Document name
Suspension of Benefits
Document number
POL 15/2016

Effective date: October 1, 2016

Application: All claims.

Policy subject: Termination, reduction or suspension of benefits

Purpose:

To establish guidelines for the suspension of benefits.

DEFINITION

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Section detail

Customer means an injured worker or a surviving dependent spouse.

Good reason means circumstances or matters beyond the customer’s control. An employer would normally find such a reason and the length of absence from work to be acceptable.

Medical aid, also referred to as health care, means “the provision of medical and surgical aid, of hospital and professional nursing services, of chiropractic and other treatment and of prosthetics or apparatus” (Section 2(1)(v) of The Workers’ Compensation Act, 2013 (the “Act”)).

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.

BACKGROUND

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  1. The Worker’s Compensation Board (WCB) is required to issue compensation for injuries that result in a loss of earnings beyond the day of injury (Section 68).
  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 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 benefits when “without good reasons” the customer (Section 101(1)(b)):
    1. Declines or is unavailable for a job offer that is considered suitable for the customer, or
    2. Fails to co-operate in, or is not available for, health care or an IVP that intends to help the customer return to employment.
  6. Section 101(1) will apply to dependent spouses after the expiration of benefits provided under Sections 81(1) and 81(2) of the Act.
  7. This policy does not apply to the suspension of benefits involving pregnant workers. POL 01/2008, Suspension of Benefits – Pregnancy, will apply.

POLICY

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  1. Benefits may be suspended if a customer is absent from health care or does not agree to participate with the development of or with an IVP.
  2. The WCB will establish if an absence or non-compliance is with good reason when determining whether to suspend benefits.
  3. Benefits may not be suspended where a worker is absent from treatment on the advice of their primary care provider (PCP) and where an objective medical reason for non-participation has been provided to the WCB. The corresponding procedure provides further direction for WCB staff to determine when a suspension may apply.

Absence With Good Reason

  1. When the customer's absence is for good reason, the WCB may continue wage loss benefits during a notice period. This will provide opportunity for the customer 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.
  2. For casual absences, the WCB will follow “Appendix A – Casual Absences Good Reasons Guidelines” attached to the corresponding procedure.
  3. Suspension of benefits may be delayed for a maximum of four weeks or until the customer qualifies for an alternate source of support, whichever occurs first.
  4. During the notice period, a customer who received partial wage loss benefits prior to an absence from health care or an IVP will continue to receive benefits in the amount paid prior to the absence.
  5. Following an absence for good reason, WCB benefits will resume when the customer is medically fit or available to:
    1. Continue health care.
    2. Attend appointments, or
    3. Continue an IVP.

Absence Without Good Reason

  1. Where the customer’s absence is without good reason benefits will be suspended. The WCB will not provide a notice period prior to the suspension and the suspension will continue until the customer:
    1. Attends the appointments.
    2. Returns to health care, or
    3. Resumes an IVP or participates in rehabilitation planning.

Cost Relief

  1. The WCB will charge the costs for the notice period, and any additional costs for ending an IVP, to the Second Injury and Re-Employment Fund.
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