Document name
Psychological Injuries
Document number
POL 02/2017

Effective date: December 20, 2016

Approved date: April 19, 2017

Application: All psychological injury claims, regardless of injury date.

Policy subject: Decision making - Injuries

Purpose:

To establish adjudication guidelines for psychological injury claims.

DEFINITION

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DSM, means the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association. The fifth version to be used as prescribed by The Workers’ Compensation Miscellaneous Regulations. The DSM does not include guidelines for treatment of any disorder.

DSM diagnosis, for the purposes of this policy, means a diagnosis that meets all diagnostic criteria for a disorder in accordance with the DSM, completed by a psychologist or psychiatrist licensed to practice and make diagnoses.

Mental Health Assessment (MHA) is a psychological evaluation completed by a Workers’ Compensation Board (WCB) accredited psychologist or psychiatrist and includes:

  • An assessment and diagnosis of a disorder, or confirmation of a diagnosis, in accordance with the DSM.
  • Recommended treatment plans and
  • Recommended return to work plans.

Psychological injury, for the purposes of this policy, means any psychological disorder or condition that meets DSM diagnostic criteria and has arisen, or is presumed to have arisen, out of and in the course of employment (Section 28.1(1)(a)).

Traumatic event means a single or series of events or incidents that arose out of and in the course of employment that may result in a psychological injury. This includes, but is not limited to:

  • Direct exposure to actual or threatened death or serious injury to worker and/or others.
  • An event or series of events that are specific or sudden and generally accepted from a public perspective as being unusually shocking or horrific.
  • Workload or work-related interpersonal incidents that are excessive and unusual in comparison to pressures and tensions experienced in normal employment. These must be beyond the normal scope of maintaining employment from a public perspective.

BACKGROUND

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  1. In 2016, The Workers’ Compensation Act, 2013 (the “Act”) was amended to direct that, “unless the contrary is proven, if a worker or former worker is diagnosed with a psychological injury by a psychiatrist or psychologist, that injury is presumed to be an injury that arose out of and in the course of the worker’s employment.” (Section 28.1(2)).
  2. This presumption applies to a worker who is, or former worker who was, exposed to a traumatic event (Section 28.1(1)(b)) and suffers a psychological disorder that is diagnosed in accordance with the DSM (Section 28.1(1)(a)).
  3. An injured worker must report an injury to their employer and the WCB (Sections 44(1) and 47). However, failure to give notice does not prevent the worker from receiving benefits (Section 46).
  4. Employers have an obligation to report work injuries to the WCB when they become aware of an injury that prevents a worker from earning full wages or that requires medical attention (Section 52).
  5. Health care providers examining or treating injured workers are expected to provide any reports the WCB may require (Sections 55, 56, and 57).
  6. The WCB is authorized to gather information needed to determine all matters or questions arising under the Act (Sections 20 and 25).
  7. The WCB may use funds “for any other purposes that the board considers necessary to carry out the intent of this Act” (Section 115(j)).

POLICY

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  1. A psychological injury is presumed to be an injury that arose out of and in the course of the worker’s employment when all of the following criteria is met:
    1. The worker is, or the former worker was, exposed to a traumatic event.
    2. The traumatic event arose out of and in the course of employment.
    3. The traumatic event has caused the worker or former worker to suffer a psychological disorder that is diagnosed in accordance with the DSM, and
    4. The psychological disorder is diagnosed by a psychologist or psychiatrist licensed to practice and make diagnoses.
  2. The WCB will obtain relevant information to determine if the psychological injury claim meets the statutory presumptions and arose out of and in the course of the worker’s employment.
    1. If there is evidence demonstrating that the worker’s employment is not the predominant cause of the psychological injury, the presumption will be rebutted.
    2. If the evidence regarding employment and non-employment related causes are evenly balanced, the presumption is not rebutted.
    3. Entitlement for a work-related psychological injury will not be denied due to the existence of a pre-existing psychological condition (points 19 to 21).
  3. WCB will obtain information from the worker, employer and care providers to gain an understanding of the traumatic event(s) or incident(s). In sensitive situations where it may be difficult for the worker to discuss the event, WCB will gather information from the worker’s care provider and employer.

