Permanent total disability decision

Review the diagnosis, relevant medical information and/or the PCI rating to determine whether worker meets the criteria for PTD as outlined in Policy 04-04, Part I. 

Note: If the worker has already reached normal retirement age, they are not eligible for PTD. End this procedure. 

If the worker's PCI on the current claim is assessed at 100%, the worker’s PTD status requires review. Continue to step 3. 

If the worker's PCI on the current claim is assessed below 100%, consider whether the worker has other claims with PCI and, if so, whether the cumulative PCIThe worker has a cumulative total PCI rating on one or several claims is at least 75%. If the cumulative PCI is not at least 75%, the worker is not eligible for PTD. End this procedure.

If the worker’s cumulative PCI or single PCI assessment is at least 75%, review the DOA. When the DOA is:

• Before January 1, 2025, and the worker's cumulative PCIThe worker has a cumulative total PCI rating on one or several claims is less than 100%, the worker is not eligible for PTD. If the review was requested by the worker, document the outcome and send the appropriate decision letter and end this procedure.
• On or after January 1, 2025, continue to the next step to confirm the total cumulative PCI rating before starting the PTD review. If the PCI is at least 75% based on a single PCI assessment, continue to step 3. 

Review the PCI assessments from all the worker's claims and request an opinion from a PCI medical consultant.

When cumulative PCI is greater than or equal to 75% send a referral to a PCI medical consultant to request an updated cumulative PCI rating. 

Note: when previous PCI ratings were calculated using different sources (e.g., the Alberta Permanent Clinical Impairment GuideThe medical consultant will review the results and apply the approved WCB-Alberta rating schedule (Alberta Permanent Clinical Impairment Guidelines) to recommend a percentage of whole body impairment for the injury. or the  American Medical Association Guides for the Evaluation of Permanent Impairment Where the Alberta PCI guidelines do not adequately address the impairment, the medical consultant will then refer to the American Medical Association Guides to the Evaluation of Permanent Impairment.), the PCI will need to be recalculated. This ensures the total cumulative PCI amount is accurate and consistent. 

Review the opinion and determine if the claim requires a PTD review.  

Review the medical consultant's opinion. If the opinion supports the worker's cumulative PCI rating is:

• 75 to100%, proceed to the next step.
• Less than 75%, the worker is not eligible for PTD, document the rationale and end the procedure. If the review was requested by the worker, send the appropriate decision letter explaining why the PCI rating decreased. 

Note: Recalculation of cumulative PCI is a requirement for PTD decision-making purposes only. If the cumulative rating is less than 75%, any NELPNon-economic loss payments payments previously issued will not be adjusted as a result of the recalculation.

All PTD decisions are rendered by a Special Care Services (SCS) case manager. If the decision maker is a SCS case manager, go to the next step. If the decision maker is not a SCS case manager, discuss the claim with the supervisor.Physical injury team Supervisor The supervisor will consult with the SCS Supervisor to determine whether a referral to a SCS case manager is appropriate.

• If the referral is appropriate: Document a file note requesting a SCS case manager assess entitlement to PTD.
• If the referral is premature Missing medical reporting, cumulative PCI not recalculated, PCI less than 75%, worker has retired, DOA prior to Jan 1, 2025 etc.: Document the outcome in a file note and end the procedure. If additional information is needed to determine whether the referral is appropriate, action the recommendations and follow up with the supervisor.

The existing case manager remains the claim owner and continues to manage all other aspects of the claim. The SCS case manager is responsible only for the PTD decision.

Special Care case manager

Review the claim and confirm the worker is eligible to be considered for PTD status as outlined in Policy 04-04, Part I.  

If additional information is required and the claim is assigned to a physical injury case manager, consult with the physical injury case manager to gather the relevant documents. Consult with the SCS Supervisor when needed.  

