Expenses – Orthotics/Appliances – Provision, Replacement and Repair
Effective date: August 1, 2016
Application: All workers requiring orthotics/appliances.
Policy subject: Allowance and expenses
To establish eligibility guidelines for the provision, repair and replacement of orthotics/appliances.
Additional expense, for the purpose of this policy, means an out-of-pocket expense incurred by a worker for the provision, repair or replacement of an orthotic/appliance.
Orthotics/Appliances include, but are not limited to, orthopaedic footwear, eyewear, hearing aids, dentures, artificial limbs, artificial eyes, belts, braces and supports.
Orthopaedic footwear means footwear prescribed by a health care professional and is specifically manufactured or custom-made as a functional aid. Ordinary good quality footwear that is designed for everyday use and can be purchased in a retail store is not considered orthopaedic footwear.
Authorizing Agent means a Claims Entitlement Specialist, Case Manager, Case Management Support, or Vocational Rehabilitation Specialist who is authorized to approve orthotic/appliance expenses for injured workers on behalf of the Workers’ Compensation Board (WCB).
- The purpose of reimbursing orthotic/appliance expenses is to ensure workers do not incur additional expenses arising out of a work injury or incident for the provision, repair and replacement of such devices.
- Section 103(1)(a) of The Workers’ Compensation Act, 2013 (the “Act”) directs that every worker who is entitled to compensation or who is disabled only on the day of the injury is entitled without charge to “any prosthetics or apparatus that may be necessary as a result of the injury, and to have any prosthetic limbs and eyes and any surgical appliances such as belts, braces, supports and orthopaedic shoes repaired, maintained and renewed when necessary by reason of accident or ordinary wear and tear.”
- Section 109(a) of the Act states that in addition to any other compensation, the WCB may assume the expense of “replacing or repairing any prosthetics or apparatus, including broken dentures, eye glasses, artificial eyes or prosthetic limbs when breakage is caused by an accident or injury in the course of the worker’s employment”. In this context, the WCB interprets ‘accident’ as an ‘incident,’ not necessarily resulting in an injury.
- Personal responsibility for ordinary maintenance (e.g., cleaning, proper fitting, storage) does not end while the worker is engaged in their employment duties.
Originating from the Work Injury
- The WCB will provide payment for the purchase of an orthotic/appliance, where the following criteria are met:
- The original need for the orthotic/appliance was caused by the compensable work injury;
- The orthotic/appliance is prescribed or recommended by the worker’s treating physician or a licensed health care professional.
- Based on the above criteria, the WCB will also be responsible for any repair or replacement due to ordinary wear and tear, loss or accidental damage, whether work-related or not, as long as the worker requires the device because of the injury, and providing the expense is not the result of wilful destructive conduct by the worker.
Not Originating from the Work Injury
- Where orthotics/appliances are required for reasons other than the compensable injury, entitlement is based on whether the incident causing damage or loss occurred in the course of employment versus personal responsibility (e.g., cleaning, proper storage).
- Where the original orthotic/appliance is required for reasons other than a compensable injury and a work injury or incident prompts the need for repair, modification or replacement of the orthotic/appliance, the WCB will cover the associated costs.
- Providing reimbursement or payment for orthotic/appliance expenses is subject to approval by the authorizing agent. Where possible, workers will be advised in advance of the expenses that will be allowed. In all instances, where the approved expense is less than the amount claimed by the worker, reasons will be provided in writing.
Coverage – Replacement/Repair
- Entitlement is based on reasonable repair or replacement of the orthotic/appliance that is in the worker’s possession at the time of the injury or incident. The WCB is not responsible for additional costs based on the worker’s preference (e.g., the worker requests to have a protective coating put on their lenses, but the damaged or lost pair of glasses did not have a protective coating).
- Entitlement for repair or replacement expenses covers the cost of medical examinations including refraction.
- The following examples set out WCB principles for the adjudication of claims for damage or loss to orthotics/appliances:
- The worker removes a non-work injury related orthotic/appliance to perform routine maintenance. The orthotic/appliance is damaged or lost as a result of the worker’s actions (e.g., worker drops the orthotic/appliance on the floor) rather than an intervening work-related cause. This is ordinary maintenance, a personal responsibility, with no work-related injury or incident. Claim for reimbursement is denied.
- An injury or incident occurs during the course of employment (e.g., the worker is struck by a falling object and sustains damage to his glasses). The orthotic/appliance is lost or damaged. Independent of whether the loss or damage is accompanied by personal injury, the loss or damage is work caused. The claim is acceptable.
- Where a work injury or incident requires the worker to wear prescription lenses or requires a change in the worker’s current prescription, entitlement is to include the actual costs of the prescription lenses and up to the maximum allowable for frames as set out in PRO 14/2019, Consumer Price Index – Annual Increase, as well as replacement or repair necessitated by normal wear and tear.
- Where the worker wore prescription lenses prior to the injury, which are subsequently damaged or lost as a result of a work injury or incident, entitlement is to include the actual costs of the prescription lenses (based on the features of the actual lost or damaged pair) and up to the maximum allowable for frames as set out in PRO 15/2020, Consumer Price Index – Annual Increase.
- The decision to provide orthopaedic footwear or to modify the worker’s existing footwear will be assessed on a case-by-case basis with reasonable input from the worker.
- Where modification of existing footwear is required due to the effects of a work injury (e.g., to accommodate a brace), the WCB will cover the cost of the initial and subsequent modifications. If there is no need for orthopaedic footwear, the cost of the footwear will continue to be the worker’s responsibility and the payment made by the WCB will be limited to the costs of the modifications.
- Where the worker’s existing footwear is of insufficient quality to accommodate modifications, the WCB will cover the full cost of one pair of footwear sufficient for modification. Where existing footwear becomes prematurely worn due to the use of an orthotic/appliance, the WCB will also cover the costs for the repair or replacement of the footwear.
- Where a work injury has prompted the need for modified footwear and the modified footwear requires repair or adjustment, if the worker is unable to work without this footwear (e.g., while the footwear is being modified), the WCB will cover the full cost of an extra pair of footwear to be used in the interim.
- Where a work injury creates the need for orthopaedic footwear, the WCB will be responsible for the initial cost, repair and replacement of orthopaedic footwear prescribed by the worker’s treating physician or a licensed health care professional.
- Where a worker is unable to wear shoes of the same size (e.g., one foot is larger than the other) as a result of a work place injury (e.g., crushed foot, burns, severed toes, etc.), the WCB will cover the full cost of both pairs of footwear at the initial purchase. When replacement shoes are required, coverage is limited to reimbursement for one pair of shoes.
- Where the work injury has necessitated a job change and the worker’s existing footwear is of insufficient quality to assist in return to meaningful employment, the WCB may consider reimbursement of the purchase of one good quality pair of footwear available at a retail store.
Leisure/Sports Footwear and Prostheses
- In situations where a worker requires orthopaedic or modified work footwear due to the effects of a work injury and the footwear is not suitable for casual or leisure wear, coverage for the costs of the second pair will be provided.
- Requests for specialized sports prosthesis (e.g., for skiing, swimming) will be considered on a case-by-case basis in accordance with Section 111 of the Act.
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