WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 710/15

Transcription

1 WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 710/15 BEFORE: L. Petrykowski : Vice-Chair B.M. Young : Member Representative of Employers M. Ferrari : Member Representative of Workers HEARING: April 10, 2015 at Hamilton Oral DATE OF DECISION: May 5, 2015 NEUTRAL CITATION: 2015 ONWSIAT 963 DECISION(S) UNDER APPEAL: WSIB Appeals Resolution Officer dated March 14, 2013 APPEARANCES: For the worker: For the employer: Interpreter: Mr. B. Allen, union representative Ms. A. Ibrahim, lawyer N/A Workplace Safety and Insurance Appeals Tribunal Tribunal d appel de la sécurité professionnelle et de l assurance contre les accidents du travail 505 University Avenue 7 th Floor 505, avenue University, 7 e étage Toronto ON M5G 2P2 Toronto ON M5G 2P2

2 Decision No. 710/15 REASONS (i) Introduction to the appeal proceedings [1] The worker appeals a decision of the Appeals Resolution Officer ( ARO ) of the Workplace Safety and Insurance Board ( Board ), dated March 14, 2013, which concluded that the worker did not have entitlement for a Non-Economic Loss ( NEL ) assessment for hand arm vibration syndrome ( HAVS ). The ARO made a decision based on the written record and without an oral appeal hearing at the Board s Appeals Branch. [2] The worker attended the Tribunal hearing with Mr. Allen, a union representative. The employer attended the Tribunal hearing through its in-house lawyer, Ms. Ibrahim. [3] In a preliminary discussion, both parties agreed that their understanding of the case was that initial entitlement for HAVS had not been established under the worker s claim at the Board and that this issue would have to be necessarily decided before a determination concerning the NEL assessment for HAVS could be made. (ii) Issue [4] As such, the issue to be decided in this appeal is as follows: 1. Whether the worker has initial entitlement, and entitlement for a NEL assessment, for HAVS? (iii) Background [5] The Panel has reviewed the entirety of the documentary record and the following background facts are briefly noted. [6] The worker, now age 55, began work with the accident employer around November The Board established a claim for this worker for a gradual onset HAVS (also known as Raynaud s phenomenon) condition after the worker sought medical attention on March 29, The Board s operating level denied entitlement for this condition as being work-related in a decision dated October 1, That decision was appealed by the worker to the Board s Appeals Branch. The ARO reviewed the objection on January 4, 2012, and found that the first part of the WSIB HAVS policy requirement concerning occupational exposure was met and ordered the Board to arrange a specialized medical assessment to confirm entitlement in relation to the second part of WSIB HAVS policy requirement. [7] As such, arrangements were made by the Board for the worker to be assessed at an occupational disease specialty program, which deals with HAVS, on April 12, Dr. House s report dated June 8, 2012 did not confirm that the worker was suffering from HAVS. Therefore, the worker was denied entitlement for a NEL assessment for HAVS on the basis that he did not have HAVS within the meaning of applicable Board policy. [8] The worker objected to that decision and the matter was referred to the Board s Appeals Branch. The determinations of the Board s operating level were upheld by the ARO in a decision dated March 14, 2013, which included the following analysis and findings:

