Aggravation of a pre-existing condition decision

If not already completed, follow the 1-1 Initial entitlement decision, 1-2 Initial entitlement decision - psychiatric or psychological injury or 1-10 Additional entitlement decision procedure to determine if the accident, compensable injury, or treatment for the compensable injury was sufficient to cause the diagnosed injury, regardless of whether the worker has a pre-existing condition.  If not, review the claim, mechanism of injury and the medical information to determine if:

• There was a work accident that caused disability, or the worker had an extreme emotional reaction to their compensable injury or treatment for their compensable injury,
• There is evidence of a condition that might have existed prior to the accident (evidence may be identified in x-rays or other diagnostic testing, physician’s reporting, surgical reporting, medical opinions, etc., and/or the worker or employer may report that the worker has a pre-existing condition) and
• There is a possibility the work accident, compensable injury, or treatment for the compensable injury caused the condition to worsen, deteriorate or become symptomatic to the point that the worker is unable to perform their date of accident duties.

Consider:

• Could the work duties have caused a pre-existing condition to worsen over time, with gradual onset of symptoms that advanced and increased (i.e., progressive onset)?
• Could a single work accident have resulted in rapid or sudden worsening of a pre-existing condition (i.e., acute onset)?
• Did the worker have a pre-existing compensable injury on another claim? If so, could the work duties/accident, compensable injury, or treatment for the compensable injury have worsened this condition? Or is it more reasonable that the current symptoms are a continuation of the disability accepted on the other claim (in this case entitlement for the continuation should be considered on the other claim)?
• Could an extreme emotional reaction to the worker's injury or treatment for their compensable injury have resulted in a worsening of a pre-existing psychiatric or psychological condition?

Determine what informationConsider collecting a PDA, Job description, outstanding medical and any other documents that may assist in determining if there was a pre-existing condition and if it was aggravated may still be required to confirm the presence of a pre-existing condition and if the condition was aggravated.  Anticipate questions that may arise during the initial conversations with the worker and employer.

When speaking to the worker

Ask questions to gain an understanding about the status of their pre-existing condition prior to and after the work injury:

• Are you aware you have a diagnosed condition that may have existed prior to the work accident (i.e., pre-existing)?  Did you know whether you had this condition before the accident?
• How long have you had this condition?  What, if anything, led to the development of the condition?
• Prior to the work accident, did you seek medical treatment or testing related to the condition. If so, who provided the treatment and when?
• Were you experiencing symptoms in relation to the condition before the work accident?  When did you start to experience symptoms?
• How did the condition impact you at work (if at all)? Were you able to perform all the work duties required in your position in spite of the condition?
• Are you currently receiving medical treatment from a physician, psychiatrist, psychologist or health care professional for the condition?  If yes, who provided treatment and when?

Explain the next steps in the process for determining entitlement when it appears a pre-existing condition may be aggravated by the work accident, compensable injury, or treatment for the compensable injury.  This may include requesting additional medical information, further assessments, and/or obtaining a medical opinion.  

Address any questions or concerns that arise during the conversation.

For possible aggravation of pre-existing psychiatric/psychological conditions:

If there's a reasonable likelihood

• If there’s a reasonable likelihood that the psychiatric/psychological difficulties are related to the accident/injury/treatment, 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.
• If the worker accepts the offer of counseling, refer to the 4-3 Psychological counselling procedure. Should they decline, continue to monitor and consider repeating the offer in two weeks if symptoms persist or do not improve. 

If there's not a reasonable likelihood 

• When it’s unlikely the psychological condition is related to the claim, consider if the worker has access to an Employee and family assistance program (EFAP) provider through work or has already started treatment through an EFAP provider or with a counsellor on their own. If the worker does not have an EFAP provider and does not have access to counselling, the decision maker can offer the worker a referral to Community Supports. If the psychological/psychiatric issues are a significant barrier to return-to-work and Community Supports cannot identify a reasonable option for counselling, the decision maker can also offer 5 sessions of counselling.
• If the worker accepts the offer of counseling, refer to the 4-3 Psychological counselling procedure. Should they decline, consider if 3-3 Duty to cooperate could be applied. Continue to monitor and consider repeating the offer if symptoms persist or do not improve. 

