noting Dr. Liu is a specialist in RA, who also had the benefit of physically assessing the worker for almost two years, I accept the opinion as provided by Dr. Liu. Therefore, I find that as of April 9, 2024, the worker no longer has entitlement to an exacerbation of the RA.

3. Does the worker have entitlement to CPD?

For the reasons that follow, I find the worker does have entitlement to CPD.

In reviewing the worker’s entitlement to CPD, I refer to Policy 15-04-03. As stated in this policy, the WSIB will accept entitlement for CPD when it results from a work-related injury, and there is sufficient credible, subjective, and objective evidence establishing the disability.

For a worker to qualify for compensation for CPD, the following conditions must exist, and must be supported by all the indicated evidence:

1. A work injury occurred

2. The chronic pain is caused by the work injury

3. The pain lasts six months or more past the usual healing time for such an injury

4. The degree of pain is inconsistent with organic findings

5. The chronic pain impairs earning capacity

Criteria 1 - A work-related injury occurred

In order for Criteria 1 to be met, a claim for compensation for an injury must be submitted and accepted.

Entitlement in this claim has been allowed for the COVID infection. As a work-related illness has been allowed, I find Criteria 1 has been met.

Criteria 2 - Chronic Pain is caused by the injury

This criterion requires subjective or objective medical or non-medical evidence that supports the worker’s continuous, consistent, and genuine pain has been present since the time of the injury. A medical opinion is also required that supports the characteristics of the worker’s pain, (except its persistence and/or its severity) are compatible with the worker’s injury and are such that the physician concludes the pain resulted from the injury.

Dr. Tanner, the worker’s family doctor submitted clinical notes for the worker’s medical visits prior to developing COVID. These notes confirm that the worker has a 10-year history of joint pains related to their diagnosed RA. Specifically, in May 2018, the worker saw Dr. Morassut, Rheumatologist who reviewed the worker’s blood work, and the reported joint symptoms, and they diagnosed the worker with RA. However, in September 2018, Dr. Morassut notes that the worker’s RA was no longer active, and they questioned fibromyalgia.

In addition to RA, Dr. Tanner’s clinical notes support a history of polyarthralgia, diverticulosis, and mental illness including a pre-existing diagnosis of depression, panic attacks, anxiety, and fibromyalgia. The worker was off work from July 2020 to August 2020, due to an increase in anxiety. Symptoms included SOB, tightness in chest, palpitations, and fatigue. At the time, the worker reported a number of other stressors including their husband’s illness, worries about their own health, their job, their medical treatment for diverticulitis, fibromyalgia, and RA. The worker went off work again in October 2021, for mental health reasons.

I find no medical evidence to support the worker sought medical attention with Dr. Tanner between October 2021, and the workplace illness on March 17, 2022.

Following the COVID illness, the worker followed up with Dr. Tanner multiple times, and they underwent assessments at the CAP. On September 8, 2022, and September 9, 2022, the worker underwent a psychological assessment at the CAP. Dr. Colosimo, psychologist submitted the assessment report, and they confirm they reviewed the worker’s medical history as provided in the CAP assessment report dated April 21, 2022. The worker attended psychological treatment with Dr. Colosimo, who submitted treatment reports based on the worker’s visits from December 2022 to June 14, 2023.

In the reports submitted, Dr. Colosimo states the worker reported that in the five years prior to the injury, they had been taking medication for anxiety and depression, and they experienced anxiety attacks related to personal stressors. Additional information gathered during the assessment revealed a significant history of trauma. The worker had engaged in some sessions of outpatient psychotherapy to address these traumas, and otherwise they were treated with psychotropic medication. Dr. Colosimo states the worker’s COVID illness has been highly protracted with minimal resolution of multiple severe somatic symptoms.

Dr. Colosimo goes on to state that the worker’s experience of the COVID illness has been a significant source of trauma for them in that there were moments after contracting the COVID virus that they felt their life was in danger. The worker experienced a pattern of recurrent night, negative alterations in mood, and cognition, hyperarousal, and fear avoidance behavior linked to the COVID illness.

Dr. Colosimo states that diagnostically these concerns are best conceptualized as representing a form of PTSD, but that the worker has a host of severe somatic symptoms that are clinically significant, and that their SSD was precipitated by the occupational illness. Noting the worker’s pre-existing conditions, and their non-occupational stress related to their ill husband, Dr. Colosimo provides an occupational diagnosis of PTSD (precipitated by the occupational illness, and in the context of a significant complex trauma history), and SSD, persistent Severe.

I specifically note that in the treatment discharge report dated June 14, 2023, Dr. Colosimo states that although there has been at least a partial resolution of the worker’s PTSD, there has been no material change in the worker’s diagnosed SSD, persistent, severe.

