Recurrences - Archived April 9, 2021

Policy

A worker may be entitled to benefits for a recurrence of a work-related injury/disease if the worker experiences a significant deterioration that

does not result from a significant new incident/exposure, and
is clinically compatible with the original injury/disease.

Purpose

The purpose of this policy is to outline the circumstances under which a worker may be entitled to benefits for a recurrence of a work-related injury/disease.

Guidelines

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 the clinical findings.

Indicators of a significant deterioration may include

the need for active (non-maintenance) clinical treatment
a change in functional abilities, or
a change in the ability to perform a job or suitable occupation.

While a worker may take an occasional day off from work, this is generally not indicative of a significant deterioration.

For additional information about significant deterioration, see 18-03-06, Final LOE Benefit Review.

New incident/exposure

If the significant deterioration results from a significant new incident/exposure (work-related or not) a recurrence is not considered. Instead, if the significant new incident/exposure is work-related, a new claim is considered.

If the significant deterioration occurs when there is no new incident/exposure or results from an insignificant new incident/exposure (work-related or not) a recurrence is considered.

A significant new incident/exposure is one of some consequence or importance (e.g., falling from a ladder). An insignificant new incident/exposure is one of negligible consequence or importance (e.g., reaching for an object on a shelf).

Clinically compatible

To establish that the significant deterioration is clinically compatible with the original injury/disease, the WSIB must determine that

the body parts and/or functions affected now are the same as, or related to, those affected by the original injury/disease, and
there is a causal link between the significant deterioration and the original injury/disease.

To make these determinations, the WSIB considers the nature and severity of the significant deterioration, the original injury/disease and any relevant non-work-related conditions that are present.

The WSIB may also consider whether a worker has experienced continuing symptoms since the original injury/disease. Generally, continuing symptoms are an indicator of a causal link, though they are not required to establish a causal link.

Indicators of continuing symptoms may include

continuing clinical treatment
continuing workplace accommodations, or
evidence that continuing symptoms were reported to health care providers, supervisors or co-workers on an ongoing basis.

If the WSIB determines that the existing evidence does not clearly demonstrate whether the significant deterioration is clinically compatible with the original injury/disease, the WSIB may seek a clinical opinion to assist in making this determination.

Loss of earnings (LOE) benefits

Generally, a worker who experiences an actual loss of earnings due to a recurrence is entitled to LOE benefits.

A worker who does not experience an actual loss of earnings due to a recurrence may be entitled to LOE benefits if, at the time of the recurrence, he/she was expected to have actual earnings in the near future.

To determine whether a worker was expected to have actual earnings in the near future, the WSIB may consider whether the worker

was expected to return to an existing job
was scheduled to start a new job
was actively engaged in formal job search activities, or
recently completed a work transition plan.

A worker who had permanently exited the workforce or was not actively engaged in the workforce at the time of the recurrence would not be expected to have actual earnings in the near future.

A worker who has elected the “no review” option is not entitled to additional LOE benefits if he/she has a recurrence, see 18-03-04, LOE Benefits for Workers 55 Years of Age or Older.

Most recent earnings

For information about determining the most recent earnings for claims with

accident dates before January 1, 1998, see 18-06-04, Most Recent Earnings for Recurrences.
accident dates on or after January 1, 1998, see 18-02-06, Determining Average Earnings - Recurrences.

Pre-existing conditions

If a non-work-related pre-existing condition affects the same body parts and/or functions as the recurrence, see 15-02-03, Pre-existing Conditions, to determine how ongoing entitlement to benefits is considered.

Application dates

This policy applies to all decisions made on or after January 1, 2018, for all accidents.

The guidelines for determining entitlement to loss of earnings benefits apply to all decisions made on or after January 1, 2018, for all accidents on or after January 1, 1998.

Policy review schedule

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

Document History

This document replaces 15-02-05 dated November 3, 2014.

This document was previously published as:
15-03-01 dated February 18, 2009

References

Legislative Authority

Workplace Safety and Insurance Act, 1997, as amended
Sections 13, 21(2), 23(1), 37(1), (2), 43(1), 44, 107

Workers’ Compensation Act, R.S.O. 1990, as amended
Sections 4, 133, 22.1, 51

Minute

Administrative
#2, December 11, 2017, Page 550