To determine if an injured worker is entitled to receive workers' compensation benefits.
The decision maker works collaboratively with the worker, employer and medical professional(s) to compile the necessary information about the incident, work environment and injury.
When all of the necessary information is obtained, decision makers determine eligibility for workers’ benefits in accordance with the Workers' Compensation Act and WCB-Alberta policies.
Decision makers are encouraged to use their discretion and reasonable judgement to guide their decisions and conversations in order to make the most appropriate, fair decision.
Under section 24 of the Workers' Compensation Act, compensation is payable to a worker who suffers personal injury as the result of an accident or work exposure.
To be compensable, an accident must meet two conditions: It must arise out of and occur within the course of employment. This means:
There was a hazard present in the workplace that caused the worker's injury and the worker was performing an activity consistent with the expectations and obligations of their employment.
The worker's accident happened at a time and place consistent with their job duties.
Injuries may be either physical or psychological. They may be the immediate result of an accident or may develop over time. It is important to ask the right questions and use discretion when identifying whether there was an employment hazard and keep in mind that a hazard is not always tangible or easily recognized.
Detailed business procedure
1. Review all documents on file and gather initial information
Before contacting the worker, take the time to fully review and understand the information on the file, and get an understanding of the worker’s injury, their workplace environment and what they may need to assist them in their recovery.
From there, determine what information may still be required to make the entitlement decision and anticipate questions that may arise during the initial conversations with the worker and employer (see step #2 for more details about this conversation).
When reviewing the documents on file, confirm:
That there is a worker and employer, as defined by the Workers’ Compensation ActPolicy 06-01 , WC Act 1.1 (z).
Whether the injury falls under the Workers’ Compensation ActThere was a hazard present in the workplace that can explain the worker's injury and the worker must have been performing an activity consistent with the expectations and obligations of their employment. The worker's accident happened at a time and place consistent with their job duties..
The type of injury or illness.
The date of the accident.
For progressive injuries, consider selecting the date of accident as the first date which medical treatment was provided or of earnings loss.
If the worker's shift overlapped two calendar days, their date of accident is the date the shift began.
If the worker has personal coverage (in the case of a self-employed worker).
If the worker has any previous claims and if the injury or illness is a pre-existing condition.
If the injury resulted in time off work.
Any possible third party action claims.
Some exceptions or special circumstances may require further consideration to make a decision, such as if:
The accident occurred outside of Alberta or the injured worker resides outside of Alberta.
For out-of-province claims, consider the following:
Whether the employer performed any business and/or operations in Alberta at the time of the worker's accident.
The nature of the work the worker was performing inside and outside of Alberta.
The length of time the worker has been working inside and out of the province.
* The worker must first elect which province they want to claim in before an entitlement decision is made.
The claim was not filed within 24 monthsSection 26 of the Workers’ Compensation Act of the accident or date of initial medical attention.
Claims that were filed past the 24 month time frame may be accepted if:
There are reasonable and justifiable grounds for the delay.
The claim is a just claim and should be allowed despite the failure to report within the prescribed time frame.
Out of province claims
Confirm with Employer Services if the employer had a waiver in place prior to the date of the accident.
Determine where the worker has the right to elect to claim and their preferred location to claim.
Send the appropriate form:
If the employer did not perform business and/or operate in the province where the worker resided at the time of their accident, request completion of employer confirmation of interjurisdictional accounts forms (C1137).
Determine worker’s preferred province to claim compensation and send confirmation letter:
Send a confirmation letter to the appropriate jurisdiction:
Worker elected to claim with other board letter (GE001C)
Was incident reported to other board? letter (GE001B)
2. Contact the worker, employer and health care provider(s)
This is an important step in the initial entitlement decision process, as it establishes relationships with the affected stakeholders. It involves all parties sharing information about the injury, the worker’s and employer’s needs, possibilities for modified work and details about the claims process and what to expect along the way.
Communication takes many different forms, and can be customized based on the situation. It can be face-to-face, over conference calls or phone calls or through letters.
During these initial conversations, be prepared to answer questions, investigate options, review payments and address any concerns that arise. Include any additional information that arises during the communication to the claim file.
Most importantly, take the time to learn about the worker and employer’s needs and perspectives, building confidence and trust through open, honest and proactive conversations.
If initial contact with the worker and employer is required, ensure it takes place within within five business days after a claim is assigned.
When speaking to the worker:
Listen to their concerns and ask the right questions to gain information regarding the injury, work status and pay, and medical treatment plan:
How are you feeling?
How and when did your injury occur?
What are your recovery and treatment goals?
What’s your job and what are your duties?
Have you received any medical treatment or testing related to this injury so far?
Were you able to return to work or are you still off?
Are you receiving any health benefits through your employer?
When speaking to the employer:
Educate the employer about the nature of the worker’s injury and the important role that they play in the worker’s recovery.
Explain the responsibility and obligation to provide modified and/or permanent employment.
Determine if the employer is facing any challenges while their worker is hurt and away from work.
Encourage them to stay connected with their worker and keep them engaged in the workplace while they recover.
When communicating with the health care provider via telephone or letter, confirm:
Diagnosis and treatment recommendations.
The degree of the disability.
The worker’s fitness for work and opportunities for safe modified work.