As per the CAP reports submitted, the worker continued to report ongoing symptoms of fatigue, SOB, muscle/joint pain, memory problems, concentration difficulties, dizziness, cough, and decreased activity tolerance. The worker was discharged from the CAP on February 16, 2023. At the time of discharge, the worker continued to report the same ongoing symptoms with no improvement after treatment. Dr. Trudel recommends no further treatment until the worker’s pain decreased to a manageable level.

In the report dated April 9, 2024, Dr. Liu states the worker was seen with complaints of pain everywhere, they use a walker to walk, and they continue to have SOB. Dr. Liu states the worker no longer has definite signs to support a continued diagnosis of RA.

Based on my review of the medical reports as described above, I accept there is subjective and objective medical evidence that support the worker’s continuous, consistent, and genuine pain has been present since the onset of their illness, and that the worker’s chronic pain is a result of the work-related COVID. While I have considered the medical evidence pertaining to the worker’s pre-existing conditions, I accept the opinions as provided by Dr. Trudel and Dr. Colosimo support the worker’s ongoing pain symptoms, including their diagnosed SSD are a result of the COVID infection accepted in this claim. Therefore, I find this policy criterion has been met.

Criteria 3 – The pain persists six (6) or more months beyond the usual healing time of the injury.

The evidence in order to support criteria 3 must include a medical opinion of the usual healing time of the injury, the worker’s preaccident health status, and the treatment received. Subjective or objective medical or nonmedical evidence is also required to support the worker’s continuous, consistent, and genuine pain for six (6) or more months beyond the usual healing time for the injury.

As per the evidence on file, when first seen at the CAP in April 2022, the expectation was for the worker to fully recover from the COVID illness within 10 to 12 weeks. However, the evidence as provided in the CAP follow up reports confirm the worker’s symptoms never improved with treatment, and when discharged from the CAP almost a year later in February 2023, the worker was not expected to make any further recovery. Therefore, I find the evidence as provided in the CAP reports support the worker’s pain did persist for six (6) months beyond the usual healing time of the injury. As such, I find this policy criterion has been met.

Criteria 4 - The degree of pain is inconsistent with organic findings:

For criteria 4 to be met, the medical findings on file must support the worker’s degree of pain is inconsistent with the organic findings.

Having considered all medical evidence, I find the worker’s degree of pain is inconsistent with the organic findings. In stating this, I refer to the CAP reports on file. I accept the findings in these reports confirm the worker’s degree of pain is inconsistent with the COVID illness, and the secondary Long COVID accepted in this claim. I specifically place weight on the CAP discharge report as Dr. Trudel states that although the worker received treatment, the worker’s pain levels were not under control. As such, Dr. Trudel recommends the worker be discharged from treatment, and referred back to the CAP if the worker’s pain becomes controlled. In addition, and as previously noted, I find the psychological reports on file support the worker’s diagnosed SSD is a result of the workplace illness.

Based on my review of the medical evidence noted above, I accept the worker’s degree of pain is inconsistent with the accepted COVID illness, and the accepted secondary Long COVID condition. Therefore, I find this criterion has been met.

Criteria 5 - The chronic pain impairs earnings capacity:

The CPD policy requires that the worker’s genuine pain be demonstrated through evidence of marked life disruption. In order to establish the chronic pain impairs earning capacity, there must be subjective evidence supported by medical or other substantial objective evidence that shows the persistent effects of the chronic pain in terms of consistent and marked life disruption. The policy goes on to state that since pain is a subjective phenomenon, marked life disruption is the only useful measure of disability or impairment in chronic pain cases. To properly assess this criterion, there must be clear and distinct disruption to a worker’s life, but there is no particular requirement for the disruption to be either major or minor. The disruption in the worker’s personal, occupational, social, and home life must be consistent, though the degree of disruption in each need not be identical.

As per the memorandum dated January 7, 2025, the OD Adjudicator conducted a marked life disruption review. The OD Adjudicator refers to the medical evidence that supports the worker has pain in bilateral shoulders, hips, ankles, and chest, and that the worker uses a walker to be mobile. Although the worker has been prescribed medication to assist with pain management, the worker reports the medication does not help, and they rate their pain at eight or nine out of ten. In terms of vocational life, the worker has been unable to RTW as they feel incapable of performing any work activities. The worker reported multiple changes in their home and personal life including their inability to walk without their walker no more than three feet without getting tired. The worker relies on assistance from family to perform ADLs such as, grocery shopping, laundry, cleaning the house, getting dressed, and showering. In addition, the worker now avoids using the stairs in their home. Although the worker enjoyed gardening prior to the work-related illness, since contracting COVID, they are only able to water the plants. The worker’s social life has been limited, as they no longer socialize in large groups. The worker specifically noted they avoided their grandson’s birthday. The worker also avoids music that they use to enjoy, and they reported that they have lost friends.

