An injured worker complained that the WSIB had not properly considered Policy 15-02-03 (Pre-existing Conditions) in determining that his low back injury had resolved with no permanent injury. Although he had a prior back condition, it had not prevented him from working in the past. At the time of the decision, however, he was not able to perform his pre-injury job, and his employer had laid him off as a result.

He escalated his concerns to a manager and the President’s Office. The WSIB upheld its decision after reconsideration. However, the worker found the decision letter confusing and pointed out that it did not provide a clear analysis of how the policy applied to his case.

In reviewing the complaint, we noted that the WSIB’s policy and internal guidelines provide a framework on how to approach these decisions, including a requirement to obtain a clinical opinion when distinguishing between the contribution of a work-related injury and a pre-existing condition to an ongoing impairment.

When we raised this information with a manager, he agreed to send the file for a medical opinion. The medical opinion supported an ongoing work-related impairment, leading the case manager to overturn his previous decision. As a result, the WSIB reinstated the worker’s loss of earnings benefits and referred him to a WSIB specialty clinic for further treatment.