Difference between revisions of "Introduction to Compensation Claims for Injured Workers (7:III)"

After a worker makes an application for compensation, a Board officer issues a decision (usually in writing) accepting or denying the claim. For a compensation claim to be accepted, the Board must generally find:

If a claim is denied by the Board, it is typically because one or more of the above conditions was not met. The Board decision typically sets out the reason why the claim was denied and cites the relevant policy from RSCM II. However, the evidence on which the decision is based may or may not be summarized in the decision.                  

All the evidence on which the decision is based will be in the claim file, which may also include memos from case managers (CMs) and clinical opinions from Board Medical Advisors (BMAs). The claim file may also contain detailed phone memos providing the CMs with a summary of the worker’s evidence. The claim file evidence as a whole provides the basis for the Board’s decision and is evidence which will be available and considered by the appeal bodies, RD and WCAT.                

Workers are entitled to a copy of their claim file (paper or CD) on request and will also automaticallybe sent a copy of the claim file if they file an appeal. In addition, the worker may obtain online access to parts of their claim file by calling the Board. These matters are covered in the section below on Access to Files (see section VII). Disclosure may be given directly to the worker’s representative if the disclosure request or appeal notice is accompanied by a valid authorization of representation, signed by the worker. [Authorization forms are available on the Board website].                   

If the worker (or the employer) disagrees with the Board’s decision, he or she may appeal the decision to the Review Division (RD) '''within 90  days of the Board decision'''. The RD is a review body internal to the Board; links to RD material, including RD appeal forms, are available on the [http://www.worksafebc.com/en/review-appeal Board website]. The RD must issue a decision within 180 days of the appeal being filed. The RD decision may then be appealed to an independent tribunal, the Workers’ Compensation Appeal Tribunal (WCAT) within '''30 days of the RD decision'''. WCAT appeal forms are available on the [http://www.wcat.bc.ca WCAT website]. See [[Appeals in Worker%27s Compensation Claims (7:VI) | Section VII: Appeals]] for more details.

Section 55 of the WCA requires that generally, a worker must apply for compensation '''within one year''' of the date of injury. The one year deadline to claim under Section 55 provides three exceptions when late applications may be accepted:

# If exceptional circumstances exist which precluded the worker from making an application within one year and the application is less than three years after the injury and the application is more than three years old (s.55(3.2)); or

# Death or disablement is due to an occupational disease, sufficient scientific evidence did not exist at the time of the application and there is new scientific evidence regarding the occupational disease causation; in addition, the worker has made an application not more than three years after this new date (s.55 (3.2)); or

# The Board may reconsider an old occupational disease decision that meets the Section 55 (3.2) criteria. If a worker's application has been denied because of a late application, please consult section 55 of the WCA and Policy #93 of the RSCM II to assess what evidence of "exceptional circumstances" may be relevant in that case.