3 Page: 2 Decision No. 710/15 ASSESSMENT OF THE EVIDENCE In arriving at a decision in this claim, I have had regard for the record, the applicable law and policy, as well as the interested parties view on the issue. In considering a worker's entitlement to WSIB benefits, a decision maker is mandated to have regard for WSIB legislation and related policy. WSIB Policy concerning HAVS states in part: Vibration Induced White Finger Disease is accepted as an industrial disease under sections 2(1) and 15 of the Workplace Safety Insurance Act as peculiar to, and characteristic of a process, trade or occupation involving exposure to high frequency, rapid acceleration vibratory tools. Vibration Induced White Finger Disease may be labeled: Vibration Disease Chipper's Syndrome Raynaud's Phenomenon associated with the use of vibratory tools, or Dead Hands Syndrome. Based on medical evidence, claims for vibration induced white finger disease are favourably considered when the following circumstances apply there is a clear and adequate history of 2 or more years continuous employment on high frequency, rapid acceleration vibratory tools immediately preceding the onset of vasospastic response, and the condition has been confirmed on medical examination by a specialist consultant in vascular disease. As previously noted the worker was assessed at the HAVS specialty clinic on April 12, The detailed report of June 8, 2012 is on file. The conclusion reached was that "the assessment could not confirm the presence of the vascular component of HAVS...Therefore, a diagnosis of Raynaud's phenomenon could not be confirmed. The assessment also did not confirm the presence of digital sensory neuropathy, which is the typical neurological lesion associated with HAVS...The nerve conduction studies were normal bilaterally". In summary the [HAVS] specialty clinic assessment concluded that the worker does indeed have significant exposure to hand-arm vibration at work. It was noted that therefore if his hand symptoms worsen, he could be re-assessed for HAVS. But typically the re-assessments are done at least several years after the initial assessment. Given all of the information available to me, the evidence suggests and I conclude that entitlement to a NEL assessment for HAVS is not in order at this time. Should his condition worsen in the next several years, a re-assessment for HAVS can be reconsidered at that time. But with the objective medical evidence available at this time, a NEL assessment for HAVS is presently not in order. CONCLUSION I conclude that based on the objective medical evidence available at this time, the worker is not entitled to a NEL assessment for HAVS. As previously noted, should his condition worsen in the next several years, the operating area may revisit this issue at that time. The worker s objection is therefore denied.

4 Page: 3 Decision No. 710/15 [9] The worker objects to this decision, and the above-noted issue agenda delineates the matter at hand before the Tribunal in the present appeal. (iv) Law and policy [10] The worker first sought medical attention for his claimed HAVS condition in 2006, and therefore the Workplace Safety and Insurance Act, 1997 (the WSIA ) is applicable to this appeal. All statutory references in this decision are to the WSIA, as amended, unless otherwise stated. [11] Subsection 13(1) of the WSIA states a worker who sustains a personal injury by accident arising out of and in the course of his or her employment is entitled to benefits under the insurance plan. [12] Subsection 2(1) of the WSIA defines impairment as a physical or functional abnormality or loss (including disfigurement) which results from an injury and any psychological damage arising from the abnormality or loss. [13] Subsection 2(1) of the WSIA defines permanent impairment as an impairment that continues to exist after a worker reaches maximum medical recovery. [14] Subsection 46(1) of the WSIA provides that if a worker s injury results in permanent impairment, the worker is entitled to compensation for non-economic loss. [15] Pursuant to section 126 of the WSIA, the Board stated that the following policy packages: 12, 18, 261, and Revision #9, would apply to the subject matter of this appeal. [16] The Panel has considered these policies as necessary in deciding the issues in this appeal, in particular: (v) Operational Policy Manual ( OPM ) Document # , Adjudicative Process ; OPM Document # , Vibration Induced White Finger Disease ; OPM Document # , Determining Permanent Impairment Due to Hand Arm Vibration Syndrome ; OPM Document # , Determining the Degree of Permanent Impairment ; and OPM Document # , Determining Maximum Medical Recovery. The worker s testimony [17] The worker testified that he has worked for his employer for 30 years. He does not have carpal tunnel syndrome. Nothing outside of work affected his hands. He started working with vibratory tools fifteen years ago. He always used them since that time. He bought special gloves to help him. They helped him but only for a limited time. He also used splints which helped him for a couple of years. They did not work after that. He changed jobs to an environment with less vibratory tools. This reduced use of vibratory tools was better for his hands. There was a jobrotation and he went to different work-stations. This was better for his hands. [18] The worker then testified that his problems worsened over time. He had numbness and coldness in his hands throughout the 15 years. His doctor considered this work-related. The

