The overall goal
The Workplace Safety and Insurance Board (WSIB) Service Delivery Model aims to reduce the “duration” of claims, which is the length of time a worker is off work due to a workplace injury or disease. The WSIB uses a case management approach based on discussions with the workplace parties (WPPs). WSIB decision-makers are expected to provide decision letters in all cases to the WPPs that explain their reasoning. The decision-maker’s Manager is the employer’s point of contact if issues cannot be resolved with frontline staff.
Forms 6, 7 and 8 are received by the Central Claims Processing department. Registration Clerks set up the claims. If a Form 8 is received prior to a Form 7, the Registration Clerk will call the employer with the claim number and ask if he/she is aware of the accident. Always include the claim number on all documents you send to the WSIB, if you know what it is.
Primary Adjudicators determine eligibility on claims that meet the WSIB’s five-point check system (there is a worker, an employer, proof of accident, personal injury and compatibility) and are likely to be allowed. This covers approximately 70-80% of all claims registered with the WSIB, most of which are no-lost-time claims.
Eligibility Adjudicators make initial entitlement decisions on more complex claims. Claims are also referred from Primary Adjudicators to Eligibility Adjudicators in cases where the Form 7 is received before the Form 8.
Initial entitlement decisions that are made based on the information available at the time remain the responsibility of the Eligibility Adjudicator. This includes all decisions rendered by a Primary Adjudicator. Eligibility Adjudicators have access to a Nurse Consultant who can obtain outstanding information in a claim file to help with the decision-making process. Investigators are not staffed in the WSIB’s regional offices, but there are some investigators at the WSIB’s Head Office in Toronto. If need be, an investigator can be sent out to do an investigation elsewhere in the province.
If the Form 7 says modified work is available and the claim is allowed, the claim is transferred to a Short Term Case Manager to address the work reintegration (WR) issues. No-lost-time claims where the worker is doing modified work are also referred to the Short Term Case Manager so the recovery process and return to pre-injury work can be monitored.
If one of the WPPs raises a concern about the Eligibility Adjudicator’s initial entitlement decision, the Case Manager sends the claim back to the Eligibility Adjudicator for reconsideration. Employers who have concerns with respect to specific cases should contact the appropriate Eligibility Manager.
1. Short Term Case Manager
All cases will be transferred from the Eligibility Adjudicator to the Short Term Case Manager no later than 30 days after the claim has been registered at the WSIB. Cases may be referred to a Short Term Case Manager as early as the first day of the claim if it is recognized that help is needed to manage the WR issues, although ownership of the case will remain with the Eligibility Adjudicator.
The Short Term Case Manager makes decisions on entitlement for recurrences that occur less than three months after the worker’s WSIB benefits have ceased. He/she is responsible for determining ongoing benefits and for making decisions on entitlement based on new information.
In all cases, the Case Manager will discuss return to work (RTW) opportunities with the employer and worker to see if suitable work options can be identified, including accommodation of the pre-injury job.
If the worker is capable of returning to work in some capacity, and
- the Case Manager has been unable to remove any obstacles, or
- there is uncertainty about work availability, suitability or sustainability with the accident employer, or
- the employer is unable/unwilling to provide suitable work,
the Case Manager will refer the claim to a Return to Work Specialist (RTWS) who will meet with the worker and employer on the employer’s premises to facilitate the WR process.
2. Long Term Case Manager
All cases will be transferred from the Short Term Case Manager to the Long Term Case Manager no later than 180 days after the claim has been registered with the WSIB.
Only the Long Term Case Manager can make decisions regarding work transition (WT). Long Term Case Managers also determine whether the worker has experienced a permanent impairment and needs to be referred for a non-economic loss (NEL) assessment.
WSIB Nurse Consultants make decisions on health care entitlement, resolve objections to health care entitlement decisions, and intervene in WR obstacles.
