Workers' Requirement to Claim and Consent

Policy

The WSIB only issues one benefit payment (up to two weeks of loss of earnings benefits) to workers who are entitled to benefits under the insurance plan, but who have not met the claim and consent requirements. No further benefits are provided unless the worker meets the requirements.    

As soon as possible after an accident, workers must file a claim for benefits. They must also consent to disclose their functional abilities information, which is provided by the treating health professional.

A claim must be filed within six months of an accident or, in the case of an occupational disease, within six months of the worker learning of the disease. The WSIB may extend the six-month deadline, or waive the dual requirement altogether if in the WSIB's opinion it is just to do so.

If the worker does not file the claim for benefits, or consent to the disclosure of functional abilities information within the six-month deadline, the WSIB does not provide benefits unless, in its opinion, it is just to do so.

Purpose

The purpose of this policy is to outline how workers can meet the requirements for claiming benefits, and to identify when the WSIB may extend the time to claim and consent.

Guidelines

How workers claim

Workers meet their requirement to claim for benefits by signing Form 0006A - the Workers' Report of Injury/Disease Form 6 (Form 6) or Form REO6 - Worker's Continuity Report.

How workers consent

Workers meet their requirement to consent to disclose functional abilities information by signing

The FAF may also be available from employers.

Signature on Form 6

The WSIB sends a Form 6 to the worker to complete if the WSIB receives

This request for a completed Form 6 is made whether or not the worker has consented to the disclosure of functional abilities information on the FAF. Once completed, the worker keeps a copy of the Form 6, and must give their employer a copy of the claim for benefits at the same time they give a copy to the WSIB. In the case of occupational diseases, workers must give a copy of the claim to the employer who most recently employed them in the employment to which the disease is associated.

NOTE

Any reference to Form 6 includes the relevant occupational disease forms.

Providing benefits

If the worker is

  • entitled to benefits under the insurance plan, and
  • mentally and physically capable of meeting the requirements to claim and consent,

the WSIB issues the first benefit payment (up to two weeks of benefits) even if the worker's claim and consent has not been received. However, the WSIB does not provide further benefits until it receives the claim and consent.

If the worker does not provide the claim and consent by the end of the six-month filing period, the WSIB does not provide any benefits to which the worker may be entitled beyond the initial benefit payment.

Disablements

In disablement claims (conditions that emerge gradually over time), the six-month deadline begins from the date the worker reports the disablement as work-related. This can be reported to the employer, health professional, or the WSIB.

Concurrent entitlement

Workers who are entitled to benefits under the insurance plan in Ontario may also be entitled to benefits in another jurisdiction, or to take legal action against a third party. If so, workers who wish to claim benefits under the insurance plan must make an election.

Signature on Form 6

If the worker has already claimed for benefits on the Form 6, the WSIB gives the worker the appropriate election form to complete.

No signature

If the worker has not used the Form 6 to claim for benefits, the WSIB gives the worker the appropriate election form and the Form 6 to complete.

Because the law requires the worker to complete an election form within three months of the accident, the WSIB expects the worker to complete the election form and Form 6 at the same time.

In both cases, no benefits are provided until the worker completes and returns the relevant forms to the WSIB.

For more on entitlement in Ontario and other jurisdictions, see 15-01-09, Entitlement in Ontario and Other Jurisdictions. For more on third party actions, see 15-01-05, Third Party Rights of Action.

Claiming after the 6-month deadline

Whether or not the WSIB issued an initial benefit payment, the WSIB does not accept a worker's claim and consent past the six-month deadline unless it agrees to waive the requirements, or extend the deadline.

Deadline for right of action determinations

In some cases, workers may ask the Workplace Safety and Insurance Appeals Tribunal (WSIAT) to determine whether they may have the right to pursue a legal action against a third party under the Workplace Safety and Insurance Act, 1997.  If WSIAT rules that they do not have that right, the deadline for filing for benefits is six months following WSIAT's decision.

Waiving the requirements to claim and consent

Mentally/Physically incapable

If, as a result of the accident, the worker is mentally or physically incapable (e.g., unconscious) of claiming benefits and consenting to the disclosure of functional abilities information, the WSIB waives the requirements and issues the first and subsequent benefit payment(s) to the guardian.

As part of the ongoing management of the file, the WSIB monitors the worker's medical progress to determine whether the worker is capable of meeting the dual requirements.

If at any time the WSIB determines that the worker is capable of meeting the dual requirements, the WSIB sends a Form 6 to the worker and asks the worker to complete it within thirty calendar days of receiving it.

If this happens

  • before the six-month deadline to file a claim has expired, the WSIB withholds any further benefits to which the worker may be entitled until it receives the worker's claim and consent. If the worker does not file by the end of the six-month period, or thirty calendar days, whichever is greater, the WSIB does not subsequently accept the worker's claim and consent, and no further benefits are provided.
  • after the six-month deadline, and the worker does not meet the thirty calendar day deadline, the WSIB does not subsequently accept the claim and consent, and no further benefits are provided.

Extending the 6-month deadline

Changes in law or policy

If changes in law or policy expand new areas of entitlement for claims which may have been denied previously, workers may subsequently file a claim for benefits.

