Administrative practice document: Loss-of-earnings (LOE) benefit reviews

Note: This is a supplementary document to the policy showing how we apply the Workplace Safety and Insurance Act, 1997, (WSIA) Payment and Reviewing LOE Benefits (Prior to Final Review) (Policy 18-03-02), and Final LOE Benefit Review (Policy 18-03-06). In cases of a conflict between this administrative practice document and the WSIA and/or WSIB policy, the decision-maker will rely on the WSIA and/or the WSIB policy.

Key principles

People are entitled to receive benefits for injuries and illnesses that arise out of and in the course of employment.
Decision-makers make quality decisions ensuring people who are injured or made ill at work receive fair compensation, reducing the impact of workplace injuries and illnesses, and improving people’s employment opportunities/prospects and earning ability/capacity after being injured or made ill at work.
When a review leads to a change in someone’s benefits, we’ll tell them ahead of time about the change and the reason for it.

Definitions

Person with injury or illness – a person who experiences a workplace injury or illness is described in the WSIA and in the WSIB policy as a “worker” or “injured worker”. In this document we’ll use “person with injury or illness”, or just “person”.

Loss-of-earnings (LOE) benefits – LOE benefits are payments made to a person with injury or illness who has lost time and wages/earnings because of the work-related injury. These benefits are payable at 85 per cent of net average earnings (gross earnings less probable deductions, such as EI, income tax, and CPP).

Short-term average earnings – the person’s earnings from their employer at the time of their injury or illness and all other employment at the time of the injury or illness.

Long-term average earnings – the person’s earnings from one or two years before the date of their injury, illness or layoff. They are based on their employment pattern (permanent or non-permanent) at the time of the injury.

Escalated average earnings – each January 1, a cost-of-living indexing factor is applied to the gross average weekly earnings and the short-term or long-term average earnings are adjusted accordingly. We use “escalated” to describe earnings that need to be recalculated and where we’ve applied the cost-of-living indexing factor.

Suitable occupation (SO) – a suitable occupation is a category of jobs suited to a person’s transferable skills that are safe, consistent with their functional abilities, and, as much as possible, restores the person’s pre-injury earnings.

Introduction

A person who loses wages because of a work-related injury or illness, is entitled to loss-of-earnings (LOE) payments, under Section 43 of the Workplace Safety and Insurance Act, 1997 (WSIA). These benefits start when the loss of earnings begin, and continue until:

the day their loss of earnings stops, or
the day they reach 65 years of age, or
two years after the date of injury, for people who are age 63 or older on the date of injury, or
the day they are no longer impaired because of the injury – whichever comes first.

Once we approve a claim, decision-makers decide if a person is eligible for LOE benefits and the amount of benefits they should be paid. LOE benefits are initially paid based on the individual’s short-term average earnings. If they continue to receive LOE benefits for longer than 12 weeks, we may recalculate their earnings. When the short-term average earnings don’t accurately reflect what a person may earn over a longer period of time, we usually recalculate the long-term average earnings. These recalculations happen 13 weeks after the injury or illness. See more information about how we calculate short-term average earnings.

Outlined in section 44 of the WSIA, we may review LOE benefits because:

the person has a material change in circumstances,
of an annual review up to 72 months after the date of the person’s injury or illness
a final review at 72 months after the date of the injury or illness.

We may also defer the 72-month final LOE benefit payment review in certain circumstances and in exceptional circumstances allow for review of LOE benefits after the final 72-month review.

We may review LOE benefit payments at any time up to 72 months after the date of injury or illness. During a review, we may confirm, adjust or discontinue the LOE benefit payment amount based on changes in the circumstances of the claim.

We use the WSIA and Policies Payment and Reviewing LOE Benefits (Prior to Final Review) (Policy 18-03-02), and Final LOE Benefit Review (Policy 18-03-06), along with sound case management principles and procedural fairness to guide these reviews.

Factors affecting LOE benefit payments

We determine the amount of LOE benefit payments based on the circumstances of the claim. The benefits replace the actual loss of earnings the person experiences because of the work-related injury or illness.

Decision-makers regularly assess and monitor new information about a person’s ongoing work-related impairment, functional abilities and review a person’s entitlement to LOE benefits. We adjust the amount of the LOE benefits payable in relation to their recovery and return-to-work status. A person who is able to return to some form of work, but is unable to restore all of their pre-injury average earnings in suitable and available employment, is generally entitled to partial LOE benefits.

