Document name

Appeals – Claims

Document number

PRO 21/2013

1. POL 21/2013, Appeals – Claims has been approved, which provides workers and employers (or their representatives) with an easily accessible review or reconsideration of any claim decision.
2. The following guidelines ensure that staff apply Workers’ Compensation Board (WCB) policy and the appropriate provisions of The Workers’ Compensation Act, 2013 (the “Act”) when reviewing a decision, keeping in mind the individual merits and justice of the issue.
3. Service quality is maintained by responsible managers at each stage, setting suitable standards for quality and timeliness, and monitoring claims to ensure that delays are minimized in:
   1. Collecting information needed for a well-informed decision.
   2. Arriving at an Appeals Officer decision or Board Appeal Tribunal decision.
   3. Implementing an Appeals Officer decision or Board Appeal Tribunal decision.

Appealing WCB Claim Decisions (Workers or Employers)

Review

1. The worker’s or employer’s first step should be to contact the staff member responsible for the original decision. The staff member will consider any new information provided by the worker or employer, and gather any additional information necessary.
2. The staff member will provide a written response or document any discussion with the worker or employer.
3. Where the original decision is upheld, the worker or employer will be reminded of the Appeal process.

Appeals Department

4. Upon receipt of a written request for a review, the Appeals Department will conduct an immediate initial review to determine if:
   1. The decision was previously considered by the Board Appeal Tribunal and ruled on and, if so, the request will be sent directly to the Board Appeal Tribunal.
   2. A reconsideration decision has been made and communicated by the original decision-maker.
   3. There is sufficient information on file to proceed with an appeal.
   4. There is new information in the appeal, which was not previously available.
5. Depending on the last three criteria noted in point 4 above, the review may be delayed and appropriate directions will be given to the Operations Division concerning further inquiries to collect additional information. The worker is advised by the Appeals Department in writing as to how the situation will be handled. Alternatively, Operations staff will be asked to review the original decision, and respond directly to the request.
6. When the Appeals Department provides direction on a claim file, and where the decision is not changed by Operations staff, Operations staff will inform the Appeals Department to facilitate a review by the Appeals Department on a priority basis.
7. Where it is determined that a review can proceed, the Appeals Department will immediately acknowledge the appeal in writing and provide the appellant a time estimate of when the review will take place.
8. The worker and employer are advised in writing of the decision(s) in dispute, and invited to provide additional information in support of their respective positions.
9. An Appeals Officer will review all claim information relevant to the issue in dispute. The Appeals Officer may then make inquiries to collect additional information, direct Operations staff to make such inquiries, or seek advice from a WCB medical consultant. Under normal circumstances, the review is limited to the decision(s) in dispute. However, the Appeals Officer has authority to consider other issues, which may come to light in the course of the review, in cases of blatant error or non-compliance with policies.
10. The worker or employer may request a meeting or telephone conference with the Appeals Officer. The purpose of such a meeting is to allow them the opportunity to provide additional information or clarify certain issues related to the appeal.
11. Following a thorough review, the Appeals Officer will provide a written appeal decision to the worker and employer. The appeal decision will provide detailed reasons, including the information used and the applicable authority as set out in the Act and/or WCB policy. The worker or employer who submitted the appeal will be invited to discuss the decision with the Appeals Officer to facilitate understanding.
12. Where an appeal decision relates to multiple claims and/or multiple employers, each employer will only be provided with information directly related to their own interests.
13. Any decision or direction of the Appeals Officer will be carried out by Operations staff without delay.

Board Appeal Tribunal

14. If the worker or employer disagrees with the decision of the Appeals Officer, they may request a further review by the Board Appeal Tribunal as outlined in policy POL 22/2013, Appeals – Board Appeal Tribunal.
15. In accordance with Section 20 of the Act, WCB has established that only the Board Appeal Tribunal will have exclusive jurisdiction to reach a decision in the first instance, or to review an appeal, which includes the following issues:
    1. Section 29 of the Act regarding presumption claims filed prior to January 1, 2003 (PRO 04/2014).
    2. Section 73 of the Act regarding proposals for alternate forms of annuities (POL 05/2020).
    3. Section 82 of The Workers’ Compensation Act, 1974 (the “Old Act”) regarding the commutation of pensions (POL 13/2016).
    4. Section 100 of the Act regarding payments to dependant(s) of an incarcerated worker (POL 10/2016).
    5. Section 169 regarding applications as to whether court action is barred under the Act (POL 01/2013), and
    6. Matters relating to the Canadian Charter of Rights and Freedoms (POL 05/2005).
16. Where appeals are received by the Appeals Department citing the issues noted in Point 15 above, they will first review the appeal to determine if there is a bona fide issue of exclusive Board jurisdiction. If it is so determined, the appeal is forwarded to the Director, Board Services and Corporate Governance for consideration by a Board Appeal Tribunal.

Medical Review Panel

17. A Medical Review Panel will only be convened after all other avenues of appeal have been exhausted, and only for bona-fide medical questions (POL 18/2010 – Medical Review Panels).