The following material is the property of the Workers Compensation Board of British Columbia and may not be reproduced by those outside of B.C. For those within British Columbia, this material may only be reproduced for the sole purpose of personal safety training. This material is not to be reproduced for sale. You may order this publication from WCB Publications and Videos, e-mail pubvid@wcb.bc.ca. Please quote ordering number PH7.
CLAIMS APPEAL GUIDE FOR EMPLOYERS
CONTENTS Why appeal?... 1 When a claim decision is made... 1 Getting advice... 2 Types of appeals... 3 The appeal process... 4 Who you will deal with... 5 Obtaining a claim file... 11 Payment of claims during an appeal... 12 WCB offices... Inside back cover WHY APPEAL? When a worker files a compensation claim, a Workers Compensation Board staff member decides whether to allow the claim, based on the Workers Compensation Act and WCB policy. If the claim is allowed, your premiums and those of other employers in your industry could increase. If you disagree with the claim decision, you can appeal it. This pamphlet applies to workers claims for compensation. It does not refer to Assessment or Prevention decisions. For information on those, contact your nearest WCB office, listed on the inside back cover, or the Employers Advisers Office, listed on page 2. WHEN A CLAIM DECISION IS MADE You will receive a letter once a claims decision is made if: You protested the claim earlier, but it is allowed. (If you did not protest the claim, you won t receive a letter.) 1
The WCB staff member decides not to allow the claim. The WCB staff member decides to reopen an old claim. The WCB staff member decides to pay an employee a pension. You ve applied for relief of claims costs. Clarifying the decision If you don t understand a decision, contact the WCB staff member who wrote the letter. He or she will explain the decision more fully and try to answer your questions. You may also contact his or her manager by writing a letter. Note: Keep a record of all letters and phone calls to the WCB. GETTING ADVICE To ensure you have an opportunity to obtain impartial advice on an appeal, the B.C. legislature has provided impartial advisers. The Employers Advisers are independent of the WCB and have a right to access information on your behalf. This service is available at no cost. Advisers are available to advise and assist employers on appealable issues before various workers compensation appeal tribunals. You can contact Employers Advisers at: Richmond 604 660-7253 Prince George 250 565-4285 Victoria 250 952-4821 Toll free 1 800 925-2233 2
TYPES OF APPEALS You can appeal a decision on a workers claim, or a denial of relief of claims costs. When you appeal a claim decision, it must be based on specific medical or non-medical issues. Non-medical issues are factual and legal issues, such as whether the claim should be accepted, how much the worker should be paid, and what type of activities the worker can do. Medical issues include the type of occupational injury or disease, the cause of the injury or disease, what part of the disability is caused by occupation, and what part is caused by other factors. Denial of relief of claims costs The WCB relieves claims costs when: A disaster or other circumstance unfairly burdens the employers in a class A pre-existing disease, condition, or disability prolonged a worker s recovery or made a worker s disability worse If relief of claims costs is allowed, this may have an impact on the employer s WCB assessment, depending on such factors as the employer s current experience rating. If a WCB staff member denies relief and you disagree on the basis of an error of law or fact or contravention of published policy, you can appeal the decision to the Appeal Division. 3
APPEAL PROCESS How you appeal a decision depends on whether you disagree with a decision on a worker s claim or are appealing a denial of relief of claims costs. Decision on a worker s claim WCB decision Manager s review (optional) Time limit: 90 days from the date of the decision letter. Medical Review Panel You can appeal medical issues directly to a Medical Review Panel after a decision by the: Workers Compensation Review Board Time limit: 90 days from the date of the decision letter. Appeal Division of the Board Time limit: 30 days from the date the Review Board s finding was mailed. WCB staff member Manager Review Board Appeal Division Time limit: 90 days from the date of the letter containing the medical decision you are appealing. Denial of relief of claims costs Manager s Review (optional) Time limit: 30 days from the date of the decision letter. Appeal Division of the Board Time limit: 30 days from the date of the decision letter. 4
