Reopening A Claim for Recurrence of Symptoms (POL-60)

Chapter:
CLAIMS

Subject:
REOPENING A CLAIM FOR RECURRENCE OF SYMPTOMS

Effective Date:
June 21, 2001

Last Updated On:
April 6, 2023

PURPOSE STATEMENT

The purpose of this policy is to explain how the Workers Compensation Board (WCB) determines entitlement to benefits on a closed claim if a worker is experiencing a recurrence of symptoms that may be a result of a previously accepted work-related injury. 

REFERENCE

Workers Compensation Act R.S.P.E.I.1988, Cap. W-7.1, Section 6, 32, 40, 41

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

Workers Compensation Board Policy, POL-160, Decision Making

DEFINITION

In this policy:

“Average earnings” means the daily, weekly, monthly, or regular remuneration the worker was receiving at the time of the accident or any consecutive twelve month period during the two years preceding the date of accident, whichever, in the opinion of the Workers Compensation Board best represents the worker’s loss of earning capacity. This includes any remuneration the worker received as a result of the employment and Employment Insurance.

“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.

“Maximum annual earnings” means the maximum annual earnings amount for compensation and assessment purposes, as determined by the Workers Compensation Board each year.

“Medical information” means information provided by a health care provider that is related to the medical condition and treatment of a worker. 

“Objective information” ” means information or evidence that can be quantified or measured. 

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

“Recurrence” means a return of symptoms that are reasonably attributed to a work-related injury from which the worker has previously recovered. 

POLICY

1. Claims generally close after a worker recovers from a work-related injury. A claim will be reopened when the condition or symptoms occur as a reasonable medical consequence of the original injury on the balance of probabilities.

   This policy does not apply to workers who have received an Impairment Award and therefore have an open claim. Ongoing entitlement to benefits and services for these workers will be determined as set out in WCB policies, POL-160, Decision Making and POL-71, Conditions for Entitlement.

Criteria for Reopening a Claim for Recurrence of Symptoms

2. Closed claims will be reopened when:
   

   • The current condition is medically compatible with the original work injury, and

   • No other variables have intervened as the dominant cause of the current condition.

Medical Compatibility

3. To assess medical compatibility, objective information is reviewed to determine whether the current condition is reasonably related to the accepted diagnosis when the claim closed.

   The WCB may rely upon the worker’s medical history, medical research and medical opinions to determine medical compatibility.

4. Where there is conflicting information regarding medical compatibility, the information will be assessed using the criteria set out in WCB policy, POL-160, Decision Making. 

   Continuity of Symptoms

5. Continuity of symptoms, as supported by objective information, is a reliable indicator of a direct relationship between the current condition and the original injury. 
6. Specific indicators that may support a continuity of symptoms include: 
   
   • Objective information of a continued need for medical care since the original injury. 
   • Ongoing work restrictions or job modifications following the original injury. 

Where there is no evidence of the specific indicators above, the lack of evidence will be considered as a factor in determining whether there is a continuity of symptoms.

Other Variables

7. When assessing whether the current condition or symptoms can be reasonably attributed to the work-related injury, the following variables will be considered: 
   

   • New or pre-existing health conditions.

   • The passage of time.

   • The effects of natural physical deterioration processes (e.g., aging, degeneration).

   • Aggravating lifestyle factors. 

   • An incident, event, activity or exposure which, by itself, may have caused a new injury. 

8. If the variable(s) is the dominant cause of the current condition or symptoms, the claim will not be reopened.

9. A new work-related incident, event, activity or exposure will be considered as a new and separate claim and will be adjudicated under the provisions of WCB policy, POL-71, Conditions for Entitlement.

10. If a claim is reopened, entitlement will be determined as per WCB policies, POL‐86, Temporary Wage Loss Benefits and POL‐92, Health Care Benefits.

HISTORY

July 23, 2020 – Non-substantive changes to reflect new policy, POL-160, Decision Making.

July 25, 2018 – Amended to differentiate between a re-opening and a recurrence, to clarify how medical compatibility is established, and to clarify how intervening variables are considered when determining if a claim is a recurrence. 

January 1, 2014 - Amended to reflect the revisions made to the Workers Compensation Act that became effective January 1, 2014.

September 27, 2007 - The policy was updated as a result of the 60 month policy review process.

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.