Document name

Suspension of Benefits

Document number

PRO 10/2021

POL 10/2021, Suspension of Benefits outlines when the Workers’ Compensation Board (WCB) considers the suspension of earnings loss benefits. The following procedure provides guidelines for Operations staff to determine whether to suspend earnings loss benefits.

1. How are injured workers notified of their health care or individual vocational plan (IVP) attendance responsibilities?
   1. The WCB will ensure that a worker understands their responsibilities regarding attendance for all appointments related to health care or IVP.
   2. A worker will be notified of WCB’s suspension guidelines both verbally and through a letter:
      1. Upon initial claim acceptance.
      2. At the start of a recommended health care treatment plan or IVP, and
      3. After any missed appointments.
   3. A worker who is on a wait list will be sent a letter outlining the possible consequences of missing a diagnostic appointment or surgery date.
2. What happens when a worker is unable to attend an appointment for health care or IVP?
   1. If a worker will be absent from an appointment for health care or IVP, the worker must first inform the WCB and provide a reason for their absence.
   2. If possible, the WCB will assist with removing any potential barriers to attendance.
   3. If the worker is still unable to attend they must subsequently notify the health care or training facility.
3. What happens when a worker misses an appointment for health care or IVP?
   1. Once notified of an absence, Operations staff will conduct an immediate review of the claim file and conditions surrounding the absence.
   2. Operations staff will determine whether the absence was due to an acceptable circumstance and whether earnings loss benefits should be suspended for the time the worker was absent.
   3. Operations staff will notify the worker first verbally and then in writing the reason(s) why their earnings loss benefits are being suspended.
4. What happens when the WCB is unable to contact a worker to confirm the reason for their absence from health care or IVP?
   1. Operations staff may temporarily pause earnings loss benefits until the reason for an absence from treatment or IVP is received.  
   2. Upon notice of an absence, the WCB may also retroactively suspend earnings loss benefits. For example, if a worker fails to provide a reason for a previous absence within a reasonable time, Operations staff may consider establishing an overpayment of any earnings loss benefits paid beyond the start of the worker’s absence.
5. In order to avoid an unnecessary overpayment to a worker, earnings loss benefits may also be temporarily paused when there is a medical reason for a worker’s inability to return to employment or continue with treatment or IVP, but there is insufficient or no medical verification to confirm the absence.
6. What happens when a worker’s primary care provider (PCP) does not approve of the worker participating in a recommended health care or IVP?
   1. Operations staff must determine if there are any contradictions or medical restrictions outlined that prevent the worker from participating in the proposed plan.
   2. WCB’s Health Care Services will contact the PCP, and any other party necessary, to discuss the worker’s medical condition(s), options for participation in the recommended treatment plan, and if the PCP can provide an alternative treatment plan.
   3. If the PCP confirms that a non-work related medical or physical condition(s) would prevent the worker from participating in a recommended health care plan or IVP, the suspension of earnings loss benefits will follow the long-term absence guidelines due to a personal illness or disablement (i.e., the worker may receive earnings loss benefits during a notice period).
   4. If the PCP cannot confirm that a non-work related medical or physical condition(s) would prevent the worker from participating in health care or IVP, and the worker does not participate, earnings loss benefits will be suspended.

Short-Term Absence Guidelines

7. Under what circumstances may the WCB suspend earnings loss benefits for a short-term absence?
   1. Operations staff will first determine whether the absence was due to an acceptable or non-acceptable circumstance prior to suspending earnings loss benefits.
      1. The following are examples of what WCB considers acceptable circumstances for short-term absence from a health care or IVP program:
         1. Personal illness.
         2. Urgent personal reasons (e.g., child care, pressing necessities, non-work-related medical appointment, etc.).
         3. Bereavement leave.
         4. Severe weather restricting travel.
         5. Other urgent matters which WCB determines reasonable for missed treatment.
      2. The following are examples of what WCB considers non-acceptable circumstances for short-term absence from a health care or IVP program:
         1. Vacation leave.
         2. Not willing to attend treatment.
         3. A worker fails to comply or does not demonstrate active involvement in health care or IVP.
         4. A worker does not agree to participate in the formation of an IVP.
         5. No reason provided (i.e., worker fails to provide verification for the reason of the absence when requested by WCB staff).
8. Earnings loss benefits will generally not be suspended for up to one calendar day per month when a worker’s absence from health care or IVP is due to an acceptable circumstance.
   1. Any further time missed from health care or IVP within the same calendar month may result in an immediate suspension.
   2. These days will not be carried over from month to month.
9. When the worker’s absence from health care or IVP is determined to be the result of a non-acceptable circumstance, earnings loss benefits will be suspended immediately.
10. A worker may be eligible for other forms of support from their employer for short-term absences (e.g., employer sick leave, short-term disability plan, pressing necessity leave, etc.). Where it has been confirmed that the employer provides coverage for short-term absences, Operations staff will suspend benefits for that time period.

