“Now that this has happened…what am I going to do about it?” Rabbi Harold S. Kushner, Author When Bad Things Happen to Good People
For those that are unfamiliar with Ontario’s Workplace Safety and Insurance Board (WSIB) process, the following is a brief tutorial of the forms and process for proactive WSIB Claims Management:
1. WSIB Forms and RTW Expectations
- WSIB coordinates information as provided by the Employer (7-initial Claim and 9-Closing Report), Employee (6-Statement) and Doctor (8-Initial Medical and subsequent FAF’s – Functional Ability Forms)
- Where there are discrepancies, the WSIB Adjudicator will review to ensure speedy resolution before a decision is made to deny the initial claim or accept the claim to be placed to the WSIB Case Manager
- REMEMBER: although the Employer has the duty to accommodate the Employee has a duty to cooperate
- TRANSLATION: failure by Employer = $$$ and failure by Employee = no $$$
- Employer is Responsible for Prompt RTW
- Modified Work should be readily available (i.e. the best defense is a good offense)
- Modified Work is immediately offered verbally, followed-up in writing and must be worked
- Whatever is entered on the Form 7 will be what WSIB takes as “gospel” from the Employer until told otherwise
- Vacations or out-of-country trips are not authorized unless the WSIB Case Manager approves in advance and in writing
- Where FAF is not available follow Standard Restrictions as provided for RTW activities
- Ensure most up-to-date forms are used following this link: WSIB_Employer_Forms
- Where possible for prompt claims management, complete WSIB Forms online and use the Document Upload Tool for submission using this link: WSIB_Online Document Uploads
2. Prepare and Follow the RTW Plan
- Using FAF or Standard Restrictions, outline RTW Plan and online upload or fax to WSIB Case Manager noting how the Employee’s job is modifiable to avoid Loss of Earnings
- Use the same information on the RTW Progress Report and online upload or fax to WSIB Case Manager, weekly is suggested, noting any issues in a cover letter
- Follow-up with detailed RTW Letter if no RTW and/or if WSIB Mediation is required, especially if the Employee is using unsubstantiated medical reason (this shows Employer Due Diligence) – be sure to online upload or fax to WSIB Case Manager
3. Claiming Medical Complications
- REQUEST SIEF in the initial Form 7 and follow up in a letter to WSIB at a later date if the claim has pre-existing conditions and is prolonged. Claiming SIEF (Secondary Injury and Enhancement Fund) allows the Employer to reduce WSIB costs where “a prior disability caused or contributed to the compensable accident, or if the period resulting from an accident becomes prolonged or enhanced due to a pre-existing condition, all or part of the compensation and health care costs may be transferred” from the Employer to WSIB.
4. STILL Not Returning to Work??
- REQUEST MEDIATION and outline in a letter to WSIB that the Employee is non-cooperative
- REMEMBER: Medical information must support that the Employee is not able to perform any regular or modified duties to be off work and accepted by WSIB
WSIB’s Zero Tolerance Strategy
- The WSIB will identify noncompliance, fraud and irregularities by employees/employers/providers/suppliers and take appropriate action for:
- Failing to notify WSIB within 3 days of learning of an Employee”s accident that requires health care or causes the Employee to earn less than full wages (Sec. 152(3), Workplace Safety and Insurance Act)
- Making a false statement or representation to WSIB relating to benefit entitlement (Sec. 149(1), Workplace Safety and Insurance Act)
- Failing to inform the Board of a material change in circumstances within 10 days (Section 149(3), Workplace Safety and Insurance Act)
- This includes inaccurate reporting on Form 7. It is considered falsification where:
- no RTW has occurred although reported by the Employer and/or
- information is not reported with respect to Employee non-compliance for RTW and/or Modified Duties
- Information on fines / penalties found at this link: WSIB Fraud / Non-Compliance
Always Document, Document, Document…
- Maintain written record of contact with the Employee and WSIB (whether with the Adjudicator, Case Manager and/or Nurse Case Manager for medical follow-up or Mediator when non-cooperation is evident) – yes, this can mean MULTIPLE TIMES in a day…
- Keep detailed notes at all times of work completed including Time Cards, times/dates of conversations, etcetera, as this information will become evidence in cases where either the Employer or Employee file an Appeal