If the worker has completed five counselling sessions, determine if an extension is required or if the symptoms are resolving/resolved. Refer to the 4-3 Psychological counselling procedure. 

An entitlement decision for psychological injury should be completed after no more than ten counselling sessions.

When speaking to the employer

Explain that additional information will be gathered to determine if the worker has a pre-existing condition that was aggravated by the work accident, compensable injury, or treatment for the compensable injury. Ask:

• Were you aware that the worker experienced symptoms from a pre-existing condition prior to the accident?
• Did the worker advise you that they had a pre-existing condition?
• Was the worker able to perform all aspects of the date of their date of accident duties despite any pre-existing condition?

Discuss the next steps in the process for determining entitlement for pre-existing condition and address any questions or concerns that arise.

When communicating with the health care provider

Contact the health care provider by telephone or letter to confirm:

• Diagnosis and treatment recommendations for the condition that may have existed prior to the accident.
• If there is evidence/the provider’s opinion as to whether the worker had a pre-existing condition and whether the condition or the symptoms of the condition worsened after the accident or as a result of the compensable injury or treatment for the compensable injury.
• The worker’s fitness for work and opportunities for safe modified work.

If the health care provider was reached by telephone, advise that a letter to request for all outstanding medical information related to the condition, including copies of chart notes, diagnostic testing, medical consultations, etc., will be sent.

Notes:

• In some cases, it may be necessary to request an Alberta Health Cost Benefit StatementAn Alberta Health Cost Benefit Statement will provide a history of service information may be requested through Alberta Health. This service information can be used to request reports from health care professionals which could lead to the identification of pre-existing conditions or problems and help to consider or rule out associated medical conditions that may impact recovery from work related injuries.  to confirm if the worker was treated or tested for a preexisting condition and when the treatment and testing occurred so reporting can be requested from the appropriate health care provider.
• WCB may pay benefits to a worker while an entitlement decision is pending on the acceptance of an aggravation of a pre-existing condition, as long as a medical investigation is required to make the entitlement decision. Refer to the medical investigation procedure for criteria.

Once all the available information is received, review the information and determine if the medical evidence supports there is a pre-existing condition and if the condition was worsened by the work accident, compensable injury, or treatment for the compensable injury, either temporarily or permanently. Refer to Policy 03-02, Aggravation of Pre-existing Condition.  If the worker has a pre-existing psychiatric or psychological condition, refer to the Aggravation of pre-existing psychiatric or psychological conditions section, for additional information.

Based on the evidence received, confirm:

• If the medical evidence supports that the worker had a medical, psychiatric or psychological condition that existed prior to the work accident.
• The worker's baselineThe status of the worker's pre-existing condition prior to their work accident.  The status of the worker's pre-accident condition prior to their work accident.prior to the work accident.
• If the worker was experiencing symptoms or seeking medical treatment prior to the work accident.
• When the worker started to experience symptoms or noticed an increase in symptoms following the work accident.  
• If there is another intervening incident or cause for the increase in symptoms.
• What impact the mechanism of injury, the compensable injury, or treatment for the compensable injury  had on the pre-existing condition.
• If the medical evidence supports a worsening of symptoms or any structural changes (i.e. current x-rays or diagnostic tests show structural changes in comparison to older tests).
• If the worker's symptoms are expected to resolve back to their baselineThe status of the worker's pre-existing condition prior to their work accident..
• If there are work restrictions identified as a result of the aggravation of the pre-existing condition.
• For aggravation of pre-existing psychiatric or psychological conditions, whether the applicable standard of causation is met. Refer to the Aggravation of pre-existing psychiatric or psychological conditions section.

