Home » WSIB Claims and Appeals: What You Need to Know

WSIB Claims and Appeals: What You Need to Know

February 23, 2022 by dccinc

If you are a Canadian resident living in Ontario and have been injured on the job or developed a disease related to the work you have been doing, you may be eligible to receive compensation from the Workplace Safety and Insurance Board (WSIB).

In this article we will be introducing you to the Ontario WSIB system to help you gain a greater understanding of the following:

About The Workplace Safety Insurance Board (WSIB) in Ontario

In Ontario, the workplace insurance system provides benefits and services to workers who have been injured at work or who have diseases related to work. This includes a range of rehabilitation services, loss of earnings benefits, health care coverage for workers, and financial support for retraining programs.

Workplace insurance is a “no-fault” system with access to industry-specific information for employers. This means that employers share the responsibility for paying for an employee’s injury if the cause cannot be determined.

The benefits of this system are clear. Employers can get protection for work-related injuries while paying into an accident insurance fund. Meanwhile, workers in Ontario can receive workplace safety and insurance benefits, so long as they can prove that the injury or disease was work-related.

The Workplace Safety and Insurance Board (WSIB) is an agency of the government of Ontario, in charge of managing the workplace safety and insurance system, in accordance with the Workplace Safety and Insurance Act, of 1997. Additionally, WSIB is entirely funded by employer premiums alongside the income earned from investments.

It is the WSIB’s mandate to:

1. - Promote workplace health and safety
  - Assist injured workers in returning to work, recovering, and re-entering the workforce
  - Insurance provided compensation and other benefits to injured workers and their survivors

The WSIB is completely governed by a board of directors, in charge of:

1. - Setting policies and processes for determining how the WSIB sets out to achieve its objectives.
  - Carrying out the roles and responsibilities of the WSIB that are assigned under the legislation.
  - Being accountable to the Government of Ontario, regarding the implementation of its mandate, through the Minister of Labor.

The WSIB head office is located in Toronto and is supplemented by district and area offices throughout the province.

Disability Credit Canada is here to help with WSIB claims and applications for Injured and affected employees in Ontario. Check out the following article which goes into detail about understanding WSIB Claims.

Types of WSIB Claims

There are two primary types of WSIB claims that can be made by workers in Ontario, who have been injured at work or who have occupational diseases, they are as follows:

1. - No Lost Time (11-02-01)
  - Lost Time Claims (11-02-02)

The purpose of these two primary types of claims is to highlight when a claim is a “no lost time” or “lost time” claim and the benefits and services a worker may be entitled to receive regarding the type of claim they’re applying for.

No Lost Time (11-02-01)

A “no lost time” claim can be classified as a work-related injury, which does not result in lost time from work, other than on the day that the accident occurred, where healthcare is still required. Any costs associated with the injury will then be paid out by the WSIB.

The employer is responsible for reporting a claim within 7 business days, after learning of the injury, regardless of whether there has been no time lost from work or loss of earnings.

NOTE: If any time after a “no lost time” claim is granted, the injury necessitates the worker to take time off work, the claim then becomes a “lost time” claim.

Lost Time Claims (11-02-02)

A “lost time” claim is classified as a work-related injury/disease, which results in lost time from work past the day of the accident, a loss of wages/earnings, or a permanent disability/impairment.

When making a “lost time” claim the WSIB reviews the information provided on file to determine what benefits a worker may be entitled to receive. As such, clinical evidence on file must indicate that the inability to work is due to a work-related injury/disease. Without clinical authorization to be off work, wages loss benefits, or loss of earnings benefits will not be paid out.

Although, once entitlement has been granted and the initial payment has been made the WSIB, takes on the responsibility for issuing wage loss benefits or loss of earning benefits, while monitoring treatment and recovery proceedings.

Under the guidelines for this policy the WSIB will assess and monitor the following:

1. 1. Length of disability/impairment: Here they will weigh the health care information provided in the worker’s claim film to determine whether they have recovered from their work-related injury/disease.
  2. Total disability/impairment: If the worker is unable to perform their work duties, they will be provided with wage loss or earnings benefits from the WSIB. WSIB claims are typically monitored through progress reports and reviews. If the severity of an injury warrant, these reports and reviews can be very frequent to ensure the worker is progressing as expected.
  3. Return To Work (RTW): Here, the WSIB seeks information through clinical information, to determine whether a worker is fit to return to their pre-injury work or suitable and available work.
  4. RTW assessments/plans: If the workplace parties have difficulties coming to an agreement on how the worker can RTW, WSIB may conduct an RTW assessment for further insight into the matter.

