The Appeal CommissionThe Workers Compensation Act of Manitoba

Preamble

The worker is appealing the decision made by the Workers Compensation Board ("WCB") that he was not entitled to coverage for certain prescriptions after December 31, 2015. A file review was held on September 26, 2016 to consider the worker's appeal.

Issue

Whether or not the worker is entitled to coverage for prescription medications Effexor and Lorazepam after December 31, 2015.

Decision

That the worker is not entitled to coverage for prescription medications Effexor and Lorazepam after December 31, 2015.

Background

On April 10, 2008, the worker suffered a heart attack while moving boxes at work. His claim for compensation was accepted by the WCB and benefits and services were paid to the worker while he underwent treatment for his heart condition. The worker's claim was last considered by the Appeal Commission on December 12, 2014. For further details regarding the worker's claim history, please see Decision No. 165/14. On November 19, 2015, the worker was advised that no responsibility would be accepted for the costs of Effexor or Lorazepam as of January 1, 2016 as the WCB had no information to indicate that the medication continued to be related to his original 2008 compensable heart attack. On February 1, 2016, the worker appealed the decision to Review Office. On February 16, 2016, Review Office confirmed there was no coverage for Effexor and Lorazepam beyond December 31, 2015. In reaching its decision, Review Office relied on the medical opinion of a WCB psychiatrist dated July 29, 2015 which stated: I assessed [the worker] at the WCB in June, 2010. At that time, his diagnosis was Adjustment Disorder with Mixed Anxiety and Depressed Mood, Chronic, in Partial Remission; versus Anxiety Disorder - Not Otherwise Specified. [The psychologist] reports indicate that there has been stability in [the worker's] mood, and some improvement in his anxiety and emotional reactivity. There has been no change in his diagnosis. The medical information does not substantiate that there has been any deterioration in his psychiatric condition. The family physician reports have not referenced any changes in his psychiatric symptoms and there has been no change in his medication. The medical information does not substantiate that there is an indication for Effexor or Lorazepam in regard to [the worker's] psychiatric diagnosis. Review Office concluded that based on the above findings, the worker's ongoing need for Effexor and Lorazepam was not related to his compensable injury. On February 26, 2016, the worker appealed Review Office's decision to the Appeal Commission and a file review was arranged.

Reasons

Applicable Legislation and Policy 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. Medical aid payments for expenses such as medication are payable in accordance with subsection 27(1) of the Act. The WCB makes these payments where it determines that the medical aid is necessary to cure and provide relief from an injury resulting from an accident. The WCB has established WCB Board Policy, 44.120.10, Medical Aid, which notes that "the provision of medical aid attempts to minimize the impact of the worker's injury and to enhance an injured worker's recovery to the greatest extent possible." The WCB pays for prescription medications under this policy. "All treatments must satisfy the WCB that their use will aid in the recovery of an injured worker or minimize the impact of the injury." Worker's Position In a written submission dated September 12, 2016, the worker noted that he was first prescribed the medications known as Effexor and Lorazepam in January 2009 by his primary caregiver and that the WCB has covered the costs of the medications for many years. The worker pointed out that his cardiologist wrote on February 16, 2016 that: It has been my observation from the initial meetings and subsequent ongoing follow-ups with [worker], that he has suffered from substantial stress and depression, evolving since his heart attack in April 2008. As such, the medication has been provided on an ongoing basis by his family physician, and I believe that there is value in continuing it. The worker stated that: Each medication serves a different purpose in treating my cardiac rehabilitation and should not be arbitrarily lumped together. Both medications have been approved on numerous occasions by several WCB Medical Advisors and the Review Office. Employer's Position The employer did not participate in the appeal. Analysis The issue before the panel is whether or not the worker is entitled to coverage for the medications Effexor and Lorazepam. In order for the worker's appeal to be approved, the panel must find that the medications are necessary to cure and provide relief from the injury resulting from an accident. We are not able to make this finding. In addressing this appeal the panel is cognizant that Appeal Commission Decision 118/11 provided that the psychological difficulties resulting from matters related to the administration of the claim are not compensable and that Appeal Commission Decision 165/14 provided that further psychological treatment after June 30, 2014 should not be authorized. In this appeal, the worker's position is that the medications are not for a psychological condition, but rather assist in treatment for his compensable cardiac condition. The panel notes, however, that the worker's cardiologist did not prescribe these medications. In a letter dated February 16, 2016, noted by the worker in his written submission, the worker's treating cardiologist advised that he believes the worker's family physician prescribed the medications. The cardiologist suggests: Should you require further details regarding this noncardiac-related question, kindly address further queries to [family physician]. (highlighting added) The panel finds that this referral by the cardiologist to the family physician supports a finding that the medications are not prescribed for the cardiac condition. Regarding the family physician's reasons for prescribing the medications, the panel notes that in a hand written note bearing fax date 02/22/2016 from the family physicians' clinic, the family physician noted: "He still feels and it is my opinion also, that he still requires his Effexor XR + Lorazepam for his depression + anxiety, related to his MI's + his fight with WCB. He did not see any psychologist lately, he cannot afford a private one due to financial problems." In regards to the explanation provided by the family physician for prescribing the medication, the panel notes that they are prescribed for "depression + anxiety related to his MI's + fight with WCB". (highlighting added). In Appeal Commission Decision 118/11, the Appeal Commission found that the worker's psychological difficulties resulting from matters related to the administration of the claim are not compensable. As such, this panel is barred from reconsidering this issue, given the previous Appeal Commission decision. The panel also notes that Appeal Commission Decision 165/14 provided that further psychological treatment after June 30, 2014 should not be authorized. Accordingly the payment for the medications for the treatment of depression and anxiety, are not compensable. The panel finds that the medications are not necessary to cure and provide relief from the injury resulting from an accident. The worker's appeal is dismissed.

Panel Members

A. Scramstad, Presiding Officer
A. Finkel, Commissioner
P. Walker, Commissioner

Recording Secretary, B. Kosc

A. Scramstad - Presiding Officer
(on behalf of the panel)

Signed at Winnipeg this 6th day of October, 2016