Lost Time Claims

Policy

A worker may be entitled to benefits/services if the worker suffers a work-related injury/disease and the worker loses time from work, has a loss of wages/earnings, or has a permanent disability/ impairment.

Purpose

The purpose of this policy is to outline when a claim is considered to be a "lost time" claim and the benefits and services a worker may be entitled to in a lost time claim.

Guidelines

A "lost time" claim is created when a worker suffers a work-related injury/disease which results in

  • being off work past the day of accident
  • loss of wages/earnings, or
  • a permanent disability/impairment.

NOTE

For the purpose of this policy, impairment plus a loss of earning capacity refers to disability in pre-1990 claims.

Decision-makers review the information on file to determine a worker's entitlement to benefits. Clinical evidence on file must show that the inability to work is due to the work-related injury/disease. If the worker does not have clinical authorization to be off work, wage loss benefits or loss of earnings benefits cannot be paid.

Once entitlement has been determined and the initial payment has been made, decision-makers are responsible for issuing wage loss benefits or loss of earnings benefits and monitoring the treatment and recovery of the worker.

Length of disability/impairment

Decision-makers monitor, assess and weigh the health care information in the worker's claim file to determine whether the worker has recovered from his/her work-related injury/disease.

Periods of disability/impairment can be prolonged by

If the disability/impairment is prolonged, the decision-maker may obtain a clinical opinion regarding the appropriateness of the treatment program.

Decision-makers consider

  • if recent clinical evidence indicates any change in the worker's disability/impairment, and
  • if the worker is currently receiving or will receive treatment that is likely to improve the work-related injury/disease.

See 11-01-05, Determining Permanent Impairment for more information.

Total disability/impairment

While the worker is unable to perform any type of work, the WSIB issues wage loss benefits or loss of earnings benefits. Decision-makers monitor the claim through the use of progress reports, which are reviewed as often as the severity of the injury dictates to ensure the worker is recovering as expected.

Work reintegration

Decision-makers determine, through the review of clinical information, when a worker is fit to go back to his/her pre-injury work, or suitable and available work.

If the worker is only able to do work that is available at a partial loss of wages/earnings, the worker may be entitled to a partial wage loss benefit or a partial loss of earnings benefit, see 18-03-02, Payment and Reviewing LOE Benefits (Prior to Final Review) and, 18-06-02, Calculating Temporary Partial Disability Benefits.

Work transition

The WSIB provides the worker with a work transition (WT) assessment and, if necessary a WT plan, if the work reintegration activities do not result in a return to work that

  • is suitable
  • is available, and
  • to the extent possible, restores the worker's pre-injury earnings.

While participating in the WT plan, the worker continues to receive wage loss or loss of earnings benefits, see 19-02-01, Work Reintegration Principles, Concepts and Definitions.

Application date

This policy applies to all decisions made on or after January 1, 2015, for all accidents.

Document History

This document replaces 11-02-02 dated February 15, 2013.

This document was previously published as:
11-02-02 dated November 3, 2008
11-02-02 dated June 1, 2006
11-02-02 dated October 12, 2004
02-03-03 dated March 4, 1997.

References

Legislative Authority

Workplace Safety and Insurance Act, 1997, as amended
Sections 2(1), 42, 43, 46

Workers' Compensation Act, R.S.O. 1990, as amended
Sections 1(1), 37, 42, 43

Minute

Administrative
#4, December 12, 2014, Page 521