Case Study: When WCB Benefits are Denied in Bad Faith

The Anatomy of an Unjust Denial

Workers’ compensation systems are designed to provide support to injured workers, ensuring that they receive fair compensation when their injuries prevent them from working. These systems operate with the intent of balancing the interests of workers and employers, offering financial assistance and medical coverage without requiring workers to establish fault. However, challenges can arise in the adjudication of claims, particularly in cases where medical complexity or pre-existing conditions are involved. This case study examines the experience of a flight attendant who sustained a workplace injury that led to the development of persistent sciatica. Despite medical evidence supporting a connection between her work duties and her condition, her claim for Temporary Total Disability benefits was denied. The case raises important considerations regarding how WCB assesses medical causation, weighs medical opinions, and applies its own policies, including Balance of Probabilities, Weight of Medical Evidence, and Benefit of Doubt. The key issue in this case is how WCB approached conflicting medical opinions, particularly in its evaluation of evidence from the treating orthopedic specialist versus an internal medical consultant who had not personally examined the worker. This case highlights broader questions about how WCB interprets its policies, the role of medical consultants in claims adjudication, and the standards used to determine work-related aggravation of pre-existing conditions.

The Worker and Her Injury: A Career-Ending Incident

The injured worker, a seasoned flight attendant, had spent years performing physically demanding duties in a high-paced and strenuous environment. The Physical Demands Analysis for airline crew members confirms that their duties require:

• Lifting heavy baggage into overhead bins exceeding 67 inches in height, often while balancing in a confined, unstable space.
• Maneuvering heavy service carts, some of which require over 45 pounds of force to push on carpeted surfaces.
• Performing repetitive bending, twisting, and reaching while serving passengers, managing safety equipment, and responding to emergencies.

Despite these high physical demands, the worker had no significant history of disabling back pain prior to the work-related incident. However, during her shift, she sustained an acute injury that resulted in the onset of severe left-sided sciatica—a condition she had never experienced before. As her symptoms worsened, she underwent L4-L5 decompression and instrumented fusion surgery, performed by a leading orthopedic spine surgeon specializing in complex spinal injuries.

WCB’s Initial Acceptance—Followed by an Abrupt Reversal

Initially, WCB accepted the claim, recognizing that the workplace incident triggered an aggravation of a pre-existing degenerative condition, resulting in severe disability. Temporary wage-loss benefits were provided while the worker underwent treatment. However, WCB suddenly reversed its decision, citing the opinion of an internal medical consultant—a physician who never physically examined the worker and conducted only a file review. The consultant claimed:

• The worker’s pre-existing lumbar degeneration was the true cause of her symptoms.
• The work-related injury did not materially contribute to the need for surgery.
• Therefore, ongoing benefits were unjustified.

This decision directly contradicted the treating surgeon’s findings, who had already unequivocally stated that the work injury was the primary cause of the disabling sciatica and subsequent surgical intervention.

The Fight for Justice: Procedural Misconduct by WCB

1. Handling of Medical Evidence in This Case A key issue in this case is how WCB weighed and interpreted medical evidence from the treating orthopedic spine surgeon. The surgeon had already provided a clear and well-supported report, in which he stated:

• The work injury directly contributed to acute spinal damage and severe left-sided sciatic pain.
• While pre-existing degeneration was present, it had not previously required surgical intervention—it was the work injury that resulted in the need for surgery.
• The sudden denial of benefits created financial uncertainty for the worker, despite medical confirmation of work-related causation.

WCB subsequently requested additional input from the surgeon, even though his initial report had already provided a clear medical opinion on causation and necessity of treatment. When the surgeon did not respond to this follow-up inquiry—likely due to his clinical workload—WCB interpreted the lack of response as agreement with its internal medical consultant’s review, which had reached a different conclusion. This raises important procedural considerations:

• Should a lack of response from a treating physician be interpreted as a shift in medical opinion?
• What weight should be given to a treating surgeon’s initial report when no contradictory evidence has been provided?
• Is it appropriate to continue seeking clarification when a medical opinion has already been provided in clear terms?

