Document name
Suspension of Benefits
Document number
PRO 09/2017

Effective date: August 1, 2017

Application: All claims.

Policy subject: Termination, reduction or suspension of benefits

Purpose:

To establish guidelines for the suspension of benefits.

BACKGROUND

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Section detail

The Saskatchewan Worker’s Compensation Board (WCB) approved POL 15/2016, Suspension of Benefits. The following procedure provides specific guidelines for WCB staff when determining whether to suspend benefits under POL 15/2016.

PROCEDURE

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  1. The WCB will ensure that customers understand their responsibilities regarding attendance to diagnostic and specialist appointments and health care treatment plans.
  2. Operations staff will provide customers with information about their responsibilities while receiving WCB benefits at the start of treatment. Customers will also be notified of WCB’s suspension policy through a letter to the customer:
    1. At the start of a recommended health care treatment plan and individual vocational plan (IVP).
    2. After any missed appointments.
  3. Customers on wait lists will be sent a letter outlining the possible consequences of missing a diagnostic appointment or surgery date.
  4. Customers will provide the reason(s) for their absence to Operations staff or the health care facility.
  5. Upon notice of an absence, the WCB may retroactively suspend benefits. For example, if the customer fails to provide a reason for the absence within a reasonable time, Operations staff may consider establishing an overpayment of any  earnings loss benefits paid beyond the start of the customer’s absence.
  6. If a customer’s primary care provider (PCP) does not approve their participation in a recommended health care treatment plan, it must be determined if there are medical restrictions that prevent the worker from participation.
    1. WCB’s Health Care Services (HCS) will contact the PCP to discuss the worker’s medical condition(s), any options for participation in the recommended treatment plan, and if the PCP can provide an alternative treatment plan.
    2. If the PCP confirms that a non-work related medical or physical condition(s) would prevent the customer from participating in a recommended health care treatment plan, the suspension of benefits will follow the guidelines around an absence for “good reason” due to an illness or disablement (i.e., the customer may receive earnings loss benefits during a notice period).
    3. If the PCP cannot confirm that a non-work related medical or physical condition(s) would prevent the worker from participating in treatment, and the worker does not participate, benefits will be suspended.

Illness or Disablement Guidelines

  1. Customers absent from health care or IVP due to illness or disablement 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.
  2. The four week notice period is intended for customers who are suffering from an illness or disablement not related to the work injury (e.g., heart attack, pneumonia, hospitalization or treatment for substance abuse).
  3. In cases of chronic or prolonged absences, the WCB may require medical verification of the illness or disablement.
  4. Prior to determining the notice period, Operations staff will contact the employer to determine:
    1. Benefit eligibility, and
    2. The effective date for other forms of support (for example, employer sick leave, and other private or government long or short-term disability plans). Operations staff will not consider vacation pay as an alternate form of support.
  5. When the worker’s alternate form of support does not cover the entire four week notice period, Operations staff will reinstate benefits for the remaining balance of the notice period.
  6. During the notice period, a customer who received partial earnings 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.
  7. In general, the WCB will only provide a notice period once during the lifetime of a claim. However, the WCB may provide an additional notice period if the customer has a new good reason for further absence. The good reason must be unrelated to the circumstances associated with the original suspension.

Casual Absences Guidelines

  1. Typically, the WCB will not suspend benefits for short term casual absences that do not serve to extend the health care or IVP (Appendix A).
  2. The period of absence allowed will be equivalent to what the WCB would reasonably allow its own staff.
  3. Casual absences may result in a suspension, if:
    1. Due to casual absences, the customer will not meet health care treatment goals.
    2. The customer shows a pattern of casual absences.
    3. The customer is absent from three or more specialist or diagnostic appointments within a 12 month period, or
    4. The customer fails to provide verification for the reason of the absence when requested by WCB.
  4. The customer may be eligible for other forms of support from their employer for casual absences (e.g., employer sick leave, short-term disability plan, pressing necessity leave, etc.). Where it has been confirmed that the employer provides coverage for casual absences, Operations staff will suspend benefits for that time period.

Absence Reviews

  1. Where a customer has three or more casual absences during a health care treatment plan the Case Manager, HCS staff, the treatment team and the customer will meet to review their ongoing absenteeism.
  2. The purpose of the meeting is to:
    1. Remind the customer of their responsibility to attend treatment while receiving earnings loss benefit,
    2. Discuss issues around attendance and to help resolve ongoing absenteeism, and
    3. Outline consequences of ongoing casual absences, which may include suspension of benefits.
  3. HCS may also complete an evaluation to determine:
    1. The need for ongoing medical treatment, or
    2. The length of the current program.
    Operations staff will provide the results of the program review to the treatment team. The treatment team will modify the treatment program in accordance with HCS’s recommendation.
  1. Where a customer’s benefits are suspended and reinstated, further casual absences may result in immediate suspension for the day missed or discharge from the treatment program until the customer is able to participate fully.

Suspension or Reduction of Benefits

  1. Before suspending benefits, Operations staff must consider if the absence was for good reason.
    1. If the absence was for a good reason, benefits will be reinstated when the customer is available for or fit to resume health care treatment(s), medical appointment, training or IVP.
    2. If the absence was not for a good reason, benefits will be reinstated when the customer actually resumes the health care treatment(s) or IVP.
  2. Operations staff may reduce benefits if it is determined the claim would involve an ongoing loss of earnings, regardless of the absence. Operations staff will:
    1. Estimate what the earnings loss would be if the customer had completed the health care or IVP, and
    2. Arrange for payment accordingly.
  3. If Operations staff cannot determine if a customer will qualify for earnings loss entitlement after the conclusion of the health care and IVP, suspension of benefits may occur in full until the customer returns to the treatment or programming.
  4. Operations staff will make a retroactive adjustment when a customer with a full suspension later qualifies for a long term earnings replacement. The adjustment will reflect the worker’s long term earnings capacity.
  5. The WCB will not assume costs relating to an illness or disability not associated with the work injury. This includes costs for:
    1. Health care or travel, or
    2. The obtainment of a medical certificate.
  6. When appropriate, Operations staff will provide non-financial assistance. For example:
    1. Referral to an appropriate support agency, or
    2. Assistance with completion of an application for an alternate source of support.
  7. In the case of a lengthy suspension, Operations staff will attempt to return the customer to an acceptable program as soon as possible. This may include arranging a suitable alternate health care or IVP.
  8. Operations staff will provide the customer with a written explanation for the suspension of benefits.

Evaluation

  1. Team Leaders or Claims Entitlement Supervisors will approve and monitor all suspensions of benefits to ensure compliance with The Workers’ Compensation Act, 2013 (the “Act”) and POL 15/2016. This includes monitoring:
    1. The circumstances of the suspension, and
    2. The staff involved in the suspension decisions.

Attachments

Attachments
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