Initial entitlement decision - psychiatric or psychological injury

Review the information on the claim to get an understanding of the worker’s injury. Refer to the 1-1 Initial entitlement decision procedure, step 1 for more information on what evidence should be gathered and reviewed to determine claim acceptance. 

For psychological or psychiatric injuries, consider if:

• there is evidence of a traumatic incident. Refer to Policy 03-01, Part II, Application 6 - Psychiatric or psychological injury (Question 5).
• there was exposure to an accumulation of non-traumatic work-related stressors (chronic onset) or bullying and harassment. Refer to Policy 03-01, Part II, Application 6 - Psychiatric or psychological injury (Questions 6 to 8).
• the worker was employed in a job where presumptive coverage applies, and the worker experienced traumatic event(s) at work. Refer to Table 1 Presumptive Coverage for Psychiatric or Psychological Injury, Policy 03-01, Part II, Application 6 and the Presumptive coverage section.

Determine what information may still be required to make the entitlement decision and anticipate questions that may arise during the initial conversations with the worker and employer. Refer to step 2 and 3 for more details about this conversation.

Call the worker to discuss the psychiatric or psychological issues or stressors they are experiencing. Explain that WCB has been notified of their work accident/injury and clarify the decision maker's role in making a decision about their entitlement to compensation benefits. Gather information about the worker's injuries and the traumatic incident or work-related stressors, considering the sensitive nature of the discussion. Inform the worker that the topics may be difficult and encourage them to take their time when answering questions.

During the discussion, confirm: 

• Well-being: Ask open ended questions such as: How are they feeling? How are they coping with their injury? What does a typical day look like for them?
• Incident Details: Review the description of the traumatic incident, work-related stressors or bullying and harassment. Ask if they have additional information. Confirm when and where the incident, stressors or bullying and harassment occurred if not already on file.
• Reporting: If the incidents were reported, to whom, and is there documentation? Were there any witnesses? Obtain contact information for the person(s) the incidents were reported to and any witnesses, or other forms of information such as correspondence (emails, texts, letters, video, audio recordings, etc.).
• Medical treatment: What treatment have they received for their injury? Are they are currently attending treatment? Confirm the name of their treatment provider (s) and any upcoming medical appointments. If they were seeking medical attention from a psychologist prior to their date of accident, confirm if the psychologist can become non-contracted provider. Refer to the 4-3 Psychological counselling procedure.
• Diagnosis and Goals: What are their recovery and treatment goals?
• Pre-existing conditions: If the medical reporting suggests the worker may have a pre-existing psychiatric or psychological condition, explain that further reporting may be required to confirm the status of their pre-existing psychiatric or psychological condition to establish a baseline for comparison to their status since the work injury.
• Employment status: Are they working?
  • Review medical reports and discuss their fitness for work, if applicable.  
  • If they have returned to work, confirm if it is regular or modified duties and the return date. If they are performing modified work, what duties are they are performing, and are there any concerns?
  • If they have not returned, ask if they have any concerns about future return to work.
• Employer contact: Are they in contact with their employer? Encourage maintaining this relationship.
• Worker Status: If it is unclear if they are a worker under the WCA (refer to the 1-1 Initial entitlement decision procedure), gather necessary information.
• Self-Employment: If self-employed, confirm personal coverage.
• Unique Employment Situations: If they have a unique employment situation (e.g., subcontractor, student, pieceworker, owner/operator), gather relevant information.
• Report of injury: If not on file, request they complete and sign a Worker's Report of Injury or Occupational Disease form (C060).
• Additional Assessments: Identify any additional assessments needed for an entitlement decision (e.g., Return-to-Work Planning Meeting, psychological assessment), why they are needed and obtain the worker's agreement to attend.

Review their responsibility to make reasonable, good faith effortFor additional information, refer to Section 89.1 of the Act and Policy 04-11, Part 1 and Part II - Application 1.s to cooperate in the return-to-work process.

