Document name
Psychological Injuries
Document number
PRO 02/2017

Effective date: December 20, 2016

Approved date: April 19, 2017

Application: Applies to all firefighter cancer and cardiac claims on or after the effective date.

Policy subject: Decision making - Injuries

Purpose:

To establish the process for adjudicating psychological injury claims.

BACKGROUND

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  1. The Workers’ Compensation Act, 2013, creates a rebuttable legislative presumption that may apply when a worker or former worker receives a diagnosis in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM) due to an exposure to a traumatic event or series of events or incidents that arose out of or in the course of employment.
  2. POL 02/2017, Injuries – Psychological establishes adjudication guidelines for all psychological injury claims.

PROCEDURE

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General

  1. When the WCB receives a psychological injury claim, Claims Entitlement Specialist III (CES III) staff will determine if:
    1. The worker was exposed to a traumatic event or a series of traumatic events that arose out of and in the course of employment.
    2. The worker has received a DSM diagnosis by a psychologist or psychiatrist licensed to practice and make diagnoses.
    3. A Mental Health Assessment (MHA) is required.

DSM Diagnosis

  1. CES III staff will determine if a DSM diagnosis has been completed by the worker’s psychologist or psychiatrist.
    1. If the worker has received a DSM diagnosis for the injury, CES staff will confirm that the DSM diagnosis was completed by a psychiatrist or psychologist licensed to practice and make diagnoses.
    2. CES staff will obtain the relevant healthcare information from the care provider (e.g., name and location of care provider, DSM diagnosis, treatment dates, treatment plan, etc.). CES staff may request the worker to fill out a Worker Medical Release of Information Request form (WMROI) to authorize the care provider to release the information to WCB (e.g., if the DSM diagnosis was provided by an out of province psychologist).
    3. Once the DSM diagnosis is received from the worker’s care provider, CES staff will request WCB’s Psychological Consultant to confirm if the diagnosis meets all of the diagnostic criteria in accordance with the DSM.
      1. If there is insufficient evidence in the diagnosis to make this determination, staff will request WCB’s Health Care Services (HCS) to arrange a MHA.
      2. If the DSM diagnosis provided is from a previous version of the DSM, WCB’s Psychological Consultant may recommend a MHA to determine what issues the worker is currently experiencing and how it relates to the original work injury.
      3. If WCB’s Psychological Consultant confirms that all diagnostic criteria is met, staff will gather addition information to determine if all the requirements for the presumption are met. This may include arranging a MHA where causal relationship between the worker’s employment and the injury is not evident.
  2. If a DSM diagnosis is not provided by the worker’s psychologist or psychiatrist, the WCB will obtain all relevant information to determine if the worker was exposed to a traumatic event that arose out of and in the course of employment and suffered a psychological injury.
    1. Where the CES III does not have enough information to determine entitlement, the CES III will request WCB’s HCS to arrange a MHA, including diagnosis, while CES III staff proceed with file development.
    2. Where the causal relationship between the worker’s employment and the injury is evident and irrefutable, a DSM diagnosis may not be required for the claim to be accepted. CES III staff will proceed with file development and adjudication.

Mental Health Assessments (MHA)

  1. Doctorial psychologists, accredited by WCB, will perform MHAs in accordance with the:
    1. DSM published by the American Psychiatric Association, and
    2. Mental Health Assessment Template (MATR) provided by WCB’s HCS.
  2. MHAs will help determine:
    1. Current DSM diagnosis.
    2. The predominant cause of psychological problems.
    3. The ongoing effects of the injury.
    4. The level and expected duration of appropriate care.
    5. An appropriate return-to-work plan.

File Development

  1. Where at the time of initial review a decision cannot be made, the CES will contact the worker to explain:
    1. The policy and procedure and what information is required to adjudicate a psychological injury claim.
    2. How long it will take for the WCB to adjudicate and determine entitlement.
    3. Options for financial resources until the WCB determines entitlement.
  2. The CES III will gather information from the worker, employer, coworkers, care provider and/or any other person with knowledge of the event or events. This could involve, but may not be limited to, the following:
    1. Taking statements.
    2. Interviewing witnesses.
    3. Reviewing:
      1. Employment records.
      2. Relevant/available medical documentation, including any history of psychological health issues, and
      3. Any other evidence related to the injury.
  3. If the CES III cannot gather the required information to determine entitlement, the CES III may refer the file to a Claims Representative. A Claims Representative will gather evidence and further information from the customer, employer, co-workers, witnesses and others. They may view the worksite where the event occurred. Any findings will be provided to the CES III.
  4. In sensitive situations where it may be difficult for the worker to discuss the traumatic event, staff will gather information from the worker’s care provider and employer.
  5. The CES III can request the assistance of WCB’s Psychological Consultant at any time during the review or development of claims.
  6. The CES III may provide coverage for medication and or counselling services while the claim is adjudicated (PRO 50/2017, Health Care Services – Psychologists will apply).
    1. The CES III will request consent from the worker to view their counselling reports. These reports may help the CES III in determining if a claim is acceptable.
    2. If the CES III denies the claim, the medication and counselling services will be covered up to the date of notification. Medication and counselling services will not be charged to the employer.
  7. If the CES III accepts the claim, the CES III will:
    1. Notify the worker and employer by telephone and in writing of the decision.
    2. Arrange for initial earnings loss benefits and expense payments.
    3. Refer the claim to a Case Manager (CM) to develop a return-to-work plan.
  8. The CM may request HCS to arrange additional MHAs during the ongoing management of the claim. Where the worker has not recovered and/or returned to work within four weeks of diagnosis, the CM will request HCS to arrange a MHA.

Permanent Functional Impairment (PFI)

  1. If the CM determines that a worker’s psychological injury is unlikely to improve, the CM will request the Psychological Consultant to confirm that the worker has reached their Maximum Medical Improvement (MMI).
  2. If the Psychological Consultant determines that the worker has reached their MMI, HCS will arrange a Permanent Functional Impairment (PFI) Mental Health Assessment with a doctorial psychologist who has experience providing DSM diagnoses and determining scores associated with the following scales:
    1. Global Assessment of Functioning (GAF) Scale.
    2. Brief Psychiatric Rating Scale (BPRS).
    3. Psychiatric Impairment Rating Scale (PIRS).
  3. The doctorial psychologist will:
    1. Perform the PFI Mental Health Assessment in accordance with POL 23/2010, Permanent Functional Impairment (PFI) – General, and
    2. Determine GAF, BPRS and PIRS scores.
  4. The Psychological Consultant will review the file, including the PFI Mental Health Assessment, and provide a PFI rating.

Critical Incident Response Information Sessions

  1. To address and respond to the emotional and psychological consequences resulting from exposure to or witnessing a traumatic workplace incident, the WCB offers post-incident response information sessions.
  2. After a traumatic workplace event, WCB staff will inform employers that an information session with a psychologist can be arranged. The employer will notify WCB if there are workers requiring a session.
  3. WCB’s HCS staff will determine what an appropriate response is in consultation with a WCB Medical Officer and/or Psychological Consultant and will complete any needed referrals with a WCB approved psychologist.
  4. The purpose of any post-incident response information session is to focus on the well-being of the worker(s). Non-incident related emotional issues or labour relations concerns are not discussed during a session.

Policy references

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Section heading

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).
 

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