WSIB - Claims Management

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WSIB Claims Management

Workplace Safety & Insurance is increasingly becoming a financial burden on organizations, especially for small to medium sized organizations that do not have the time or the resources to properly manage their claims.

When an accident or incident is reported to management at your workplace, do you have a Claims Management System in place the will ensure you have acted in good faith and protected both your company’s rights and your employee’s rights under the Workplace Safety & Insurance Act?

The Workplace Safety & Insurance Act reads as follows:

PART I - Interpretation

Purpose

1. The purpose of this Act is to accomplish the following in a financially responsible and accountable manner:

To promote health and safety in workplaces and to prevent and reduce the occurrence of workplace injuries and occupational diseases.
To facilitate the return to work and recovery of workers who sustain personal injury arising out of and in the course of employment or who suffer from an occupational disease.
To facilitate the re-entry into the labour market of workers and spouses of deceased workers.
To provide compensation and other benefits to workers and to the survivors of deceased workers. 1997, c. 16, Sched. A, s. 1; 1999, c. 6, s. 67 (1); 2005, c. 5, s. 73 (1)

Definitions

2. (1) In this Act,“accident” includes,

a wilful and intentional act, not being the act of the worker,
a chance event occasioned by a physical or natural cause, and
disablement arising out of and in the course of employment; (“accident”)

If the reported accident or incident does not fall within and meet the above criteria, then your company most likely is paying for costs that do not fall within the definition of the WSIA. Do you have a system in place to ensure the above criteria as established by the WSIB is fulfilled. If you do not, then you are not exercising your rights and protections established for Employers by the Board.

Bill 99 has imposed new responsibilities on the employer including:

contacting the worker after the injury and maintain contact during the workers recovery
try to arrange for suitable work that the worker can do (Early and Safety Return to Work)
provide the W.S.I.B. with information upon their request

THE ONUS TO MANAGE INJURIES IS NOW PLACED ON THE EMPLOYER!

Poorly managed claims will lead to increased costs incurred by the WSIB.
Poorly managed claims will result in:

Minimize your potential for a NEER refund
A NEER surcharge or increased premiums for those employers under the MAPP program
A Workwell Audit
Potential Increased Premiums

HRCMS will manage claims and set up Return to Work programs, which will have the potential to maximize your N.E.E.R refund or control your premiums. In addition, we will effectively manage all W.S.I.B claims to reduce the cost to the company and to maintain high employee moral.

Mission

The staff and associates of HRCMS LTD. are committed to providing employers of all sizes and from every sector with professional, effective, well-informed and timely advice and direct assistance on all disability management related matters, including, but not limited to: WSIB and non-occupational Disability Claims Management, WSIB Financial management, and Occupational Health & Safety Certification training.

Claims Management

HRCMS LTD. provides a comprehensive claims management system designed to reduce employer costs associated with Occupational and Non-Occupational injuries or illness. This hands-on program will assist the employer to control frequency and duration of claims. Our program begins at point of occurrence and continues systematically to the final resolution of the claim.

SERVICE ELEMENTS:

Reporting / Forms Completion Liaise With Health Care Practitioner Early Safe Return To Work (ESRTW)

functional abilities information
employer/worker co-operation
role of treating physicia
listing with WSIB decision-makers

Return to Work Plan

development
implementation
closure

Communication with WCB/WSIB Decision Makers or __Insurance Carrier
Medical Rehabilitation Plan
Labour Market Re-entry
WCB/WSIB Dispute Resolution and WSIAT
Mediation & Re-employment Hearings Branch
Toll-free Telephone Service / E-mail Access / On-site __assistance

Your Health and Safety Rights and Responsibilities

Employers

As an employer, you have the responsibility to:

Keep a Safe and Well-Maintained Workplace.
You are required by law to take all reasonable precautions to protect your workers from illness or injury. Provide Proper Safety Equipment and Training

Provide First Aid Training and First Aid Kits.
The Workplace Safety and Insurance Act requires you to provide specific first aid equipment and training for your workers.