Discuss the plan for making an entitlement decision, including the next steps like requesting medical information or referring for reviews and/or assessments. Explain the expected decision timeline and establish a plan for regular contact (e.g., a phone call every two weeks). 

If additional medical assessments are needed to make the decision, consider if the claim meets the criteria for payment of benefits during the medical investigation. 

Consider approving five counselling sessions while determining entitlement. If the worker accepts the offer of counselling, approve treatment with an authorized provider. If they are already working with a provider, consider if ongoing counselling can be supported with the same provider. 

If the worker has completed five counselling sessions, consider an extension in five session increments until a decision is made. 

Contact the employer and explain that WCB has been notified of a work accident/injury and clarify the decision maker's role in making a decision about the worker's entitlement to compensation benefits.

Employer:

During the discussion, confirm: 

• Incident Details: The traumatic incident, work-related stressors or bullying and harassment. Ask if they have any additional information?
• Incident Reporting: When and where the incident(s) occurred, who they were reported to and if there are witnesses. Ask if and when the incident(s) was documented. Gather additional information such as investigation reports, workload information, information from Human Resources, contact information for the person(s) the incidents were reported to and any witnesses. Refer to the Employer Fact Sheet -Reporting a psychological injury: Checklists for employers.
• Report of injury: If not on file, request they complete and sign an Employer's Report of Injury or Occupational Disease report along with other relevant forms. Discuss any concerns noted on the reports and confirm if the employer agrees there was a traumatic incident(s), workplace stressors or bullying and harassment at a time and place consistent with employment.
• Employer's Role: Educate the employer about the worker’s injury and emphasize the important role they play in the worker’s recovery. Encourage them to stay connected with the worker and keep them engaged in the workplace while they recover.
• Work Status: If the worker has returned to regular or modified work, and if not, discuss available modified work. Request the employer offer the modified work in writing, if not already done. If modified work is being considered, consider if the nature/location of the modified duties could be a potential trigger for increased psychological/psychiatric symptoms. For example, a worker who experienced a traumatic incident in a specific location might experience an increase in psychological/psychiatric symptoms if the available modified duties are in the same location. Consider the information from the Cognitive psychosocial job demands analysis form when an employer wants to offer modified duties.
• Obligation for employment: When the date of accident is between September 1, 2018, up to and including March 31, 2021, also explain their responsibility and obligationRefer to Policy 04-05, Part 1 and Part II, Application 2. to provide modified and/or permanent employment.
• Worker/Employer Status: If it is unclear if worker is a Worker under the WCA or the employer is an Employer under the WCA, gather the necessary information to make this determination. Additionally, confirm if the worker is employed in a job where presumptive coverage applies.
• Reporting Discrepancies: Address any discrepancies in the reporting (e.g., worker's incident description differs from employer's) between the worker and employer. Clarify what the employer thinks about the discrepancy.
• Earnings Information: Confirm earnings information as required.
• Additional Assessments: Identify any additional assessments needed for an entitlement decision (e.g., psychological assessment) and explain why.
• Any Concerns/Additional Information: Ask the employer if they have any concerns with the claim or additional information to add.

Review their responsibility to make reasonable, good faith effortFor additional information, refer to Section 89.1 of the Act and Policy 04-11, Part 1 and Part II - Application 1.s to cooperate in the return-to-work process.

Discuss the plan for making an entitlement decision, including the next steps like requesting medical information or referring for reviews and/or assessments. Explain the expected decision timeline and establish a plan for regular contact (e.g., a phone call every two weeks with updates by email in between). 

Call the health care provider, if required to obtain clarification when needed.

