Cutting Your WSIB Costs: Claims Management & Return to Work Carissa Tanzola Health & Safety Symposium March 28, 2015 250 Yonge Street Suite 3300 Toronto, Ontario M5B 2L7 Tel 416.603.0700 Fax 416.603.6035 24 Hour 416.420.0738 www.sherrardkuzz.com
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
Agenda Claims Management The Players Entitlement Recurrences, Aggravations or Pre-Existing Conditions Appeals Return to Work and Accommodation 3
Claims Management 4
The Players Initial reporting and entitlement Registration Clerks Primary Adjudicators Eligibility Adjudicators 5
The Players Claim management Short Term Case Manager Long Term Case Manager Return to Work Specialist Work Transition Specialist 6
The Players Medical assistance Nurse Consultants Medical Consultants Specialty Clinics Regional Evaluation Centers 7
The Players Other teams Re-Employment Recurrence and Work Disruption Second Injury and Enhancement Fund (SIEF) 8
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
Entitlement Critically consider whether worker is entitled to benefits Critically assess whether the benefits match the injury 10
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
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
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
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
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
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
Appeals Appeals Services Division WSIB Three levels 1. WSIB 2. Appeals Services Division (WSIB) 3. WSIAT WSIAT 17
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
Return to Work & Accommodation 19
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
Return to Work & Accommodation Employer Obligations Re-Employment Co-operation 21
Return to Work & Accommodation The longer the worker is off, the higher the claim cost Can be significant 22
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
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 150.00 01 16 790.00 0 760.00 0 363.40 1,153.40 7 weeks 250.00 06 16 5,850.00 0 5,850.00 4,981.28 4,982.31 15,813.67 28 weeks 1,100.00 08 16 23,500.00 0 23,500.00 22,038.30 20.947.62 66,485.92 24
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
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
250 Yonge Street, Suite 3300 Toronto, Ontario, Canada M5B 2L7 416.603.0700 Phone 416.420.0738 24 Hour 416.603.6035 Fax www.sherrardkuzz.com 27
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