Law
Section 33 of the Workplace Safety and Insurance Act provides:
A worker who sustains an injury is entitled to such health care as may be necessary, appropriate, and sufficient as a result of his or her injury.
The WSIB may arrange for the worker’s health care or may approve arrangements for his or her health care. The WSIB shall pay for the worker’s health care and may establish fee schedules for health care.
No health care practitioner shall request a worker to pay for health care or any related service provided under the insurance plan.
No action lies against the WSIB for payment of an amount greater than is established in the applicable fee schedule for health care provided to a worker. No action lies against a person other than the WSIB for payment for health care provided to a worker.
The WSIB shall determine all questions concerning the necessity, appropriateness and sufficiency of health care provided to a worker or that may be provided to a worker, and payment for health care provided to a worker.
Policy
The WSIB may enter into agreements with preferred suppliers for the provision of health care products/services to injured workers.
The WSIB expects Ontario workers to use preferred suppliers when the WSIB has entered into such agreements. Use of preferred supplier(s) ensures a worker will not have to pay when obtaining a health care product/service that is required as a result of a work-related injury/disease and for which there is entitlement in his or her claim. The preferred supplier(s) will submit the bill directly to the WSIB for payment.
Guidelines
Definitions
Preferred supplier is
- an organization that has entered into an agreement (e.g., contract, memorandum of understanding) with the WSIB for the ongoing provision of specified health care products/services that injured workers may require as a result of a work-related injury/disease
- the only organization(s) authorized by the WSIB to provide the specified health care products/services to injured workers unless an exception is met (see “Exceptions to the general rule” below)
- identified and communicated to the public, stakeholders and other interested parties, as the organization(s) of choice for WSIB clients, and
- accountable for any service processes and quality standards set and monitored by the WSIB.
Health care products are
- products that are prescribed by a health professional, and
- used as a treatment or functional aid during the worker’s recovery from a work-related injury, or used to improve or maintain the worker’s independent living.
Examples include wrist supports, toilet seats, crutches, etc.
Health care products do not include prescription, over-the-counter or off-the-shelf medications.
Health care services are
- services that are required by the worker for the provision or maintenance of certain health care products, and
- are supported by health care reports.
Examples include the installation/maintenance of home/vehicle modifications.
NOTE
Health care products/services should be pre-approved by the WSIB, see the specific Operational Policy manual (OPM) document(s) such as 17-07-06, Health Care Equipment and Supplies.
General rule
Workers are expected to use a preferred supplier to obtain the health care product/service that he or she requires as a result of the work-related injury/disease.
The WSIB will pay for the health care product/service if
- the claim is allowed and there is ongoing entitlement to benefits and/or services, and
- the entitlement criteria for the health care product/service are met (see relevant OPM document(s) for specific entitlement criteria).
The WSIB will make payment to
- a preferred supplier, or
- a worker or a non-preferred supplier, if one or more of the following exceptions are met.
NOTE
For examples of which health care products/services are covered by a preferred supplier agreement, see the relevant OPM documents, such as 17-07-06, Health Care Equipment and Supplies.
Exceptions to the general rule
There may be situations when an injured worker cannot be expected to obtain a health care product/service from a preferred supplier, consideration will be given to these cases if one or more of the following five exceptions are met:
1. Purchases made prior to claim allowance
Purchases are made by the worker prior to the WSIB allowing the claim (e.g., provision of health care products/services at a hospital or clinic on the day of accident). The WSIB will provide reimbursement if the claim is allowed and there is entitlement for the health care product/service.
2. Urgent need
The worker may be aware of the preferred supplier relationship but urgently needs a health care product/service because
- the health care product breaks or requires service and the worker is unable to function without it for any length of time, so he or she purchases a replacement at, or requests service from, the most immediately available location, or
- the health care product is out of stock or not carried by the preferred supplier(s) and waiting for delivery of the health care product will not meet the immediate need.
3. Fitting, Precise Sizing or Adjustment required
A worker requires a health care product
- that needs to be fitted, precisely sized, or adjusted, or
- for the first time, that needs to be adjusted and this cannot easily be done over the phone or when ordering from a catalogue (e.g., adjustable cane) and there are no preferred suppliers in the worker’s community.
NOTE
This is not an exception when the worker requires a replacement health care product and an identical health care product to the one being replaced is available from a preferred supplier.
4. Out of province
If a worker
- is working outside of Ontario at the time of the accident see “Purchases made prior to claim allowance” above, or
- is travelling or living temporarily/permanently outside of Ontario, the worker should contact the WSIB for pre-approval of the health care products/services, except when the criteria for “Urgent need” are met.
NOTE
This exception should be read in conjunction with OPM 17-01-04, Health Care Outside Ontario.
5. Worker not aware of policy
Occasionally, in spite of WSIB best efforts, a worker may be unaware of the policy to use preferred suppliers. This situation may occur if the worker was
- never advised of the requirement to use the preferred suppliers, or
- advised of the requirement to use the preferred suppliers but due to a language barrier was unable to understand this requirement.
Compliance
The WSIB does not tolerate an offence against the system by external suppliers of products/services, for more information see 22-01-06, Offences and Penalties - External Supplier of Goods and Services.
Suppliers of health care products/services should not be directing workers to pay for and request reimbursement from the WSIB for the health care product(s)/service(s).
Application date
This policy applies to all purchases of health care products/services, covered by a preferred supplier agreement, made on or after March 3, 2008, for all accidents.
Document History
This document replaces 17-01-07, dated March 3, 2008.
References
Legislative Authority
Workplace Safety and Insurance Act, 1997, as amended
Sections 32, 33 (1),(2),(3),(5),(6),(7)
Workers' Compensation Act, R.S.O. 1990, as amended
Sections 50 (1),(2),(3),(4),(6),(7)
Minute
Administrative
#17, March 2, 2009, Page 473