WSIB physicians are engaged in the WR process by contacting the injured worker’s doctor and clarifying perceived WR obstacles as the WPPs work towards a resolution. They do not provide a medical opinion to WSIB decision-makers for decision-making purposes.
Return to Work Specialists
The RTWS acts as a facilitator. He/she does not conduct formal mediations. Discussions with the WPPs are not confidential and can be recorded in the claim file. Employers are entitled to have a representative attend these meetings with them. Employers may wish to contact the Office of the Employer Adviser (OEA) for advice and possible assistance in such cases.
During collaborative RTW discussions with the WPPs, the RTWS may determine that additional services are needed in order to better understand the worker’s vocational potential, and/or that retraining may be required before the worker can return to suitable work with the accident employer. At that point, the RTWS will close off his/her services, and advise the Case Manager that a referral to a Work Transition Specialist (WTS) is required.
Case Management Re-employment Team
This Specialty Team facilitates employer cooperation and re-employment, and makes all re-employment decisions while the Short Term Case Manager or Long Term Case Manager continues to manage the claim. Employer cooperation issues are also referred to the re-employment team.
Recurrence & Work Disruption Team
This Specialty Team makes all decisions involving short-term, long-term and permanent work disruptions including strikes, seasonal layoffs and permanent shut-downs.
It also makes all decisions involving recurrences or secondary conditions that occur at least three months after the worker’s WSIB benefits ceased, or at least three months after a no-lost-time claim was approved. If the recurrence claim is approved, the Recurrence Case Manager makes the initial payment to the worker, and then sends the claim back to the Short Term Case Manager or Long Term Case Manager to manage the claim.
Work Transition Specialists
The WTS helps the WPPs and the Case Manager to facilitate the WT process when the worker has not returned to suitable and available work. In each case, a claim will transition from a RTWS to a WTS between six and nine months after the date of injury, in conjunction with the claim being transferred from a Short Term Case Manager to a Long Term Case Manager. A referral to a WTS may also be made if the injury employer has identified a potential job opportunity that requires some form of retraining, i.e., short-term training, training-on-the-job, computer skills, etc.
Employer Liaison Specialists
The Employer Liaison Specialist focuses on improving WR outcomes by sharing best practice approaches in WR, and actively supporting employers to become self-sufficient in the development and implementation of disability management and WR programs. They refer employers to the Health and Safety Associations (HSAs) for all prevention/health and safety issues. Working with an Employer Liaison Specialist is voluntary.
Second Injury and Enhancement Fund (SIEF) Team
Employers seeking SIEF relief should send their written request to the Short Term Case Manager or Long Term Case Manager who will refer that one issue in the claim file to the SIEF adjudication team. The SIEF Case Manager, who is also the person to whom a request for SIEF reconsideration should be directed, signs SIEF decision letters. Employers can contact the Short Term Case Manager or Long Term Case Manager to obtain the contact information for the SIEF Case Manager assigned to a particular file.
SIEF Appeals Resolution Officers (AROs)
The WSIB’s Appeals Branch has designated SIEF AROs. They are the only individuals on the ARO teams who are authorized to address SIEF appeals, and any appeal that includes a SIEF issue is to be assigned to one of them.
Appeals/Future Economic Loss (FEL) Team
This Specialty Team implements all WSIB Appeals Branch decisions and Workplace Safety and Insurance Appeals Tribunal (WSIAT) decisions that are allowed either in whole or in part. It also makes all decisions involving FEL awards. It does not address issues involving SIEF, pre-1990 claims, claims that are addressed by the Serious Injury Program, or occupational diseases that are adjudicated by the Occupational Diseases and Survivor Benefits Program.
Employer Services Centre
The Employer Services Centre deals with all revenue issues. Account Analysts focus on the transaction work such as balance enquiries and address changes. Account Specialists are the key decision-makers on all revenue issues including premiums, reconciliations, etc. Employers can call the WSIB’s General Enquiry Number at 416-344-1000 or 1-800-387-0750, provide their account number and be referred to an Account Specialist who will address their account issues.