5 Page: 4 Decision No. 710/15 worker did not seek out medical attention or have any further tests since the specialty clinic in He does what he has to do in relation to work. He changed jobs to reduce vibration in 2005 and then his symptoms diminished. He did the new job for five years and then went to a new job where things got worse. He went to the new job in 2007 which had vibratory tools. He has been working this new job for two and a half years and worked the previous job for five years. He was a tool setter from 1984 to He worked on the V-8 assembly line from 1999 to He switched to the V-6 line where there were sixteen jobs. This helped a lot for his hands. He was doing something different every half-hour and this helped a lot. He is now on the transmission assembly line. [19] The worker stated that he has not received treatment since the specialty clinic in 2012 and just tries to manage as best as he can. His current transmission job line has changed. There was talk of two shifts and it was not a good idea for him to move to a different work-area. He moved to the transmission line and this had nothing to do with his medical condition. There are three jobs on that line including a vibrating tool job, one lift job, and one marking job. He rotates through them every half-hour. His hands are numb all the time, especially at the end of his workshift. This feeling is always there. It is difficult for him to figure out which job is good for him there. He is right-handed. His condition has gotten worse and he has pain in both wrists. It is not as much as before the change to the transmission assembly work. He was wearing the gloves on the V-6 line. The gloves did not help him so he stopped using them and this was before the transmission line. [20] The worker then testified that he has numbness, a tired feeling, and pain in his wrists. It is there all the time, whether he is working or not. There is no change in the degree of his numbness. There is more numbness since the specialty clinic in It has definitely increased since then. He does not attend the medical aid station at work for his problems. He has not lost anytime from work. He takes no medication to treat his medical problem. He has had no whitening of his fingers or toes. He used air gun tools for the last 15 years. They vibrate, especially when torqueing down. He talked to the WSIB hygienist who looked at the right job when he came to the plant. The worker talked with him and explained his concerns. [21] The worker stated that he saw Dr. Klimek two times and the tests were negative. He thinks he has HAVS from the vibration tools. This is because he has read about this condition and went to the city of T. for the testing. He started working on the assembly line 15 years ago. His current work cell has three guys doing three jobs. They are marking, lifting, and using the vibrating tool. He takes care of his problem by putting his hands on his thighs. He goes through life and puts up with it. This affects him at home with trimming, hammering, cutting his lawn, and riding a bike. His hand goes numb from hammering. He can cut the grass but it bothers him. It also affects his driving and holding onto the steering wheel. He has not taken Tylenol for this. He has not used hot or cold compresses. He bought gloves at a retail store in the United States and they provided anti-vibration support. He does not go on long trips such as to Florida. He still has coldness in his hands today. His condition is now constant but years ago it helped to be away from work, such as two to three weeks for holidays. (vi) Submissions of the worker s representative [22] On behalf of the worker, Mr. Allen submitted that the WSIB denied initial entitlement. The worker has a coldness and pain problem in his hands, which is now worse. There is a pronounced loss of grip strength. When looking at HAVS and carpal tunnel syndrome, the

