WSIB Decision-Making
How the WSIB decides whether a worker is entitled to LOE payments and other services
The WSIB decides if the claim is work-related. In order for a claim to be considered work-related, all of the following conditions must exist
- the employer’s business activity is covered under the WSIA
- the worker is covered under the WSIA
- there is a personal work-related injury
- there is proof of accident, and
- the medical diagnosis is compatible with the accident or disablement history.
Following an injury, the WSIB weighs the evidence and makes a decision based on the merits of the particular claim, ensuring that its decision is consistent with the provisions of the WSIA and WSIB policies. In cases where evidence is approximately equal on both sides of an issue, the WSIB will decide in favour of the worker (or spouse or dependant) who is making the claim. This provision is known as the “benefit of doubt.”
How the WSIB makes decisions on occupational disease claims
O. Reg. 175/98 includes Schedules 3 and 4 which list the specific diseases for which there is a presumption of entitlement. The WSIB also has policy guidelines for several specific diseases including asbestosis, noise-induced hearing loss, tinnitus, occupational aluminum exposure, dementia, Alzheimer’s disease and other neurologic effects, tuberculosis, scleroderma, and post-exposure prophylaxis for occupational exposure to HIV. Occupational disease claims that are not covered by the schedules or the policies are adjudicated on the merits and justice of the case.
Occupational disease claims are complex and have special rules. Contact the OEA for assistance if you have such a claim.
