Document name

Suspension of Benefits

Document number

POL 10/2021

Acceptable Circumstance means situations or matters which are generally beyond the worker’s control (also referred to as “good reason”).

Individualized vocational plan (IVP) means a plan approved and signed by the Workers’ Compensation Board (WCB) and signed by the customer to meet a vocational goal. The IVP outlines the short and long-term goals for a suitable return-to-work plan.

1. The Worker’s Compensation Board (WCB) issues compensation for injuries that result in a loss of earnings beyond the day of injury (Section 68 of The Workers’ Compensation Act, 2013 (the “Act”)).
2. The Act outlines that workers are required to (Section 51):
   1. Take all reasonable action to reduce the earnings loss resulting from an injury, and
   2. Co-operate with the WCB in a rehabilitation plan to return the worker to suitable productive employment.
3. The WCB follows an integrated partnership model of recovery and return to work with open communication between all partners (i.e., the employer, health care providers, the injured worker, etc.). This includes an awareness of the role each plays in achieving the most appropriate, timely and safe return to work (POL 08/2014, Continuum of Care).
4. The WCB may terminate or reduce earnings loss benefits when the worker’s loss of earnings is not related to the effects of the injury (Section 101(1)(a)).
5. The WCB may terminate or reduce earnings loss benefits when “without good reason”, the worker (Section 101(1)(b)):
   1. Declines or is unavailable for an offer of employment that is considered suitable for the worker, or
   2. Fails to co-operate in, or is not available for, health care or an individualized vocational plan (IVP) that intends to help the worker return to employment.

1. Earnings loss benefits may be suspended if a worker is absent from health care or does not agree to participate with the development of, or with, an IVP.
2. When determining whether to suspend earnings loss benefits, the WCB will:
   1. Establish if an absence or non-compliance was the result of an acceptable circumstance when determining whether to suspend earnings loss benefits.
   2. Determine the number of absences that have occurred during the length of the claim. 
   3. Make a decision based on the merits and justice of each case considering the individual facts and circumstances.
3. Earnings loss benefits may not be suspended where a worker is absent from treatment for a work-related injury on the advice of their primary care provider (PCP) and where an objective medical reason for non-participation has been provided to the WCB.

Short-Term Absences

Acceptable Circumstances

4. Generally, if a short-term absence from health care or IVP is beyond a worker’s control, WCB will consider it an acceptable circumstance.
5. 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.
6. Any further time missed from health care or IVP within the same calendar month may result in an immediate suspension of earnings loss benefits. These days are non-accumulative and will not be carried over from month to month.
7. Following an absence for an acceptable circumstance, earnings loss benefits will resume when the worker is available or has objective medical verification that they are able to:
   1. Continue health care.
   2. Attend appointments, or
   3. Continue an IVP.

Non-Acceptable Circumstances

8. Generally, if a short-term absence from health care or IVP is within a worker’s control, WCB will consider it a non-acceptable circumstance.
9. Short-term absences which are considered to be the result of a non-acceptable circumstance will result in an immediate suspension of earnings loss benefits.
10. Following an absence for a non-acceptable circumstance, benefits may be suspended until the worker:
    1. Returns to health care.
    2. Attends appointments, or
    3. Resumes an IVP or participates in rehabilitation planning.

Long-Term Absences

11. A worker may suffer from a long-term absence as a result of personal illness or disablement that is not related to their work injury. In these situations, the worker 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.
12. These absences are generally expected to last at least four weeks and will prevent a worker from continuing health care or IVP for their work injury. Earnings loss benefits may be suspended at the end of a notice period if the worker remains absent from health care or IVP.
13. This notice period (i.e., maximum of four weeks) will allow the worker to:
    1. Return to the program, or
    2. Access an alternate source of support, such as employer sick leave, and other private or government long or short-term disability plans.
14. During a notice period, a worker who received partial earnings loss benefits prior to an absence from health care or IVP will continue to receive benefits in the amount paid prior to the absence.
15. A worker who experiences a long-term absence from health care or IVP for reason(s) other than personal illness or disablement will not be provided with a notice period. All other reasons for absence from health care or IVP will fall under the short-term absence guidelines.

Pregnancy

16. In situations involving pregnancy, the payment of earnings loss benefits to the pregnant worker will not be suspended if the worker’s pregnancy presents a valid medical reason for the delay or interruption of:
    1. Medical or vocational rehabilitation programs intended to help return the worker to productive employment; or
    2. Medical or other appointments related to the treatment or rehabilitation of the worker’s injury.
17. A notice period of up to four weeks will be provided prior to suspending earnings loss benefits under the following circumstances:
    1. 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.
18. A worker who received partial earnings loss benefits prior to an absence from health care or IVP due to pregnancy will continue to receive benefits in the amount issued prior to the absence. Partial earnings loss benefits will also continue through a notice period.

Extension of Benefits

19. 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).

Long-Term Earnings Loss

20. 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.

Cost Relief

21. The WCB will charge the costs of a notice period for a worker’s long-term absence to the Second Injury and Re-Employment Reserve. Such costs may include:
    1. Earnings loss benefits.
    2. Any additional costs for ending an IVP (e.g. training costs).
    3. Any additional costs for ending a treatment program (e.g. medical costs).
22. In situations involving pregnancy, the costs of a notice period will be charged to the Second Injury and Re-Employment Reserve.
    1. Cost relief will also be provided if, prior to a notice period, a worker’s pregnancy presents a valid medical reason for the delay or interruption of medical treatment, appointments or IVP. Such costs may include:
       1. Earnings loss benefits.
       2. Any additional costs for ending an IVP (e.g. training costs).
       3. Any additional costs for ending a treatment program (e.g. medical costs).