6 Page: 5 Decision No. 710/15 worker does not have the latter condition. He used to wear splints previously. He used gloves in the past. This has been a longstanding impairment. There was a previous diminishment of symptoms outside of work. The symptoms are now unrelenting and his impairment is worse. The symptoms have existed for 15 years. Dr. House suggested in his medical report that a worsening was expected. The worker has a history working with vibratory tools. There was high exposure/intensity in that regard, even acknowledged by the specialty clinic. Dr. Saary related this to HAVS. The WSIB only focused on some symptoms. The OHCOW report is relevant and supportive of the worker s position. The preponderance of evidence supports that the worker has initial entitlement and a permanent impairment for HAVS. The worker s appeal should be allowed. The worker s current one-third vibratory tool exposure confirms continuity with past employment. The symptoms have been consistent. This has perpetuated the worker s experience and it does not take much to aggravate it. The 15 years of symptoms means that a permanent impairment has been established. There is a clear association between the work and the condition and nothing other than HAVS applies, neither carpal tunnel syndrome nor tenosynovitis. (vii) Submissions of the employer [23] On behalf of the worker, Ms. Ibrahim submitted that there is no medical evidence to support the worker s position. The WSIB hygienist concluded there was a low exposure history. The worker only uses vibratory tools one-third of the time now. The job description that was given to the doctors is unknown, and this affects their opinions. The specialist did not confirm a HAVS diagnosis. The worker s appeal should be denied. (viii) Analysis and conclusions [24] The initial question that needs to be determined by the Panel in this appeal is whether there is sufficient evidence to accept that the worker has initial entitlement for HAVS. In reaching our conclusion that the worker has not established entitlement for HAVS, we have considered the totality of evidence presented in this appeal including the documentary record and the worker s testimony. The worker s appeal is denied in this regard for the following reasons. [25] The Panel first notes that it is required to apply WSIB policy in the adjudication of this appeal as a result of the applicable provisions of section 126 of the WSIA. OPM Document # , entitled Vibration Induced White Finger Disease, provides the following: Vibration Induced White Finger Disease is accepted as an industrial disease under sections 2(1) and 15 of the Workplace Safety Insurance Act as peculiar to, and characteristic of a process, trade or occupation involving exposure to high frequency, rapid acceleration vibratory tools. Guidelines Vibration Induced White Finger Disease may be labelled: Vibration Disease Chipper's Syndrome Raynaud's Phenomenon associated with the use of vibratory tools, or "Dead Hands" Syndrome.

7 Page: 6 Decision No. 710/15 Signs and symptoms Characterised by blanching and numbness of the fingers induced by prolonged use of vibratory tools of high frequency and rapid acceleration, the signs and symptoms are due to vasospasm in the digital arteries. When the condition is established, the vasospasm is triggered by exposure to cold, e.g., localised cooling of the extremity or generalised whole body cooling. Prognosis If the worker avoids working with vibratory tools in the early stages of the disease, recovery does occur. In cases where the pathology is quite advanced, the worker will never completely recover from sensitivity to cold. Hazardous vibratory tools Vibration Induced White Finger Disease is associated with tools handled by: foundry workers employed in grinding, chipping, scaling, and caulking thor-hammer operators in the automotive industry stone cutters using pneumatic tools of medium to light weight and high frequency vibration chainsaw operators underground miners who use high frequency jack-leg drills. Entitlement criteria Based on medical evidence, which is supplied on the Doctor's Report-Vibration Induced White Finger Disease, Form 8W, claims for vibration induced white finger disease are favourably considered when the following circumstances apply there is a clear and adequate history of 2 or more years continuous employment on high frequency, rapid acceleration vibratory tools immediately preceding the onset of vasospastic response, and the condition has been confirmed on medical examination by a specialist consultant in vascular disease. Adjudication If the diagnosis is medically compatible to the worker's employment history, which is received on the Worker's and Employer's Report of Vibration Induced White Finger Disease, Forms 6W and 7W respectively, the claim is allowed... Permanent Disability/Impairment Award A permanent disability or impairment award is considered two years after a diagnosis is confirmed [26] The primary issue in dispute in the case is whether the worker has HAVS from a medical standpoint. While there was some suggestion in the medical reporting that the worker could have had HAVS, the Panel finds that the worker does not have a clinically-verified HAVS. The main obstacle identified for the worker s entitlement in the ARO s decision dated January 4, 2012 was summarized as follows there: without a definitive HAVS diagnosis, the second requirement of the policy has not been met and entitlement cannot be accepted. The ARO then accepted that the worker had the necessary exposure history that could be compatible with HAVS and ordered that this diagnosis be confirmed through the involvement of a specialist. The specialist selected

