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Difference between revisions of "Introduction to Compensation Claims for Injured Workers (7:III)"
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Introduction to Compensation Claims for Injured Workers (7:III) (view source)
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The plateau decision also sets out whether the Board thinks that the worker can return to his pre-injury job, performing full duties, with the impairment. If the worker can return to his pre-injury work, the Board does not need to retrain him and there is no referral made to VR. | The plateau decision also sets out whether the Board thinks that the worker can return to his pre-injury job, performing full duties, with the impairment. If the worker can return to his pre-injury work, the Board does not need to retrain him and there is no referral made to VR. | ||
However, if the Board considers that the worker cannot return to full duties with his impairment, the “plateau decision” will state this and the worker will be referred to VR for further help with employment. | |||
The VR process is set out below and goes through four stages. The first stage is to see if the employer can or will accommodate the worker and his impairment. If there is no accommodation and the worker does not have a job to return to, VR goes to the next stage to assesses what VR assistance the Board should provide to help the worker become employable, given his permanent injury. VR benefits are discretionary but typically include a VR plan for the worker to re-train and/or have a job search and wage loss benefits for this period of VR time. If successful, VR results in the injured worker successfully adapting to employment with a permanent injury. | |||
It is possible that VR is not successful or that a seriously injured worker is simply too disabled to ever be competitively employable. In these cases, the Case Manger must decide if the impact of the worker’s disability is “so exceptional” that a PFI pension is inadequate financial compensation for the worker’s loss of employability. In such cases, the worker may be entitled to be assessed for a wage replacement pension, known as a “loss of earnings” or LOE pension. The “LOE pension decision” is issued by the case manager, either as part of the plateau decision or after a VR process. If awarded, full LOE pension benefits are equivalent to ongoing TWL benefits. However, the criteria for having an LOE assessment are quite onerous under the new WCA. | |||
== D. Overview: Claims Procedures & Process == | |||
=== 1. Reporting the Injury === | |||
All injuries that cause a loss of work (or which could lead to a future claim) should be reported '''as soon as possible''' by the employee or, if death results, by the employee’s dependents, to the superintendent of the place of employment, first aid attendant, or other official. Claims have been denied (at least until an appeal took place) because a worker waited even a few days, hoping the pain would go away. In all but the most minor cases, workers should also seek medical attention promptly. | |||
The employer must complete a report to the Board '''within three days''' of receiving the employee’s report, or immediately if death results. The attending physician also completes a Physician’s First Report within three days of first seeing the worker, and fills out progress reports after each visit. | |||
=== 2. Making a Claim === | |||
An employee has '''one year''' to make a claim for compensation under s. 55 of the WCA. This may be extended to three years in certain circumstances. In extreme cases, the Board may consider even longer extensions. | |||
Workers can call the WCB directly to report an injury and file a claim. Teleclaim is available to workers across the province, Monday to Friday, from 8 a.m. to 4 p.m. See the Board website for current contact details. Teleclaim is designed to simplify the process, reduce the amount of paperwork and provide a personalized service based on each individual’s needs. Before calling the Board to report an injury, the worker should write down the key information about the job, how the injury occurred, and what the doctor has said about the condition. The worker’s statement during a Teleclaim report will form part of the claim file, and could be used as evidence in a future appeal proceedings. The Teleclaim transcript may be sent to the worker. If it is not sent, the worker should request a transcript. | |||
=== 3. Procedure After Application === | |||
The family doctor plays a crucial role in the worker’s claim as well as his or her treatment. The WCA requires that the doctor file an initial report with the Board, as well as progress reports for each visit. Doctors are also required to give all necessary advice and assistance to a worker making an application for compensation, including furnishing proof that may be required. Some doctors are very helpful to injured workers, while others refuse to get involved in what they consider to be a legal issue. Such an attitude can be very harmful if there is a medical dispute between the Board and the worker. | |||
The Board has extensive inquiry and investigative powers. It may require the worker to be medically examined by a WCB staff doctor or by independent consultants. WCB officers called Claims Adjudicators, Disability Awards Officers, and Rehabilitation Consultants decide whether to accept the claim and what benefits, if any, should be paid. Although rarely used, the Board has the authority to conduct a formal inquiry at which the claimant and other witnesses are compelled to appear and be questioned. Important decisions occur at various times as a result of the interaction and correspondence between various WCB officers, the worker, the family doctor, and any specialist. | |||
=== 4. The Case Management Process === | |||
The WCB operates under a case management process in cases where the individuals are recovering from complex and costly injuries and illnesses. The key features of case management include a case manager who oversees the delivery of services for the entire life of the claim. It is also supposed to include regular multidisciplinary team meetings, clinical care planning, site visits, and a return to work plan, which sets out expectations surrounding medical treatment, physical rehabilitation, and a return to work option. In theory, the worker, union or other representative, the worker’s doctors, and the employer are all expected to participate. Advocates for injured workers have found that this crucial part of the case management model is rarely followed. | |||
=== 5. Claims Management Solutions === | |||
On May 11 2009, WCB launched a “Claims Management Solutions”(CMS) system to streamline and manage the claims process more effectively, and improve service to customers. CMS manages all data related to previous, current and future claims and helps integrate services throughout the life cycle of a claim. It is supposed to result in faster case handling and claim payments, more support for injured workers, and less administrative work for employers and service providers. Workers can obtain real-time access to their claim file by registering online, and can authorize a representative to have access as well. | |||
=== 6. Initial Decisions === | |||
Most decisions are made by frontline WCB officers. The major issues to be decided are: whether the worker is covered by the WCA; whether the injury arose out of and in the course of employment; and what benefits the worker is entitled to. The most important WCB officers, and the decisions that they make, are as follows: | |||
==== a) Case Manager ==== | |||
*accepts or rejects claims; | |||
*approves wage loss benefits, determines the initial wage rate, and terminates or reduces wage loss benefits; | |||
