A worker who is receiving benefits under the insurance plan, or who is entitled to do so, is required to
- provide the WSIB with any information necessary to adjudicate the claim
- co-operate in health care measures the WSIB considers appropriate
- undergo an examination by a health professional selected and paid for by the WSIB
- undergo an examination by a health professional selected and paid for by the employer if directed by the WSIB
- co-operate in all aspects of work reintegration (WR), including work transition (WT) assessments and plans.
If a worker does not fulfill these obligations, the worker's benefits may be reduced or suspended.
The purpose of this policy is to set out a worker's co-operation obligations and the penalties for non-compliance.
Workers must give the WSIB information necessary to assist in the adjudication of their claims. For example, workers whose employment pattern was non-permanent or irregular at the time of the injury are required to submit proof of earnings information by the 13th week of benefits, see 18-02-03, Determining Long-term Average Earnings - Workers in Permanent Employment, and 18-02-04, Determining Long-term Average Earnings - Workers in Non-permanent Employment.
If a worker must obtain the information from a third party, the WSIB must be satisfied that the worker failed to take all reasonable steps to acquire the information before making a finding of non-co-operation.
When a worker does not provide the necessary information, the WSIB may reduce or suspend the worker's benefits until the information is provided.
Workers must co-operate in the health care measures the WSIB considers appropriate. If they do not, the WSIB may reduce or suspend their benefits until they co-operate.
Examples of non-co-operation include
- changing health professional without WSIB approval, see 17-01-03, Choice and Change of Health Professional
- not following prescribed treatment
- intentionally abusing prescription medication, or
- missing appointments with health care practitioners.
If a worker has a legitimate reason for failing to follow prescribed treatment, the decision-maker, in consultation with WSIB health care staff, considers acceptable alternative treatments.
For information regarding workers with non-work-related health problems interfering with the treatment of a work-related condition, see 17-03-04, Health Care for Non-work-related Conditions.
If a worker refuses to undergo a health examination requested by the attending health professional or the WSIB, or if the worker obstructs the examination, the WSIB may reduce or suspend benefits until the worker co-operates. For more information on WSIB-requested health examinations, see 17-04-03, WSIB-Requested Health Examinations.
If the WSIB directs that an employer-requested health examination take place, the worker must undergo the examination as directed. If a worker fails to do so, the WSIB may reduce or suspend benefits until the worker co-operates. For information on employer-requested health examinations, see 17-04-02, Employer-Requested Health Examinations.
For information on the specifics of the worker's obligation(s) to co-operate in WR, see 19-02-02, Responsibilities of the Workplace Parties in Work Reintegration.
Notice of non-co-operation
If the WSIB determines that a worker is not co-operating with the obligation(s), the decision-maker notifies the worker of the
- obligation to co-operate
- finding of non-co-operation, and
- consequences of this finding (i.e., the reduction and/or suspension of benefits).
Notice is given verbally (if possible), and confirmed in writing in every case.
Reducing or suspending benefits
The WSIB may reduce or suspend a worker's benefits if after notifying the worker of the obligation(s), the worker
- fails to co-operate with the obligation(s), and
- does not have a legitimate reason for not co-operating.
The WSIB does not restore benefits for any period that they were reduced or suspended due to non-co-operation unless the WSIB
- did not communicate to the worker the obligation(s) and the consequences of non-co-operation, or
- made an error in finding the worker to be non-co-operative.
When a worker does not meet an obligation, the WSIB determines whether there was a legitimate reason. Workers are not penalized for non-co-operation if there is a legitimate reason. Legitimate reasons include
- unexpected illness, accidents, severe weather conditions
- compelling personal reasons, such as a death in the family
- the actions or inactions of a relevant third party, such as Canada Revenue Agency (CRA), if tax records are involved.
A worker may request up to 3 weeks vacation time per year. Vacation time may be approved if the worker and the decision-maker agree upon the time of the vacation, and it does not interfere with the worker's ability to fulfill any of the obligations.
Offences - Fraud
When a worker commits a claim-related offence or fraud, the WSIB reduces or suspends benefits in accordance with 22-01-05, Offences and Penalties - General.
This policy applies to all decisions made on or after February 15, 2013, for all accidents.
This document replaces 22-01-03 dated October 12, 2004.
This document was previously published as:
11-01-07 dated June 15, 1999.
Workplace Safety and Insurance Act, 1997, as amended
Sections 23, 34, 35, 36, 40, 42(7), 43(7)
Workers' Compensation Act, R.S.O. 1990, as amended
Sections 23, 34, 37, 43, 69(3), (4)
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