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 and/or has a loss of wages/earnings.
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.
Periods of disability/impairment can be prolonged by
- age
- pre-existing conditions, see 14-05-03, Second Injury and Enhancement Fund (SIEF)
- complications
- accidents resulting from treatment, see 15-05-02, Accidents Resulting from Treatment
- psychological conditions, see 15-04-02, Psychotraumatic Disability, or
- malingering.
If the disability/impairment is prolonged, the decision-maker may consult with WSIB clinical staff regarding the appropriateness of the treatment program.
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 disability/impairment.
Decision-makers determine the expected length of disability/impairment based on the following information which includes but is not limited to
- clinical reports from the treating health professional(s)
- specialists' report(s), where appropriate
- reports from agency(ies) providing treatment and/or evaluation, (e.g., Regional Evaluation Centres)
- information from the worker on his/her disability/impairment
- external, evidence-based medical/scientific guidelines on disease and injury-specific disability/impairment and treatment, and
- if obtained, the advice of WSIB clinical staff.
Decision-makers consider
- if recent clinical reports indicate 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 worker's disability/impairment, see 11-01-05, Determining Maximum Medical Recovery (MMR).
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), 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
- 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, see19-02-01, Work Reintegration Principles, Concepts and Definitions.
Application date
This policy applies to all decisions made on or after February 15, 2013, for all accidents.
Document history
This document replaces 11-02-02 dated November 3, 2008.
This document was previously published as:
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), 43
Workers' Compensation Act, R.S.O. 1990, as amended
Sections 1(1), 37
Minute
Administrative
#3, January 28, 2013, Page 503