Denial of Treatment: ‘Functional Gain’ Versus ‘Quality of Life’
AWCC has found that the WCB of Alberta is often too focused on achieving “functional gain” as opposed to overall quality of life for severely injured Albertans.
Recently a severely injured worker was denied ongoing physiotherapy and massage therapy on the premise that cost coverage could not be extended in the absence of identifiable “functional gain”.
Through well researched and compelling submissions produced by AWCC we were able to have the prior denial overturned and physical therapy and massage therapy reinstated for cost coverage on behalf of our client.
Here is an excerpt from one of AWCC's submissions made on the client’s behalf that helps inform WCB responsibilities in this regard:
‘Policy 04-06 Part 1 advises:
“WCB provides or pays for any reasonable and necessary medical aid to treat injuries or alleviate the effects of injuries resulting from compensable accidents.”
Although one of the objectives of providing medical aid is to “promote safe and early recovery and return to work” said aid is not limited in this regard.
A further objective noted in said policy is as follows:
“To alleviate the effects of workplace injury or illness by facilitating the timely and safe delivery of appropriate, quality and cost-effective care and treatment,…”
In this context medical aid coverage would not be required to result in functional progress/gains as the WCB objectives are not exclusionary.”
Although the Board will not use the term “quality of life” in relation to these types of decisions, the following formed part of the response from the WCB and we share this with you here:
“In XXX case I would agree that as functional improvement is not always reflected as a result of his treatment, that other measures may need to be considered including subjective reporting of improved wellness and alleviation of pain.
With this in mind, we will do our best going forward to collaborate with XXX, his treatment providers and our own physiotherapy consultants to develop clinically advisable treatment plans to help “treat or alleviate” the effects of XXX injuries.”
Note: the citation above was utilize with the full permission of AWCC’s client. Although the client gave permission to identify them, AWCC has chosen not to. We take the confidentiality of our clients seriously and do everything in our power to protect that.
It is relevant to also note, as quoted above, the case manager advised that these therapies can be covered for cost when the goal(s) is/are for “improved wellness and the alleviation of pain”.
That is a ‘quality of life’ metric.
Therefore, the case manager’s original decision to deny the therapies on the grounds that further ‘functional gains’ were not being achieved was not a supportable rationale for the denial.
The Board has a fiduciary responsibility to ensure that they support an injured worker fully; including improved wellness and the alleviation of pain outside of a 'functional gain' scenario.
If you been denied any form of entitlement call us at 780-440-6047 for a free consult.