Having considered the evidence noted above, I find the worker’s chronic pain impairs the worker’s earnings capacity. Therefore, I find this policy criterion has been met.

In summary, I find the available medical and non-medical evidence supports that all five of the criteria for entitlement to benefits under the CPD policy have been met. As such, I find the worker does have entitlement to CPD.

4. Does the worker have entitlement to psychotraumatic disability?

For the reasons that follow, I find the worker does not have entitlement to psychotraumatic disability.

With respect to CPD and psychotraumatic disability entitlement, I recognize that entitlement for CPD and psychotraumatic disability cannot be stacked. Thus, if there are elements of both CPD and a psychotraumatic disability, it must be determined, which condition is the predominate contributing factor to the worker’s ongoing impairment.

As previously noted in this decision, I find the worker meets all of the conditions for entitlement to CPD, and that the most appropriate entitlement in the claim, based on the available evidence, is entitlement for CPD (versus a psychotraumatic disability). Therefore, since I have accepted entitlement to CPD, I find the worker does not have entitlement in this claim to psychotraumatic disability.

5. Does the evidence support entitlement to ongoing full LOE benefits effective July 15, 2024?

For the reasons that follow, I find the worker does have entitlement to LOE benefits as of July 15, 2024.

Policy 18-03-02 states that 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 RTW process.

As per the evidence on file, full LOE benefits have been paid in this claim from March 18, 2022 to July 15, 2024. The issue in dispute in this appeal is the termination of LOE benefits as of July 15, 2024.

In determining the worker’s ongoing entitlement to LOE benefits, I have placed significant weight on the medical evidence as provided in the February 16, 2023, CAP discharge report. I specifically note that in terms of RTW, Dr. Trudel provides the opinion that based on the severity of the worker’s symptoms, and the prognosis provided, a RTW is not expected.

In addition, in their report dated June 18, 2024, Dr. Liu provides the opinion that the worker’s ongoing joint issues are not due to RA, but instead related to the worker’s diagnosed Long COVID. Dr. Liu notes that RA medications have not been helpful, and the worker reports consistent full body pain. Based on the worker’s presentation during their assessments, Dr. Liu provides the opinion that the worker is not fit to perform any job.

I have also placed weight on Dr. Markus’s medical claim review. While I note Dr. Markus’s review is dated January 10, 2023, based on their review of the medical evidence at that time, Dr. Markus provides the opinion that the worker is totally disabled from symptoms associated with post-COVID syndrome. Having considered the medical evidence received to file after this medical claim review, I find the evidence supports the worker’s symptoms did not improve. Instead, the worker continued to experience the same symptoms at the same severity level. In addition, as previously noted, I have also accepted entitlement to CPD.

Based on my review of the evidence, I find that since July 15, 2024, the severity of the work-related COVID and Long COVID have prevented the worker from performing any type of work. As such, I find the worker does have entitlement to full LOE benefits as of July 15, 2024. In coming to this conclusion, I have accepted the medical opinions as provided by Dr. Markus, Dr. Trudel, and Dr. Liu. Dr. Markus is a specialist in occupational disease conditions, and they had the benefit of reviewing all medical evidence, which includes the worker’s pre-existing conditions. Dr. Markus provides the opinion that the worker’s COVID symptoms render the worker totally disabled. I find Dr. Markus’s opinion is consistent with the medical opinions as provided by Dr. Tudel and Dr. Liu who had the benefit of assessing the worker on multiple occasions, and they both also provide the opinion that the worker is unable to return to any type of work. I accept these medical opinions are consistent in terms of the worker’s level of impairment, and I find there are no medical opinions on file that argue the findings or opinions as provided by these specialists. Therefore, I accept the medical opinions support the worker’s work-related conditions have prevented the worker from returning to any type of work.

In summary, I find that since July 15, 2024, the seriousness of the work-related conditions have completely prevented the worker from returning to any type of work. As such, I find the worker does have entitlement to full LOE benefits as of July 15, 2024.

CONCLUSION

1. I find the worker did not fully recover from the work-related COVID virus and Long COVID as of April 9, 2024.

2. I find the worker did fully recover from the accepted exacerbation of their pre-existing RA.

3. I find the worker does have entitlement to CPD.

4. I find the worker does not have entitlement to psychotraumatic disability.

5. I find the worker does have entitlement to LOE benefits as of July 15, 2024.

The worker’s objection is allowed-in-part.

DATED March 26, 2025

Kelly Gordon

Appeals Resolution Officer

Appeals Services Division