APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER:
20250072
OBJECTING PARTY:
WORKER
REPRESENTED by:
WORKER REPRESENTATIVE
RESPONDENT PARTY:
EMPLOYER (NOT PARTICIPATING)
HEARING:
HEARING IN WRITING
HEARD by:
DATED:
TRACY FRASER, APPEALS RESOLUTION OFFICER
JULY 24, 2025
ISSUE(S)
The worker, through their representative, is objecting to the following:
Decision dated March 22, 2022, wherein it was determined that the worker had reached maximum medical recovery (MMR) for their compensable injuries without a permanent impairment.
Decision dated September 20, 2023, which denied entitlement to a psychological condition under Policy 15-04-02, Psychotraumatic Disability.
Decision of August 21, 2024, wherein entitlement under Policy 15-04-03, Chronic Pain Disability
was denied.
BACKGROUND
On October 5, 2021, the worker was descending stairs when they slipped on a wet step and fell down a few steps, landing on their back. The worker reported the incident to the employer the same day and sought medical attention on October 7, 2021.
Initial entitlement was accepted for health care and loss of earnings (LOE) benefits for sprain/strain injuries to the worker’s upper and lower back in the decision dated October 12, 2021. On October 15, 2021, entitlement was updated to include a left elbow bruise/contusion, neck sprain/strain and a head bruise/contusion. In a decision dated March 22, 2022, the case manager determined that the worker reached MMR for their injuries as of March 16, 2022, without a permanent impairment.
In the decision of September 20, 2023, entitlement to a psychological condition under Policy 15-04-02, Psychotraumatic Disability was denied as none of the criterion as defined in the policy had been met. Reconsiderations of January 22, 2024 and February 15, 2024, upheld the original decision.
In the decision dated August 21, 2024, entitlement under Policy 15-04-03, Chronic Pain Disability was denied as the conditions of the policy were not satisfied. A reconsideration dated September 11, 2024, upheld the August 21, 2024 decision.
The worker’s representative submitted Intent to Object forms dated September 29, 2023 and August 30, 2024 and the Appeals Readiness Form dated December 2, 2024, confirming that they are objecting to the decisions of September 20, 2023 and August 21, 2024.
PRELIMINARY MATTER
Upon my initial review of the claim file, I noted that the determination of MMR for the worker’s organic injuries was referenced within the decisions that formed the worker’s appeal. The MMR decision was communicated in a letter dated March 22, 2022. The worker objecting to this decision in the Intent to Object Form dated April 7, 2022. I noted that in the decisions of September 20, 2023, and August 21, 2024, that the case managers based part of their decisions relating to psychotraumatic disability and chronic pain disability on the fact that the worker reached MMR without a permanent impairment. As such, I determined that there was necessity to take a holistic view of the claim and for this reason I expanded the jurisdiction of issues to include the intertwined issue of MMR and the determination that the worker did not suffer a permanent impairment with respect to their organic injuries.
AUTHORITY
Operational Policy Manual
Published
11-01-05 Determining Permanent Impairment 15-02-03 Pre-existing Conditions
15-04-02 Psychotraumatic Disability 15-04-03 Chronic Pain Disability
November 3, 2014
November 3, 2014
September 7, 2018
July 20, 2023
ANALYSIS
I find that the worker reached MMR for their work-related injuries on April 22, 2022, with a permanent exacerbation of their pre-existing low back condition and that initial entitlement to Psychotraumatic Disability is in order. I have carefully considered all of the available information, legislation, and relevant operational policies in reaching this decision.
Worker’s Position
In their submission dated January 23, 2025, it is the worker representative’s position that the worker meets the criteria for entitlement to both Psychotraumatic Disability and Chronic Pain Disability. They have indicated that if it is not found that the worker is entitled to Psychotraumatic Disability, that the worker should be granted entitlement to Chronic Pain Disability along with LOE benefits based on the medical evidence and the Marked Life Disruption review.
In their recent submission dated June 4, 2025, the worker’s representative contends that the worker did not reach MMR without a permanent impairment as of March 16, 2022, as per the decision dated March 22, 2022. They have referenced and provided several medical reports in support of their position.
Employer’s Position
The employer is not participating in this appeal and has not provided a submission for my review.
Maximum Medical Recovery
I find that the worker reached MMR as of April 22, 2022, with a permanent exacerbation of their pre- existing low back condition.
