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Difference between revisions of "Workers' Compensation Claim Benefits (7:XI)"
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Workers' Compensation Claim Benefits (7:XI) (view source)
Revision as of 00:59, 3 December 2021
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Many workers need immediate income if they are waiting to be accepted or their benefits have been disallowed or terminated. They should consider alternate sources: social assistance, which may provide a crisis grant for immediate temporary relief or longer-term relief if a decision is being appealed, EI sickness benefits, CPP disability pensions, any plans available through their place of work or union, ICBC (if an automobile was involved), or private disability insurance. | Many workers need immediate income if they are waiting to be accepted or their benefits have been disallowed or terminated. They should consider alternate sources: social assistance, which may provide a crisis grant for immediate temporary relief or longer-term relief if a decision is being appealed, EI sickness benefits, CPP disability pensions, any plans available through their place of work or union, ICBC (if an automobile was involved), or private disability insurance. | ||
== | == L. “Resolved/Plateau” Decision Letters == | ||
There are other key decisions in a worker’s claim including the initial decision to accept or deny a claim and any vocational rehabilitation or pension decision. Additionally, it is important to note the decision that is issued at the end of a period of temporary disability. This decision, referred to as a “resolved/plateau” decision, usually includes several key decisions, each of which may be appealed. | There are other key decisions in a worker’s claim including the initial decision to accept or deny a claim and any vocational rehabilitation or pension decision. Additionally, it is important to note the decision that is issued at the end of a period of temporary disability. This decision, referred to as a “resolved/plateau” decision, usually includes several key decisions, each of which may be appealed. | ||
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=== 1. Has the Worker's Injury/Occupational Disease Stabilized? === | === 1. Has the Worker's Injury/Occupational Disease Stabilized? === | ||
The first key issue is an accurate medical assessment of the worker’s compensable condition at the critical point of a “resolve/plateau” decision. As noted above, if a work injury or Occupational Disease has resolved entirely, the Board issues a “resolve” decision and the claim file is closed. If the injury has only stabilized, then the Board issues (or should issue) a “plateau” decision. If the injury has not yet stabilized, the Board should continue to treat it as a temporary disability with temporary benefits (wage loss and/or health care benefits). | |||
An appealable matter arises if the Board issues a “resolve” decision but the worker or the medical evidence indicates that there are ongoing effects, conditions or impairments from the injury (e.g. chronic pain). In this case, both the medical evidence and the Board’s adjudication should be assessed. The medical evidence should be assessed to determine if the compensable conditions are still temporarily disabling (i.e. the worker is not able to fully return to pre-injury work) so that the worker continues to be entitled to temporary ongoing benefits, or if the compensable conditions have reached a “plateau” as defined by RSCM II Policy #34.54 and the worker is entitled to a referral to Disability Awards and (sometimes) Vocational Rehabilitation. | An appealable matter arises if the Board issues a “resolve” decision but the worker or the medical evidence indicates that there are ongoing effects, conditions or impairments from the injury (e.g. chronic pain). In this case, both the medical evidence and the Board’s adjudication should be assessed. The medical evidence should be assessed to determine if the compensable conditions are still temporarily disabling (i.e. the worker is not able to fully return to pre-injury work) so that the worker continues to be entitled to temporary ongoing benefits, or if the compensable conditions have reached a “plateau” as defined by RSCM II Policy #34.54 and the worker is entitled to a referral to Disability Awards and (sometimes) Vocational Rehabilitation. | ||
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=== 2. Plateau Date === | === 2. Plateau Date === | ||
If the worker has plateaued, there should be a particular date identified in the decision letter as being the date of “stabilizing” or “maximum medical recovery” (MMR) or “plateau”. You can assess whether this date is appropriate | If the worker has plateaued, there should be a particular date identified in the decision letter as being the date of “stabilizing” or “maximum medical recovery” (MMR) or “plateau”. You can assess whether this date is appropriate by considering: | ||
*a) Have all the compensable conditions been considered? And | *a) Have all the compensable conditions been considered? And | ||
*b) Is it appropriate given the criteria in | *b) Is it appropriate given the criteria in RSCM II Policy #34.54 and the medical evidence? | ||
'''EXAMPLE:''' If further treatment (physiotherapy or surgery) is likely to make a significant change in the worker’s condition within three months, then the condition should continue to be temporarily disabling and the worker should get | '''EXAMPLE:''' If further treatment (physiotherapy or surgery) is likely to make a significant change in the worker’s condition within three months, then the condition should continue to be temporarily disabling and the worker should get temporary wage loss benefits until then. | ||
=== 3. What Permanent Conditions are Accepted and what Conditions are Denied? === | === 3. What Permanent Conditions are Accepted and what Conditions are Denied? === | ||
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The pre-existing condition or disease was '''non-deteriorating''': | The pre-existing condition or disease was '''non-deteriorating''': | ||
As set out in | As set out in RSCM II Policy #16.00 for injury and Policy #25.20 for Occupational Disease, if the post-plateau condition is not significantly worse than before the injury, then the condition was not permanently aggravated by the work injury/Occupational Disease. This is an issue for which medical records are important; or | ||
The pre-existing condition or disease was '''deteriorating''': | The pre-existing condition or disease was '''deteriorating''': | ||
If the worker had a pre-existing deteriorating condition, the test is whether the work injury “significantly accelerated, activated or advanced” the condition more quickly than would have occurred in the absence of the work injury ( | If the worker had a pre-existing deteriorating condition, the test is whether the work injury “significantly accelerated, activated or advanced” the condition more quickly than would have occurred in the absence of the work injury (RSCM II Policy #16.00). The Board commonly denies permanent disability on the basis that it arises from a natural degeneration of a pre-existing condition such as degenerative disc disease or osteoarthritis. | ||
=== 5. Missing Conditions === | === 5. Missing Conditions === | ||
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If this is not the case, this is a very important issue to challenge. Since an appeal of a plateau decision often involves seeking additional temporary wage loss benefits, a new plateau date, additional permanent conditions, etc., the return to work finding of fact can be addressed in the context of these additional issues. | If this is not the case, this is a very important issue to challenge. Since an appeal of a plateau decision often involves seeking additional temporary wage loss benefits, a new plateau date, additional permanent conditions, etc., the return to work finding of fact can be addressed in the context of these additional issues. | ||
However, if there are no other issues in the plateau decision | However, if there are no other issues in the plateau decision other than this return to work finding, the plateau decision should be appealed on the grounds that the worker cannot return to their pre-injury job and is entitled to additional vocational rehabilitation benefits. Framing the appeal issue in this way ensures that the Review Division has an entitlement decision to address. | ||
=== 7. If Not, Referral to Vocational Rehabilitation === | === 7. If Not, Referral to Vocational Rehabilitation === | ||