In addition to the age factors in section 43 of the WSIA, other factors may affect their LOE benefits and/or the amount of benefits they receive, including changes in their:

Health and recovery status – while someone continues to be impaired and have a loss of earnings because of a work-related injury or illness, they usually continue to be entitled to LOE benefits. Benefits end when clinical evidence indicates the person with injury or illness is no longer impaired because of the work-related injury or illness.
Post-injury earnings – when someone is or becomes able to work, the earnings they receive, or are capable of earning, are considered when we determine the amount of their LOE benefits. We will also consider earnings from self-employment. LOE benefit payments stop when the person earns or can earn their pre-injury (escalated average) earnings. We consider Canada Pension Plan (CPP) or Quebec Pension Plan (QPP) disability benefits received for the work-related injury or illness post-injury earnings when considering LOE benefit payments. Calculating CPP/QPP Offsets from FEL/LOE Benefits (Policy 18-01-13) has more details.
Co-operation in health care or return-to-work activities/plan – if a person doesn’t co-operate in their health care or return-to work plan, we may reduce or suspend their LOE benefit payments, depending on the specific facts of the case.  You can find more details in our policy on Workers’ Co-operation Obligations (Policy 22-01-03).
Material change – people with claims are responsible for reporting a material change in circumstances to us within 10 calendar days of when a change happens. This can be a change to their health status or earnings – anything that may affect someone’s entitlement to benefits and services under the WSIA.

Decision-makers review the material change information to determine if the person is still entitled to WSIB benefits and services.

If we need to make an adjustment to benefits and services because of a material change, the decision-maker will let the person know and the adjustments become effective the date the material change happened. This might mean that the person will need to pay the WSIB back for benefits paid after that date.

You can learn more in our policy on Material Change in Circumstances– Worker (Policy 22-01-02) and Adjusting Benefits Due to Post-accident, Non-work-related Change in Circumstances (Policy 15-06-08).

We use sections 43 and 44 of the WSIA and our policies on Payment and Reviewing LOE Benefits (Prior to Final Review) (Policy 18-03-02) to guide reviews of a person’s ongoing entitlement to LOE benefits. If a person doesn’t fully recover from the work-related injury or illness, decision-makers continue to review and monitor the claim and the LOE benefit payments until all health care measures and return-to-work activities or plan are completed.  At that time, the person may be entitled to ongoing LOE benefit payments, if they continue to have an impairment and a loss of earnings because of the work-related injury or illness.

We conduct regular case management reviews while someone is receiving health care and return-to-work activities. After this time, we do annual reviews of LOE benefits until the final LOE benefit review date.

Annual LOE reviews

We need up-to-date information about the person’s work-related impairment, employment, self-employment, and earnings status to conduct the annual review of LOE benefit payments.

For the annual review of LOE benefits, decision-makers consider the following:

get an update on their recovery status and identify any changes in their functional abilities
find out their employment status and identify any material changes, including changes in entitlement to CPP/QPP disability benefits
request updated earnings information (we will send a questionnaire and the person will need to complete it to validate tax and earnings information)

We use our policy on Payment and Reviewing LOE Benefits(Prior to Final Review) (Policy 18-03-02) to guide decision-makers in the annual LOE benefit payment reviews.

At any time, decision-makers may also arrange additional health care assessments, request input from a medical consultant and/or return-to-work services if this may help improve the person’s recovery and return-to-work opportunities.

For the annual review of LOE benefits, decision-makers consider the following:

What are the person’s demonstrated functional abilities and ability to work?
Has the person received return-to-work services to identify a suitable occupation, with their employer or in the labour market?
Is the person employed or self-employed?
Does the employment align with the person’s work ability/capacity and identified suitable occupation?
Is the suitable occupation still available in the local labour market?
What are the person’s current earnings, or current labour market earnings for their identified suitable occupation?
Is the person underemployed with respect to hours of work and/or wages?
Are there other relevant material changes, according to our policy on Material Change in Circumstances - Worker (Policy 22-01-02)?
Are there other post-accident changes to consider?

Note: If there’s a suitable occupation identified with their employer or in the labour market, the person is generally considered capable of full-time employment in that suitable occupation. We may also consider part-time employment when medical and functional abilities information clearly shows a capacity for permanent part-time work only. In these cases, the earnings used to determine the LOE benefit payable would reflect this reduced work ability/capacity.

After the annual LOE benefit review is complete, the decision-maker may confirm, adjust, or stop the LOE benefit payments depending on the claim.