Note: To accept an aggravation of a pre-existing condition, there must be a work accident or an extreme emotional reaction to a compensable injury/treatment for a compensable injury, a confirmed and documented presence of a pre-existing condition, and evidence to support the pre-existing condition was made worse by the work accident, compensable injury, or treatment for the compensable injury. 

Consider a referral to an internal consultant for a medical or psychological opinion, when additional assistance is needed to determine if a condition existed prior to the work accident and/or if the condition was aggravated. Send the referral to a medical consultant, unless the worker has a long-standing or complex psychiatric/psychological condition. In that case, send the referral to a psychological consultant.

Review the medical or psychological consultant's opinion, if applicable. Call the worker and employer to discuss the decision to accept or not accept the aggravation. Communicate the decision in writing and update the care plan as appropriate.

Note: If the decision maker is uncertain as to whether the worker is aware of a serious pre-existing condition (e.g., cancer), consult with the worker's family physician before informing the worker.

Accepting an aggravation

When the work accident, compensable injury, or treatment for the compensable injury caused the pre-existing condition or the symptoms of the pre-existing condition to worsen or deteriorate, to the point the worker is no longer able to perform their date of accident duties, continue to manage the claim.  Refer to the 3-1 Modified work and the 3-2 Collaborative care planning procedures.

Note: If a pre-existing condition is initially accepted as being temporarily aggravated, but then permanent work restrictions are later confirmed, the original decision must be reassessed to determine if the aggravation is actually permanent. 

Not accepting an aggravation

When the work accident, compensable injury, or treatment for the compensable injury did not cause the pre-existing condition to worsen or deteriorate, determine if the accident was sufficient to cause the diagnosed injury (regardless of whether the worker had a pre-existing condition). Refer to the applicable 1-1 initial entitlement decision, 1-2 Initial entitlement decision - psychiatric or psychological injury and 1-10 Additional entitlement decision (Secondary psychological injury) procedures, when appropriate. 

Consider other ways the pre-existing condition may impact entitlement to benefits:

• Is the pre-existing condition that was not aggravated reasonably a concurrent conditionA concurrent condition is a non-compensable condition that exists at the same time as a compensable disability. When a concurrent condition affects the rehabilitation or healing of a compensable injury, thereby prolonging the period of disability, WCB will continue paying temporary benefits until healing of the compensable condition or death.  that is impacting the worker's recovery from their accepted work injury? Refer to Policy 04-02, Part II, Application 1, Question 11.
• Was the pre-existing condition accepted on another claim? If so, determine if the current disability is a continuation of a previous work-related injury. Refer to the 1-5 Claim reopen decision procedure.

Do not continue with this procedure.

Review the claim for cost reliefCost relief is the practice of moving individual employer costs to the industry rate group level for claim costs related to pre-existing conditions or costs resulting from extraordinary circumstances outside of an employer’s control. Some cost relief is applied automatically but most requires a WCB decision maker review to make the decision. when a worker's pre-existing conditionA pre-existing condition is a physical or mental condition which pre-dates a work-related injury. has prolonged the period of recovery for the accepted work injury (beyond the expected recovery period for that injury). 

When an aggravation is confirmed to be permanent (the aggravation of the pre-existing condition results in permanent disability or work restrictions), review the claim for permanent clinical impairmentA permanent clinical impairment evaluation measures the worker’s physical and/or psychological function and determines whether their injury has resulted in a lasting functional impairment. The evaluation can be completed by a trained WCB specialist or general practitioner examiner and can be done simultaneously with an independent medical exam for multiple issues or questions.. 

Review for permanent clinical impairment (PCI) should take place 24 months from the date of accident or surgery (whichever is latest).  Refer to Policy 03-02, Part II, Application 1, Question 5 - Aggravation of a Pre-existing Condition.