Policy 11-01-05, Determining Permanent Impairment, states, in part
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. MMR means that a plateau in recovery has been reached and it is not likely that there will be any further significant improvement in the work- related injury/disease.
In their submission dated June 4, 2025, the worker’s representative contends that the worker did not reach MMR without a permanent impairment as of March 16, 2022 noting that the worker continued to have physical problems long after this date.
As previously noted, the worker was descending stairs on October 5, 2021, when they slipped on a wet step and fell down a few steps, landing on their back. Entitlement was accepted for sprain/strain injuries to the worker’s upper and lower back, a left elbow bruise/contusion, neck sprain/strain and a head bruise/contusion.
In the decision of March 22, 2022, the case manager determined that the worker reached MMR as of March 16, 2022, for their compensable injuries without a permanent impairment based on the expected recovery timelines for sprain/strain injuries. I did not come to the same conclusion.
Policy 15-02-03, Pre-existing Conditions defines a pre-existing condition as follows:
A pre-existing condition is any condition that existed prior to a work-related injury/disease, and may include injuries, diseases, degenerative conditions, and psychiatric conditions. The existence of the condition must be confirmed by pre-injury or post-injury clinical evidence and may have been evident prior to the occurrence of the work-related injury/disease or it may become evident afterwards.
In this case, there is clear evidence of a pre-existing degenerative condition in the worker’s low back. Upon my review of the prior medical information on file, I note that the worker had been treated for chronic back pain dating back to May of 2019 and was referred for an x-ray of the spine on June 11, 2019, that revealed a normal examination. I further note that they were treated for chronic back pain on July 16, 2021, prior to the workplace incident in this claim, and the doctor opined that they worker was likely experiencing symptoms related to degenerative disc disease (DDD) and osteoarthritis.
While I acknowledge that the worker had a pre-existing condition in their low back, I find no evidence that this condition was impacting their ability to perform their regular job duties prior to the work-related incident on October 5, 2021. It was not until they fell down the stairs that the pre-existing condition worsened and became chronic.
The worker commenced treatment through the Low Back and Musculoskeletal Programs of Care on November 11, 2021. In the initial assessment reports of the same date, I note that the worker was complaining of neck, back, and left elbow pain along with daily headaches and difficulty sleeping. The physiotherapist provided the diagnoses of sprain/strain injuries to their left knee, left elbow, left hip, low
back, cervical and thoracic spine as well as headaches. I note that the worker stopped attending treatment, with their last appointment on November 17, 2021.
The workplace parties met with the WSIB return to work specialist (RTWS) on December 8, 2021, and a graduated return to work (RTW) plan was developed for the worker that allowed them to perform office work, working at reduced hours starting at 2 hours per day on December 13, 2021. It was expected that the worker would resume their full hours on January 24, 2022. I note that during the meeting, the worker reported that they were experiencing pain, most notably when they were driving. The employer was able to accommodate the worker with flexibility of their start/end times to avoid rush hour traffic travel times and also advised that they would provide taxi from the GO station that was located in close proximity to the work site. The worker returned to work on December 13, 2021 as per the plan.
A report from Clinic A dated December 16, 2021, notes that the worker commenced physiotherapy in November 2021, with minimal relief. The physiatrist recommended that the worker apply heat and stretch and also discussed trigger point injections and prescribed Pregabalin and Flexeril. The worker confirmed that they wanted to continue with conservative treatment before considering the injection.
I find that the worker may not have had a known symptomatic low back condition just prior to the workplace accident of October 5, 2021; however, they still had a pre-existing condition as defined under the policy.
An MRI dated February 12, 2022, revealed facet degenerative changes in the lumbar spine that were most prominent and severe in the bilateral L4-L5 facets; mild spinal stenosis at the L4-L5 level; no significant spinal stenosis in the remainder of the lumbar spine; neuroforaminal narrowing is most prominent and mild in the bilateral L4-L5 neural foramina; and the T1 marrow signal was somewhat lower than expected. I find that these findings were not caused by the workplace accident and represent a pre- existing condition.
In the physiatrist’s report of February 23, 2022, they reviewed the MRI and opined that there were severe bilateral L4-L5 degenerative changes and that the findings were consistent with the diagnosis of left greater than right L5 sensory radiculopathy. It was recommended that the worker participate in an active rehabilitation plan that included stretching, strengthening and a home exercise program.
