The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB")that the need for an angiogram was not related to his compensable injuryand therefore he was not entitled to travel expenses to attend theappointment.  A hearing was held on April 22, 2015 to consider the matter.

Issue

Whether or not the worker is entitled to travel expenses inorder to attend an angiogram appointment.

Decision

That the worker is entitled to travel expenses in order toattend an angiogram appointment.

Decision: Unanimous

Background

The worker has an accepted claim with the WCB for a left knee injury that occurred in the workplace on August 11, 1999.

In September 2013, the worker's orthopedic surgeon recommended a partial knee arthroplasty to help with the pain. The WCB accepted responsibility for this procedure and authorization for surgery was granted. In the context of pre-operative medical examination, the worker's family physician recommended the worker be seen by a cardiologist for further investigation of chest discomfort.

On June 24, 2014, the worker was seen by a cardiologist, who noted that the worker had chest discomfort that could be atypical angina, in keeping with intermediate probability of flow-limiting coronary artery disease. The cardiologist recommended that the worker undergo CT coronary angiogram and to consider classic coronary angiogram if there was significant proximal plaque burden in the main coronary arteries.

On August 5, 2014, the worker travelled to a hospital for pre-operative blood tests. Travel expenses for this trip were covered by the WCB.

On August 7, 2014, the worker travelled to a further hospital for a CT angiogram. Travel expenses for this trip were covered by the WCB.

The worker was then scheduled to have a pre-angiogram medical examination by a cardiac nurse and subsequently a classic angiogram procedure on October 31, 2014. He asked the WCB to provide him with travelling expenses for these medical appointments.

On October 10, 2014, Compensation Services determined that the worker was not entitled to travel expenses for the angiogram appointment as it was not medically related to his compensable injury. The decision was based on WCB Policy 44.120.10, Benefits Administration - Medical Aid. The worker disagreed with the decision and an appeal was filed with Review Office on October 14, 2014.

On January 21, 2015, Review Office upheld that the worker was not entitled to travel expenses related to the angiogram appointment. Review Office noted that the file evidence showed that the worker made complaints of chest pains to his family physician on and off over a period of months independent of his compensable injury. The attending cardiologist's report of June 24, 2014 noted the same history of complaints regarding the worker's chest pains. Review Office felt the need for the angiogram was discovered in part due to testing for his compensable injury and in part due to his complaints to his family doctor, independent of his need for left knee surgery.

Review Office acknowledged that the current medical recommendation was for the worker's cardiac condition to be treated before going ahead with his compensable proposed surgery. Review Office felt the worker's cardiac condition was a co-occurring condition and not a secondary condition to the compensable injury as there was no causal relationship between the two. The WCB had no jurisdiction to approve coverage or associated costs for non-compensable injuries. On January 29, 2015, the worker appealed Review Office's decision to the Appeal Commission and an oral hearing was arranged.

Reasons

Applicable Legislation:

The Appeal Commission and its panels are bound by The Workers Compensation Act (the “Act”), regulations and policies of the Board of Directors.

When a worker suffers personal injury by accident arising out of and in the course of employment, compensation is payable to the worker pursuant to subsection 4(1) of the Act. Provision of medical aid to injured workers is payable in accordance with subsection 27(1) of the Act which provides as follows:

Provision of medical aid

27(1) The board may provide a worker with such medical aid as the board considers necessary to cure and provide relief from an injury resulting from an accident.

Worker’s Position

The worker was self-represented at the appeal. The worker advised that he was recommended for a partial knee replacement but that he also had anxiety issues, for which the WCB took responsibility. He would get chest pains but he did not know whether these were caused by anxiety or angina. Even before he was scheduled for the partial knee replacement, the worker was to see a cardiologist to investigate the chest pain. When he saw the cardiologist in consultation, the worker was told that he would be sent for a CT angiogram. The worker attended, then sent the receipts to the WCB and received reimbursement for his travel expenses. After the CT angiogram results came back the cardiologist said that there should be more investigation by way of a conventional angiogram. The worker agreed to undergo the procedure, but when he asked the WCB for travel expenses, they refused.

The worker submitted that as the WCB paid travel expenses for the first procedure, they should also pay travel expenses for the second. It was all part and parcel of the pre-operative investigations. The worker stated that he had to be cleared by the cardiologist before he could proceed with the left knee surgery. He had to make sure that his heart would be able to undergo the knee replacement surgery. The worker advised that he was still waiting to follow-up with his cardiologist again and as at the date of the hearing, he had not yet received an opinion from the cardiologist that he was clear to proceed with the surgery.

Analysis

The issue before the panel is whether or not the worker is entitled to travel expenses in order to attend an angiogram appointment. In order for the worker's appeal to succeed, the panel must be satisfied that the expenses are necessary to cure and provide relief from the injury resulting from an accident. We are able to make this finding.

The worker's compensable injury relates to his left knee and responsibility for a partial knee arthroplasty has been accepted. A prerequisite for the arthroplasty was to obtain pre-operative medical clearance for the surgery. This is something which is regularly covered by the WCB as a necessary adjunct to a compensable surgery, and in this case, the worker's expenses related to pre-operative blood tests and a CT angiogram scan were reimbursed.

The question in this case relates to whether the expenses associated with a further angiogram procedure performed in Winnipeg on October 31, 2014 can be considered to be part of the pre-operative medical clearance, or whether this procedure was in the nature of treatment for the unrelated cardiac condition. At the hearing, the worker acknowledged that his heart condition was separate from the knee injury and that the WCB would not be responsible for treatment of the heart condition. He was adamant, however, that the October 31, 2014 procedure was "part and parcel" of the pre-operative investigations and that it was a test which was needed to medically clear the worker for the arthroplastic surgery. The worker's evidence was that after the angiogram was performed, he was advised at the hospital that his arterial blockage did not warrant the insertion of a stent and so no further action was taken. At the time of the hearing, the worker was still awaiting a follow-up appointment with his cardiologist to review the results of the angiogram. He did not yet know whether or not he was medically cleared for the arthroplasty.

The June 24, 2014 report of the cardiologist tends to support the worker's position that the October 2014 angiogram was a continuation of the investigations, as opposed to treatment of the heart condition. Under the "recommendations" section of the report, the cardiologist indicates that the worker agreed to undergo CT coronary angiogram and that he was also agreeable to consider classic coronary angiogram if there was significant proximal plaque burden in the main coronary arteries. In the panel's opinion this suggests that there was a two stage process in investigating the worker's cardiac condition. As the WCB accepted responsibility for travel expenses related to the first stage CT coronary angiogram, the panel finds that responsibility should also be accepted for the expenses related to the second stage of the investigation, that is, the October 2014 classic coronary angiogram. Based on the results from both procedures, the cardiologist would be able to inform his opinion as to whether or not the worker was clear for surgery, from a cardiac point of view. While it is evident to the panel that both forms of angiogram were done primarily for the purpose of determining the extent of the cardiac condition, the panel accepts that the angiograms also served the dual purpose of determining whether or not the worker would be medically able to undergo the compensable knee arthroplasty.

The panel therefore finds that the worker is entitled to travel expenses in order to attend anangiogram appointment. The worker's appeal is allowed.

Panel Members

A. Finkel, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

A. Finkel - A. Finkel

Signed at Winnipeg this 8th day of May, 2015