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Operational policy manual

Supplement Following Significant Deterioration

Benefit Payments
Application Date
This policy applies to all decisions made for entitlement periods on or after January 1, 2018, for accidents from January 2, 1990 to December 31, 1997.
Published
02-Jan-2018
Subject
Future Economic Loss (FEL) (Accidents from 1990-1997)
Title
Supplement Following Significant Deterioration
Document No.
18-04-12

Policy

Workers in receipt of a future economic loss (FEL) benefit, or a FEL sustainability benefit, are entitled to receive a FEL supplement if, within 12 months of a determination that there is a significant deterioration in their clinical condition, they co-operate and participate in

The supplement is added to the FEL benefit. The combined total of the FEL benefit and the supplement equals 90 per cent of the worker’s pre-injury net average earnings, see 18-04-06, Initial Determination - Where Suitable Occupation has been Determined. A supplement paid based on participation in an MR program or WR activities ends upon completion of the program or activities.

Purpose

The purpose of this policy is to outline when a worker is entitled to receive the FEL supplement following a significant deterioration of the worker's condition.

 

Guidelines

Supplementary benefit duration

MR program

An MR program is any course of medical or paramedical treatment or care for a work-related injury/disease. The purpose of an MR program is to bring the worker to a state of maximum medical recovery so that the worker may return to suitable and available employment. For additional information about MR programs, see 18-04-11, Supplements for Programs and Work Reintegration Activities Before and After 24 Months and 18-06-03, Definitions for Adjudicating Pre-1998 Claims.

Generally, an MR program does not simply consist of the continued use of prescription medication and/or maintenance physiotherapy or chiropractic treatments. A worker is considered to be in an MR program if any of the following situations occur, but is not limited to

  • receiving active treatment due to a recurrence of the work-related injury/disease
  • attending a WSIB arranged specialist consultation
  • having a prosthesis repaired or replaced.

Significant deterioration

A significant deterioration refers to a marked degree of deterioration in the work-related impairment that is demonstrated by a measurable change in clinical findings.

To determine if there is evidence of a significant deterioration, decision-makers should consider factors such as

  • the need for further active clinical/health care intervention to improve the worker’s condition (e.g., surgery)
  • establishment of objective clinical evidence to support a significant deterioration
  • evidence of increased clinical precautions or whether functional abilities have changed (i.e., evidence of an increase in restricted activities may support a finding of significant temporary deterioration), or
  • job change impacts.

For additional information, see 15-02-05, Recurrences.

If a worker experiences a significant deterioration in his/her clinical condition that is

  • temporary, or
  • likely to be permanent, and
  • where a non-economic loss (NEL) redetermination may be appropriate,

the FEL supplement is payable from the start of the deterioration/recurrence provided that the worker is co-operating and participating in an MR program.

The supplement ends when

  • the worker no longer participates in the MR program, or
  • the temporary significant deterioration ends, or
  • the NEL redetermination concludes that there is no increase in the degree of the worker’s permanent impairment.

WR activities

If a worker is co-operating and participating in WR activities, the FEL supplement is payable from the start of the activities.

The supplement ends when

  • the worker no longer participates in WR activities, or
  • the WR activities are concluded.

Post-60 month review - supplementary benefit entitlement

Criteria

Following the final FEL review at 60 months post-initial determination, a worker may be entitled to a FEL supplement if

  • the worker experiences a significant deterioration in his/her work-related clinical condition, and
  • the worker co-operates and participates in an MR program or WR activities.

General considerations

If a worker experiences a significant deterioration (recurrence) after 60 months post-initial FEL determination, the WSIB may either pay supplementary benefits or adjust the FEL benefit from the start of the significant deterioration, provided that entitlement is accepted and the worker is co-operating and participating in an MR program or WR activities, see 18-04-20, Final FEL Benefit Review.

Although supplementary benefits may be paid at the outset in these cases, the WSIB should conduct a further review of the FEL benefit before that review opportunity ceases. The review should normally take place when a significant temporary deterioration ends, or at the completion of an MR program or WR activities, based on the facts of the case, see 18-04-20, Final FEL Benefit Review.

Annual indexing

On January 1 every year, the WSIB indexes ongoing FEL benefits, including the supplement, by applying the indexing factor to the amount payable, see 18-01-14, Annual Indexing.

Loss of retirement income (LRI) benefit

The WSIB sets aside additional funds equal to 10 per cent of every FEL payment, including FEL supplements, for the worker's LRI benefit, see 18-04-17, Loss of Retirement Income Benefits (Accidents from January 2, 1990 to December 31, 1997).

Application date

This policy applies to all decisions made for entitlement periods on or after January 1, 2018, for accidents from January 2, 1990 to December 31, 1997.

Document history

This document replaces 18-04-12 dated January 2, 2015.

This document was previously published as:
18-04-12 dated February 15, 2013
18-04-12 dated October 3, 2007
18-04-12 dated October 12, 2004
18-04-12 dated December 24, 2003
18-04-12 dated June 15 1999
7.11 dated January 1, 1998.

References

Legislative authority

Workplace Safety and Insurance Act, 1997, as amended
Sections 102, 106, 107, 107.1, 108

Workers’ Compensation Act, R.S.O. 1990, as amended
Sections 42, 43, 44

Minute

Administrative
#4, November 15, 2017, Page 543

Compass: Guiding you to a healthy and safe workplace