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Operational policy manual

Determining the Degree of Permanent Impairment

Benefit Payments
Application Date
This policy applies to all decisions made on or after March 30, 2011, for injuries / diseases on or after January 2, 1990.
Published
01-Oct-2011
Subject
Non-Economic Loss (NEL) (Accidents from 1990)
Title
Determining the Degree of Permanent Impairment
Document No.
18-05-03

Policy

Workers who have a work-related permanent impairment are eligible for non-economic loss (NEL) benefits.

To rate permanent impairments, the WSIB uses a prescribed rating schedule, all relevant health care information in the claim file and, if required, the report from a NEL medical assessment.

Guidelines

When the worker reaches maximum medical recovery (MMR), see 11-01-05, Determining Maximum Medical Recovery, the WSIB attempts to determine the degree of the worker’s permanent impairment by considering all relevant health care information in the claim file. The worker and employer are advised of this procedure.

If the existing health care information in the claim file is insufficient to determine the degree of the worker’s permanent impairment, the WSIB requests additional health care information from the worker’s physician or other treating health professionals. If the information is still insufficient, the WSIB requires the worker to attend a NEL medical assessment conducted by a roster physician.

Permanent impairment

Permanent impairment means any permanent physical or functional abnormality or loss (including disfigurement) which results from an injury, and any psychological damage arising from the abnormality or loss.

A worker's degree of permanent impairment is expressed as a percentage of total permanent impairment of the whole person.

Rating schedule

The prescribed rating schedule is the American Medical Association's Guides to the Evaluation of Permanent Impairment, 3rd edition revised, (the AMA Guides).

If a type of impairment is not listed in the AMA Guides, the WSIB considers the listings for the body parts, systems, or functions which are most similar to the worker's condition.

NEL medical assessment

Roster of physicians

The WSIB maintains a roster of physicians to conduct NEL medical assessments. If the worker is required to attend an assessment, the worker will receive a list naming at least three (3) roster physicians who practice in the appropriate area of clinical expertise and are located within the worker's region. From this list, the worker selects the physician to conduct the assessment. Workers have 30 calendar days to select a roster physician to conduct the initial assessment. If a worker does not make a selection within this time, the WSIB appoints a physician.

Physicians on the list cannot conduct an assessment if they

  • are employed by the WSIB
  • have examined the worker for the same condition
  • have treated the worker or a member of the worker's family, or
  • have acted as a consultant in the treatment of the worker or as a consultant to the employer.

NOTE

Physicians named on a roster who are employed by the WSIB, or who have acted in one of the ways listed above, should notify the WSIB.  The WSIB may waive these conditions for workers who live in small or remote communities, or if the worker and employer consent to the selection of a particular physician in writing.  If there are not enough suitable physicians in a worker's region, the WSIB may include on the list the name(s) of physicians from another region which is convenient for the worker.

Requesting further information

If a NEL medical assessment is conducted, the WSIB reviews the report to ensure it is accurate and complete.

If an assessment report is incomplete or requires clarification, verification, or elaboration, the WSIB makes every reasonable effort to contact the roster physician who conducted the assessment to obtain the necessary information.

Information obtained by telephone must either be confirmed by the roster physician in writing, or documented in the NEL medical assessment report by the WSIB, and proxy stamped. The proxy stamp verifies that the information was obtained from the roster physician over the phone.

Second NEL medical assessment

The WSIB requests a second NEL medical assessment if

  • the findings in the first NEL medical assessment report and those in the claim file are significantly different, or
  • it was not possible to obtain a complete and accurate medical assessment.

The worker or employer (if the employer previously requested a copy of the report) may contact the WSIB to comment on the completeness or accuracy of the first NEL medical assessment, but cannot object to the WSIB's decision to accept the report or request a second NEL medical assessment.

When the WSIB requests a second NEL medical assessment, workers are sent a list of suitable roster physicians. The worker has 30 calendar days to select the physician to conduct the second NEL medical assessment. If the worker does not make a selection within this time, the WSIB appoints a physician. The physician who conducted the initial NEL medical assessment cannot conduct the second NEL medical assessment.

The WSIB uses the new NEL medical assessment, along with any health care information in the claim file up to the date of the second NEL medical assessment, to determine the degree of the worker's permanent impairment. Any part of the first NEL medical assessment could also be used, if appropriate.

Disclosure of NEL medical assessment reports  

The WSIB sends a copy of the initial NEL medical assessment report to the worker.

The WSIB will send a copy of the NEL medical assessment report to the employer upon request, without there having to be an issue in dispute. The WSIB notifies the worker and gives him or her an opportunity to object to the disclosure of the report within 21 days.  In the event the worker objects to the disclosure of the report, the WSIB resolves the dispute by applying the procedure set out in 21-02-02, Disclosure of Claim File Information (Issue In Dispute), under the heading “Worker’s objection to release of health care information.”

In the event the WSIB requests a second NEL medical assessment, the above process applies.

The disclosure of NEL medical assessment reports are subject to the guidelines outlined in 21-02-02, Disclosure of Claim File Information (Issue in Dispute), that pertain to the removal of harmful medical information or irrelevant personal information, and to the restrictions on the disclosure of copies of the report to third parties.

