The WSIB pays for requested clinical assessments or reports used solely to adjudicate claims. These assessments/reports are considered benefit expenses.
Nature of assessment
The WSIB pays the costs of clinical assessments used to adjudicate claims. This includes payment for assessments used for health care or return-to-work purposes.
Nature of report
If the WSIB receives reports not specifically requested, payment is made only if the information submitted is necessary and/or useful for making a decision. If the report repeats information already on file or, if it contains information that is of no value to the adjudicative process, no payment is made.
The WSIB does not pay for clinical reports submitted by employers or their representatives for adjudicative purposes, although the information may be used to help decide an issue.
Payment in denied claims
If a claim is denied, the WSIB may pay for the following
the initial health care visit, not including treatment or procedures
consultation fees when workers are referred by their attending health professional and the consultation report is used to adjudicate the claim
diagnostic procedures for adjudication purposes
x-rays taken at the time of the initial consultation, provided they are used for diagnostic purposes
hospital fees if workers are admitted to hospital at the WSIB's request to investigate a non-work-related condition
consultant's fees for examinations made at the WSIB's request
initial treatment if a worker does not have any other clinical coverage and at the time of treatment presents a WSIB "Treatment Memorandum" form signed by the employer
clinical investigation and/or emergency treatment authorized by the WSIB
unsolicited clinical reports when the information in the report is used for adjudicative purposes, and/or
if a health professional is requested to submit a copy of a clinical report or a report expressing an opinion regarding prognosis.
Health care fees
For information on health care fees, see 17-03-01, Health Care Fees.
Workers' personal health care insurance
The WSIB reimburses workers whose insurance policies pay for their health care benefits and clinical accounts, as if the accounts were paid for by the workers themselves.
This policy applies to all decisions made on or after July 1, 1994, for all accidents.
This document replaces 17-02-03 dated October 12, 2004.
This document was previously published as:
17-01-06 dated June 15, 1999.
Workplace Safety and Insurance Act, 1997, as amended
Sections 33, 37, 131(1)
Workers' Compensation Act, R.S.O. 1990, as amended
Sections 50, 51, 72(1)
#7, November 15, 2006, Page 430
Board of Directors
#7, December 5, 1991, Page 5490