Types of Injuries/Diseases You Can File a WSIB Claim For

In this section of the article, we will be covering the different types of injuries/diseases for which you can file a WSIB claim for. It is our hope that with this information you will have a clearer understanding of the various claim categories that are available to you through the WSIB. There are many kinds of work-related injuries/diseases that you can file a WSIB claim for.

The different kinds of work-related injuries/diseases you can file a claim for are as follows:

Accidents:

An accident can be classified as an injury that occurs because of a single work-related incident. For example, if you fall and break a bone, injure/pull your back while lifting a heavy object, or get cut by a sharp object while on the job.

Disablements:

An injury that occurs gradually over time, because of the type of work you do and does not require a specific incident. For example, developing pain in your arms, shoulder, or back due to several hours or days of working on an assembly line.

Psychological Conditions:

A psychological condition that develops because of a recognized workplace accident/disease. For example, developing depression or anxiety, due to being injured and off work for an extended period.

NOTE: It’s important to note that if you develop a psychological condition due to workplace stress, you should consult a qualified representative. As special rules apply under these conditions.

Occupational Diseases:

A work-related disease or illness caused by exposure to chemicals or other substances. For example, developing lung cancer because of exposure to asbestos found in the workplace.

You can file an occupational disease claim if you have been diagnosed with a disease linked to your employment or if you were removed from all exposure to the substance to avoid contracting the disease.

NOTE: It’s important to note that some diseases develop over time. In this case, you can still file a claim for occupational disease, regardless of if you still work at the same job linked to the disease.

Hearing Loss:

A loss of hearing, caused by exposure to loud noises while on the job, is referred to as noise-induced hearing loss. For example, developing partial hearing loss because of exposure to loud machinery.

NOTE: It’s important to note that whether you experience full or partial loss of hearing you can file a WSIB claim for hearing loss.

Survivors’ Benefit:

If you are the spouse, child, or other dependent of a worker who has passed away from a work-related injury or occupational disease/illness you may be eligible to file a claim for the survivors’ benefits.

This includes a lump sum payment and monthly benefits, with additional assistance for surviving spouses looking to re-enter the workforce. On top of that, funeral expenses, and counseling services for survivors, may also be covered.

NOTE: The Office of the Worker Adviser (OWA) offers special assistance to the families of workers who died under traumatic work-related incidents, through the Fatalities and Immediate Response (FAIR) partnership.

When to File a WSIB Claim

To file a WSIB claim, you must be working at a job that is covered by workplace insurance. Additionally, to ensure you receive WSIB benefits for a work-related injury/disease a claim must be filed as soon as possible or no later than six months from the date of the accident or diagnosis.

In cases of an occupational disease, the six-month period begins from the date it was first discovered that you have the disease and was confirmed to be work-related. Similarly, for cases of disablement, that grace period begins from the date it was first reported as a work-related injury or medical problem.

NOTE: All claims can be reported to either an employer, a doctor (health care professional), or the WSIB.

You should file a WSIB claim if any of these incidents apply to you:

1. - You are injured due to a work-related accident (For example, falling off a ladder, pulling out your back, getting cut by a sharp object, or getting pinned by a piece of machinery).
  - You gradually develop a medical problem, believed to be work-related (For example, tendonitis or carpal tunnel syndrome caused by repetitive movements).
  - You develop a disease or medical problem, believed to be work-related (For example, exposure to loud noise, chemicals, or dust).

Reporting Rights & Responsibilities:

Under the rights and responsibilities portion of this article, we will be touching upon the legal responsibilities of the worker to report his or her work-related injury or disease to the WSIB.

According to this policy:

1. - You have 6 months from the date of injury or diagnosis to claim benefits, by filing a report to the WSIB.
  - If you are unsure about a potential injury or occupational disease, always report it to the WSIB, even if you think you might not be covered.
  - It is important to always report your workplace injury or disease even if:
    - You’re instructed by your supervisor or manager not to make a report, otherwise, you will lose your job.
    - Your employer informs you that your injury or occupational disease will not be covered by WSIB.
    - You’re prompted by your employer to use sick days to recover from a work-related injury or disease, versus reporting it to the WSIB.
  - If there are options for you to choose a healthcare practitioner.

Extended Time Limit of a Claim:

Under the extended time limit of a claim portion of this article, we will be clarifying how to file a claim with the WSIB, despite missing the six-month deadline.

If you file a claim late, you may still file your claim, if you ask the WSIB for an extended time limit and explain why you missed the deadline. Given that, there are exceptional circumstances where the WSIB might grant extensions for filing a claim late, which will be outlined here.