Diagnoses and Mental Health Assessments (MHA)

  1. All DSM diagnoses submitted by the worker, or their care provider, will be reviewed to determine if:
    1. The diagnosis meets the diagnostic criteria in accordance with the DSM, and
    2. The initial diagnosis meets the required full assessment diagnosis level:
      1. The full assessment diagnosis level means the psychologist or psychiatrist has included both the clinical information (e.g., history, presentation, functioning levels) and psychological testing information.
      2. A working diagnosis means the worker receives treatment for the presumed diagnosis. These are interview-based and do not include any required formal testing.
      3. A reason for visit diagnosis means the worker has attended an appointment after an event or incident or at the onset of symptoms. The care provider has recorded the reason for the appointment and the treatment provided. These are interview-based and do not include formal testing.
  2. The WCB may require a MHA completed by a WCB-accredited psychologist or psychiatrist to confirm assessment and DSM diagnosis when:
    1. The diagnostic criteria in accordance with the DSM was not provided by the care provider and/or
    2. The initial diagnosis does not meet the full assessment diagnosis level.
  3. If a DSM diagnosis is not submitted by the worker or their care provider, the WCB will determine if the worker was exposed to a traumatic event and if a MHA is required to complete an assessment and diagnosis.
  4. If the onset of psychological symptoms are delayed (do not begin immediately or close in time to the traumatic event) and a DSM diagnosis has not been provided, a MHA will be required to confirm a DSM diagnosis consistent with exposure to a traumatic event.
  5. A MHA may be required during the ongoing management of the claim to recommend treatment and return to work plans.

Traumatic Events – Acute and Cumulative

  1. If the presumption criteria is met, the WCB will presume that the psychological injury arose out of and in the course of employment unless the contrary is shown. Evidence that can be considered in determining whether the presumption has been rebutted can include information such as, but not limited to:
    1. The worker did not witness and/or was not directly involved in a traumatic event or a series of traumatic events.
    2. The traumatic event did not arise out of and in the course of employment.
    3. The traumatic event is not the predominant cause of the worker’s psychological injury (i.e., there is evidence that the disorder was caused by something not related to employment).
  2. Symptoms from a single traumatic event often occur immediately or shortly after the event. Where the causal relationship between the worker’s employment and the injury is evident and undeniable, a DSM diagnosis may not be required for the claim to be accepted (e.g., experiencing a robbery while working, witnessing the death of a co-worker, etc.).
  3. Due to the nature of particular occupations, some workers, over a period of time may be exposed to a series of traumatic events. If the worker has a reaction to the most recent traumatic event, the presumptions will be considered even if the worker was able to tolerate the past traumatic events.

Incidents – Workload and Interpersonal

  1. The daily pressures or stressors of work are normal expectations for maintaining employment.
    1. Any reasonable action taken by an employer relating to management is considered a normal part of employment and is not considered a traumatic event. Normal employment expectations include, but are not limited to, the following:
      1. Hiring and firing employees.
      2. Performance evaluations and/or performance corrective actions.
      3. Staff assignments, transfers or restructuring.
      4. Promotions, demotions and lay-offs.
      5. Periodic workload fluctuations and/or assignment changes.
      6. Timeline pressures.
      7. Work environment.
    2. Interpersonal incidents between a worker and co-workers, management or customers are not generally considered traumatic events unless the incidents result in behaviour that is considered aggressive, threatening or discriminatory.
  2. If the worker is involved in a series of workload or work-related interpersonal incidents that are beyond the normal expectations of maintaining employment, the incidents may be considered a traumatic event.
  3. WCB will obtain all relevant information to determine if the psychological injury meets the statutory presumptions and arose out of in the course of the worker’s employment. Evidence that can be considered in determining whether the presumption has been rebutted can include information such as, but not limited to:
    1. The incident(s) did not cause the worker to suffer a psychological disorder diagnosed in accordance with the DSM.
    2. The incident(s) did not arise from work requirements and/or are not work-related (i.e., employment is not the predominant cause of the worker’s psychological injury).
    3. The workload issues or work-related interpersonal incidents are not considered traumatic in comparison to normal pressures and tensions experienced within employment.
    4. The incident(s) did not escalate to the point of aggressive, threatening or discriminatory behaviour.
    5. The worker’s workload does/did not differ significantly from their or their co-worker’s usual workload and is not considered beyond the normal scope of maintaining employment (e.g., amount or type of tasks, etc.).
    6. Information gathered from others (e.g., employer, coworkers) with knowledge of the incidents contradicts the workers perception of the incident.
    7. Information that the unusual workload has not been in effect for a significant time.
    8. Information that the incident(s) are a result of voluntary personal relationships and/or their breakdown within the workplace.

