Document name
Serious and Wilful Misconduct
Document number
PRO 08/2017

Effective date: September 1, 2017

Approved date: June 20, 2017

Application: All work injury claims on and after the effective date.

Policy subject: Decision making - Principals

Purpose:

To establish adjudication guidelines for injury claims involving serious and wilful misconduct.

BACKGROUND

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Section detail

POL 08/2017, Serious and Wilful Misconduct establishes guidelines for determining benefit eligibility for injuries involving serious and wilful misconduct.

PROCEDURE

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Claim File Development

  1. If an injury arises out of and in the course of employment, the Claims Entitlement Specialist (CES) will review information provided by the employer and worker to determine if the injury was the sole result of serious and wilful misconduct.
  2. The CES may need to gather additional information to clarify:
    1. The nature and extent of the misconduct.
    2. If the injury is the sole result of the misconduct.

Adjudication

  1. If a worker’s injury is the result of the serious and wilful misconduct of another worker and it is determined the worker was a non-participant in the misconduct, the CES will determine claim acceptance as per POL and PRO 03/2017, Arising Out of and In the Course of Employment.
  2. If the injury is the sole result of the serious and wilful misconduct of the worker, the CES will:
    1. Deny the claim if the worker has an estimated:
      1. Permanent Functional Impairment (PFI) rating of less than 10 per cent, or
      2. Time loss of less than three months.
    2. Accept the claim if the worker has an estimated:
      1. PFI rating of 10 per cent or more, or
      2. Time loss of three months or more.
  3. The CES will estimate if a claim will have time loss of three months or more based on:
    1.  A review of the medical information received, or
    2. They may request that a WCB Medical Officer (MO) review the claim and provide an estimate.
  4. An estimate of whether the worker has a PFI rating of 10 per cent or more must be completed by an MO.
  5. The CES will review claims that are initially denied to determine claim acceptance, if the WCB receives notification from the worker:
    1. That they have medically confirmed time loss of three months or more, or
    2. There is medical confirmation that the injury has worsened. CES staff will request an MO to provide an updated estimate of a worker’s PFI rating if the injury has worsened.
  6. If a claim is accepted because of an estimation that the injury would result in serious functional impairment, but subsequent information demonstrates that the injury did not result in serious functional impairment, the decision to provide benefits will not be reversed but additional benefits will be not be issued going forward. The employer will be eligible for cost relief.
  7. If the WCB accepts a claim involving serious and wilful misconduct because the injury resulted in death or serious functional impairment, Operations staff will identify what amount of claim costs will be charged to the Second Injury and Re-Employment Reserve.

Policy references

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Legislative Authority

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The Workers’ Compensation Act, 2013
Sections 2(1)(r), 20, 26, 27, 29, 30, 66

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Document History

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(1)    POL and PRO 13/2011, Serious and Wilful Misconduct (effective December 1, 2011 to August 31, 2017).

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Complements

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