When the LOE benefit is to be reduced

When we do a LOE benefit review and we decide that the LOE benefit payment should be reduced, we provide the decision verbally, when possible. We also provide information on where they can get support and representation, like the Office of the Worker Adviser, which provides services to people who are not members of a union. We send a letter communicating the decision to confirm the changes in LOE benefits are generally effective one week from the date of the letter. The effective date of the change in benefits may be extended up to four weeks from the date of the letter, but no later than the end of the 72-month period. We consider special circumstances like:

the length of time on benefits,
an earlier decision on employability,
the length of time since the WSIB’s last communication with the person

Note: If the person failed to report a material change in circumstances that affects their entitlement to WSIB benefits, their benefits paid may be made retroactive from the date of the material change. For example, LOE benefits may be reduced retroactively to the date the person received a wage increase, or the date of the notice of CPP/QPP disability benefit entitlement. This may mean that the person must repay their benefits. You can see more information in our policy on Recovery of Benefit-Related Debts (Policy 18-01-04).

Material change in earnings

An increase or decrease in a person’s post-injury earnings doesn’t automatically mean an adjustment of their LOE benefit payment. Decision-makers compare the updated post-injury net average earnings with the net average of the earnings used to calculate the LOE benefit. Generally, we only adjust the LOE benefit if the difference is 10 per cent or greater.

72-month final LOE benefit reviews

The WSIA says that LOE benefit payments can’t be reviewed more than 72 months after the date of the person's injury or illness. As a result, we conduct a final LOE benefit review before the end of the 72nd month after the injury. After the final LOE benefit review, the person is paid the benefits until they reach age 65 without further review. You can read about exceptions later in this document.

The decision-maker usually starts this review by the 67th month after the date of injury or illness. This review gives enough time to gather and review information before the end of the 72nd month. Decision-makers can begin the process earlier, if they need more time.

We send written notice at the 67th month that this review will happen and we outline the information we need for the final LOE benefit review, advising them:

they must submit the declaration and information we request promptly to prevent a disruption in their LOE benefit payments, and
that the final LOE benefit review must be completed by the end of the 72nd month after their injury or illness.

If the person doesn’t respond after one follow-up, we will suspend their LOE benefits at the 70th month, unless there are exceptional circumstances – like a Canada Revenue Agency (CRA) closure. We send the person a final follow-up letter at the 71st month. We don’t restore their LOE benefits until we are able to complete a full review. If we aren’t able to complete the final review by 72nd month, we usually can’t restore the LOE benefit retroactively.

Decision-makers use Final LOE Benefit Review (Policy 18-03-06) to guide the final review. The amount of LOE benefits that we determine at the final LOE benefit review, are payable to the date the person reaches age 65 and can’t be reviewed, unless one of the exceptions outlined applies.

It’s important that people understand the final LOE benefit review decision. Decision-makers discuss all decisions made at the final review verbally, where possible. They also follow up in writing – whether LOE benefits are confirmed, adjusted or discontinued.

Exceptions to annual and final LOE reviews

People who were 55 years of age or older when they became entitled to LOE benefits may qualify for the “no review” option when they:

reach their maximum medical recovery, and complete a RTW plan (with training) for a new job

need a return-to-work plan (with training) with job skills training, and choose a 12-month self-directed transition plan to get employment.

If they choose a “no review” or the combined “self-directed/no review” option they can’t change it, and we continue to pay their LOE benefits until age 65 without any further reviews. We reduce their LOE benefits to account for earning capacity of the suitable occupation identified in their return-to-work plan. If a person chooses the “self-directed/no review” option, we maintain LOE benefits during the self-directed plan and then recalculate them at the end of the 12-month plan based on the suitable occupation identified in their return-to-work plan.

Lump sum LOE benefit payments (Commutations)

If the person chooses either the “no review” option or if the final review is completed, and the LOE benefit payable is 10 per cent or less of the person’s full LOE benefit rate, it’s automatically paid in one lump sum. However, the person may also decide to receive bi-weekly payments. Once they make this decision, they can’t change to a lump sum.

For more information, see our policy on Commutations (Policy 18-03-05).

72-month final LOE benefit review deferrals

The final review of the LOE benefit payment at 72 months can be deferred if, at the time the 72-month period is reached, the person is co-operating in:

health care measures the WSIB considers appropriate, or
return-to-work activities with their employer, or
a return-to-work plan (with training) for re-entry into the labour market

If we defer the final LOE benefit review, we let the person know the reason. Decision-makers will continue to review and monitor the claim and the LOE benefits, until the health care measures, return-to-work activities, or the return-to-work plan (with training) are completed.

We complete the final LOE benefit review when the health care measures or return-to-work activities with their employer are completed. The review must be complete no later than 24 months after the 72-month period expired, regardless of whether health care measures or return-to-work activities are complete.

