Why Do Workplace Accident Claims Typically Get Denied?
For those Ontario workers who have Workplace Safety Insurance Board (WSIB) claims arising from a workplace accident, the process of submitting a claim can be confusing and difficult at the best of times. This is especially true if the claim is ultimately denied as an unfavourable outcome only adds “insult to injury” as the old saying goes.
With every WSIB claim it is important to advance all favourable evidence in order for the claim to have an optimal chance of success. In order to optimize the claim of success, it is also helpful to be aware of the more common pitfalls in WSIB claims. Here are some of them:
The Worker is Not Injured “Enough”
Injured workers’ claims for compensation are routinely rejected on the basis that injury falls short of demonstrating that it meets the “permanent impairment” threshold within the defined meaning in the Workplace Safety and Insurance Act.[1] The primary requirement is defined to mean “impairment that continues to exist after the worker reaches maximum medical recovery”.[2]
From a practical perspective, the denial of a claim on the basis that the injury is not permanent 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
WSIB claims often get rejected because the worker fails to present enough strong evidence in support of his or her benefit eligibility. An example of a worker’s claim being denied on this basis occurred in one recent decision[3] the worker suffered permanent ankle injuries after he sustained a fall at work. Within a few years of the accident the worker also reported having low back pain which he claimed was a result of the accident or as a secondary condition arising from the fact that his stance and gait were now changed due to the ankle injury.
The Workplace Safety and Appeals Tribunal (WSIAT) rejected the worker’s low back pain claim as the worker had not reported low back pain in the two years after the accident and no medical evidence or opinions supporting his claim. While the Tribunal conceded that the circumstances of some accidents might point to a low back injury even without medical evidence, the worker’s case was not one of those cases as “[l]ow back difficulties can start for many reasons and in all ages with or without a traumatic incident.”
Non-Compliance with WSIB Requirements
Even where the worker’s injury meets the permanent standard, the claim can be denied if it fails to specific WSIB requirements for documenting and submitting claims and there is a failure to adhere with prescribed medical protocols. As 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 fails to comply with an approved gradual return-to-work program; or
- The worker has failed to co-operate in a retraining program or in efforts to return to work, to keep in touch with the employer or to fill out needed forms or attend prescribed programs.
The above are just a few of the many reasons claims get denied. If you are experiencing difficulties in establishing your entitlement to WSIB benefits, Van Dyke Law is here to assist.
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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