Aggravation of a pre-existing condition decision

If not already completed, follow the initial entitlement procedure to determine if the accident 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,
• 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 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 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)? 

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 or under the care of a physician 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 or mechanism of 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.

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.  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. 
• 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. See 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, either temporarily or permanently. See Policy 03-02, Aggravation of Pre-existing Condition.

Based on the evidence received, confirm:

• If the medical evidence supports that the worker had a medical 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 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.

Note: To accept an aggravation of a pre-existing condition, there must be a work accident, 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.

Consider a referral to an internal consultant for a medical opinion, when additional assistance is needed to determine if a condition existed prior to the work accident and/or if the condition was worsened by the work accident. 

Review the medical 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 caused the pre-existing condition to worsen or deteriorate, or the symptoms of the pre-existing condition worsened to the point the worker is no longer able to perform their date of accident duties, continue to manage the claim.  See the 3-1 Modified work and the 3-2 Collaborative care planning procedure.

Not accepting an aggravation

When the work accident 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). See 1-1 initial entitlement and the 3-2 Collaborative care planning procedure, 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? See 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. See the 1-5 Claim reopen decision procedure.

Do not continue with this procedure.

Pre-existing condition from another claim

When the worker's pre-existing condition was accepted on another claim, complete a review of that claim to determine if the current disability is a continuation of a previous work-related injury. Follow the Claim reopen decision procedure.

When the ongoing problems and disability are due solely to the pre-existing condition and the worker requires surgery for a non-compensable pre-existing condition, consider if the worker is eligible for a rehabilitation surgeryRehabilitation surgery assistance is a cost-effective means of reducing future claims costs by making it possible for the worker to undergo surgery for a non-compensable pre existing condition that would otherwise continue to be aggravated by employment. WCB provides the worker with financial support for the period of treatment and convalescence. allowance. Refer to the Rehabilitation surgery assistance section.

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).  See Policy 03-02, Part II, Application 1, Question 5 - Aggravation of a Preexisting Condition.