Discuss the following:

• DSM diagnosis and treatment recommendations: If there is no DSM diagnosis or they can only provide a working diagnosis, discuss what is needed to help confirm a diagnosis and offer to request additional assessments if required. If the provider says they are unable make a diagnosis or are only able to provide a working diagnosis, discuss whether they are able to determine if the worker meets the DSM criteria to diagnose an alternate psychological or psychiatric diagnosis. For example, a psychologist might determine a worker meets the criteria to diagnose Acute Stress Disorder while they continue to investigate if the worker meets the diagnostic criteria for a more complex diagnosis like PTSD.
• Additional assessments: Any recommendations for further assessments (e.g., comprehensive psychological assessment, independent medical examination with a psychiatrist).
• Reporting discrepancies: Any discrepancies between the worker's report and the health care provider's report.
• Fitness for work: The worker’s fitness for work and opportunities for safe modified work. Review the Cognitive psychosocial job demands analysis (C1447) form with the provider, when available. Discuss any work factors that could reasonably trigger additional psychological/psychiatric symptoms.
• Missing medical, psychiatric/psychological information: Any missing medical or psychological information and request necessary reports. Send the appropriate letter to request any the missing information or reports.

Once all the medical and psychiatric or psychological information is gathered, confirm there is a DSM diagnosis  A DSM diagnosis Is a confirmed psychological/psychiatric diagnosis listed in the most current edition of the DSM such as Major Depressive Disorder, Generalized Anxiety Disorder, and Mood Disorder due to a General Medical Condition. There must be evidence that the diagnostic criteria listed in the DSM for the particular condition was used to arrive at the diagnosis. related to the traumatic event(s) or work event(s). Refer to the Psychiatric or psychological diagnosis section for details. 

Determine if there is enough information to make the initial entitlement decision for a psychiatric or psychologist injury. This includes confirmation of traumatic or chronic events which meet policy, a confirmed DSM diagnosis and confirmation that the psychological injury was caused by these events. Refer to Policy 03-01, Part II, Application 6. 

When the entitlement decision can be made, go to step 6.

If additional information or assistance is required, make the appropriate referral based on the claim circumstances. Consider a:

• Referral to the Investigations Unit if there is not enough information to determine if a traumatic incident, workplace stressors or bullying and harassment occurred and attempts to gather the information have been unsuccessful (e.g. assistance in obtaining worker and employer reports or witness statements, interviewing witnesses, relevant history of events/stressors, or conflicting information).
• Referral for a medical or psychological consultant opinion. Send the referral to:
  • A medical consultant when most of the available reporting is from a physician (including psychiatrists) or the reporting is from a combination of physician, psychiatrist or psychologist.
  • A psychological consultant when most of the available reporting is from a psychologist or psychiatrist.
• Referral for further psychological assessment if required to confirm a DSM diagnosis and its relationship to the work injury. Refer to the Psychiatric or Psychological Assessments section. 

When a referral is needed, consider if the worker is eligible for benefits during the medical investigation.

Review all available information, including assessments, medical or psychological consultant opinion, and any relevant information from the Investigations Unit.

Consider if:

• A DSM psychiatric or psychological diagnosis has been confirmed. If not, return to step 5 to consider necessary assistance or assessments.
• The events experienced fit the definitions of a traumatic event or the policy criteria for chronic onset. Refer to Policy 03-01, Part II, Application 6.
• The appropriate causation test has been met.
  • The “But for” test is met for traumatic onset psychological injury claims. This means the traumatic event(s) at work was a necessary factorThe traumatic event does not need to be the sole factor, just a necessary factor. This is also referred to as "but for" as outlined in Policy 02-01, Part II, Application 7. The “but for” test is a finding of fact – the work exposures were necessary for the accident and injury to occur. In other words, if not for the work exposures, the injury or disease would not have happened. for the development of the psychiatric/psychological condition, unless presumptive coverage applies.
  • If the workplace stressor(s) is the predominant causePredominant cause means the prevailing, strongest, chief, or main cause of the chronic onset psychological injury.  Predominant cause means the prevailing, strongest, chief, or main cause of the chronic onset psychological injury.for chronic onset psychiatric or psychological claims.
• Presumptive coverage applies and/or the psychiatric or psychological injury relates to a traumatic incident at work (traumatic psychiatric or psychological injury). Refer to the Key Information and Table 1 Presumptive Coverage for Psychiatric or Psychological Injury, Policy 03-01, Part II, Application 6 and the Presumptive coverage section.
• There is a pre-existing psychiatric or psychological condition. If so, determine if the condition was aggravatedThe symptoms of the pre-existing psychological condition were worsened. due to a traumatic event at work or chronic workplace stressors. If assistance is needed to confirm this, return to step 5 to request a medical or psychological consultant opinion. 

