Why Do Workplace Accident Claims Typically Get Denied?

For those Ontario workers who have Workplace Safety Insurance (WSI) claims arising from a workplace accident, the process of submitting a claim can be confusing and harrowing at the best of times. This is especially true if the claim is ultimately denied; an unfavourable outcome can add “insult to injury,” as the old saying goes.

With every WSI claim it is important to put one’s best foot forward, to give it the optimal chance of success. It is also wise to know and avoid the more common pitfalls. Here are some of them:

The Worker is Not Injured “Enough”

Injured workers’ claims for compensation are routinely rejected for a basic reason:  they fall short of demonstrating that the injury meets the “permanent impairment” threshold within the defined meaning in the Workplace Safety and Insurance Act, 1997.[1] That term is defined to mean “impairment that continues to exist after the worker reaches maximum medical recovery”.[2]

From a practical perspective, this usually involves one or more of the following scenarios:

  • The worker has clearly sustained some injury, but it is adjudged by the Board to fall short of the type that meets the “permanent impairment” criteria in the legislation;
  • Based on medical opinions, the worker is believed to be able to work in some capacity;
  • The worker has what is called “residual work capacity” and is thus not considered “permanently impaired”;
  • The worker’s disability is either unknown, or is still-undiagnosed at the time of his or her claim; and
  • There are other medical thresholds or requirements for meeting the “permanent impairment” designation that the worker cannot meet, in his or her particular circumstances.

Insufficient Medical Information

Next, WSI claims often get rejected because the worker fails to assemble evidence of the right caliber to support his or her benefit eligibility.

To use a typical real-life example, in one recent decision[3] the worker had permanent ankle injuries after he sustained a fall at work. However, within a few years of the accident he reported having low back pain he said was a result of the accident as well, either from the fall or as a secondary condition arising from the fact that his stance and gait were now changed due to the ankle injury.

The WSI Appeals Tribunal rejected his low back pain claim.   It pointed out that the worker had not reported low back pain in the two years after the accident, and – importantly – had no hospital evidence, or medical opinions supporting his claim.  While conceding that some accident circumstances might point to a low back injury even without medical evidence, this was not one of those cases.  The Tribunal added that “[l]ow back difficulties can start for many reasons and in all ages with or without a traumatic incident.” The Tribunal rejected the worker’s claim for lack of evidence.

Non-Compliance with WSI Requirements

Finally, even where the worker’s injury meets the defined standard, the claim can be denied if it fails to adhere to specific WSI requirements for documenting and submitting claims, and for complying with prescribed medical protocols.  To give specific examples, the claim may be turned down if:

  • The injured worker has missed some medically-prescribed treatments or appointments that are relevant to the claimed injury;
  • The worker is required to comply with a gradual return-to-work program, but (for reasons of his or her own) is unable to comply with its prescribed steps; or
  • He or she has failed to co-operate in the efforts to return to work, to keep in touch with the employer, or to fill out needed forms or attend prescribed programs.

These are just a few of the many reasons WSI claims get denied.  If you are experiencing difficulties in establishing your entitlement to WSI benefits for lack of meeting the “permanent impairment” threshold, or if you are having troubling marshalling the right evidence to establish our WSI claim, we are here to help.

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[1] In section 46.

[2] Section 2.

[3] Decision No. 1234/15, 2015 ONWSIAT 1412 (CanLII), http://canlii.ca/t/gl6nq