The WSIB can extend the deadline for filing a claim if:

1. - You’re in the process of waiting to hear back on whether you can sue someone instead of claiming WSIB benefits.
  - Your physical or mental limitation prohibits you from filling out the Worker’s Report of Injury/Disease (Form 6), and thereby giving your healthcare practitioner permission to file a report on your behalf.
  - A change in the laws may permit you to get benefits that you couldn’t get in the past.
  - You filed your claim improperly. For instance, making a claim for benefits in another province by mistake.
  - Your employer did not file an Employer’s Report of Injury/Disease (Form 7) and put pressure on you to not file a Form 6.

The WSIB can also extend the deadline for filing a claim if there are exceptional circumstances, such as:

1. - You or a relative having an accident or serious health issue.
  - You had to leave the province due to an illness or death in the family.
  - You were unaware of the deadlines or what would happen if you didn’t meet them.
  - You had informed either your employer, a healthcare practitioner, or a co-worker of the accident (injury/disease) but weren’t aware that you had to also report it to the WSIB.

NOTE: All the above are just a few examples of some of the reasons the WSIB might grant you an extension for filing a claim late. However, there are a variety of other reasons the WSIB might take into consideration as well. Although, you will still have to provide them with a good reason for why you didn’t file your claim on time.

WSIB Eligibility Criteria

If you’re a Canadian citizen living in Ontario, you may be eligible to receive WSIB benefits if one or more of the following applies:

1. - Your workplace/employer is covered under WSIB.
  - You suffered a work-related injury or disease.
  - You or your employer report your work-related injury or disease to the WSIB, and your claim is approved.
  - You provide the WSIB with sufficient clinical and employment information needed to form a decision about your benefits.
  - You consent to share information about your functional abilities with the WSIB and your employer.

NOTE: The WSIB’s Functional Abilities Form (PDF) provides information about your physical condition in addition to your ability to work. This form is to be completed by a healthcare practitioner (doctor, physiotherapist) who is treating you. In this form, they will identify specifics about your ability to walk, stand, sit, lift, and perform other work-related tasks. The information provided in this form will then be used by the WSIB to help you plan your return to work.

What Benefits Can Be Claimed Under WSIB Compensation

The WSIB works on your behalf to provide you with the care and support you need to recover and safely return to work. This is accomplished by providing you with benefits, compensation, and return-to-work services on account of a work-related injury or disease.

This portion of the article has all the information you need to know about the benefits and services offered by the WSIB. These include health care, income replacement, and return-to-work services. Additionally, if your claim is allowed (approved), you may be eligible to receive WSIB benefits, including benefits for lost pay, help to recover, return to work and more.

Benefit for loss-of-earnings:

This particular benefit offered by the WSIB can be classified as a “lost time” claim, which results in a loss of time from work past the day of the accident because of a work-related injury or disease/illness. If the WSIB allows your claim you may be entitled to receive loss-of-earnings and healthcare benefits. Meaning the WSIB will pay for your loss of wages. Although, while you receive said benefits you will also be required to participate in your recovery and return to work.

Benefit for non-economic loss:

A non-economic loss benefit compensates you based on the degree of your permanent disability resulting from a work-related injury or disease/illness. For this, you are eligible under section 46 of the Workplace Safety and Insurance Act, 1997 (WSIA). The WSIB pays you a non-economic loss benefit when you have an ongoing impairment after your work-related injury or disease has reached the maximum medical recovery date, where it is not expected to improve.

According to the WSIA a “permanent impairment” is defined as a physical or functional abnormality or loss (including disfigurement) resulting from an injury or psychological damage sustained from the abnormality or loss that continues to exist after you reach the point of maximum medical recovery.

Health-care benefits:

If you require assistance with your recovery, the WSIB can provide you with benefits for medical treatment, and hospitalization, including emergency care and surgery, medical devices and orthotics, equipment and supplies, prescription medications, and even reasonable travel and accommodation expenses associated with your occupational injury/disease. If your claim is allowed the WSIB will pay for all approved healthcare costs related to your claim, even if you have not missed time from work, or have your own insurance coverage.

Benefit for loss-of-retirement income:

This benefit applies to persons under the age of 65 on the date of your work-related injury or disease/illness who have also been receiving loss-of-earnings benefits (LOE) non-stop for 12 months. Under the policy for this benefit, the WSIB will set aside an amount equal to 5 percent of all subsequent LOE benefits to pay for a loss-of-retirement income (LRI) benefit. However, you will not receive this amount until the age of 65. Additionally, with the LRI benefits, you can make additional contributions yourself by having the WSIB deduct five percent from your payments each month.