8 Page: 7 Decision No. 710/15 by the Board, Dr. Ronald House, is an expert in occupational medicine, whose clinic has a HAVS stream to which the worker was referred to in This is the same Dr. House who authored the Tribunal s medical discussion paper entitled Hand-Arm Vibration Syndrome (dated August 2010). [27] The Panel finds it significant that Dr. House s objective and most recent diagnostic testing for possible HAVS did not find evidence for the existence of HAVS affecting the worker. His report dated June 8, 2012 is the most significant piece of medical evidence on file and cannot be ignored. Dr. House accepts that the worker had a long history of exposure to hand-arm vibration of high intensity in his employment. However, he also noted that the worker did not report finger blanching, something confirmed in the worker s testimony at the Tribunal hearing when he responded no to the question about whether he ever experienced whitening of his fingers/toes. The Panel finds it significant that the worker did not have clinically-verified blanching/whitening affecting his fingers. The presence of such blanching/whitening is a classic manifestation of HAVS, something explicitly noted in OPM Document # and something that the Board s Medical Consultant (Dr. Smith) also suggested to be the case in Board Memoranda #21 (September 22, 2009) and #26 (August 13, 2010). The fact that the worker did not have this particular sign/symptom suggests that he does not have HAVS, although it in itself is not determinative on that point. [28] The Panel has further considered that Dr. House undertook a series of tests, in addition to interviewing the worker and performing a physical examination, and concluded as follows: IMPRESSION: 1. The assessment could not confirm the presence of the vascular component of HAVS which is a form of secondary Raynaud's phenomenon due to hand-arm vibration exposure. [The worker] has a history of increased cold intolerance of the fingers of both hands but no history of blanching. Therefore, a diagnosis of Raynaud's phenomenon could not be confirmed. 2. The assessment also did not confirm the presence of digital sensory neuropathy, which is the typical neurological lesion associated with HAVS. In particular, the physical examination did not indicate any decreased sensation in the fingers of either hand, and the CPT test results did not indicate the diffuse abnormalities typical of digital sensory neuropathy. 3. The nerve conduction studies were normal bilaterally and therefore, there was no evidence of any neurologic co-morbidity such as median or ulnar nerve compression. His most bothersome symptom is numbness and tingling in the fingers of both hands which sometimes wakes him at night. On physical examination, Tinel s test was positive bilaterally evoking numbness in a median nerve distribution. These findings were consistent clinically with carpal tunnel syndrome, although as mentioned the nerve conduction studies did not indicate significant median nerve compression at the wrist. MANAGEMENT: [The worker] does have significant exposure to hand-arm vibration at work. Therefore, if his hand symptoms worsen, he could be re-assessed for HAVS. Typically, the reassessments are done at least several years after the initial assessment. [The worker] should try to avoid cold exposure as much as possible and dress warmly and in particular wear warm gloves or mittens whenever he is exposed to cold ambient conditions. He should wear ISO-approved anti-vibration gloves if he uses vibrating tools in the future.