An MRI of the cervical and thoracic spine dated March 7, 2022, revealed multilevel degenerative disc and facet disease in both the cervical and thoracic spine.
In the Functional Abilities Form dated March 2, 2022, the physiotherapist noted that the worker was having difficulty driving to and from work. They opined that this was an aggravating factor that hindered their function. It was suggested that working from home would be more appropriate.
In a medical note dated March 11, 2022, the doctor indicated that the worker was in considerable discomfort and was continuing with modified duties. The doctor noted that the worker’s progress had stalled despite the use of medication and ongoing physiotherapy.
A revised RTW plan was developed on March 14, 2022, after the worker reported that they were unable to increase their hours beyond 4 hours per day. The worker confirmed that there were no barriers with the suitable work but that the issue was related to their commute to the work site. They requested work from home; however, the employer advised that this was not an option for their job classification. The employer confirmed that the accommodated duties remained available based on 8 hours per day.
In the case manager’s Memo A0036 dated March 22, 2022, they determined that the findings in the MRI were degenerative conditions in the worker’s low back and were pre-existing. They further concluded that the workplace injury had aggravated the pre-existing condition. I agree with their conclusion.
In a follow-up report dated April 22, 2022, the physiatrist indicated that the worker’s health had remained stable since their previous appointment. There was no further follow-up arranged and the worker was advised to continue with their treatment through a pain clinic.
I find the evidence outlined above, establishes that by April 22, 2022, the worker had reached a plateau in their recovery with no further significant improvement likely in the work-related low back injury. The physiatrist confirmed that the worker’s condition had remained stable and there was no further follow-up recommended. In addition, I note that the worker completed treatment with the physiotherapist on March 16, 2022. Therefore, I conclude that the worker reached MMR for their compensable injuries by April 22, 2022.
As I have concluded that the worker reached MMR by April 22, 2022, I next considered whether there is an ongoing work-related impairment.
Policy 11-01-05, Determining Permanent Impairment, states that once MMR has been determined, decision-makers consider whether there is an ongoing impairment based on the clinical evidence.
In order to determine the work-relatedness of an ongoing impairment, decision makers consider:
Whether the diagnosis is the same as or compatible with the initial work-related injury diagnosis.
Whether the clinical evidence of impairment is related to the diagnosis, and
Whether a pre-existing condition or other non-work-related factors are causing or contributing to the impairment.
With respect to ongoing impairment, the WSIB considers:
a physical abnormality to be a change to or damage to a body part or organ system
a physical loss to be a loss of some or all of a body part or organ system
a functional abnormality to be a malfunction of a body part or organ system
a functional loss to be a loss of some or all of the functioning of a body part or organ system
a disfigurement to be an altered or abnormal appearance such as an alteration of color, shape, structure, or a combination of these, and
psychological damage to be the loss of or abnormal psychological functioning.
Factors such as the type or duration of treatment are not generally considered indicators of ongoing impairment in the absence of other clinical evidence of impairment.
The medical evidence on file supports that the worker continued to experience ongoing back pain beyond the MMR date for which they were receiving treatment including injections. In a medical note dated January 28, 2024, the doctor opined that the worker was considered to be disabled from their previous job over the last two years and did not anticipate a return to work noting the duration, nature, and severity of their symptoms.
Policy 11-01-05, Determining Permanent Impairment states that a work-related impairment is considered permanent when it continues to exist after MMR has been reached. I find that the worker has consistently followed up with their doctor since the workplace incident of December 13, 2021, for their low back symptoms.
Following my review of the evidence before me, I find that the worker sustained a permanent exacerbation of the pre-existing degenerative condition in their low back as a result of the workplace accident.
Entitlement to Psychotraumatic Disability
I find that there is entitlement to Psychotraumatic Disability.
Operational Policy 15-04-02, Psychotraumatic Disability states,
If it is evident that a diagnosis of a psychotraumatic disability/impairment is attributable to a work-related injury or a condition resulting from a work-related injury, entitlement is granted providing the psychotraumatic disability/impairment became manifest within 5 years of the injury, or within 5 years of the last surgical procedure.
Psychotraumatic disability/impairment is considered to be a temporary condition. Only in exceptional circumstances is this type of disability/impairment accepted as a permanent condition.