NOTE: If you happen to pass away before the age of 65, because of your injury, any dependents will receive the survivors’ benefits. Instead of the amount set aside by the WSIB and the investment income earned on that portion.

Services for seriously injured people:

If you have sustained a serious injury or impairment while on the job, WSIB can provide you with specialized services to aid in your recovery to improve your overall quality of life. Moreover, according to the WSIB, you’ve experienced a serious injury if your impairment is permanent and you receive a non-economic-loss benefit of 60 percent or more, or permanent and you receive permanent disability benefits totaling 100 percent or rather both.

Survivors’ benefits:

If you are the spouse, child, or other dependent of a worker who has died of a work-related injury or occupational disease/illness you may be eligible to file a claim for the survivors’ benefits. The WSIB provides four types of survivor benefits, being: survivor payments, funeral, and transportation costs, bereavement counseling, and support for spouses looking to rejoin the workforce.

Benefit for future economic loss (FEL):

For individuals who have been permanently injured after January 1, 1990, and before January 1, 1998, you may be eligible to receive the benefits for future economic loss provided by the WSIB. This benefit is based on 90% of the difference between a worker’s take-home pay prior to the work-related injury and their expected take-home pay after the date of the injury. Adjusted annually for inflation.

Benefits for claims made before 1990:

If you sustained a work-related injury or disease prior to January 2, 1990, you may be eligible to receive WSIB benefits. Additionally, if you have never fully recovered from a workplace injury or disease that happened before 1990, you may also qualify for permanent disability benefits. Although, the amount you may be eligible to receive depends on, how much you earned prior to your injury, the date of your injury or diagnosis, and lastly the level of your permanent disability.

Why WSIB Denied My Claim

As is the case with every WSIB claim, it is important to ensure all favorable evidence for the claim to have an optimal chance of success. Especially when there are a variety of reasons why a WSIB claim may be denied. Though it is through, understanding these reasons, that we can improve upon the success of future claims.

Some of the key reasons why the WSIB claim may be denied are as follows:

1. - The worker is not injured enough: Often, injured workers’ claims for compensation are denied on the basis that they fall short of meeting the “permanent impairment” threshold, as is defined in the Workplace Safety and Insurance Act, 1997.
  - Insufficient medical/clinical information: Other times WSIB claims are rejected solely on the basis that the worker making a claim due to a work-related injury or disease, fails to provide the WSIB with enough strong evidence to support their claims eligibility.
  - Non-compliance with WSIB requirements: On the rare chance that a worker’s injury or disease meets the WSIB permanent disability standard, the claim can still be denied on the basis that it fails to meet the specific WSIB requirements. Such as the requirement for documenting and submitting a claim or a failure to adhere to prescribed medical protocols.

The above are only a few examples of the many potential reasons why a WSIB claim may be denied. Although, if you are experiencing issues with establishing your entitlement to WSIB benefits, the experts at Disability Credit Canada are here to help.

What To Do If WSIB Denies Your Claim

Shortly after filing for WSIB benefits, you’ll receive a letter indicating to you a decision on your claim or the claim of your employee. If you disagree with their decision, the WSIB urges you to respond to the letter as soon as possible by reaching out to the decision-maker to discuss any concerns. In addition to explaining why you disagree with their decision, such as facts you feel were overlooked. From here you can prompt the decision-maker to reconsider the decision of your claim.

NOTE: The person who signed the decision letter you received in the mail is the decision-maker. As such, they can assist you in starting and going through the objection process. In an effort to clear up any misunderstandings and avoid unnecessary objections.

Workers and employers have a right to object to any decisions that are made by a decision-maker. However, if the decision-maker doesn’t change their decision, you can move forward with a formal appeal. From here your objection is then referred to the Appeals Branch (Appeals Service Division) of the WSIB. At this point, you will be asked to file an Intent to Object Form within the time limit to the WSIB. After which, the original decision-maker will review the completeness of the form and any new information that has been provided. If the original decision is confirmed the WSIB will send you an Appeals Readiness Form and a copy of your claim file.

NOTE: Both the Intent to Object Form and Worker Instruction Sheet are available for download from the WSIB’s website, or through phoning the WSIB @ 1-800-387-0750.

You can file an appeal to the WSIB if you are:

1. - An injured worker or an injured worker’s employer.
  - The spouse, dependant, or estate of a deceased injured worker.

Frequently Asked Questions – FAQ

Is there a deadline for objecting to a WSIB decision?

Yes. According to the Workplace Safety and Insurance Act, of 1997, there are legislated time limits for filing a formal objection. This time limit can be found on your decision letter from the WSIB. Though officially speaking, you have 30 days to object to a WSIB decision about return-to-work transition issues, including re-employment decisions. Or, six months to object to any other type of WSIB decision.

