Document name
Hernia
Document number
PRO 02/2016

Effective date: April 1, 2016

Approved date: March 8, 2016

Application: All hernia claims on and after the effective date.

Policy subject: Decision making - Principles

Purpose:

To establish adjudication guidelines for hernia claims.

DEFINITION

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Hernia means a bulge of an organ through the structure that usually contains the organ. Excessive strain or direct trauma may cause hernias.

Incarceration means instances where the protrusion of tissue through the hernia becomes trapped and cannot be pushed back in easily.

Strangulation means instances where the protrusion of tissue becomes twisted and cuts off its own blood supply.

Pre-existing condition means a non-work-related medical condition or physical condition that existed prior to the work-related injury.

BACKGROUND

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  1. Under The Workers’ Compensation Act, 2013 (the “Act”), the WCB will determine if a worker’s (Section 20):
    1. Condition or death is a result of an injury, and
    2. Injury arose out of or in the course of employment.
  2. The inguinal canal is an area in the groin where hernias occur due to a developmental tissue weakness which occurs prior to birth in many individuals. The WCB does not consider a developmental weakness a pre-existing condition. Therefore, the WCB will not consider new hernia protrusions that arise from work incidents as aggravations or accelerations of pre-existing conditions because the hernia did not exist before the incident.

PROCEDURE

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New Hernia

  1. Claims Entitlement Specialists (CES) will review hernia claims. Claim acceptance will be according to the following guidelines:
    1. Indirect/direct inguinal hernia develops in the groin region. For such claims to be acceptable, the CES will confirm that the herniation:
      1. Arose out of straining activity that could significantly increase the pressure inside the abdomen, and
      2. Resulted in pain or swelling in the groin region during or immediately after the straining activity.
    2. Femoral hernia develops in the inner upper thigh or groin region. For such claims to be acceptable, the CES will confirm that the herniation:
      1. Arose out of straining activity that could significantly increase the pressure inside the abdomen, and
      2. Resulted in pain or swelling in the inner upper thigh or groin region during or immediately after the straining activity.
    3. Umbilical and paraumbilical hernia develops in the belly button region. For such claims to be acceptable, the CES will confirm that the herniation:
      1. Arose out of straining activity that could significantly increase the pressure inside the abdomen, and
      2. Resulted in pain in the belly button region during or immediately after the straining activity.
    4. Incisional hernia develops at the site of a surgical scar. For such claims to be acceptable, the CES will confirm that the herniation:
      1. Arose out of straining activity that could significantly increase the pressure inside the abdomen.
      2. Resulted in pain at the incision site during or immediately after the straining activity, and
      3. Is not a recurrence of a previous herniation at the site of the surgical scar.
    5. Hydrocele is a collection of fluid in a saclike cavity. For such claims to be acceptable, the CES will confirm that:
      1. The hydrocele is a direct result of an accepted inguinal hernia claim, or
      2. There is direct trauma to the area of the hydrocele.
  2. Other hernia claims may not have a direct link to employment. The CES may refer such claims to a Medical Officer for review. Types of hernias that may not have a direct link to employment include, but may not be limited to, the following:
    1. Hiatus.
    2. Diaphragmatic.
    3. Cystocele.
    4. Rectocele.
    5. Uterine prolapse.
    6. Enterocele.

Pre-Existing Hernia

  1. A pre-existing hernia may incarcerate or strangulate due to straining work. The WCB will provide coverage for surgery and recovery when:
    1. There is an incarceration or strangulation immediately after a specific straining activity, and
    2. Emergency surgery is required.
  2. If the incarceration or strangulation is manually reduced by the attending physician and the worker does not need emergency surgery, the WCB will:
    1. Provide coverage for medical aid and time away from work while putting the herniated tissue back into place.
    2. Not provide coverage for subsequent surgery and time away from work.
  3. The CES or Case Manager will determine if a claim that involves a pre-existing hernia is eligible for cost relief (POL 03/2021, Second Injury and Re-Employment Reserve).

Recurrent Hernia

  1. If the worker previously had a hernia claim that arose out of employment and the recurrence happens:
    1. Within one year of the hernia repair, the CES will provide coverage under the original hernia claim.
    2. After one year of the hernia repair, the CES will adjudicate the recurrence as a new injury claim.
  2. If a non-work-related herniation recurs because of a work-related incident, the CES will adjudicate the recurrence as a new work injury.

Policy references

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Legislative Authority

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The Workers’ Compensation Act, 2013
Sections 20, 49

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Document History

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(1)    PRO 03/2013, Injuries – Hernia (effective April 1, 2013 to March 31, 2016).
(2)    PRO 37/86, Injuries, Hernia (effective October 1, 1986 to March 31, 2013).
 

Section heading

Complements

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