9 Page: 8 Decision No. 710/15 He should follow up with his family physician about the ongoing management of his hand symptoms. As I mentioned, he has symptoms compatible with clinical carpal tunnel syndrome. Therefore, he might find that the use of a carpal tunnel splint at night is helpful in preventing his neurologic symptoms. (our emphasis added) [29] The Panel finds it significant that Dr. House s impression was that the worker s HAVS could not be confirmed from either a vascular or neuropathic/neurological perspective. Dr. House instead suggested that the worker had bilateral carpal tunnel syndrome (based on the worker s clinical presentation and positive Tinel s sign) and that he could wear a splint at night to assist with the symptomology that he experiences, which is a common form of symptom management associated with carpal tunnel syndrome. The fact that earlier electromyographic testing did not support the existence of carpal tunnel syndrome did not dissuade Dr. House from suggesting that the worker had bilateral carpal tunnel syndrome as opposed to HAVS. In the Panel s view, Dr. House s ultimate assessment and diagnosis has to be given significant weight given its recency, the intricacy of his diagnostic testing, his ability to interview and examine the worker, and his exceptional qualifications in the area of HAVS, which include being a program director for an occupational medicine clinic and having authored peer-reviewed medical publications on the topic of HAVS (as demonstrated by his curriculum vitae attached to the above-noted Tribunal medical discussion paper which forms part of the documentary record in this case). [30] The Panel has also considered that Dr. Pysklywec, a physician from the Occupational Health Clinics for Ontario Workers Inc., reviewed the worker s chart and provided an opinion dated April 5, Dr. Pysklywec concluded there that the worker has hand/arm vibration syndrome secondary to his work at [the employer]. He worked as a toolsetter with pneumatic tool use. This vibration led to neurological and vascular damage of his hand. The Panel notes that Dr. Pysklywec relied on the medical reporting that was available to him, which pre-dated Dr. House s ultimate assessment of the worker s medical condition. He did not have the benefit of personally examining the worker nor were the results of Dr. House s medical investigations available to him since they were identified two years later than Dr. Pysklywec s opinion. While Dr. Pysklywec holds that the worker had neurological/vascular damage in his hand, this was not confirmed in Dr. House s later objective/diagnostic testing. As such, the Panel prefers to rely on Dr. House s medical opinion about whether the worker actually has HAVS. [31] The Panel has also carefully considered that the Board s Medical Consultant, Dr. Smith, reviewed the worker s file on two occasions, as earlier noted. He took specific issue with Dr. Pysklywec s opinion on the latter of those two occasions, as will be discussed further below. On September 22, 2009, Dr. Smith opined that the worker has no hand symptoms consistent with Raynaud s phenomenon. Vascular testing showed minimal risk for vasomotor disturbance. Vascular HAVS cannot be confirmed and that compatibility of HAVS would not be apparent to him. Dr. Smith further reviewed the matter on August 13, 2010, where he opined as follows: it would be my understanding that the exposure from these air guns would be low, especially if there is no hammer like force to screw in the bolts. Minimal handtransmitted vibration would be associated with the torque of the air gun. HAVS would be defined by WSIB occupational disease policy and HAVS would be a diagnosis of exclusion, in the absence of any other causes. The intent of the policy was to define vascular HAVS as Raynaud's phenomenon, and neurological HAVS as digital sensory neuropathy. We are directed to measure grip strength within the parameters outlined by AMA guide iii(r), page 53 for musculoskeletal HAVS.

10 Page: 9 Decision No. 710/15 Any other upper extremity conditions or musculoskeletal issues may not be considered within the scope of a HAVS claim. They may be submitted under a separate claim to be reviewed by operations based on the merits of the case. This man does not report clinical symptoms consistent with vascular hays. This man stated clearly that he did not have any blanching of the hands. As such, confirmatory testing of the vascular component of HAVS would have low sensitivity and specificity, and in the opinion of the undersigned would not be clinically relevant, see Laroche GP. et al. Validity of plethysmography and the digital temperature test in the diagnosis of primary and occupational Raynaud's phenomenon. Clin Invest Med Mar;10(2): Although I agree with the OHCOW representative that subjective reporting of symptoms in these cases may not always be accurate or reliable especially when compensation may be involved, it is usually confounding by over reporting, rather than under reporting if history alone is used as the gold standard. Objective testing has been recommended to confirm clinical impression obtained by an experienced examiner in these cases. Youakin, S. has reported that a presenting history of Raynaud's phenomenon in workers seeking compensation for HAVS may not be accurate as approximately half of cases are unable to objectively document photograph evidence of Raynaud's phenomenon. See Youakim S. The validity of Raynaud's phenomenon symptoms in HAVS cases. Occupational Medicine 2008; 58: Ergo, false positive testing and likely a response within physiological normal limits in the absence of clinical symptoms does not confirm a condition. The reader may consult with an experienced vascular surgeon for additional details in interpretation of vascular studies. Although [hospital] has raised the possibility that this man may have vascular HAVS, the eligibility adjudicator of WSIB makes the determination of compensation based on all of the evidence available. This man reports symptoms of paresthesias of the hands for approximately 10 years. This is a common symptom in the population with a point prevalence of up to 35%. See Walker-Bone K. et al. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Rheum Aug 15;51(4): Symptoms of numbness or paresthesias would be one of the commonest symptoms initiating a referral to a neurologist for a diagnosis. If [hospital] felt that this gentleman had neurological HAVS, I am sure that a referral would have been made to their consulting neurologist for confirmation of neurological hays. Previous nerve conduction studies were reported to be within normal limits. [Hospital] was unable to verify a diagnosis of neurological HAVS on the basis of the medical information available. DeQuervain's tenosynovitis would not be within the scope of a claim for HAVS. [32] The Panel has considered that Dr. Smith carefully reviewed the medical evidence available to him, along with epidemiological studies, and provided a well-balanced rationale as to why he felt that the worker did not have HAVS. This was largely in response to the earlier report provided by Dr. Pysklywec. Dr. Smith took issue with the reliability of some of the medical reporting which was largely based on the worker s subjective reporting of his complaints. Dr. Smith also explained the limits of plethysmography testing for HAVS and the fact that paresthesia, which the worker has complained of for years, was a common symptom in the general population that is not necessarily indicative of the existence of HAVS. Dr. Smith further noted that the worker may be suffering from DeQuervain s tenosynovitis, which is not

