Document name

Injury Claims – Administrative Errors

Document number

PRO 03/2022

1. POL 03/2022, Injury Claims - Administrative Errors, provides guidelines for administrative errors and how they are corrected by WCB staff.
    
2. Operations staff will consider the following guidelines when determining if an administrative error has occurred. Examples are also provided in the Appendix.

1. What does the WCB consider to be an administrative error on an injury claim?
   1. Administrative errors are clerical, calculation or file management errors made by WCB staff members.
2. What does the WCB not consider to be an administrative error?
   1. Administrative errors do not include those caused by external conditions that are outside WCB’s control. This includes, but is not limited to, the following:
      1. Delay in a worker receiving medical treatment/diagnostics as a result of treatment centre availability or other general health care delays that may occur.
      2. The activities or actions of an employer or worker, such as:
         (a) Postponing attendance for medical appointments.
         (b) Delays in providing necessary information to the WCB.
         (c) Incorrect information provided to the WCB.
      3. Errors committed by other parties involved in the management of a claim.
      4. Delays in treatment or vocational rehabilitation caused by limited health care services available during a provincial state of emergency or natural disaster.
   2. Administrative errors also do not include certain conditions within the WCB’s control. This includes, but is not limited to, the following:
      1. File management delays that occur for specific WCB processes such as the earnings verification process for long-term earnings loss benefits or when benefits are extended to a worker with missing or outstanding information.
      2. Outstanding administrative tasks or pending decisions (i.e., unadjudicated claims, outstanding appeal decisions).
      3. Coverage or workload constraints which have the potential to broadly impact multiple customers.
      4. Minor delays by WCB staff or failure to take certain actions during the management of a claim that have a minimal impact on the overall expected recovery period for an injured worker.
3. Operations staff will review all situations involving potential administrative errors on a case by case basis considering the individual circumstances of each claim.
    
4. In addition to the policy and procedure guidelines, Operations staff will consider the following questions for guidance when determining if a file management error has occurred: 
   1. Was a file management error made by a WCB staff member or was the error a result of external conditions that were outside the WCB’s control?
   2. Did WCB staff delay in arranging required medical treatment or approved services for a worker?
      1. Was there a significant delay between when a request was received and when it was handled?
      2. Did the delay in arranging medical treatment or approved services extend the expected recovery period for an injured worker? Can this be confirmed by a WCB Medical Officer?
      3. Did WCB staff have all the information necessary in order to make a decision or take action?
      4. Were additional claims costs incurred over and above what would normally have been anticipated had the delay not occurred?
      5. Did the delay specifically impact an individual customer based on the unique circumstances of the claim? Would other customers have experienced a similar result?
   3. Did Operations staff fail to make a decision or take certain actions during the course of a claim that impacted the expected recovery period for an injured worker?
      1. Was there a decision that was missed which impacted the expected recovery of an injured worker? 
      2. Was a system task created without any action taken?
      3. Is it reasonable that the delay was substantial enough to result in an extended period of disablement for an injured worker? Can this be confirmed by a WCB Medical Officer?
      4. Did the delay specifically impact an individual customer based on the unique circumstances of the claim? Would other customers have experienced a similar result?
5. Can a decision be reversed as a result of an administrative error?
   1. The identification and correction of an administrative error as directed through POL 03/2022 is not considered to be a reconsideration of a previous decision.
   2. Situations when an actual decision is reversed are directed through POL 23/2014, Reversing Decisions.
6. What happens when an administrative error has occurred?
   1. Once an administrative error has been discovered, Operations staff will immediately review the error.
   2. Following a review, Operations staff will:
      1. Notify the worker verbally (i.e., over the phone),
      2. Provide written notice to the worker and employer detailing the error that occurred and impact on benefit entitlement or claims cost experience, and,
      3. Correct the error.
7. The impact of an administrative error may result in either an overpayment or underpayment of benefits to a worker.

Overpayment

8. What happens when an administrative error results in an overpayment of benefits?
   1. An overpayment of benefits resulting from an administrative error will be pursued by the WCB.
   2. If benefits are ongoing, Operations staff will reduce the rate of benefits to the correct level once the debtor is made aware of the overpayment.
9. Is there a time limit for when Operations staff can pursue an overpayment of benefits as a result of an administrative error?
   1. The WCB has two years from when the overpayment occurs, or when WCB staff could reasonably have discovered the overpayment, to recover the overpayment or register a Board Order as a judgement of the Court (POL 17/2016, Overpayment Recovery – Compensation).
      1. Staff may, however, set off overpayment debts against any present or future entitlements that may be payable to a worker.
10. Are there situations where an administrative error results in an overpayment of benefits and benefits are not recovered from a worker?
    1. Overpayments may not be recovered when a worker is still entitled to the benefits they have received, typically as a result of a file management error.
       1. Some examples may include, but are not limited to, the following:
          (a) A delay in arranging medically requested treatment/diagnostics where a worker is still unable to return to employment as a result of a work-related injury.
          (b) Where Operations staff fail to make a decision or take certain actions at specific points in the management of the claim.
          (c) A prolonged period of disablement as a result of significant file management delays.
          (d) Where Operations staff determine that it would not be fair and reasonable to recover benefits from a worker when an administrative error has occurred.
11. When recovery of an overpayment is not pursued, Operations staff will follow the claim overpayment write-off process. An Overpayment Write-Off (OPWR) form will be documented on the claim file and include, but not limited to, the following information:
    1. The amount of overpayment.
    2. Reason for write-off.
    3. Signature of secondary approval.
       1. All decisions to write-off an overpayment must be reviewed at minimum, by an Operations Team Leader or Supervisor in accordance with Secondary Approval Levels, ADM PRO 01/2022.
       2. Depending on the type of benefit being written-off, Operations staff may have to submit a task to another department to complete the write-off process.
12. Will an employer receive cost relief when an administrative error has resulted in an overpayment of benefits to a worker?
    1. In accordance with POL 27/2016, Experience Rating Program – Discounts or Surcharges, additional claim costs incurred from an overpayment are automatically removed from the employer’s claims cost experience when the overpayment is discovered and recorded on the claim file.

Underpayment

13. What happens when an administrative error results in an underpayment of benefits?
    1. Where an administrative error has resulted in an underpayment of benefit entitlement to a worker, Operations staff will recalculate earnings loss benefits to provide additional entitlement.
14. Is there a time limit for when Operations staff can provide additional benefits as a result of an administrative error?
    1. No. Additional entitlement resulting from an administrative error will be provided to a worker regardless of how much time has passed since the error occurred.
15. Will an employer receive cost relief when an administrative error has resulted in an underpayment of benefits to a worker?
    1. Employers are not provided cost relief for the additional claims costs that result from an administrative error when a worker is provided additional benefit entitlement.

Other

16. At least one authority level above the original decision maker must review and approve all decisions that involve a potential administrative error. Decisions will be documented.
    1. This includes decisions where it has been determined by Operations staff that an administrative error has not occurred.