Update on WSIB claims and benefits
Who is eligible for Workplace Safety and Insurance Benefits?
Anyone who has been injured while in the course of employment, and whose employer has WSIB coverage or is required to have coverage is eligible for benefits.
How much time do I have to submit a claim?
You must bring your workplace injury to the attention of the Workplace Safety and Insurance Board (WSIB) within six months of the injury or learning of the disease. If you do not, the WSIB will, in most circumstances, deny your claim for benefits and it can be time-consuming and expensive to get the time limit extended.
How do I make my claim?
If you sustain a workplace injury/disease your claim can be established by:
- Completing a workers’ report of injury/disease (Form 6) to the WSIB (available on the WSIB website or from a WSIB office)
- Seeking medical attention and reporting your injury as work-related [the treating physician is required by law to submit a report (Form 8) to the WSIB]
- Reporting your injury to your employer [they are required to complete an employers’ report of injury (Form 7) if you require healthcare attention].
What do I do once my claim is set up?
The WSIB assigns a claim number to each individual claim for benefits. This will be communicated to you and you should keep it available for reference every time you telephone or write the WSIB. Every piece of correspondence that you send to the WSIB should have your name and claim number on it. Remember that if you move or change your phone number you should advise the WSIB as soon as possible.
How will the WSIB make a decision on my claim?
To determine initial entitlement to benefits, the WSIB reviews the accident history and the medical diagnosis. In many cases, it is simple to confirm that there is a causal relationship between the accident and the diagnosis. However, when the accident history is not clear, the employer is objecting or information is outstanding, injured workers can experience delays in receiving benefits.
Am I entitled to any other benefits while I am waiting for the WSIB to make a decision?
There can be considerable delays in having a claim processed. This may leave an injured worker financially strapped. Depending on the circumstances, you may be entitled to Employment Insurance, Long-Term Disability (LTD) benefits, Ontario Disability Support Program (ODSP), or Canada Pension Plan (CPP) Disability benefits. You should not automatically assume that you will not qualify. Investigate each option to determine if you meet the eligibility criteria. In most cases, if another agency is aware that you are awaiting a benefit decision from the WSIB, they will require you to sign an assignment of benefits form, to ensure that they are repaid when benefits are authorized.
How can I expedite the processing of my claim?
The WSIB will routinely forward forms and reports to you, that may be needed to make a decision in your claim or continue paying benefits. You should not delay in completing the forms or taking them to your physician for completion if required. If the WSIB determines that they have not received the completed reports in a timely manner, they can, and will most likely, reduce, suspend, or terminate benefits.
Once my claim is approved, how will my benefits be authorized?
Loss of Earnings (LOE) benefits are paid based on 85% of pre-injury net average earnings. In other words, you will be entitled to 85% of your take-home pay, subject to the maximum and the minimum insurable rate for the year of your injury. Generally the first 12 weeks of benefits are paid based on your actual earnings at the time of the injury. If in the WSIB’s opinion you are not a permanent regular worker, your earnings may be adjusted at the 13th week. The WSIB will request your earnings information, generally for the two years prior to your injury, and determine your average weekly earnings. If you are a seasonal worker, this will usually result in a downwards adjustment.
Will the WSIB tell me when to return to work?
Since the new Workplace Safety and Insurance Act came into effect, employers and injured workers are supposed to work together in the return to work process. This means that the WSIB only intervenes when it appears that the workplace parties are not achieving a successful result.
If problems arise during the return to work process, the WSIB offers mediation services. Also, there is a requirement for injured workers to keep their employer updated regarding medical progress. This can easily be accomplished by telephoning the appropriate person with a status update.
I do not agree with the duties that I’ve been assigned upon my return to work. What should I do?
If you do not feel you are capable of performing the duties that have been assigned to you upon your return to work, you can do one of three things. Through the WSIB, you can request intervention by the adjudicator involved in your case, make a formal objection in writing, or request a return to work mediation.
The mediation process allows the injured worker and the employer to meet with a WSIB mediator to discuss a mutually agreeable plan for returning to work. If either party should decide to back out of the mediation process, the issue would be referred by to the case adjudicator for a final decision. Please note that the mediation process is confidential and will not be communicated to the adjudicator or influence their decision.
What is the time limit for an appeal?
Decisions issued by the WSIB indicate that if there is an issue in dispute, an objection must be communicated to the Board in writing within the specified time limit. The appeal time limit for return to work and labour market re-entry plans is 30 days. The time limit for all other decisions is six months. If you miss the time limit, the WSIB will not likely process your objection. It is a good idea to follow-up to verify that the appropriate person received the objection letter.
Do I have access to my WSIB file?
Every injured worker should request a copy of their WSIB file, whether there is an issue in dispute or not. The claim file will provide insight into the decisions that are being made with regard to the benefit rate, medical treatment, return to work and various other issues. It is a good idea to request the file updates every few months to ensure that you are up to date regarding the decisions that are being made with regard to your file.
Is there financial assistance available for retaining consulting services?
If you require financial assistance with representation, please check with your union representative. Many unions are now providing financial support for these services.
Can you offer me any other general tips?
- Keep copies of all documentation forwarded to the WSIB.
- The WSIB can only make decisions based on the documentation that is forwarded to them – i.e. if your physician authorizes you off work but does not communicate this to the Board in writing, then lost time benefits are not likely to be authorized.
- Also, if your physician takes you off work, they will need to provide the WSIB with a detailed report. Please note that a physician’s note will not suffice.
- Read all correspondence sent out by the WSIB as you may miss something important. Many injured workers do not read the literature sent out by the Board because they do not believe that they will be on benefits for a significant period of time.
- When possible, have recommended medical treatment pre-approved to ensure that you do not have to pay for the treatment out of your own pocket and then have to request reimbursement by the WSIB.
- Ensure that you forward all original receipts that you are entitled to be reimbursed for as soon as possible. Do not let them build up. The WSIB has a new health care payment system and requests for reimbursement can take up to eight to twelve weeks to process.