In this case, the absence of a follow-up response should not have been treated as agreement with WCB’s internal consultant. The original specialist report had already outlined a detailed assessment of causation, treatment necessity, and the impact of work duties. Without a contradictory statement from the surgeon, the original report should have remained the guiding medical opinion. 2. The Role of Internal Medical Consultants in Adjudication WCB frequently relies on internal medical consultants to assess claims, particularly in cases where pre-existing conditions are present. These consultants conduct file reviews rather than physical examinations, which raises questions about how their assessments should be weighed against firsthand evaluations from treating physicians. In this case, the internal consultant’s findings differed from those of the treating surgeon, leading WCB to rely on the paper-based review rather than the physician who had physically examined and treated the worker. While internal consultants can play a role in assisting with medical adjudication, their conclusions should be considered within the broader context of the worker’s medical history, functional impact, and specialist findings. A fairer approach in cases like this would involve:

• Acknowledging the weight of direct, treating physician reports, particularly when they come from specialists in the relevant field.
• Ensuring that a lack of response from a treating physician is not automatically interpreted as agreement with an alternate medical opinion.
• Clearly documenting why one medical opinion is being prioritized over another, rather than relying on procedural gaps to justify a denial.

In a claim where the treating surgeon has provided a definitive statement on work-related causation, and where no new medical evidence contradicts it, WCB should have considered the treating surgeon’s report as the most authoritative assessment of the injury. 3. Violating Balance of Probabilities (Policy 01-03, Part I) WCB’s own Balance of Probabilities standard states that if the evidence suggests that work “likely” contributed to the injury, benefits must be granted. This standard does not require absolute certainty—only that the evidence supports a probable connection.

• The worker had never before experienced disabling sciatica until the work injury.
• The treating surgeon directly linked the onset of symptoms to work activities.
• Even if a pre-existing condition existed, the work injury was the proximate cause of disability.

Yet, WCB applied an unreasonably high standard of proof, effectively demanding that the worker disprove the pre-existing condition as a contributing factor—a complete reversal of their own policy. 4. Disregarding the Weight of Medical Evidence WCB policies require decision-makers to give greater weight to medical professionals with firsthand experience treating the claimant.

• The treating surgeon had physically examined, diagnosed, and treated the worker, providing a detailed, evidence-based opinion on causation.
• The internal medical consultant had never examined the worker and relied solely on a paper review, making their opinion significantly less credible.

Despite this, WCB chose to favor its own consultant’s opinion over the treating specialist—a direct violation of its own adjudicative principles. 5. Ignoring the Benefit of Doubt (Policy 01-03, Part I) WCB’s Benefit of Doubt principle states that in cases of uncertainty or conflicting medical opinions, the decision must favor the worker. Even if WCB were to claim that there was a conflict in medical opinions (which there wasn’t), its own policy requires resolving doubt in favor of the worker. Instead, WCB deliberately interpreted all doubt against the worker, shifting the burden onto her to prove that work played a role in her condition.

The Appeal: Holding WCB Accountable

Faced with an unjustified denial based on misrepresented evidence, the worker filed a Request for Review with the Dispute Resolution and Decision Review Body. A formal review hearing was scheduled, where Blue Collar Consulting submitted evidence exposing:

• WCB’s procedural misconduct, including the misrepresentation of the surgeon’s silence as agreement.
• WCB’s failure to apply its own Balance of Probabilities and Benefit of Doubt standards.
• The substantial weight of medical evidence favoring compensability.

The Takeaway

This case illustrates the unreasonable tactics used by WCB to deny legitimate claims—including:

1. Pressuring treating physicians into re-explaining conclusions already made clear and then equating their silence to agreement with WCB
2. Favoring internal consultants — general practitioners — who never examine the claimant, over firsthand opinions of medical specialists and surgeons.
3. Unfairly shifting an onerous burden of proof onto workers to obtain fair compensation.
4. Ignoring core adjudicative policies when they favor the worker’s claim.

This isn’t just a case of one worker fighting for benefits—it’s a systemic problem that forces many injured workers into unnecessary appeals simply to obtain the compensation they are legally entitled to receive.