Post the WSIB "In Case of Injury at Work" Poster (Form 82)

Put the poster in a prominent place. This poster is available in several languages and can be obtained through the forms order line at 416-344-3862. Or, download Form 688, fill it in and fax to: 416-344-4684.

Post the Occupational Health and Safety ActThe Act is conveniently printed as a small green book. It, too, should be posted in a prominent place. You can also view the Occupational Health and Safety Act online.

Have Worker Representation for Health and SafetyIf you have 20 or more workers or deal with a designated substance (Acrylonitrile, Arsenic, Asbestos, Benzene, Coke Oven Emissions, Ethylene Oxide, Isocyanates, Lead, Mercury, Silica, Vinyl Chloride), you must maintain a Joint Health and Safety Committee (JHSC). Construction projects lasting more than three months with 20 workers or more must also have a JHSC.

Follow proper procedures in case of injury:
Give first aid immediately. Get the person to a doctor or hospital if necessary. Investigate the incident and report the injury without delay to the WSIB. You can download Form 7 here. If possible, have the worker sign your Form 7. This signature permits the worker's doctor to send you a report that helps identify what tasks your worker can take on during recovery. Pay a full day's wages for the day of the injury. WSIB benefits begin the next working day after the injury occurs.

What are the penalties for failing to comply with any of these employer responsibilities? People failing to comply with the Occupational Health and Safety Act are subject to fines of up to $25,000 and/or up to a year's imprisonment. Corporations can be fined up to $500,000.

Employers are also subject to penalties for failing to report to the WSIB within three days of learning of a workplace injury or illness and other violations of the Workplace Safety and Insurance Act.

Workers

As a worker, you have the right to:

Know About Danger
Your employer must tell you about hazardous materials or equipment used in your workplace. You should also receive training before using any such materials or equipment.

Participate in Making your Workplace Safe
You're an important part of workplace safety. Ask your employer or contact your worker health and safety representative to find out how you can help. They have information and materials you can use to make a difference.

Refuse Unsafe Work
If you believe your work is unsafe you can refuse that work until the situation is corrected. You must, however, tell your supervisor immediately. In the meantime, you should remain in a safe place near your workstation. You cannot be suspended, fired, or docked pay for refusing unsafe work.

As a worker, you have the responsibility to:

Work Safely
Don't take risks. You might injure yourself or another worker.

Report Unsafe Conditions
If you see anything that looks unsafe, tell your employer immediately. Don't wait until someone gets hurt.

Wear the Right Safety Equipment for the Job
Wear your protective clothing and equipment, and get trained to use it properly.

Ask Your Employer First
Your employer needs to know about your concerns and questions about health and safety issues and take the necessary measures to avoid injuries.

For more information, you can view the Occupational Health and Safety Act online.
In this section, you'll find answers to the following questions:

What is the definition of work-related injury and illness?
Do I need to register with the WSIB?
What are the benefits of having workplace insurance?
How do I register?
How much will I pay in premiums?
How can I reduce my premiums?
How can I prevent injuries and illness in my workplace?
What happens when one of my workers gets injured or ill?
What items are included in Short-term Average Earnings?
What constitutes fraud or non-compliance?
What happens if I'm audited?

If you're an employer, you'll find valuable answers and information about Workplace Safety Insurance here.

Small Business Services
Do you operate a business with less than twenty employees? If so, this section has information and answers specifically for you.

Industry Sectors
The WSIB has services specifically for your industry. You'll find information about them here.

Registering with the WSIB
This section will tell you if you need to register with the WSIB and will help you through the registration process.

Premium Information
This section explains your WSIB premiums. You will find a calculator here to help you estimate your premium payments. You can also sign up for our new e-Service -- Calculate and Report Premium.

Benefits – An Employer's Perspective
Your premiums provide you with a number of benefits in addition to the coverage provided for your workers. You can also purchase optional insurance for yourself to receive the same coverage as your workers.

Prevention
The WSIB provides valuable tips and incentive programs that will help you prevent injuries, reduce your premiums, and minimize losses caused by work-related injury and illness.