Long-Term Absence Guidelines

11. If a long-term non-work related personal injury or illness interrupts a worker’s health care plan or IVP, are earnings loss benefits suspended?
    1. A worker who is absent from health care or IVP due to personal illness or disablement may receive earnings loss benefits during a notice period of up to four weeks or until they qualify for an alternate source of support, whichever occurs first.
    2. A notice period is intended for a worker who is suffering from a personal illness or disablement that is:
       1. Not related to the work injury, and
       2. There is evidence to suggest that the personal illness or disablement will prevent the continuation of health care or IVP for at least four weeks (e.g., heart attack, pneumonia, hospitalization or treatment for substance abuse).
    3. WCB staff will require objective medical verification of the illness or disablement.
12. How do Operations staff determine the length of a notice period?
    1. Operations staff will contact the employer to determine:
       1. Benefit eligibility, and
       2. The effective date for other forms of support (for example, employer sick leave, and other private or government long or short-term disability plans).
    2. Operations staff will not consider vacation pay as an alternate form of support.
    3. When the worker’s alternate form of support does not cover the entire notice period, Operations staff will reinstate earnings loss benefits for the remaining balance of a notice period.
13. If a worker is receiving partial earnings loss benefits prior to an absence from health care or IVP, they will continue to receive benefits during a notice period in the amount paid prior to the absence.
14. How many times may a notice period be provided during a claim?
    1. Generally, the WCB will only provide one notice period during the lifetime of a claim.
    2. An additional notice period may be provided only if the worker’s absence is unrelated to the circumstances associated with the original notice period. Any subsequent absences must also meet the long-term absence guidelines.
15. Typically, the WCB will not assume costs relating to an illness or disability not associated with the work injury. This includes costs for:
    1. Health care or travel, or
    2. The obtainment of a medical certificate.

Pregnancy

16. What steps will Operations staff take when determining earnings loss benefits for a pregnant worker?
    1. A notice period of up to four weeks will be provided prior to suspending earnings loss benefits under the following circumstances:
       1. If the pregnancy and conditions related to the pregnancy are the sole reason for interruption or delay in returning to work (i.e. worker has recovered from work injury); or,
       2. The pregnancy has ended (i.e., through childbirth) and non work-related factors cause a delay in treatment or vocational programming.
    2. In situations involving pregnancy, the payment of earnings loss benefits to the worker will not be suspended in circumstances where the worker’s pregnancy presents a valid medical reason for the delay or interruption of medical treatment.
    3. The WCB may require medical verification of a pregnant worker’s medical circumstance.

Notification of Suspension

17. How do Operations staff notify a worker that their earnings loss benefits have been suspended?
    1. Operations staff will provide the worker with verbal explanation prior to the suspension of earnings loss benefits. A written explanation will also be provided to the worker.

Absence Reviews

18. Under what circumstances will Health Care Services (HCS) and Operations staff conduct an Absence Review?
    1. When a worker has ongoing or chronic short-term absences during a health care treatment plan Operations staff, HCS staff, the treatment team and the worker will meet to review their ongoing absenteeism.
    2. The purpose of conducting an Absence Review is to:
       1. Remind the worker of their responsibility to attend treatment while receiving earnings loss benefits,
       2. Ensure that the current treatment plan is effective in assisting with recovery and return-to-work,
       3. Discuss issues around attendance and to help resolve ongoing absenteeism, and
       4. Outline consequences of ongoing short-term absences, which may include suspension of earnings loss benefits.
       5. HCS may complete an evaluation to determine:
          1. The need for ongoing medical treatment, or
          2. The length of the current program.
    3. Operations staff will provide the results of the review to the treatment team. The treatment team will modify the treatment program in accordance with HCS’s recommendation.
19. When a worker has ongoing or chronic short-term absences during an IVP, the WCB will complete a review of the program with the assistance of the educational, training or employment facility to assist with involvement back to regular attendance.

Resuming Earnings Loss Benefits

20. When do earnings loss benefits resume following a suspension decision?
    1. If the absence was the result of an acceptable circumstance, earnings loss benefits will be reinstated when the worker is available or has objective medical verification that they are able to resume health care treatment(s), medical appointment(s), training or IVP.
    2. If the absence was the result of a non-acceptable circumstance, earnings loss benefits may be reinstated when the worker actually resumes the health care treatment(s) or IVP.
21. What are the expectations in returning a worker back to a treatment program?
    1. In the case of a lengthy suspension, Operations staff will attempt to return the worker to an acceptable program as soon as possible. This may include arranging a suitable alternate health care or IVP.

Reduction of Earnings Loss Benefits

22. How do Operations staff determine a reduction of earnings loss benefits during health care or IVP?
    1. Operations staff may reduce earnings loss benefits if it is determined the claim would involve an ongoing loss of earnings, regardless of the absence. Operations staff will:
       1. Estimate what the earnings loss would be if the worker had completed the health care or IVP, and
       2. Arrange for payment accordingly.
    2. If Operations staff cannot determine if a worker will qualify for earnings loss entitlement after the conclusion of the health care or IVP, suspension of earnings loss benefits may occur in full until the worker returns to the treatment or programming.

Other Supports

23. What non-financial assistance will Operations staff offer when a worker is unable to participate for a prolonged period of time?
    1. When appropriate, Operations staff will notify the worker both verbally and in writing of alternative supports the worker may be eligible to access when benefits are being suspended.

Extension of Benefits

24. Can Operations staff extend a notice period of earnings loss benefits?
    1. In exceptional circumstances determined on a case by case basis, Operations staff may provide or extend a notice period of benefits (POL 02/2019, Decision Making).
    2. When determining if a notice period should be extended, Operations staff will consider what alternate supports the worker may be eligible to access.

Long-Term Earnings Loss

25. When a worker is in receipt of long-term earnings loss, annual verification of earnings is required. When required documentation is not received, a worker’s earnings loss benefits may be suspended. POL & PRO 07/2016, Earnings Verification and POL & PRO 01/2018, Benefits – Long-Term Earnings Loss applies.

Evaluation

26. Team Leaders or Claims Entitlement Supervisors will approve and monitor all suspensions of earnings loss benefits to ensure compliance with The Workers’ Compensation Act, 2013 (the “Act”) and POL 10/2021. This includes monitoring:
    1. The circumstances of the suspension, and
    2. The staff involved in the suspension decisions.

Cost Relief

27. When do Operations staff review a claim for cost relief for a notice period of benefits?
    1. Operations staff will apply cost relief at the time when a notice period of benefits are issued to a worker.