You may ask for a review from the manager of the WCB staff who made the decision. Write a letter specifying the reason you object to the decision. Managers will refuse requests when the objection is that the WCB staff member didn t properly consider all the evidence in the claim file. If new evidence is available since the original decision was made, the manager will turn it over to the staff member. This new evidence will be reviewed and a decision made. Based on the review, the manager will either uphold or change the original decision. Decisions on relief of claims costs can be appealed to the Appeal Division within 30 days. WHO YOU WILL DEAL WITH Workers Compensation Review Board The Workers Compensation Review Board is independent of the Workers Compensation Board. The Review Board is made up of a chair, several vice-chairs, and members with worker and employer backgrounds. You can appeal to the Review Board if you disagree with a decision on a worker s claim. The Review Board does not deal with decisions that affect only the employer, such as assessment and occupational safety and health issues, or cost relief. 5
How to appeal You have 90 days from the date of the decision to appeal to the Review Board. To appeal, use a Notice of Appeal form. These are available at any WCB office, listed on the inside back cover; at the Workers Compensation Review Board, listed below; or the Employers Advisers Office, listed on page 2. If you can t get a form, write an appeal letter. Include the claim number, the date of the original decision letter, and the reasons you object to the decision. Make sure your form or letter contains all the necessary information. Missing information could delay your appeal. If you can t appeal within the 90 day period from the date of the decision letter, fill out the Notice of Appeal and explain why it is late or send an appeal letter to the Review Board including the reasons you are late. The Review Board may want proof of your reasons. Mail or fax the signed documents to: Workers Compensation Review Board Suite 200 1700 West 75th Avenue Vancouver BC V6P 6G2 Phone 604 664-7800 Toll free 1 800 663-2782 Fax 604 664-7898 When the Review Board receives your Notice of Appeal, it will send you another form to fill in. Mail it back within six months. Be sure to include any new information, any new medical reports or opinions, and explain what you want. If you want an oral hearing, ask for one, and include the reasons you feel it s necessary. 6
The Review Board will process your appeal when it receives the second form. You can ask for a time extension if you can t meet the six-month deadline. A one- or three-person panel decides the appeal. If you disagree with the Review Board s finding, you can appeal to the Appeal Division within 30 days of the Review Board sending you its finding. If a medical issue is in dispute, you can appeal to a Medical Review Panel within 90 days of the Review Board decision. Appeal Division of the Board The Appeal Division is the highest level of appeal for non-medical issues, including denial of relief of claims costs. You can appeal to the Appeal Division if you disagree with a decision of the Review Board, or if you are appealing a decision to deny relief of claims costs. Time limits From the date the Review Board sends its finding, you have 30 days to submit a Notice of Appeal to the Appeal Division. To appeal a denial of relief of claims costs to the Appeal Division, you have 30 days from receiving the original decision letter. If you are getting close to the deadline, phone the division at 604 276-3067 or 1 800 661-2112, local 3067. You must then send in a Notice of Appeal form within 21 days. 7
In exceptional circumstances, the chief appeal commissioner can extend the deadline for filing an appeal. Your request should include reasons for the delay. How to appeal To appeal, use a Notice of Appeal form. These are available from any WCB office, listed on the inside back cover. If you can t get a form, write an appeal letter to the Appeal Division. Include the decision you are appealing, the reasons you object to the decision, whether you request an oral hearing, and whether you have file disclosure. Mail or fax the form or letter to: Appeal Division PO Box 5350 Stn Terminal Vancouver BC V6B 5L5 Phone 604 276-3067 Toll free 1 800 661-2112 Fax 604 276-3349 If you have had file disclosure, you will get an update. If you don t ask for an oral hearing, the Appeal Division tells you how much time you have to send in a written submission. A one- or three-member panel decides the appeal based on written evidence and submissions, and any other information in the claim file. The Appeal Division is the highest level of appeal for non-medical issues and denial of relief of costs. In limited circumstances, such as substantial and material new evidence that could not have been earlier discovered through the exercise of due diligence, the chief 8
appeal commissioner may consider a request to reconsider an Appeal Division decision. Medical decisions can be further appealed to a Medical Review Panel. Oral hearings Include a request for an oral hearing in your Notice of Appeal. Include the reasons you think an oral hearing is needed, and whether you would need a translator. Mail or fax the letter to: Appeal Division PO Box 5350 Stn Terminal Vancouver BC V6B 5L5 Fax 604 279-7404 Based on your reasons, the chief appeal commissioner (or delegate) decides on a preliminary basis whether to hold an oral hearing. You will receive a letter about the preliminary decision. If you are granted an oral hearing, you can request a oneor three-member panel to hear your appeal. If the chief appeal commissioner (or delegate) denies your request for an oral hearing, a letter will tell you when written submissions are due. Once written submissions are completed and the case is assigned to an Appeal Division panel, that panel can decide whether it requires an oral hearing. In the event an oral hearing is granted, the Appeal Division may decide to hold the hearing at a location close to the parties involved. Any request for an oral hearing can include a request that a hearing occur near where the parties 9
