Highlights of Noteworthy Decisions

Decision 61 20
22/04/2020
S. Peckover
  • Health care (medical aid) (drugs)
  • Health care (necessary)

The worker suffered a low back injury in July 1999, for which the Board granted the worker a 15% NEL award. In Decision No. 1240/12, the Tribunal found that the worker had entitlement for chronic pain disability. The Board then replaced the 15% organic award with a 20% NEL award for chronic pain disability. In Decision No. 1312/17, the Tribunal found that the worker was entitled to full LOE benefits.

The worker now appealed a decision of the Appeals Resolution Officer denying health care benefits for opioid medications.
Under s. 33 of the WSIA, a worker is entitled to such health care as may be necessary, appropriate and sufficient as a result of an injury.
The opioids in question are being prescribed for the worker's compensable condition. Therefore, the "necessary" criterion has been met. However, the Vice-Chair had some reservations with respect to the appropriateness of the medications, in terms of their dosage.
It is not appropriate for the Board to fund the use of opioids at levels which are so far in excess of the guidelines, especially given medical reporting indicating that these medications do not appear to be helping the worker control his pain. There is no requirement that a worker attend a medical program in order to be entitled to benefits, yet he had not been willing to participate in a medication and substance management program to help find better alternatives. Such a program would appear to be entirely reasonable in the circumstances of this case.
All three requirements (necessary, appropriate and sufficient) must be met for entitlement. The "appropriate" condition was not met in this case. Accordingly, the worker did not have entitlement for the opioid medications.
The appeal was dismissed.