11 Page: 10 Decision No. 710/15 the same diagnosis as HAVS and which does not form part of the worker s claim. Dr. Smith s review of the medical evidence ultimately did not support that the worker suffered from HAVS. His prescient opinion was ultimately in agreement with Dr. House s diagnostic testing and impressions, which were made about two years later. [33] The Panel has considered that some evidence did suggest that the worker was exposed to a history of several years of employment associated with high intensity vibratory tools. It was in this temporal context that the worker s hand-related difficulties arose. However, that would only satisfy the first part of the two-part direction found in OPM Document # The Panel finds on a balance of probabilities that the second part, that being that the condition has been confirmed on medical examination by a specialist consultant in vascular disease has not been met. The worker was given the clinical opportunity to be assessed by a renowned specialist that deals with occupational medicine, including matters related to HAVS, and Dr. House s ensuing report did not confirm the existence of HAVS. As noted earlier by Dr. Smith, HAVS is a diagnosis of exclusion, but Dr. House ruled out HAVS and suggested the presence of carpal tunnel syndrome which he recommended be further assessed and managed by the worker s family physician. In the Panel s view, this diagnosis, along with the fact that symptoms of paresthesia are common in the general population, does not suggest that the worker has HAVS within the meaning of OPM Document # [34] While the worker s work-history fits within the auspices of the first part of OPM Document # two-part requirement for HAVS entitlement, the second part has not been established on a balance of probabilities evidentiary standard. In the Panel s view, it is not probable that the worker has HAVS, especially when viewed in light of the medical opinions of Dr. House and Dr. Smith. The Panel has also been provided with no new (and no contradictory) medical evidence since the time of Dr. House s assessment (June 8, 2012) and therefore there is no medical evidence of substance that substantiates that the worker has HAVS nor is there any further medical evidence that purports to correlate the worker s work-history with such a medical diagnosis. [35] On the basis of the totality of the evidence considered, including the worker s testimony, and having regard to applicable law and Board policy, the Panel concludes on a balance of probabilities that the worker has not established initial claim entitlement to benefits under the WSIA for HAVS. Given that the worker does not have initial entitlement to HAVS, there is no basis to consider granting a NEL assessment (for a work-related permanent impairment) for HAVS in the worker s case. The worker s appeal is denied in this regard.

12 Page: 11 Decision No. 710/15 DISPOSITION [36] The worker s appeal is denied. DATED: May 5, 2015 SIGNED: L. Petrykowski, B.M. Young, M. Ferrari