Entitlement

  1. WCB may provide coverage for counselling services and required medication while the claim is being adjudicated. If the claim is not accepted, these costs will not be charged to the employer.
  2. If the claim is accepted, the WCB will provide benefits based on earnings loss, allowances or awards caused by the effects of the work injury.
  3. WCB will not base entitlement on items such as punitive damages, loss of seniority and awards for pain and suffering that may make up parts of arbitration awards (e.g., human rights action, grievance awards).
  4. WCB benefits may coincide with the worker’s disability insurance entitlement. It is the worker’s responsibility to notify their disability insurance provider if they receive WCB benefits.

Pre-Existing Conditions

  1. Entitlement for a work-related psychological injury will not be denied due to the existence of a pre-existing condition. However, the WCB does not assume any responsibility for a worker’s pre-existing condition.
  2. The WCB will determine if a work-related injury resulted in either an aggravation or acceleration of a worker’s pre-existing condition (POL 12/2017, Pre-Existing Conditions – Aggravation or Acceleration).
  3. An employer may be eligible for cost relief for claims involving a pre-existing condition under POL 11/2017, Second Injury and Re-employment Reserve.

Permanent Functional Impairment (PFI)

  1. WCB will review accepted psychological injuries that are unlikely to improve for PFI awards (POL 23/2010, Permanent Functional Impairment (PFI) – General).

Appeals

  1. If a psychological injury claim is previously denied under former legislation, a worker can request WCB to reconsider the original decision. The request to reconsider previous claims will be considered by the WCB team responsible for the most recent decision (e.g., Claims Entitlement staff, Case Manager, Appeals Officer, Board Appeal Tribunal), before progressing to the next level of appeal (e.g., the Appeals Department, Board Appeal Tribunal).
  2. Any new decisions made under this policy may be appealed (POL 21/2013, Appeals – Claims).

Critical Incident Response Information Sessions

  1. To address and respond to the emotional and psychological consequences resulting from exposure to and/or witnessing a traumatic workplace incident, post-incident response information sessions are available.

Policy references

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Legislative Authority

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The Workers’ Compensation Act, 2013
Sections 2(1)(r), 2(1)(ff.1), 2(1)(ff.2), 2(1)(ii), 19, 20, 25, 26, 28.1, 44, 46, 49, 187(1)(e.1)

The Workers’ Compensation Miscellaneous Regulations
Sections 5.1

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Document History

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(1)    20 December 2016. Bill 39, an amendment to The Workers’ Compensation Act, 2013, came into effect, which established a rebuttable presumption for all forms of psychological injuries. The amendment applies to all current and former workers eligible for coverage, regardless of injury date.
(2)    POL and PRO 01/2009, Injuries – Psychological (effective 01 May 2009 to 19 December 2016).
(1)    01 January 2014. References updated in accordance with The Workers’ Compensation Act, 2013 (Bill 58).
(2)    21 October 2013. Policy and procedure reviewed.
(3)    POL 02/92, Stress Claims (effective 28 January 1992 to 30 April 2009).
 

Section heading

Complements

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