WSIB Claims Issues Essential Elements Jason E. Mandlowitz William M. LeMay
Agenda Defining an accident Accident Reporting Accident Investigation Access and management of medical information Preparation for hearings
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
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
Adjudication Process 5 Point Check System Employer Worker Personal work-related injury Proof of accident Compatibility of Diagnosis to Accident
Adjudication Process 4 Immediates Onset of pain Medical attention Absence from work Reporting to the Employer
Adjudication Process In the Course of Employment Activity Place Time
Benefit Types Healthcare and medical costs Loss of Earnings Non-Economic Loss Labour Market Re-entry LOE and LMR from a Work Disruption
Accident Reporting WSIA: s. 21-3 days to report if: Worker requires health Care Worker unable to earn full wages WSIB Policy 15-01-02 outlines others including Modified Work Report on Form 7 Provide Form 7 to the Worker
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
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
Employer s Accident Investigation Policy Incident/accident investigation procedure Accident Investigation forms and tool kit Witness statements Root cause health and safety analysis
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
Date of Accident Defined in WSIB Policy 11-04-04 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
Accessing and Managing Medical Information Obtaining FAEs from workers Ensure clear understanding of restrictions Consider accommodation of restrictions up front
Contacting the Doctor Consider the information you want Written record No obligation to respond
WSIB File Access granted on appeals Can only be used for WSIB purposes Cannot be used in other proceedings
Preparing for Appeals Clarify the issue agenda Ensure the documents are collected Witness identification Other evidence?
WSIB Claims Issues Essential Elements Jason E. Mandlowitz William M. LeMay