Dealing with a difficult WSIB claim is time consuming and frustrating! What makes a WSIB claim difficult? Typically there isn't just one thing but rather a variety of issues including a significant physical injury being compounded potentially with a subsequent mental health related issue, claims from workers that are "repeat offenders" (someone who has had more than one claim over time, or has more than one claim at the same time), a WSIB case manager that is not helpful, a worker who is putting up barriers to return to work or it could be a combination of all of these issues.
Claims which we consider to be "difficult" are typically also very costly in terms of your WSIB NEER costs, but also the time spent managing them. At Clear Path when tackling our difficult claims we use specific tried and true strategies. These strategies help us to determine the best course of action to find resolution for our difficult claims and contain costs. We like to call these the "Essential 4" kind of like the Fantastic Four, but better!
Why object? You may be objecting to a claim because you find it suspicious due to the fact that there may have been a delay in reporting, no medical treatment was sought, maybe there is no compatibility of injury to accident or the worker is just not cooperating with RTW efforts. Always make sure your objections are in writing, quote WSIB policy where possible to back up your argument, and investigate your concerns immediately to obtain witness statements and collect all your evidence. To really be heard by WSIB, base your argument on facts not feelings.
SIEF Cost Relief
If you can't get the claim or entitlement denied, then SIEF may be the next best thing! SIEF or Secondary Injury Enhancement Fund is a cost relief program that reduces claim costs for employers. SIEF does not impact benefits paid to the worker. To obtain SIEF cost relief, understanding the medical information on file is critical, knowledge of previous claims and non-occupational health issues will also help to support your request. If the recovery period resulting from an accident becomes prolonged, and you believe it is due to a pre-existing condition consider using a third party professional to assess medical information. Assess the file in terms of accident history to determine if the accident would have caused a disability or injury, and then make your argument in writing to the WSIB, again quoting policy and providing the supporting medical information you have obtained.
The key to success in a Return to Work plan is that it is agreed upon by all participants - the worker, treating physicians, the WSIB and that the modified work or hours are always offered immediately and then follow up with a written plan. The plan should be tailored to the worker's restrictions and have a defined weekly schedule with an "end in mind". Address cooperation and performance issues immediately, and regularly review to monitor effectiveness and adjust the plan as necessary.
More and more medical management of a claim is becoming a critical strategy in reducing claim costs. Knowing when to ask for new medical, object or question existing medical or ask for an independent medical assessment can mean reducing the claim life significantly. Consider bringing in an independent medical consultant early on in the claim so that they can speak directly with treating practitioners and analyze medical results. They will also be able to connect with your worker. The initial confidential call with the worker can help to gather critical information to confirm accident history, current restrictions/limitation, treatment plans and discuss modified opportunities. A medical consultant can be a crucial when investigating difficult or sensitive situations. An independent medical consultant can ensure accommodations promised are followed through, and be a valuable resource when it comes to challenging board decisions like denial of SIEF with supporting medical opinion.
Unfortunately, the one common thing about difficult claims is they are all different and unique in their own way. Now that you know the Essential 4 - still not sure where to start? We are always available to assist with any difficult claim you might encounter be it on a one time basis or as an ongoing part of your claims management team. To learn more about how your claims management strategies and decisions affect your WSIB costs, join us for our upcoming NEER sessions to learn more.
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Clear Path Employer Services
295 Thompson Drive, Unit 2
Cambridge, Ontario N1T 2B9
T: (519) 624-0800
T: (888) 336-0950
F: (519) 624-0860
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