In some cases, a person who participated in health care measures may become involved in return-to-work activities with their employer. If these activities with their employer don’t result in a return to suitable work, we may provide them with a return-to-work assessment and a return-to-work plan (with training), if needed. In these cases, the final LOE review is done 30 days after the RTW plan is complete or 24 months after the 72-month period expires, whichever is earliest.

In cases where the person is participating in a return-to-work plan (with training) for the purposes of re-entry in the labour market at the 72nd month, we must complete a final LOE benefit review within 30 days after the return-to-work plan is completed (the 24-month rule does not apply).

Health care measures

At the time of final review, if a person is cooperating in health care measures, it generally means they are involved in a medical rehabilitation program. A medical rehabilitation program is a course of medical or paramedical treatment where significant improvement is expected and the goal is to help a person reach maximum medical recovery. This treatment is meant to support the person with their return to suitable and available employment.

Some examples of a medical rehabilitation program are any of the following situations but not limited to:

receiving active treatment due to the work-related injury/illness
attending a WSIB-arranged specialist consultation, or
having a prosthesis repaired or replaced.

Note: Ongoing use of prescription medication and/or maintenance treatment (physiotherapy, chiropractic, or psychological treatment) generally does not mean they are in a medical rehabilitation program.

Exceptions: LOE reviews after the final review

Once the final LOE benefit review is completed (at 72 months or after a deferred review), further reviews of the LOE benefit payment can only happen if the person:

didn’t report a material change that happened before the final review of the LOE benefit payments, or
suffers a significant deterioration in their work-related condition.

If a person failed to report a material change that happened before the final LOE benefit review, we will adjust the LOE benefits back to the date the material change happened. If appropriate, we will reconsider the final LOE benefit review decision to account for the material change, and we will recalculate the LOE benefits from the original review date.

A significant deterioration is a marked degree of deterioration in the work-related impairment that is shown by a measurable change in clinical findings. After the final LOE benefit review, this may include a new area of entitlement and may be temporary or permanent.

Decision-makers use the policy on Recurrences (Policy 15-02-05) to guide their decision about a significant deterioration.

When a significant deterioration is established, we may adjust LOE benefits from the date of the significant deterioration if supported by medical evidence and based on the resulting loss of earnings. Decision-makers monitor and assess clinical evidence about the work-related impairment and begin health care measures or return-to-work services to help the person’s recovery and return-to-work. A new return-to-work plan may be needed if they experience diminished functional abilities. We may also review and adjust their LOE benefit payments as appropriate.

When someone experiences a significant deterioration, we must conduct a new final LOE benefit review. The timing depends on the level of the person’s recovery from the significant deterioration and should normally take place:

when a significant temporary deterioration ends, or
when we decide that we don’t need a non-economic-loss determination or redetermination of the person’s permanent impairment, or
within 24 months of the non-economic-loss processing date if the non-economic-loss determination or redetermination confirms a significant deterioration of the permanent impairment resulting in a non-economic-loss or an increased non-economic-loss benefit, based on the facts of the case.

If a person receives a new non-economic-loss benefit or an increased non-economic-loss benefit following a significant deterioration, the 24-month period for the final LOE benefit review may be extended if they are co-operating in a return-to-work plan that is not completed by the end of the 24-month period. The review must be completed within 30 days of the completion of the return-to-work plan.

Communication of decisions

Whenever possible we should explain decisions verbally to workplace parties and then follow up in writing with a decision letter. A decision letter should:

identify the issue,
summarize the facts of the case,
show what entitlement rules we used to make the decision (legislative and/or policy criteria, or standards),
explain how the rules were not met or met and give the reason for the decision,
only give evidence that is relevant to the decision, and
include the timeframe for appealing the decision.

We aim to communicate decisions in plain language to ensure the decision and reasons for the decision are fully understood by the person and their employer.

We must send a decision letter any time there are changes to a person’s LOE benefits, whether the benefits are being adjusted, stopped or any time there is a final review. The letter must include the reasons for the decision, the accepted areas of injury or illness, functional abilities, suitable occupation, and the earnings used to determine LOE benefits. If the person is working and their actual earnings weren’t used to calculate LOE benefits, the letter should provide the reason why. Similarly, if there is conflicting medical information about person’s impairment and functional abilities, the decision-maker should explain how the medical information was considered for the decision.

Document history:

October 2025 – replaces October 2020 document

October 2020 – replaces March 2015 document

March 2015 – replaces the document titled “Loss of Earnings Reviews: Practice Guidelines”, dated December 1, 2010

Scheduled review:

October 2030

Administrative practice document: Loss-of-earnings (LOE) benefit reviews

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