Cutting Your WSIB Costs: Claims Management & Return to Work

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Sabina Stewart
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1 Cutting Your WSIB Costs: Claims Management & Return to Work Carissa Tanzola Health & Safety Symposium March 28, Yonge Street Suite 3300 Toronto, Ontario M5B 2L7 Tel Fax Hour

Yonge Street Suite 3300 Toronto, Ontario M5B 2L7 Tel 416.603.

2 Cutting Your WSIB Costs Accounts (MAP/NEER/CAD-7) Remittances Audits (Compliance) Accidents/Injuries Rebates and surcharges based on rate group and experience Appeal LOE/NEL/WT to adjust 2

3 Agenda Claims Management The Players Entitlement Recurrences, Aggravations or Pre-Existing Conditions Appeals Return to Work and Accommodation 3

4 Claims Management 4

5 The Players Initial reporting and entitlement Registration Clerks Primary Adjudicators Eligibility Adjudicators 5

6 The Players Claim management Short Term Case Manager Long Term Case Manager Return to Work Specialist Work Transition Specialist 6

7 The Players Medical assistance Nurse Consultants Medical Consultants Specialty Clinics Regional Evaluation Centers 7

8 The Players Other teams Re-Employment Recurrence and Work Disruption Second Injury and Enhancement Fund (SIEF) 8

9 Entitlement Five point check system must be met: 1. Employer 2. Worker 3. A personal injury arising out of & in the course of employment 4. Proof of accident 5. Compatibility between diagnosis & accident history 9

10 Entitlement Critically consider whether worker is entitled to benefits Critically assess whether the benefits match the injury 10

11 Entitlement A note on medical information: WSIB must make decisions based on objective medical information Employers often get detailed diagnostic information (CAUTION!) Employers entitled to information on limitations (FAF, Form 8 & Form 26) Ask worker directly for medical information to use in other proceedings 11

12 Entitlement A note on medical information: FAFs: Do not rely on FAFs exclusively Ask for your own medical information Insist on additional information, if appropriate FAFs are confidential and may not be produced in other proceedings without consent 12

Insist on additional information, if appropriate FAFs are

13 Entitlement A note on medical information: Employers are not alone there are other resources Insufficient medical information does not have to be accepted and RECs, IMEs and 3 rd party doctors can be used Consider using the WSIB to your advantage 13

information does not have to be accepted and RECs, IMEs and 3

14 Recurrence, Aggravation or Pre- Existing Recurrence Entitlement for recurrence of work-related injury if significant deterioration that: Does not result from a significant new incident, and Is clinically compatible with the original injury Consider the accident date 14

that: Does not result from a significant new incident, and Is

15 Recurrence, Aggravation or Pre- Existing Aggravation A pre-accident impairment may be aggravated by a minor work-related accident Benefits will continue if aggravated by workrelated second accident Benefits may continue if aggravated by non work-related accident 15

accident Benefits will continue if aggravated by workrelated

16 Recurrence, Aggravation or Pre- Existing Pre-Existing Condition Reduction in cost impact if: Prior disability caused or contributed to a workrelated accident Recovery is prolonged due to pre-existing condition Employers must request cost relief 16

caused or contributed to a workrelated accident Recovery is

17 Appeals Appeals Services Division WSIB Three levels 1. WSIB 2. Appeals Services Division (WSIB) 3. WSIAT WSIAT 17

18 Appeals Consider whether appeal matters: Is it inside or outside the window? Is the current accident year already maxed out? Is it worth the cost? 18

19 Return to Work & Accommodation 19

20 Return to Work & Accommodation Employer Obligations Work-Reintegration ( WR ) An early return to suitable and available employment that is within the worker s functional abilities, and, if possible, restores the worker s pre-injury earnings. Think duty to accommodate to the point of undue hardship under Human Rights Code 20

functional abilities, and, if possible, restores the worker s pre-injury earnings.

21 Return to Work & Accommodation Employer Obligations Re-Employment Co-operation 21

22 Return to Work & Accommodation The longer the worker is off, the higher the claim cost Can be significant 22

23 Return to Work & Accommodation Claim Types change depending on how long LOEs are provided Active: non-health care costs paid in year of review Inactive: no costs other than health care paid in year of review Claim Type and Claim Age used to calculate Reserve Factor 23

24 Return to Work & Accommodation Reserve Factor used to calculate Projected Future Costs Projected Future Costs + Overhead Costs = Limited Claim Costs RTW Health Care Claim Type Claim Age Non- Pension Pension Discounted Awards Future Costs OH Costs Limited Costs 4 days , weeks , , , , , weeks 1, , , , ,

25 Return to Work & Accommodation Do not wait for medical note or FAF Immediately offer modified duties in writing Consider working from home Sedentary duties Keep in regular contact Use all resources (including WSIB) If employee refuses to co-operate, act quickly Appeal if necessary 25

26 Common Traps Not appreciating the impact on the bottom line Rate groups and claims Failing to stay involved with the claim Failing to stop loss of earnings Failing to challenge entitlement where appropriate 26

27 250 Yonge Street, Suite 3300 Toronto, Ontario, Canada M5B 2L Phone Hour Fax 27

28 The information contained in this presentation is provided for general information purposes only and does not constitute legal or other professional advice. Reading this presentation does not create a lawyer-client relationship with Sherrard Kuzz LLP. Readers are advised to seek specific legal advice from members of Sherrard Kuzz LLP (or alternate legal counsel) in relation to any decision or course of action contemplated. 28

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