A worker may be entitled to benefits/services if they suffer a work-related injury/disease and lose time from work, have a loss of wages/earnings, or have a permanent disability/impairment.
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.
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.
For the purpose of this policy, impairment plus a loss of earning capacity refers to disability in pre-1990 claims.
The WSIB reviews 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, the WSIB is responsible for issuing wage loss benefits or loss of earnings benefits and monitoring the treatment and recovery of the worker.
Length of disability/impairment
The WSIB monitors, assesses and weighs the health care information in the worker's claim file to determine whether they have recovered from their work-related injury/disease.
Periods of disability/impairment can be prolonged by:
- pre-existing conditions, see 15-02-03, Pre-existing Conditions
- accidents resulting from treatment, see 15-05-02, Accidents Resulting from Treatment, or
- psychological conditions, see 15-04-02, Psychotraumatic Disability.
If the disability/impairment is prolonged, the WSIB may obtain a clinical opinion regarding the appropriateness of the treatment program.
The WSIB considers:
- 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.
While the worker is unable to perform any type of work, the WSIB issues wage loss benefits or loss of earnings benefits. The WSIB monitors 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.
Return to work (RTW)
The WSIB determines, through the review of clinical information, when a worker is fit to go back to their 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.
If there are challenges that impact the worker's return to work that the workplace parties cannot resolve on their own, the WSIB may conduct a RTW assessment.
The RTW assessment is initially used to determine if the worker is, or will be, medically able to return to their pre-injury job (with or without accommodation) or to a new job.
Following the RTW assessment, the WSIB may develop a RTW plan that outlines the assistance and services the worker requires to enable their return to work. See 19-02-10, RTW Assessments and Plans.
While participating in a RTW plan, the worker may continue to receive wage loss or loss of earnings benefits.
This policy applies to all decisions made on or after March 1, 2021, for all accidents.
This document replaces 11-02-02 dated January 2, 2015.
This document was previously published as:
11-02-02 dated February 15, 2013
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.
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
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