Psychotraumatic disability/impairment resulting from organic brain damage is assessed as a permanent disability/impairment.
I note that entitlement in this claim has been accepted for neck, upper and lower back sprains/strains, and bruises/contusions of the head and left elbow as a result of the incident the October 5, 2021 workplace incident.
As noted above, I have found that the worker reached MMR on April 22, 2022, with a permanent exacerbation of their pre-existing low back condition including the degenerative changes in the lumbar spine. The case manager determined that these findings were related to a pre-existing condition and that the incident of October 5, 2021, aggravated this condition.
Part of the process in determining a worker’s entitlement to psychotraumatic disability, is to request five years prior medical information. As per my review of the medical evidence on file, I note that the worker first experienced psychological symptoms on November 19, 2021 which continued into January of 2024.
In the chart notes from the family doctor from February to July 2022, support that the worker was continuing to experience low back pain with left-sided sciatica, neck and left shoulder pain and headaches. In February 2022, the worker reported that they were unable to tolerate their three hour commute to work and the doctor noted that they appeared anxious, down, and tired. The worker reported ongoing lower back and left leg discomfort with little change, along with neck, left shoulder and right elbow pain. They stated that they were experiencing poor sleep, irritability and feeling socially isolated.
The doctor referenced chronic pain syndrome, left sciatica and anxiety.
In light of the above, I find that the worker’s psychological symptoms, secondary to their pain, first manifested around November 19, 2021. Therefore, I find that the worker’s psychological symptoms emerged within five years from the date of injury and therefore, warrants a review under Policy 15-04-02, Psychotraumatic Disability.
Criterion 1:
Organic brain syndrome secondary to
traumatic head injury
toxic chemicals including gases
hypoxic conditions, or
conditions related to decompression sickness.
The worker’s representative has argued that the case manager was incorrect in stating that the worker did not have a head injury. I agree with the representative in that the worker did suffer a head injury; however, this was considered to be minor in nature noting the diagnosis of a bruise/contusion. There is no evidence to support that the worker suffered a traumatic head injury as a result of the work-related incident of October 5, 2021.
I find that this criterion has not been met. In this case, the worker sustained injuries to their neck, upper/lower back, head, and left elbow as a result of the work-related incident. There is no evidence to support that the worker suffered a traumatic head or brain injury, nor were they exposed to toxic chemicals and they did not experience hypoxia or decompression sickness.
I find that the first criterion of the policy is not satisfied. Criterion 2:
As an indirect result of a physical injury
emotional reaction to the accident or injury
severe physical disability/impairment, or
reaction to the treatment process.
In reviewing the second criterion, I am not persuaded that the worker had an emotional reaction to the accident, the injury, or the treatment process.
I also note that the workplace incident of October 5, 2021, was not traumatic in nature and did not result in a severe physical disablement or impairment. Entitlement in this claim remains limited to sprain/strain injuries to their neck, upper and lower back as well as bruises/contusions of their head and left elbow.
In the Health Professional’s Progress Report (Form 26) dated October 21, 2021, the worker was provided with standard restrictions for bending/twisting, climbing, kneeling, lifting, operating heavy equipment, operating a motor vehicle, pushing/pulling, sitting, standing, use of public transportation and use of upper extremities. The doctor indicated that the worker was partially recovered at that time with a full recovery anticipated in approximately four weeks. I find that the medical information supports that the worker was temporarily partially impaired as a result of their compensable injuries.
Following the injury, the worker was prescribed pain medication and they participated in physiotherapy treatment from October 26, 2021, until November 17, 2021, when they stopped attending. I note additional therapy was approved for the worker with a new provider from February 3, 2022 to March 16, 2022. There is no evidence before me to support that the worker had a reaction to the treatment process.
I find it significant that the worker was able to continue working following the injury. Although they did lose time as of October 7, 2021, they were able to return to suitable modified work on December 13, 2021, on graduated hours. I note that the worker did continue to work reduce hours after February 5, 2022 until they stopped working in April 2022.
In the chart notes from the family doctor from November 19, 2021, I note that the worker reported feeling irritable, frustrated with poor sleep, and appeared to be anxious and tired. In reviewing this information, I find that there is no clear indication as to what the worker’s psychological symptoms were related to during this time.