Make a decision to accept or not accept the psychiatric or psychological condition. If the decision is to:

• accept the psychiatric or psychological condition and the worker is missing time from work, continue to the next step. If the worker is not missing time from work, continue to step 8.
• not accept the psychiatric or psychological diagnosis, continue to step 8 to communicate the decision.

If the worker has missed time from work, set the compensation rate.

Rates are based on the worker’s:

• Employment status (permanent, non-permanent, personal coverage, owner-operator, subcontractor)
• Date of hire and history with the employer for the past 12 months
• Shift cycle
• Hourly rate of pay
• Overtime, vacation pay and shift premiums
• Additional income from other employers, if applicable

Refer complex rates to the Payment Unit for calculation.

If the employer does not provide earnings information in a timely manner, set a provisional compensation rateA provisional rate is a temporary rate that is set to ensure benefits are paid in a timely manner. Once the worker's earnings are verified, using their T1 tax return, the rate is adjusted as required..

If the employer continues to pay the worker wages/salary, the wage replacement benefits may be paid on assignmentWhen an employer keeps a worker on pay while they are missing time from work, WCB issues benefits to the employer instead of the worker. See policy 04-09, Part II, Application 1. to the employer. 

Call the worker and the employer to discuss the decision and next steps. Only discuss accepted psychiatric or psychological injuries with the employer. Do not disclose information about unaccepted claims or non-compensable conditions, including pre-existing issues.

Clearly express the rationale used to reach the decision (citing policy, medical information on the file, any important background information), if the worker or employer disagrees with the decision, consider whether their concerns require further review. If not, explain why the decision is unchanged.  

When the claim is accepted and the worker has missed time from work, explain how their compensation rate was set and when payment will be issued. If they have any concerns with how their rate was set, ask them to submit any evidence they may have (e.g., paystubs, tax returns, etc.) or follow up with the employer about their concerns. Discuss additional recommendations for treatment, modified work, if available, and the next steps in their care plan. 

When the claim is not accepted, discuss additional resources that may be available to the worker as they recover, such as counselling through the Employer Family Assistance Program (EFAP), Employment Insurance benefits, long-term sick leave through Canada Pension Plan or sick benefits through an employer plan. When appropriate, offer assistance from WCB’s Community Support Program, which can connect workers with various agencies and organizations across the province for additional support outside of the workers’ compensation system. 

Communicate the decision in writing and continue to the next step.

Monitor

Adjudicator, continue to monitor the claim for return to full duties when the claim is no time loss, the worker is working full hours but modified duties, and return to full duties is expected in four weeks or less. If modified work is extended or there is a deterioration in symptoms, consider transferring the claim to a case manager.

Transfer

Transfer to a case assistant when, there is no time loss, the worker is working full hours and duties but continues to attend treatment.  If treatment is extended beyond the expected end date, consider transferring the claim to a case manager.

Transfer to a case manager when, the worker remains on total temporary disability, there are long-term or permanent restrictions, or a long-term modified return-to-work plan in place.

Call the worker and employer and explain the reason for the transfer and discuss any related referrals, if applicable.

Ask the worker how they’re recovering and assess whether they require additional referrals or support prior to the transfer. Confirm with them that all information on their file is up to date.

Confirm with the worker that they will hear from their new contact within five business days of assignment.

Inactivate

If the worker did not miss any time from work or has already returned to their job, the file can be inactivated.

Call the worker and employer to communicate the closure of the file and ensure all benefits have been paid. Let the worker know that their file can be re-opened at any time in the future if there are any concerns or additional information related to their claim.