Pandemic flu NEW
While we see flu outbreaks every year, especially in the winter, flu pandemics historically occur every few decades. Experts believe that Avian Influenza, or Bird Flu may be the cause of the next pandemic. Learn more about how to prevent and control the spread of flu infection and prepare your workplace for a possible pandemic.

Injury and Illness
What happens when one of your workers is ill or injured? This section provides a step-by-step guide to what to do.

Early and Safe Return to Work
Getting workers back to work quickly and with minimum lost earnings is to everyone's advantage. This section explains your responsibilities – and those of your worker – in achieving this goal.

Labour Market Re-entry
What happens when an injured worker can't return to work with your company? The WSIB provides Labour Market Re-entry programs to help your worker re-enter the workforce with another employer. This section explains these programs - and who pays for them.

Employer Audits
This section explains what happens if we audit your business.

Appeals
You can appeal decisions that you do not agree with. This section tells you how.

Fraud-Noncompliance
This section will answer common questions you may have about your legal responsibilities as an employer under the Workplace Safety and Insurance Act.

Purchase Certificates
Are you buying or selling all or part of a business? Make sure you get a Purchase Certificate!

Stakeholder Information Sessions
Since January 2005, the WSIB has been holding a series of information sessions with employer representatives. View the presentations on our funding framework, prevention initiatives, return to work, and experience rating program.

Organizational Changes to Service Delivery
Learn about how we are reorganizing our service delivery model.

Injury and Illness

What happens when one of your workers is ill or injured?

Occupational Exposures

PEIR is the Program for Exposure Incident Reporting. It is a voluntary reporting program for employers and workers when an unplanned exposure incident occurs.

Tax Statements and your Injured Worker

Return to Work

Preventing workplace injuries and illness is the responsibility of everyone at the workplace. When injuries and illness do occur, however, it is important for you and your injured worker to minimize the human and financial impacts by focusing on getting the worker back to safe and productive work as soon as medically possible.

Workplace Guide to WSIB Claims Management and Return to Work Workshops NEW. The Employers' Advocacy Council (EAC) is presenting a series of workshops across Ontario on A Workplace Guide to WSIB Claims Management and Return to Work. These workshops are designed to provide participants with practical information that can be applied on such topics as:

Claims Management Process, including how to properly file a claim
File Maintenance requirements
Who to Contact and what information is important
Confidentiality of Medical Information, including key privacy issues
Return to Work Programs, including key elements, resources and structure of the program
Duty to Accommodate helps you learn what to do and what not to do
Return to Work Placement, including how to determine the best opportunity
Job Offers and Return to Work Plans show how to make these more effective

For further information, see the EAC brochure or contact the EAC.

Benefits of Early and Safe Return to Work
Most injured workers can return to some type of work even while they are still recovering. Returning to daily work and life activities can actually help in the recovery process. In fact, worldwide research shows that the longer a worker is off work due to injury or illness, the less likelihood there is of that person returning to work.

Both you and your injured workers benefit in cooperating in the injured worker's early and safe return to work. The injured worker benefits by restoring their source of income and staying active and productive, both of which are important to the healing/recovery process. You benefit by retaining valuable and knowledgeable people who contribute to your company's financial and market success.

Shared Responsibility for Return to Work
There are many participants in the Return to Work process, and each have a different role and responsibility.

In Ontario, returning an injured worker to work is a shared responsibility primarily between the employer and the worker. The WSIB is responsible for managing the claim and monitoring, providing education and assistance to the worker and employer, and to the workplace. Health care providers are responsible for providing timely health or medical and functional abilities information. Together, all parties working toward a shared goal of early and safe return to work and full productivity has the potential to reduce the human and economic impact of workplace injuries and illness. Where there are shared responsibilities, communication and cooperation toward a common goal is essential.

You, your injured workers and the WSIB all have certain legal obligations under the Workplace Safety and Insurance Act that support a safe and early return to work.

This section will explain those responsibilities, and what you can expect from the WSIB.