In some instances, there may need to be communication with other parties, such as union or employer representatives, family members. Arrange an interpreter to assist with communication, if necessary.
Develop a customized plan with the worker and employer for staying connected. The general guideline is to make contact every two weeks, and to return phone calls within 24 hours. Ensure communication takes place at every decision point (See step #5 for more information).
Request missing info letter (CL004A) if unable to reach by phone and additional information is required to make a decision.
Fill out ADJ initial worker conversation form (FM127A).
Add medical provider information in eCO:
Add provider as participant.
Add file note to address book librarian if the provider is not already in the system.
The initial entitlement decision has three outcomes:
It is confirmed that the injury is work-related (it arose out of employment and occurred in the course of employment).
In some cases, workers qualify for wage replacement benefits while they undergo further medical investigation to determine entitlement. Benefit payments are dependent on medical information to support time off work.
It is determined that the injury did not arise out of the course of employment.
The employer is not required to have worker’s compensation coverage and has opted not to purchase it.
The decision maker was unsuccessful in making contact with either the worker or employer and there is missing information.
Complete/update the required eCO screens:
Claim details - claim type and initial entitlement decision
Treatment details (only required when surgery has occurred or treatment has been denied)
Update the screens as new information is received on the claim.
Ensure the date of accident is correct on the Claims details tab and the relevant fields in the return-to-work screen are completed for time loss claims when the worker has returned to modified work.
Authorize the medical treatment by adding the Authorized Treatment line and complete the Benefit Details tab if required.
Add or update the appropriate lines to authorize other expenses or benefits as required such as authorized treatment and medications or travel.
* If contact with the worker and employer was unsuccessful after two attempts, consider making an entitlement decision when:
There is no conflicting information.
No concerns are identified.
There are no unusual circumstances.
It appears that the claim meets or does not meet Policy 02-01 criteria.
4. Set the rate for wage replacement benefits
After a claim is accepted, set the rate for wage replacement benefits within 14 calendar days of the receipt and registration of a claim.
Rates are based on the worker’s:
Employment status (permanent, non-permanent, personal coverage, owner-operator, subcontractor)
Date of hire and history with the employer for the past 12 months
Hourly rate of pay
Overtime, vacation pay and shift premiums
Additional income from other employers, if applicable
Refer complex rates to the Payment Unit for calculation.
Once the rate is set, communicate with the worker and confirm how and when they would like to receive wage replacement benefits.
Once a decision is made and the rate is set, verbally communicate the decision and next steps to the worker and employer and follow up by sending the appropriate letter within five business days.
Clearly express the rationale used to reach the decision (citing policy, medical information on the file, any important background information) during the conversation as well as within the letter.
In the letter:
Use clear, conversational, collaborative language and a respectful, positive tone. Address both the worker’s and employer’s concerns and personalize the letter based on the audience and situation.
If the claim is accepted, emphasize that the worker’s recovery is our top priority. Outline next steps such as treatment, benefits and compensation rate (and how it was calculated), return-to-work-details and plans for follow-up conversations. Offer additional services if eligible.
If the claim is denied, offer additional resources that may be available to the worker as they recover. This may include Employment Insurance benefits, long-term sick leave through Canada Pension Plan or sick benefits through an employer plan.
WCB’s Community Support Program can also connect workers with various agencies and organizations across the province for additional support outside of the workers’ compensation system.
End every letter with the decision maker’s name and direct contact number. Also provide the options to contact a supervisor or request a formal decision review within 12 months.
Document verbal communication of decision in the claim file.
Send the appropriate letter:
Entitlement determined (CL041A)
IED denial letter (CL101C)
Short-term closure letter (CL076A)
CAPS adjudicator denial letter (CL076B)
The community support referral form can be found on the internal Electronic Workplace.
6. Monitor, transfer or inactivate the claim
Continue to keep in contact with the worker and employer every two weeks. Together, discuss the worker’s progress, evaluate their fitness for work, issue the appropriate benefits and arrange services as required.
If a permanent clinical impairment is suspected, the worker will undergo a medical review with an independent medical examiner 24 months after the date of accident or most recent surgery.
Ensure a smooth transition if the file needs to be transferred to another staff member for longer term or complex care cases.
Call the worker and employer and explain the reason for the transfer and discuss any related referrals, if applicable.
Ask the worker how they’re recovering and assess whether they require additional referrals or supports. Confirm with them that all of the information on their file is up-to-date.
Provide the worker and employer with the name and telephone number of their new contact, and send a follow up letter. Confirm with the worker that they will hear from their new contact within five business days.
If the worker did not miss any time from work or has already returned to their job, the file can be inactivated.
Call the worker and employer to communicate the closure of the file and ensure all benefits have been paid. Let the worker know that their file can be re-opened at any time in the future if there are any concerns or additional information related to their claim.
If a new entitlement decision is made, add a file note (entitlement decision) and document the decision. Add a file note (contact/worker or employer, modified work/claimant/employer) documenting the discussions.
Transfer permanent clinical impairment (PCI) files to a case assistant.
Update eCO lines as needed.
Update eCO screens and add a transfer file note or FM131 form.
If contact with the worker or employer was unsuccessful, send the CL054A letter to advise of the claim transfer.
Once fitness for work has been determined, send the appropriate letter: