Managing Workers Compensation Claims

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1 Managing Workers Compensation Claims A Presentation of The Office of the Employer Advisor

2 Office of the Employer Advisor What is it? P Mandate in Sec. 85.(1) (b) of the Workers Compensation Act P Funded by WCB no fee for service P Department of Environment, Labour and Justice P Independent of WCB and Government P Located at 40 B Burns Avenue, Charlottetown P Represents employers in matters of claims, assessments, workplace health and safety and appeals

3 Workers Compensation Board An Overview P Funded by employers No-fault insurance system P Administers Workers Compensation Act Occupational Health and Safety Act P Administered by a Board of Directors Chief Executive Officer Corporate Services Client Services Occupational Health and Safety Internal Reconsideration and Appeals Tribunal

4 CLAIMS MANAGEMENT WHY DO ACCIDENTS / INCIDENTS HAPPEN? P Inexperience Lack of training, lack of appropriate equipment P Short Cuts Familiarity, tired, rushed, unsupervised P Environment Contributing factors of heat, ice, dust, wind, rain P Responding to an accident Inattentive, grief stricken, hazards, time sensitive P For every accident, there are 10 incidents!

5 CLAIMS MANAGEMENT What Is It? P A defined and consistent method to manage WCB claims P Four Steps to the Program Initial Reporting Accident Investigation Monitoring Claims Return-to-Work Programs

6 INITIAL REPORTING STEP 1 P Immediately report all injuries / incidents P Promptly investigate P Worker must complete Form 6 P Employer must complete Form 7 P Physician must complete Form 8 P All forms to WCB for entitlement decision

7 Form 6 P Reporting requirement of the worker Section 59. (1) of the Workers Compensation Act P On WCB Form 6 Worker completes it at the workplace It must be specific and as complete as possible Worker should sign and date it Sent it to WCB

8 Form 7 P Reporting requirement of the employer Section 59. (3) of the Workers Compensation Act P On WCB Form 7 Must be filed within 3 days of the accident / incident or its allegation Must be on prescribed form Accurate information is most important You can protest a claim, but you still must file Failure to report can result in a fine P Better information = better decision

9 Form 7 P What must be reported Whether the injury occurred on the premises Whether it occurred in the process of doing something for the employer Whether it occurred during a time period for which the worker was being paid Whether it was caused by some activity of the employer or of a fellow worker

10 Accident Investigation Step 2 P Legal requirement to investigate Section 25.3 (1) of the OH&S Act P The Director of OH&S must be notified within 24 hours when a serious accident occurs which causes or may cause: A fatality or places life in jeopardy Unconsciousness A loss of sight, an amputation or a fracture Substantial loss of blood A burn to a major portion of the body P Emergency Number is

11 Accident Investigation Step 2 P Questions to be answered: What happened? When did it happen? How did it happen? Who was involved? Why is work felt to be the cause? Where did it happen? Were there any witnesses? Was it a motor vehicle accident? If so, may file for third party coverage

12 Accident Investigation P Red Flags Horseplay Unauthorized activities Assaults Timing Delayed reporting Conflicting evidence Outside activities Nature of injury Treatment Step 2

13 Accident Investigation Step 2 P Contesting a Claim When red flags are raised: Do a thorough investigation Complete and send Form 7 to WCB Indicate on the Form 7 you are contesting this claim Follow up with WCB Entitlement Officer in 1 week Provide any new information at that time Ask for a decision with reasons in writing If the claim is accepted and you disagree, you may ask for a reconsideration of the decision Contact the Employer Advisor for assistance

14 Monitoring Claims Step 3 P Keep in touch With the worker With WCB P Follow-up With worker: Depends on nature of injury With WCB: On a regular basis P Disability Duration Guidelines Refer to WCB website at Click on Publications

15 Return-to-Work Programs Step 4 P Goal of early and safe Return-to-Work Return the worker to suitable employment with little or no loss of earnings P Employer s Responsibilities Contact worker ASAP after accident Maintain the communication Attempt to provide suitable work Provide all information to WCB Cooperate with worker and WCB

16 Return-to-Work Programs Step 4 P Suitable employment Productive Available Medically approved / appropriate Within worker s physical ability Within worker s skill set Will not slow recovery Not demeaning Restores pre-injury earnings as close as possible

17 Return-to-Work Programs Step 4 P RTW legislation in Sec. 86 of the Workers Compensation Act Applicable to employers with 20+ employees The construction industry is exempt Continuous employment for 1 year = a legal responsibility to re-employ This obligation is valid for 2 years after the accident date or The date the worker becomes 65 years old

18 Return-to-Work Programs Step 4 P General responsibilities of: The Employer Re-instate the worker Offer alternate employment Offer first available suitable work The Worker Seek medical treatment and cooperate with health providers Contact employer ASAP after accident Maintain weekly communication with employer Assist employer to identify alternate work Provide WCB with information on progress Cooperate with employer and WCB in RTW process

19 Return-to-Work Programs Step 4 P Responsibilities of WCB Answer questions on the worker s condition and treatments Be the contact between the worker, the employer, and the health care providers Coordinate resources with the worker s recovery and return-to-work Monitor activity, progress and cooperation of worker and employer on the RTW plan Assist with all matters concerning the claim

20 Return-to-Work Programs P What happens if Step 4 P The worker does not cooperate by Maintaining contact Agreeing to suitable work Arranging early and safe return-to-work programs P The employer must Contact WCB to assist in resolving the situation If unsuccessful, a meeting may help resolve it P Are there penalties for non-cooperation? Worker s benefits may be reduced or cut off Employer may be fined

21 Return-to-Work Programs Step 4 P To develop an RTW Program, you need: Senior management support and approval Policy and tools developed Inventory of jobs and their physical demands Work restriction identified Duties / work stations modified Cooperation of all parties Worker, union, health provider, WCB, supervisor To be creative To ACCOMMODATE!

22 Office of the Employer Advisor 40 B Burns Avenue PO Box 2000 Charlottetown PE C1A 7N8 (902)

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