WSIB Claims Issues Essential Elements

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1 WSIB Claims Issues Essential Elements Jason E. Mandlowitz William M. LeMay

2 Agenda Defining an accident Accident Reporting Accident Investigation Access and management of medical information Preparation for hearings

3 Defining an Accident Section 2(1) of the WSIA: Accident includes (a) a wilful and intentional act, not being the act of the worker, (b) A chance event occasioned by a physical or natural cause, (c) disablement arising out of and in the course of employment

4 Defining an Accident- Continued Section 13(1): must have a personal injury by accident arising out of and in the course of employment to get benefits Arising out of and in the course of employment presumptive Mental Stress excluded in many circumstances

5 Adjudication Process 5 Point Check System Employer Worker Personal work-related injury Proof of accident Compatibility of Diagnosis to Accident

6 Adjudication Process 4 Immediates Onset of pain Medical attention Absence from work Reporting to the Employer

7 Adjudication Process In the Course of Employment Activity Place Time

8 Benefit Types Healthcare and medical costs Loss of Earnings Non-Economic Loss Labour Market Re-entry LOE and LMR from a Work Disruption

9 Accident Reporting WSIA: s days to report if: Worker requires health Care Worker unable to earn full wages WSIB Policy outlines others including Modified Work Report on Form 7 Provide Form 7 to the Worker

10 Accident Reporting and the New Service Delivery Model WSIB making prompt decisions quick investigations Provide additional information on Form 7 Submit your additional documents Provide all relevant information Request written decision where accident questionable

11 Employer s Accident Reporting Policy Define types of accidents consider near misses Roles and responsibilities Emergency situations Transportation and medical attention Information requirements Critical/severe accidents Employee Information Form key to ESRTW

12 Employer s Accident Investigation Policy Incident/accident investigation procedure Accident Investigation forms and tool kit Witness statements Root cause health and safety analysis

13 Relevant Information Red Flags Prior occupational/non-occupational claims and absences Prior known medical and employment history Hobbies and activities Recent behaviour Timing of accident Inconsistencies in reporting

14 Date of Accident Defined in WSIB Policy Date worker experiences a disabling physical of functional abnormality Disablement/Occupational Disease date worker suffers the impairment Recurrences date of original injury Other injuries date on which the trauma occurred

15 Accessing and Managing Medical Information Obtaining FAEs from workers Ensure clear understanding of restrictions Consider accommodation of restrictions up front

16 Contacting the Doctor Consider the information you want Written record No obligation to respond

17 WSIB File Access granted on appeals Can only be used for WSIB purposes Cannot be used in other proceedings

18 Preparing for Appeals Clarify the issue agenda Ensure the documents are collected Witness identification Other evidence?

19 WSIB Claims Issues Essential Elements Jason E. Mandlowitz William M. LeMay

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