live. If the Appeal Division can t hold a hearing near your home, the WCB may help pay for travel to Richmond, and for accommodation. Medical Review Panel A Medical Review Panel is the last place you can appeal medical issues. It is made up of two specialists (one chosen by you, one chosen by the worker) from a list of doctors, and a chair, who is also a doctor. The provincial government appoints the chair. You can appeal a medical issue directly to a Medical Review Panel after a decision by a Board officer, the manager, the Workers Compensation Review Board, or the Appeal Division. Time limit You have 90 days from the date of the decision letter to appeal to a Medical Review Panel. There are no extensions. If you aren t sure when to appeal to a Medical Review Panel, contact the Employers Advisers Office (see page 2), or an employers organization for help. How to appeal You need two items to file an appeal: A Request for Examination by a Medical Review Panel, or you can write an appeal letter. A Certificate for Appeal to a Medical Review Panel. You must have this form to file an appeal. 10
You can get these forms from: Medical Review Panel Department 8100 Granville Avenue Richmond BC Phone 604 233-5300 Toll free 1 877 930-3131 Fill out the Request for Examination by a Medical Review Panel form, or write an appeal letter. Have a doctor complete the Certificate for Appeal to a Medical Review Panel. Mail or fax both forms to any WCB office, listed on the inside back cover, or to: Medical Review Panel Department PO Box 2166 Stn Terminal Vancouver BC V6B 3V3 Phone 604 233-5300 Toll free 1 877 930-3131 Fax 604 233-5301 The Medical Review Panel then sends you a list of specialists. You must choose one within eight days of receiving the list. The Medical Review Panel then decides the appeal. Its decision on medical issues are final and binding. OBTAINING A CLAIM FILE The WCB grants employers access to claim files if an appeal has been filed by either a worker, his or her dependant, or the employer. To get a copy of the claim file, send written requests to: Records Management Department PO Box 5350 Stn Terminal Vancouver BC V6B 5L5 Fax: 604 276-3102 11
If you re appealing a decision, request the file immediately after submitting your notice of appeal to avoid delaying your appeal. All information in the claim file is confidential it is an offence under Section 95 of the Workers Compensation Act for you to further disclose this information except in four circumstances: In compliance with a statute In compliance with a subpoena or order For the purpose of preparing a submission for a proceeding under the Act With the consent of the person whom the information is about PAYMENT OF CLAIMS DURING AN APPEAL Once the WCB staff member decides to allow a claim or reopen an old claim, the claimant receives payments, even if you decide to appeal the decision. If your appeal reverses the decision, the WCB stops payments. The WCB does not recover the money already paid, unless there was fraud, misrepresentation, or administrative error. The WCB relieves your firm class or subclass of these costs by distributing them across all classes and subclasses in an industry. 12
WCB OFFICES Visit our Web site at www.worksafebc.com Abbotsford 2774 Trethewey Street V2T 3R1 Phone 604 556-2000 1 800 292-2219 Fax 604 556-2076 Burnaby 450 6450 Roberts Street V5G 4E1 Phone 604 232-5900 1 888 967-5377 Fax 604 232-5905 Coquitlam 104 3020 Lincoln Avenue V3B 6B4 Phone 604 232-1900 1 888 967-5377 Fax 604 232-1933 Courtenay 801 30th Street V9N 8G6 Phone 250 334-8701 1 800 663-7921 Fax 250 334-8756 1 877 280-1616 Cranbrook 100 7th Avenue South V1C 2J4 Phone 250 417-7930 1 800 663-4912 Fax 250 417-7963 Kamloops 321 Battle Street V2C 6P1 Phone 1 888 922-6622 1 800 663-3935 Fax 250 371-6036 Kelowna 110 2045 Enterprise Way V1Y 9T5 Phone 250 717-4301 1 888 922-6622 1 888 922-4466 Fax 250 717-4334 1 888 922-5511 Nanaimo 4980 Wills Road V9T 6C6 Phone 250 751-8000 1 800 663-7382 Fax 250 751-8045 Nelson 524 Kootenay Street V1L 6B4 Phone 250 354-5700 1 800 663-4962 Fax 250 352-3272 North Vancouver 100 126 East 15th Street V7L 2P9 Phone 604 232-1522 1 888 875-6999 Fax 604 232-1500 Prince George 1066 Vancouver Street V2L 5M4 Phone 250 561-3715 1 800 663-6623 Fax 250 561-3703 1 888 922-8811 Surrey 100 5500 152 Street V3S 8E7 Phone 604 232-7000 1 888 967-5377 Fax 604 232-7007 Terrace 4450 Lakelse Avenue V8G 1P2 Phone 250 615-6600 1 800 663-3871 Fax 250 615-6634 Vernon 3100 35th Avenue V1T 8Y8 Phone 250 545-4401 1 800 663-4452 Fax 250 558-5242 Victoria 4514 Chatterton Way V8X 5H2 Phone 250 881-3400 1 877 280-1515 Fax 250 881-3481 1 888 265-6607 Head Office 6951 Westminster Highway V7C 1C6 Phone 604 231-8888 1 888 967-5377 Fax 604 231-8840 or 604 231-8891 R11/00
20M (R01/01) PRINTED IN CANADA PH7