For the reasons noted above, I find that the conditions under the second criterion have not been met. Criterion 3:
The third criterion for allowance, states that the psychotraumatic disability is shown to be related to extended disablement and to non-medical, socioeconomic factors, the majority of which can be directly and clearly related to the work-related injury.
In their submission, the worker’s representative contends that the case manager erred in their decision as it relates to an extended disablement. I agree with the worker representative’s position.
When reviewing for entitlement under this criterion, I must be able to support that the worker is having difficulty coping with the impact of the injury and the related impairment that the injury has had on them. This criterion is considered in cases where recovery is prolonged and/or there is a permanent injury.
Upon my review of the family doctor’s chart notes, I find that the worker had appeared anxious and tired and reported that they were having difficulties with sleep and that they were socially isolated and irritable. The family doctor consistently made these observations when assessing the worker. On April 8, 2022, the worker was referred to a psychologist to address their psychological symptoms. It is important to note that the worker continued to report that there was no change in their condition despite receiving massage, physiotherapy treatment and treatment through the pain clinic.
In the physiatrist’s report dated April 22, 2022, it was noted that worker’s injuries had affected them negatively in terms of mood, stress levels and that they were having panic attacks for which they were taking Lorazepam daily.
I note the report from the psychologist dated June 19, 2023 confirmed that the worker had been attending treatment since December 2022 for support with their mental health symptoms related to the incident in October 2021. The psychologist provided the clinical opinion that the workplace accident was a direct contributor to the worker’s major depressive disorder (MDD) and panic disorder. The psychologist opined that the worker’s mental health concerns started after their workplace accident in October 2021 and contributed to their distress and impact their ability to carry out daily activities such as completing chores, running errands, engaging in enjoyable activities, and socializing. A return to work was not recommended.
I further note the psychiatrist’s reports dated July 24, 2023 and January 22, 2024, that reference the work-related accident and that since that time the worker had been experiencing pain that caused a significant functional decline. The psychiatrist confirmed the diagnoses of MDD, generalized anxiety disorder (GAD) and posttraumatic stress disorder (PTSD). The worker was feeling overwhelmed and stressed out. I note that there were no other non-medical, socioeconomic factors contributing to the worker’s psychotraumatic disability.
In review of the prior medical information on file, I find no evidence to support that the worker had a pre- existing history of psychological problems. I note that the worker was able to function normally in the workplace until the date of the accident. I acknowledge that they attempted to return to work; however, they continued to report difficulty with trying to increase their hours due to their ongoing pain symptoms.
Policy 15-04-02, Psychotraumatic Disability notes that the majority of a worker’s psychological complaints must be directly and clearly related to the work-related injury, but does not exclude that other, non-work- related factors may also be impacting a worker. In this case, the evidence supports that the main contributor to the worker’s psychological issues is the work-related injury.
All of the available psychological reports indicate that the worker was reacting to the impact that the workplace accident has had on their life, their ability to function as well has their personal, occupational, social, and home life.
I am placing significant weight on the reports from the psychologist and psychiatrist as their assessments confirmed that the workplace accident was a direct contributor to the worker’s diagnosed psychological conditions. I am accepting the opinion of the psychiatrist that the worker was diagnosed with MDD, GAD and PTSD, noting their expertise, education, and experience in their field in.
In light of the above, I find that criterion three has been met as the evidence before me demonstrates that the worker’s psychological disability (MDD, GAD and PTSD) is a result of the workplace accident and is directly related to their extended disablement and non-medical, socioeconomic factors.
I conclude that the worker has entitlement for psychotraumatic disability. Although I am accepting entitlement for a psychotraumatic disability, I am unable to determine if the worker has suffered a permanent impairment as there is no medical information beyond January 2024 on file. In addition, there has been no recent contact with the worker since the closure of the claim file in March 2022, and no further information has been provided regarding the worker’s current psychological level of function.
Entitlement to Chronic Pain Disability
As I have determined that the worker has entitlement to psychotraumatic disability, there is no basis to review the file further under the Chronic Pain Disability policy.
CONCLUSION
I conclude the following:
That the worker reached MMR for their work-related in juries on April 22, 2022, with a permanent exacerbation of their pre-existing low back condition.
That the worker is entitled to Psychotraumatic Disability.
The worker’s objection is allowed-in-part.
I remit the nature and duration of the ongoing benefits to the operating area.
DATED JULY 24, 2025
Tracy Fraser
Appeals Resolution Officer Appeals Services Division