Asymptomatic pre-existing condition does not limit entitlement
Mr. B phoned the Commission after his case manager terminated his benefits. Medical reports showed underlying degenerative disc
disease, and the case manager decided that the worker’s injury, a back sprain, had resolved so that ongoing symptoms were related to
the disc disease. She said the decision was based on general medical knowledge.
Mr. B reviewed WSIB policies and noted the aggravation policy, which allows for benefits to be reduced in cases where a workplace
injury aggravates a pre-existing impairment and the worker has recovered to the level of his pre-accident state. A pre-existing
impairment is defined as a condition that has produced periods of impairment or illness requiring health care and has caused a
disruption in employment. There is no reference to an asymptomatic pre-existing condition
Mr. B had worked full time for two years prior to the accident with no back problems. He tried to return to work after his benefits were
terminated but lasted for less than two hours.
A Commission specialist spoke with the manager, the assistant director and the vice-president of Long Term Service Delivery about
the decision-making process, the meaning of a pre-existing condition and how it might affect benefits.
The vice-president confirmed that the WSIB aggravation policy requires the case manager to look into the worker’s pre-accident state.
The vice-president agreed that investigation did not take place in Mr. B’s case.
Mr. B’s file went back to the case manager. She collected medical records dating back to two years before Mr. B’s accident and spoke to
his employer. This evidence confirmed Mr. B had no history of back problems. The file then went for a medical consultant review.
Then the case manager reconsidered the decision and reinstated Mr. B’s benefits finding that he had not recovered to his pre-accident
state. The vice-president said he would use this case as a teaching example of the type of inquiries case managers need to undertake in
cases where workers do not return to work in the time expected.