Managing
Workers Compensation
Claims
A Presentation of
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
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
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
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
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
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
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
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
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
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?
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
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
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
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
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
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
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
Return-to-Work Programs
Step 4 P What happens if
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?
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