What are my responsibilities?
What are my worker's responsibilities?
What are the WSIB's responsibilities?
What are the penalties for non-compliance?

Download the Return to Work Self-Assessment Guide for Ontario workplaces (411k, pdf).

Return to Work Plans
Learn about Return to Work plans and see samples.

Physical Demands Information Form (PDIF)

Use the Physical Demands Information Form to gather and document specific information about the physical demands of jobs.

The PDIF helps you identify potential risk factors for injuries in a job, and may also help you modify the job to reduce risk factors and/or accommodate an injured worker's restrictions so they can return to work.

Physical Demands Information Form (1.1mb, pdf)
Example of Section 2: Duties and Physical Demands (368k, pdf)
Example of Section 3: General Physical Demands and Section 4: Additional Considerations (266k, pdf)

Want the latest info on Return to Work? We can help you find books and articles with our monthly RTW bibliography.

Appeals

If the WSIB renders a decision you do not agree with, your first step should be to discuss the issue with the person who made the decision. By communicating constructively with the decision maker you can often resolve a dispute early, without going through the substantial time and effort of a formal appeal.

Even when a formal appeal is necessary, we always encourage a positive and cooperative approach in order to reach a resolution that is fair to everyone involved.

If you are considering an appeal, here are a few things you should know:

We'll Help You Through the Dispute Resolution Process
Whether you resolve your dispute early through discussion, or actually launch a formal appeal, the WSIB will provide you with instructions on how to proceed through each step of the dispute resolution process.

If You Have Questions About a Decision, Ask Us – We're Here to Help
Clear communication prevents many disputes before they start, so it's in everyone's interest that we help you understand any decision we make about your case.

With this goal in mind, we'll send you a letter explaining any decision we make about your case. If there's anything in the letter you don't understand or don't agree with, please feel free to call us. The WSIB person responsible for the decision will be available to answer your questions or discuss your concerns. We'll also provide you with a copy of your file to help you review your case.

Time Limits
There are specific time limits for appeals. These will be clearly explained in your decision letter.

Explain Your Concerns
If you wish to object to a decision made by the WSIB, you must provide a written explanation of your objection in order to seek resolution. This will make it clear to everyone what your concerns are.

You Can Have Your Decision Reconsidered
To make early resolution of disputes easier for you, it's WSIB policy that the decision maker will reconsider decisions at your request. Information in the case file, on your objection form, and from your discussions with the decision maker will be considered. If you are not satisfied with the outcome of this reconsideration, you can still decide to make a formal appeal.

You Can Choose From a Range of Dispute Resolution Approaches
Because every dispute is different, and everyone's needs are different, the WSIB provides a variety of approaches to dispute resolution. These range from informal and timely approaches for quick resolution of simple issues, to more in-depth and formal approaches for more complex disputes. Your options in approaches will be explained to you by your WSIB decision maker.

Return-to-Work Disputes
In the case of a return-to-work dispute, you can ask the adjudicator to arrange for a return to work mediator to assist in resolution. For more details on how a return to work mediator can help you and your employer resolve an issue, download the Creating Return to Work Solutions (380k, pdf) brochure.

If this does not result in a satisfactory resolution, you can launch a formal appeal.

Want to know our guidelines for dealing with a dispute?
Download our Appeal System Practice & Procedures (109k, pdf) guide. Changes to this guide will be published each January. Updates for 2006 are highlighted with blue, italicized text.

Learn about how we work together with the Workplace Safety and Insurance Appeals Tribunal (WSIAT) to improve how appeals are managed and to ensure the best possible case process for employers and injured workers.

Fair Practices Commission

The Fair Practices Commission is the organizational Ombudsman for the Workplace Safety and Insurance Board. Neutral and independent of the WSIB, the Commission receives complaints from injured workers, employers and service providers. It is responsible for ensuring that the administrative practices and services of the WSIB are fair, reasonable, appropriate and equitable.
Workers, employers and service providers can contact the Commission by telephone or in writing.

Phone: 416-603-3010
Visit the Web site of the Fair Practices Commission.