Cutting Your WSIB Costs: Claims Management & Return to Work

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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

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Accounts

(MAP/NEER/CAD-7)

Remittances

Audits

(Compliance)

Accidents/Injuries

Rebates and

surcharges based on

rate group and experience

Appeal LOE/NEL/WT

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Sherrard Kuzz LLP, Employment & Labour Lawyers Cutting your WSIB Costs – March 24, 2015

Agenda



Claims Management



The Players



Entitlement



Recurrences, Aggravations or Pre-Existing

Conditions



Appeals



Return to Work and Accommodation

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The Players



Initial reporting and entitlement



Registration Clerks



Primary Adjudicators



Eligibility Adjudicators

(6)

The Players



Claim management



Short Term Case Manager



Long Term Case Manager



Return to Work Specialist

(7)

The Players



Medical assistance



Nurse Consultants



Medical Consultants



Specialty Clinics



Regional Evaluation Centers

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The Players



Other teams



Re-Employment



Recurrence and Work Disruption

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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

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Entitlement



Critically consider whether worker is entitled

to benefits



Critically assess whether the benefits match

the injury

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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

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Entitlement





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

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Entitlement





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

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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

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Pre-Existing



Aggravation



A pre-accident impairment may be aggravated

by a minor work-related accident



Benefits will continue if aggravated by

work-related second accident



Benefits may continue if aggravated by non

work-related accident

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Pre-Existing



Pre-Existing Condition



Reduction in cost impact if:



Prior disability caused or contributed to a

work-related accident



Recovery is prolonged due to pre-existing

condition

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Appeals

17



Three levels

1.

WSIB

2.

Appeals Services

Division (WSIB)

3.

WSIAT

WSIB

Appeals

Services

Division

WSIAT

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Appeals



Consider whether appeal matters:



Is it inside or outside the ‘window’?



Is the current accident year already maxed out?

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Return to Work & Accommodation

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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

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

Employer Obligations



Re-Employment



Co-operation

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

The longer the worker is off, the higher the

claim cost

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416.603.0700 Main / 416.420.0738 24 Hour / www.sherrardkuzz.com

Return to Work & Accommodation

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

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

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

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

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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

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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

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27

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

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

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.