The Commission received several complaints about how the WSIB adjudicates claims in which a worker has entitlement under Policy 15-04-02 (Psychotraumatic Disability) as a secondary condition to an organic (physical) injury.

In the decisions in question, the WSIB essentially determined that entitlement for the psychological condition ends when the worker recovers from the organic injury. As a result, the decision-maker did not engage in any detailed analysis of the psychological evidence in the claim.

In one of the cases, the complainant sought clarification from the WSIB’s Operational Policy Branch. The Policy Branch clarified that when an organic injury resolves, the psychotraumatic disability does not automatically end. Instead, a decision-maker should assess the facts of the case to determine ongoing entitlement.

In our initial inquiries, a manager explained that the approach taken in the claim was consistent with other decision-makers and in line with the training provided by the Psych/CPD Team.

In subsequent inquiries, a director in the Psych/CPD team explained that their team used to make all decisions related to psychotraumatic disability entitlement, but they now handle the initial entitlement decisions only. Other decisions regarding psychotraumatic disability were transitioned to the regular case management teams approximately three years ago in order to ensure consistency in management of the claim and to address a backlog that had developed in the Psych/CPD team. The Psych/CPD area can provide guidance to those decision-makers when necessary.

The director confirmed that decision-makers must address the specific medical evidence on file instead of ending all entitlement once the organic injury resolves. Following our inquiries, he disseminated a reminder to the relevant adjudicative staff. He explained that there may be exceptional cases where entitlement does not end, and in other cases it may be appropriate to follow a step-down process by allowing further psychological treatment for a limited period so workers can transition back to their regular activities.

He told the Commission that the above information is part of the refresher training on psychotraumatic disability, but he noted that some of it may be getting lost due to turnover amongst staff. The Commission will monitor for any further complaints about this issue.