Pre- Existing Conditions (POL-61)

Chapter:
CLAIMS

Subject:
PRE-EXISTING CONDITIONS

Effective Date:
June 21, 2001

Last Updated On:
December 25, 2021

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PURPOSE STATEMENT

The purpose of the policy is to explain how a pre-existing condition may affect entitlement to workers compensation benefits. 

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REFERENCE

Workers Compensation Act R.S.P.E.I., 1988, Cap. W‑7.1, Sections 1 (1) (n), 6 (9-11)

Workers Compensation Board Policy, POL-58, Cost Relief For Employers

Workers Compensation Board Policy, POL‐71, Conditions for Entitlement

Workers Compensation Board Policy, POL‐86, Temporary Wage Loss Benefits 

Workers Compensation Board Policy, POL‐92, Health Care Benefits – General Principles

Workers Compensation Board Policy, POL-160, Decision Making

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DEFINITION

In this policy:

“Accident” means an accident resulting in an injury to a worker arising out of and in the course of employment, and includes the following:

• Wilful and intentional acts that are not the act of the worker.
• Chance events of physical or natural cause.
• Disablement.
• Occupational disease.
• Stress, if it is an acute reaction to a traumatic event. 

 “Aggravation” means the temporary or permanent worsening of a work-related injury due to a pre-existing condition.

“Impairment” means a medically measurable, permanent 

1. loss of physiological function, anatomical function or anatomical structure, or
2. abnormality of psychological function, physiological function, anatomical function or anatomical structure. 

“Loss of earning capacity” means the difference between the worker’s net average earnings before the accident, and the net average amount the Workers Compensation Board determines the worker is capable of earning after the accident.

“Personal injury” means a diagnosed physiological or psychological injury or condition caused by an accident arising out of and in the course of employment.

“Plateau in medical recovery” means there is little potential for improvement or any potential changes in the condition are in keeping with the normal fluctuations which can be expected with that kind of injury.

“Pre-existing condition” means any condition inherent in the worker at the time of the accident.

“Rate group” means a group to which an industry is assigned for assessment purposes. 

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POLICY

General Principles

1. A pre-existing condition is any condition, as confirmed by medical information, which pre-dates a workplace injury. The worker may or may not have been aware of the condition, experienced symptoms or have been treated for the condition.
2. Medical information regarding the relationship between the workplace injury and a pre-existing condition is evaluated throughout the duration of the claim to determine initial and ongoing entitlement. 

Conditions for Initial and Ongoing Entitlement 

3. Where there is evidence of a pre-existing condition, the Workers Compensation Board (WCB) must determine to what extent, if any, the pre-existing condition is a factor in the worker’s claim for a workplace injury. 
4. For claims where pre-existing conditions may be a factor, entitlement will be determined using the principles set out in this policy and WCB policy, POL-71, Conditions for Entitlement.
5. To be entitled to compensation for a workplace injury that has been aggravated by a pre-existing condition, all of the following conditions must be met: 
   
   • There must be evidence that an accident occurred.
   • Objective medical information must support that the accident caused a separate and distinct new injury.
   • The injury was aggravated by a pre-existing condition. 
   • The injury must be work-related, i.e., the injury arose out of and in the course of employment.

Where all four of the conditions have been met, entitlement to wage loss and health care benefits will be determined as per WCB policies, POL‐86, Temporary Wage Loss Benefits and POL‐92, Health Care Benefits – General Principles.

7. The existence of a pre-existing condition does not necessarily mean that there is an aggravation to the workplace injury. 

   Where the pre-existing condition has no impact on the workplace injury, there is no effect on entitlement to compensation.

8. The WCB assesses and weighs all relevant information and makes the initial and ongoing entitlement decisions based on the balance of probabilities, as set out in WCB policy, POL-160, Decision Making.

Duration of Compensation

9. Where a worker is entitled to compensation for a workplace injury that has been aggravated by a pre-existing condition, compensation is payable for the full injurious result, that is, the full result of the injury.

   The full result of the injury includes:

   • The direct effects of the workplace injury.
   • The aggravation of the workplace injury by the pre-existing condition. 

The full result of the injury does not include symptoms or effects which are solely attributable to the pre-existing condition.

10. The full result of the injury is considered to be at conclusion where the weight of evidence shows that:
    
    • The worker has reached a plateau in medical recovery,
    • The aggravation has ended and ongoing symptoms or effects are more likely due to the natural progression of the pre-existing condition over time, or
    • The worker’s pre-existing condition has returned to the pre-accident state.

Where it is determined that the worker has been compensated for the full result of the injury, the WCB is not responsible for any further loss of earnings, health care or rehabilitation in relation to the pre-existing condition.

11. Where the weight of evidence supports that the worker continues to experience symptoms or work restrictions as a result of the workplace injury or the aggravation of the workplace injury, ongoing entitlement to compensation benefits and services will be considered under the WCB policies for return to work, wage loss benefits and impairment.

Treatment for a Pre-existing Condition

12. The WCB may provide treatment for a pre-existing condition where it is necessary for the recovery of a compensable injury. A worker is not entitled to benefits solely as a result of treatment for the pre-existing condition.

Apportionment of Claims Costs

13. If a worker’s impairment or loss of earning capacity is due in part to an accident and in part to a cause other than an accident, the WCB will:
    
    • Determine what portion is a result of a cause other than an accident. 
    • Charge that portion against the rate group to which the worker’s employer belonged at the time of the accident pursuant to the WCB policy, POL-58, Apportionment.
14. The WCB will use evidence-based disability duration guidelines to determine a date for the expected healing time for a work-related injury. This date will be used to determine the portion of the claims costs to be charged to the rate group.

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HISTORY

August 28, 2015 - Amended to clarify how a pre-existing condition may affect entitlement to workers compensation benefits.

April 24, 2008 - The policy was updated as a result of the 60 month policy review process.

November 27, 2002 - Policy revised to clarify intent of the Workers Compensation Act to compensate a worker for aggravation of a work related injury due to a pre-existing condition.

March 28, 2002 - Policy revised to incorporate changes required as a result of Workers Compensation Act amendments (Bill 15) to be proclaimed April 1, 2002.

Board of Directors Approval Date: June 21, 2001