Verify that all pertinent information and medical documentation is on file. Examples of relevant information include: 

• Specialist reports on fitness for work or functional limitations (e.g., consultation summaries, comprehensive functional capacity evaluation, etc.)
• Specialized assessments (e.g., independent medical exams, PCI assessments, neuropsychological or psychological assessments, cognitive assessments, personal care allowance or home assessments, occupational therapy assessments/discharge reports, etc.)
• Medical reporting (e.g., medical status exam, physiotherapy assessments/reporting, and reporting from treatment providers and/or test results, such as x-rays, CT scans, etc.)

Once all required information is obtained, proceed with the PTD review and request a medical consultant opinion.

Request and review the medical consultant opinion

Send a referral to the internal medical consultant requesting an opinion on whether the functional restrictions resulting from the compensable injuries render the worker permanently incapable of participating in employment.

Review the medical consultant opinion. When the medical information: 

• supports the worker is permanently incapable of participating in employment, continue to the next step.
• does not support the worker is permanently incapable of participating in employment, go to step 6 to communicate the decision.

Note: Refer to the key information section for the definition of permanently incapable of participating in employment. A worker receiving a zero-based ELP is not automatically considered permanently incapable of participating in employment. This is because other vocational barriers may qualify a worker for a zero-based ELP. Therefore, the presence of a zero-based ELP must be assessed in context and does not, by itself, meet the criteria outlined under permanently incapable of participating in employment.

Special Care Services case manager

Request approval for PTD

Send a proposal to the supervisor recommending approval for PTD, along with any related wage loss benefits that may result from the approval (i.e., adjustments to an existing ELP or a zero-based ELP etc.). Include the following details: 

• the compensable injury and subsequent permanent work restrictions,
• the relevant medical information supporting the PTD criteria has been met (i.e., date of medical consultant's memo, PCI assessment(s) etc.),
• the rationale outlining how the compensable injury meets the PTD criteria under Policy 04-04, Part I,
• the benefits payable upon PTD approval (i.e., zero-based ELP etc.)
• references to prior wage loss decisions (i.e., ELP approvals etc.)

The supervisor documents their decision to approve or not approve the recommendations and forwards it to the next approver level, if required. See the Levels of Authority manual.

Review the response

Review the supervisor's (and manager, if applicable) recommendation to approve or not approve PTD. 

If additional information is needed to determine whether the worker meets PTD status, action the supervisor’s (and manager, if applicable) recommendations and resubmit the PTD recommendation.

Special Care Services case manager

When the worker:

• meets the criteria for PTD:
  • Call the worker to communicate and explain how the decision impacts the claim (i.e., unreduced zero-based economic loss payment, adjustment to an existing ELP).
  • Send the appropriate letter to communicate the PTD decision and outline the next steps in the care plan.
  • Administer the applicable benefits (implement the zero-based ELP or adjust the existing ELP to a zero-based ELP).
  • Verify the NELP award was issued correctly (less any previously paid awards).
    • Note: Once a NELP has been paid based on 100% PCI on one claim or cumulatively, the system will recognize that the zero-based ELP remains unreduced for the worker’s lifetime, regardless of their retirement age.
• does not meet the criteria for PTD, determine whether formal communication of the decision is required. If the PTD review was completed:
  • at the request of a worker or representative, call the worker to explain the decision, outline the next steps in their care plan and send the appropriate letter.
  • as a self-directed review of the worker’s general benefit entitlement, formal communication may not be required. In these cases, consider whether documenting the outcome of the PTD review via file note is appropriate.  

If the PTD review was requested by a physical injury case manager, send a file note informing the case manager of the outcome. Include the next steps for setting up annual reviews to ensure the worker continues to receive the appropriate benefits and services. The physical injury case manager continues to manage the claim as appropriate. 

If the PTD review was initiated and managed by SCS, continue to manage the claim, as appropriate. 

In all cases, if no active case management is required, transfer the claim to a case assistant for monitoring.

Note: any Request for Reviews submitted regarding the PTD decision will be addressed by the appropriate SCS Supervisor.