Policy
A claim created by the WSIB for a workplace accident/disease is adjudicated based on entitlement principles and the facts of the case. The claim may be handled by a specific area of the WSIB given the nature of the injury/disease.
Guidelines
Adjudication is the process used to determine entitlement to benefits and services under the Workplace Safety and Insurance Act or the Workers' Compensation Act (the Act). An adjudicator is the person who makes decisions regarding entitlement.
Once an accident report has been received by the WSIB, a claim is set up and assigned to the appropriate operating area. A short description of the claim and adjudication types follows.
Primary adjudication
This is the first step in the adjudication process. If all necessary information is received, the facts of the claim are very straightforward, and the employer is not disputing the allowance of the claim, the claim can be allowed and paid immediately by a primary adjudicator. If a decision cannot be made immediately, the claim file is forwarded to a consolidated adjudicator to gather the relevant information required to render a decision.
Continuing adjudication
If initial entitlement in a lost time claim has been allowed, the consolidated adjudicator is responsible for the continuing payments, while monitoring the treatment, recovery, and rehabilitation of the injured worker, until the worker is fit to return to work or is assessed for a permanent impairment award (for accidents on or after January 1, 1990) or a permanent disability award (for accidents prior to January 1, 1990). If a worker has a recurrence or flare-up of the disability/impairment, this is also handled by a consolidated adjudicator.
Occupational disease adjudicators
The Occupational Disease and Survivors' Benefit Program (OD & SBP) handles claims involving fatalities, and specific occupational diseases such as asbestosis, silicosis, cancers etc.
Five point check system
All adjudicators use the same criteria for ruling on initial entitlement to WSIB benefits. This system is known as the "five point check system."
An allowable claim must have the following five points
- an employer (see 12-01-01, Who is an Employer?)
- a worker (see 12-02-01, Workers and Independent Operators)
- personal work-related injury
- proof of accident, and
- compatibility of diagnosis to accident or disablement history.
Proof of accident
Some points adjudicators consider when examining proof of accident are
- Does an accident or disablement situation exist?
- Are there any witnesses?
- Are there discrepancies in the date of accident and the date the worker stopped working?
- Was there any delay in the onset of symptoms or in seeking health care attention?
Diagnosis
If it is not clear that the (injury or disablement) diagnosis provided is the result of the accident or disablement history described, an opinion is sought from the WSIB's medical consultant.
Application date
This policy applies to all decisions made on or after May 1, 1989, for all accidents.
Document history
This document replaces 02-01-02 dated May 1989.
References
Legislative authority
Workplace Safety and Insurance Act, 1997, as amended
Section 2(1)
Workers' Compensation Act, R.S.O. 1990, as amended
Section 1(1)
Minute
Administrative
#11, June 23, 2004, Page 376