In these cases, the WSIB issues the first benefit payment even if the worker has not met the requirements. Once the WSIB sends a Form 6 to the worker and asks the worker to complete it, the worker has thirty calendar days to file the form. If the worker does not meet the deadline, no further benefits are provided.

Worker makes incorrect election

On rare occasions, workers may elect to claim benefits in another jurisdiction, only to discover that the claim can only be pursued in Ontario. If this happens

  • before the six-month deadline to file a claim for benefits has expired, workers are given the balance of the six months, or thirty calendar days from the date they discover that the claim can only be pursued in Ontario whichever is greater, to file a claim for benefits and complete the appropriate election form.
  • after the six-month deadline has expired, workers are given thirty calendar days to notify the WSIB that they wish to file a claim for benefits under the insurance plan. Upon receiving a Form 6 and the appropriate election form from the WSIB, workers are then given a further thirty calendar days to complete and return the forms to the WSIB.

In both cases, no benefits are provided until the worker completes and returns the relevant forms to the WSIB.

Accident not reported by employer

Independent of the worker's requirements to claim and consent, employers must report accidents to the WSIB, see 15-01-02, Employers' Initial Accident-Reporting Obligations. Therefore, the WSIB will accept a worker's claim past the six-month deadline if

  • the worker does not file a claim by the six-month deadline, but
  • the employer did not report the accident, and
  • Regulatory Services determines that the employer created a coercive workplace environment which resulted in the worker waiving, or forgoing, any benefits to which the worker was entitled.

Once Regulatory Services makes this determination, the worker has thirty calendar days to file the claim. In these cases, no benefits are provided until the worker meets the dual requirements. For more on employer offences, see 22-01-08, Offences and Penalties - Employer

Change in claim status 

In some cases, a claim may have been accepted in which the WSIB initially paid health care benefits only, but the worker subsequently experiences a loss of earnings and/or requires further health care.

If the worker did not meet the claim and consent requirements at the time the claim was initially accepted, the worker is now expected to meet those requirements, regardless of whether more than six months have passed since the original accident.

Similarly, workers who initially experienced a loss of earnings for less than two weeks, but did not meet the claim and consent requirements at the time the claim was accepted, are now expected to meet those requirements if they experience a recurrence, regardless of whether more than six months have passed since the original accident.

Both of these scenarios can also occur in cases when the loss of earnings is due to a breach of the employer's re-employment obligations. In these cases, if a worker did not meet the claim and consent requirements at the time the claim was initially accepted, that worker is now expected to meet those requirements, regardless of whether more than six months have passed since the original accident. For more information, see 19-02-02, Responsibilities of the Workplace Parties in Work Reintegration.

In all three cases, no benefits are provided until the worker meets the requirements to claim and consent. 

Workers can meet the requirement to claim by signing a Form 6 or Form REO6.

Workers can meet the requirement to consent to the disclosure of functional abilities information by signing 

Completing Form RE06

If the WSIB sends the worker a Form RE06 to complete

  • before the six-month deadline has expired, workers are given the balance of the six months, or thirty calendar days, whichever is greater, to return it to the WSIB
  • after the six-month deadline has expired, workers are given thirty calendar days to return it to the WSIB.

If the WSIB issues a Form RE06 to the worker after the six-month deadline has passed, and the worker does not meet the claim and consent requirements within the thirty-day period requested, the WSIB does not provide any benefits to that worker.

Exceptional circumstances

If a worker fails to file a claim by the respective deadline, the WSIB allows the claim to be filed at a later date if the worker can show that exceptional circumstances existed at the deadline.

Exceptional circumstances can include

  • compelling personal reasons, such as serious health problems or accident (experienced by the party or the party's immediate family), or the party leaving the province/country due to the ill health or death of a family member
  • the worker's ability to understand the time limit requirements and consequences of not meeting them (e.g., was the worker made aware at the workplace of the requirement to claim and consent; were language difficulties a factor?), and
  • whether the worker reported the accident to the employer, health care professional, or co-workers.

Claim by a minor

If the worker is less than sixteen years of age, the WSIB requires the worker's parent, guardian, or Children's Lawyer, as the case may be, to countersign the consent to the disclosure of functional abilities information. If the worker is sixteen or seventeen years of age, the WSIB does not require a counter-signature, see 15-01-07, Guardians for Workers/Survivors.

Application date

This policy applies to all claims submitted by the worker on or after February 15, 2013. 

Document History

This document replaces 15-01-03 dated August 1, 2007.

This document was previously published as:

15-01-03 dated November 1, 2005
15-01-03 dated October 10, 2004
15-01-03 dated August 1, 2001
15-01-03 dated May 23, 2000
15-01-03 dated June 15, 1999
3.2* dated January 1, 1998
02-02-02*.

*Documents were replaced by 15-01-03 dated June 15, 1999.

References

Legislative Authority

Workplace Safety and Insurance Act, 1997, as amended
Sections 16, 20, 21, 22, 30, 31, 152(3)

Minute

Administrative
#7, January 28, 2013, Page 503