Objecting to the validity of a Workers’ Compensation claim or to a decision made by the Board is an important part of effective claims management. Not doing this level of due diligence can be extremely costly for your organization.
There are a number of reasons an employer might decide to object to a Workers’ Compensation claim. Three key reasons include:
1. Non-occupational vs. occupational:
You may not dispute that there is a legitimate injury or illness, but question whether or not it is work-related. For example, you may have a worker complaining of a back injury on Monday morning after they spent the weekend moving to a new home or doing some other kind of manual labour.
If the injury is non-occupational, then benefits for the worker should be processed through your insurance program rather than the Workers’ Compensation Board of your jurisdiction. This is typically a much less expensive route.
Things get a bit more complicated when an injury occurs during the work day, but is not actually related to the worker’s duties. Clear Path’s Jennifer Wright-Tahiraj recalls a recent claim she objected to where a truck driver was using the bathroom at a rest stop and as he reached for the hand soap, he felt a tweak in his back. “Just because the injury happened during the work day doesn’t automatically mean that it is related to their work duties.”
2. Suspicious or fraudulent claims:
Occasionally an employer may come across a claim that they suspect is not legitimate. Some warning signs that a claim may be fraudulent include:
- Lack of compatibility of the injury to the accident
- No witnesses to the incident
- Delay in reporting the accident
- No medical treatment sought after the accident
- Worker is not cooperating with Return to Work efforts
- Timing of the claim may lead to having the summer off or is just before Christmas holidays
- Multiple employees in the same department or social group have submitted claims
When Clear Path objects to initial entitlement for a claim in Ontario, we typically reference the WSIB’s Five Point Check System (Policy 11-01-01). This policy states that an allowable claim must have the following five points:
- An employer,
- A worker,
- A personal work-related injury,
- Proof of accident, and
- Compatibility of diagnosis to accident or disablement history.
If any one of these five points are discounted by your suspicions, we recommend objecting.
3. Is this a re-occurrence of a previous injury?
If the Board has declared that a worker’s injury is a new claim but you suspect that the injury is related to a previous injury and claim, you may request that the new claim be merged with the previous claim.
This can be especially beneficial if the prior claim is outside of your NEER window (the 4 year time frame for which your company is liable for expenses related to the claim). However, Wright-Tahiraj cautions that you must be able to establish:
- Continuity of complaint,
- Continuity of accommodation, and
- Continuity of medical
She also cautions that you must always keep in mind the “72 month rule.” If the prior claim is more than six years (72 months) ago, it is very unlikely that you will have success in your objection to link the two injuries.
Want to learn more?
Try to attend one of Clear Path’s upcoming Disability Management workshops (all eligible for HRPA Recertification Points).
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