What if I miss the deadline for objecting to the WSIB decision?

Loss-of-earning benefits normally start from the day after your work-related injury or disease is reported or diagnosed or once you begin to miss time from work and will continue until:

1. - Your injury or disease no longer affects your ability to return to work; or
  - You’re no longer lose pay; or
  - The day you reach 65 years if you were less than 63 years old the day of your injury; or
  - 2 years after the date of your injury, if you were 63 years old or older on the day of your injury.

However, if your LOEs in ongoing, your benefits will be reviewed every year for 6 years. After this point, your claim will be reviewed and, in most cases, classified as permanent. Moreover, these benefits are typically paid out every two weeks.

Can WSIB force me to go back to work?

Yes. Going back to work after a work-related injury would be advised based on medical reports. Post a successful recovery if you feel medically fit or in a better state to at least hold and perform modified duties then as per WSIB guidelines you are obligated to get tested for functional abilities by a medical professional and submit the Functional Abilities Form for Early and Safe Return to Work (PDF) form to WSIB. It is the WSIB’s responsibility to assist you with return-to-work services and if needed, provide help to arrange suitable work. Even Your Employer is obligated to accommodate your return to work with the same or with modified duties.

You should be aware of your process. If you choose not to cooperate, it could affect your benefits. Penalties for non-co-operation can include an initial non-co-operation penalty. If you receive this penalty, you will have your wage-loss benefits reduced by 50 percent. This penalty comes into effect 10 business days after the date of our written notice that is:

1. - If you are still not cooperating 14 calendar days after the initial non-co-operation penalty comes into effect, we can suspend all your wage-loss benefits.
  - If you’re still not cooperating 14 calendar days after the initial non-co-operation penalty comes into effect, we can also cancel any return-to-work training assessments and/or plans.

Can you refuse modified duty?

No. You can’t refuse modified duties, in fact, if you do not abide by the WSIB requirements, set in place, your claim is likely to be denied. Although you may disagree with their requirements if you wish to receive benefits you should try to listen to what they instruct you to do.

Though, you are not required by law to perform duties that will slow down your mental or physical recovery time. In this case, it is recommended that you seek out medical evidence to show to your employer or WSIB to back up your refusal to perform modified duties. For this reason alone, you should always keep records of your attempts to cooperate.

Can an employer refuse to create modified duty?

Yes. Under the WSIB laws, an employer is not responsible nor liable for creating modified work for an employee.

Can you collect CPP and WSIB?

Yes. CPP-Disability and WSIB are two separate programs with different definitions to classify a disability. Therefore, you may be eligible to receive benefits from both, even in cases where the WSIB has decided that you are able to perform modified duties. Additionally, the CPP-D considers all associated health problems, while WSIB is more generally focused on work-related health problems.

NOTE: It’s important to acknowledge that if you are receiving CPP-Disability benefits and want to apply for Work Transition (WT), the WSIB may not allow this to take place. As they may get the impression that you are not able to work. Moreover, if you are receiving the CPP-D benefit for a work-related injury only, the WSIB may reduce your Loss-Of-Earnings (LOE) or Future Economic Loss (FEL) benefits, by the whole amount of your CPP-D benefits.

Can an employer appeal an employee’s WSIB claim?

Yes. All employers have a right to appeal an employee’s WSIB claim. In that, they have the same rights as the employee to disagree with the WSIB’s decision. Along with the right to retain a qualified representative to speak on their behalf.

Your employer may wish to appeal your WSIB claim if:

1. - They do not agree with the WSIB’s decision; to grant you the right to receive WSIB services and benefits.
  - They may wish to say something about your appeal.
  - Lastly, they may not wish to pay into your WSIB benefits. Provided that, the money WSIB receives to cover your benefits is collected through premiums paid by the employer in Ontario.

Can I sue my employer for a workplace injury in Ontario?

No. If you are employed in Ontario and you have WSIB coverage, lawyers in Ontario cannot initiate litigious action against your employer on your behalf. The Workplace Safety and Insurance Act, of 1997, prevents liability for employers in and across the province. Although, this isn’t always the case when work-related injuries are caused by a third party’s negligence. For instance, someone not employed by your employer.

Summary

Disability Credit Canada specializes in disability applications such as the WSIB.

We’ve helped thousands join the Disability program in Canada, and already have them approved for applications such as CPP-Disability and the Disability Tax Credit. Let us help you to get approved for the WSIB today!

If you are looking to apply for the WSIB or perhaps your WSIB application was denied, give us a call today and get a free assessment: @1-844-800-6020 If we can’t help you, no one can!