Other uses of the NEL medical assessment report

The WSIB may use information in either the first or second NEL medical assessment report, or both, to assist in determining a worker's entitlement to other benefits and services.

Multiple impairments referred for NEL benefit eligibility at the same time

In some cases, more than one area of permanent impairment may be considered at the same time for the purposes of determining the overall NEL benefit eligibility. The WSIB considers the health care information on file that pertains to each area of impairment in an attempt to rate all the impairments.   

If it is not possible to determine the degree of permanent impairment by using the health care information on file for all body parts, systems, or functions, a worker may be required to attend a NEL medical assessment for only the body part, system, or function that requires additional medical evidence.  

When the WSIB has sufficient health care information (including the NEL medical assessment report if such an examination was required) to rate all the body parts, systems, or functions included in the original referral, a NEL benefit decision is rendered. The WSIB rates each body part/system and then combines these values using the prescribed Combined Values Chart (CVC Chart) of the AMA Guides, see 18-05-04, Calculating NEL Benefits.

Determinations post-final benefit review

A NEL benefit can be determined post-final review (60 month post-initial FEL determination) or post-final LOE review (72 months post-injury) if

  • a worker received a zero NEL rating for an impairment (post January 1, 1998) but experiences a significant deterioration in his/her medical condition which results in an increase to the rating of that impairment    
  • a worker does not have entitlement to a NEL benefit for any impairment, however, a new area of entitlement to a permanent impairment is identified after the expiration of the final benefit review period which results in a rating which is greater than zero per cent.

For entitlement to NEL redeterminations post-final benefit review, see 18-05-09, Redeterminations.

If entitlement to a NEL determination has been established post-final FEL/LOE review, the FEL/LOE benefit may also be reviewed. The FEL/LOE benefit review period continues for a period of up to 24 months from the date the NEL benefit is processed. If the determination results in a zero NEL rating, the review ends as of the date of that determination. See 18-04-20, Final FEL Benefit Review; 18-03-06, Final LOE Benefit Review.

Special cases

In some cases, the WSIB may modify the process normally followed to determine NEL benefits. These special cases are described below.  

Workers who move outside of Ontario

In cases where a worker moves out of Ontario before reaching MMR, the WSIB monitors the worker's recovery. When the worker reaches MMR, the WSIB attempts to use the relevant health care information in the claim file to determine the degree of the worker's permanent impairment. 

If the health care information in the claim file is not sufficient to determine the degree of the worker's permanent impairment, the WSIB requests additional health care information from the worker's physician or other treating health professionals. If the information is not adequate, the WSIB may require the worker to return to Ontario for a NEL medical assessment by a roster physician.

The WSIB reimburses workers for travel expenses, (e.g., meals, accommodation, and transportation), according to the travel expenses policy, see 17-01-09, Travel and Related Expenses.

Serious illness or death

If a worker becomes seriously ill or dies after reaching MMR, the WSIB uses the relevant health care information in the claim file to determine the worker's permanent impairment and to calculate the NEL benefit.

If the health care information in the claim file is insufficient to determine the NEL benefit, the WSIB requests additional health care information from the worker's physician or other treating health professionals. The WSIB then determines the permanent impairment and calculates the NEL benefit based on all of the relevant health care information in the claim file.

NOTE

If the WSIB determines a second NEL medical assessment is required, but the worker becomes seriously ill or dies before it occurs, the WSIB requests additional health care information from the worker's physician or other treating health professionals. The WSIB then determines the permanent impairment and calculates the NEL benefit based on all of the relevant health care information in the claim file, including any part of the first NEL medical assessment to determine the degree of the worker's permanent impairment.

Incarcerated workers

See 15-06-06, Incarcerated Workers.

Payment

For information on how the WSIB pays NEL benefits resulting from an initial determination, including the special cases noted above, see 18-05-04, Calculating NEL Benefits.

Redeterminations

If a worker's condition deteriorates after a permanent impairment is rated, the worker can apply for a redetermination, see 18-05-09, Redeterminations.

Application date

This policy applies to all decisions made on or after March 30, 2011, for injuries/diseases on or after January 2, 1990.

Policy review schedule

This policy will be reviewed within 5 years of the application date.

Document history

This document replaces 18-05-03 dated July 18, 2008.

This document was previously published as

18-05-03 dated October 12, 2004

18-05-03 dated June 15, 1999

6.2* dated January 1, 1998.

* This document was replaced by 18-05-03 dated June 15, 1999.

References

Legislative authority

Workplace Safety and Insurance Act, 1997, as amended
Sections 2(1), 46, 47, 58, 59,106

O. Reg. 175/98
Section 18

Workers' Compensation Act, R.S.O. 1990, as amended
Sections 1(1), 42

R.R.O. 1990, Reg. 1102
Section 15

Minute

Board of Directors

#1, September 7, 1990, Page 5388

#1, February 11, 1991, Page 5427

#1, March 1, 1991, Page 5433

 

Administrative

#1, September 6, 2011, Page 490

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