The WSIB Claims & Appeals Process
It’s hard to imagine being injured at work. Even more difficult is to imagine being incapacitated to the point where you are unable to perform your job.
Unfortunately, workplace injuries, illnesses, and diseases are all too common. The WSIB claims and appeal process exists to give workers the ability to gain financial compensation in the event of a workplace injury, illness, or disease.
If you file a claim and are having difficulty with either your employer or the WSIB, contact your Local 12R24 steward. If you think an accident, injury, illness, or onset of pain is work-related, you must follow these steps:
- Report it to your employer.
- Complete an Employer Incident Report.
- Have the employer complete a Form 7 (Employer’s Report of Injury / Disease).
- Seek medical attention.
- Report your injury to your family doctor and have him or her complete a Form 8 (Physician’s First Report).
- Inform a co-worker or witness.
KEEP COPIES OF ALL DOCUMENTATION!
Maintain your own file of all documents relating to your claim. This includes doctor’s notes, copies of forms, and any correspondence from the WSIB, the employer, or any other involved parties.
Remember:
- WSIB claims must be filed within six months of the initial incident. Claims filed after six months may only be accepted in exceptional cases.
- You have the legal right to report any workplace accident or injury and cannot be told by anyone that you cannot file a claim.
- You have the right to be treated by your own health care professional. This could be your family physician, chiropractor, or dentist. You choose your initial health care professional when you accept treatment or emergency treatment.
- You are not permitted to change to another health care professional without the WSIB’s approval.
Workplace Safety and Insurance Board (WSIB) Appeals Process
All timelines are estimates on how long the average file takes to complete the appeals process. Some may take longer than others at certain stages. Once again, please keep a copy and any relevant detailed notes of all documents relating to your claim.
Denial Letter
To appeal a WSIB decision, you must have a denial letter from the Board indicating that your claim, or part of your claim, has been denied and the reasons for that denial. The last paragraph of the denial letter will indicate a time limit of six months to appeal the decision.
To have a Local 12R24 steward represent you in your appeal, please contact your shop steward as soon as you receive your denial letter. The Local will send you authorization forms to sign and return along with your letter of denial.
Objection
Your steward will inform the WSIB that the Local will represent you in your appeal and request a copy of your file and an objection form.
Your claim file will be sent to the Access Section of the WSIB, where they will copy your claim file and forward it to your steward. It should take between two and four weeks to process and another two to four weeks for the claim to reach your steward.
The Access Section will inform your employer of your appeal and the employer will have the option of participating in the appeals process.
Upon receipt of your WSIB claim file, your steward will review it and complete the objection form. The form is then submitted to your Adjudicator who will review your claim and either reverse their initial decision or send it on to the Appeals Branch. This process can take up to three months.
Appeals Branch
Here, your file is assigned to an Appeals Resolution Officer (ARO). Once it has arrived, you will receive a “60-day decision option form.” Should this form be completed, it allows the WSIB to make a final decision on your claim within 60 days.
This decision would be the last step of the appeals process at the WSIB level. This, however, is NOT the preferred option for appealing decisions.
If this form is NOT submitted, the ARO will contact you and your steward to discuss your file and how best to proceed with the appeal.
There are two options:
1. The ARO will review the entire claim and render a decision. This can include written submissions from your steward and from your employer (if they are participating in the appeal).
2. The ARO will conduct an oral hearing that you and your steward must attend. Your employer, if participating, may also have a representative heard.
Once a decision is made in writing by the ARO through either of the above options, it is the final decision made regarding your claim at the WSIB level.
If your appeal is denied, you may appeal to the WSIB Appeals Tribunal.
Please note: your steward will try to have your appeal processed in a timely fashion, however, due to the backlog of claims at the WSIB, your appeal could take over one year to complete.
Example of your rights to worker’s compensation
You work at The Beer Store for the summer. You earn $15 per hour and work about 20 hours per week. You have another part-time job cutting grass with a landscaping firm and earn $8 per hour for an average of 20 hours per week.
While working in the store one day, you slip on a wet floor and twist your back. You finish your shift but notice the pain and discomfort increasing. You visit your doctor the next day who advises you that you strained the muscles in your back and should not go back to work for at least two weeks.
Are you entitled to WSIB benefits?
Yes. Most employers in this province must have WSIB coverage for all their employees. If an employee suffers an injury or disease as a result of the workplace, that employee is eligible for benefits and services from the WSIB.
How do you apply for these benefits?
After seeking medical attention for a work-related injury or disease, the doctor must send a report to the WSIB, which will initiate a claim and further investigation. You must also advise the employer of your injury and your doctor’s advice. You will be required to complete a form with information regarding the accident.
For what benefits might you be eligible?
Once the claim is allowed you may receive Loss of Earning benefits – the equivalent of 85% of your net pay.
Your payments take into consideration all earnings with all employers – not just the employer where the injury took place. In this case your net pay from both jobs would be added together and you would receive 85 percent of this total.
You may also receive payment for any costs associated with medical treatment, including prescriptions or physiotherapy for example. If the injury does not heal entirely, you may be entitled to other benefits or services from the WSIB.
Is there a time limit on filing for compensation?
Yes. The WSIB specifies that an application be made as soon as possible following the initial incident. It can be no later than six months after the incident.
What if the employer threatens you or tries to talk you out of filing a compensation claim?
It is illegal for an employer not to file a report to the WSIB for any accident involving medical attention of lost time from work. If this happens, contact your union steward.
