WCB Procedures

Reconsider a previous decision (new evidence)

Procedure summary

Published On

Jul 3, 2024

Purpose

To determine if new information submitted to WCB or information discovered during an administrative review impacts a previous decision and benefits.

Description

This process is initiated by the discovery of information that could affect a previous decision during an administrative review or by a worker or employer (or their representative) submitting new information in support of a request to change a previous claim decision.

When information is submitted as new evidence to support a request to change a previous claim decision, the WCB decision maker reviews the new information and determines if it was obtained without unreasonable delay and submitted within the time limit specified in policyPolicy 01-08, Part II, Application 2, Reconsiderations.. If so, the WCB decision maker determines if the new information meets the new evidence criteria.

The decision maker determines if the previous claim decision should be changed based on either the outcome of their administrative review or the new evidence, (when the decision-maker accepted the new information was new evidence).

When a previous decision should be changed, the decision maker determines what changes should be made (for example, increasing or decreasing the worker’s benefit(s), etc.), and makes appropriate adjustments.

Key information

A reconsideration is when a decision-maker reviews its own previous decision and confirms, varies or reverses that decision.

There are two main types of reconsiderations:

Administrative review of a previous decision prompted by internal WCB-Alberta processes
A worker (or their dependant) or an employer (or their representative) submits information as new evidence to support a request that WCB reconsider a previous decision.

In both cases, WCB (that is, Customer Service) can only reconsider its own decisions that have not been reviewed by the Dispute Resolution or Decision Review Body (DRDRB) or Appeals Commission (AC). See step 1 for more information.

WCB reviews a previous decision without a request from a worker or employer (Administrative Review)

When the decision was made by Customer Service and not reviewed by DRDRB or the AC, Customer Service will not change a previous decision if:

reasoned judgment was used and the decision is consistent with the available evidence and a reasonable interpretation of legislation and policy in effect at the time the decision was made, and,
when applicable, gives the benefit of the doubt to the worker when the evidence in support of the opposite sides on an issue is approximately equal.

WCB will change or reverse a previous decision if it is apparent that the previous decision was not consistent with legislation, policy or the facts of the case. See Policy 01-08, Part II, Application 1: Reconsiderations (General).

Depending on the outcome of the administrative review, the decision maker will determine if the original decision was correct or should be changed. If the decision maker determines the original decision was incorrect, they then determine if the worker is entitled to new benefits, services and/or an increase or decrease in benefits that have already been paid.

Worker or employer submits new information to support a reconsideration

When the decision was made by Customer Service and was not reviewed by DRDRB or the AC and the worker or employer has submitted new information to support their request for a reconsideration, the decision maker carries out a three-step process as outlined under Policy 01-08 Part II, Application 2: Reconsiderations (New Evidence). First, the decision maker evaluates the information and determines if the information was obtained without unreasonable delay and submitted within the time limit. Next, the decision maker reviews the information to determine if it meets the criteriaInformation is considered new evidence when it meets all of the following criteria: it is material (relevant), new, not reasonably available at the time the decision was made, substantive, probative, factual and objective. to be considered new evidence. Then, if it meets the criteria, the decision maker reviews the previous decision and determines if the decision should be changed based on the new evidence.

If the decision maker determines the original decision was incorrect, they then determine if the worker is entitled to new benefits, services and/or an increase or decrease in benefits that have already been paid. Any reconsideration that results in new and/or changed benefits and/or services because of new evidence is a separate decision from the decision to accept new evidence.

All decisions regarding new evidence and/or changed or rescinded decisions must be communicated in writing as these decisions are subject to the same right of review or appeal as any other adjudicative decision.

Detailed Business Procedure

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1. Determine if the decision in question was already reviewed at a higher level Upon completion of an administrative review that indicates a previous decision may need to be changed or the receipt of a request to reconsider a decision based on new information, review the file to determine if the decision in question was already reviewed by the DRDRB or the AC. If it was reviewed by the: DRDRB but not the AC, only DRDRB can consider whether new information meets the criteria for new evidence and/or reconsider the original decision. AC, only the AC can consider whether new information meets the criteria for new evidence and/or reconsider the original decision. This is the case even if it seems apparent the new evidence warrants a change of the original decision. When the worker or employer requested a reconsideration and the decision was reviewed by the DRDRB or the AC, advise the requester that the request has been forwarded to the appropriate review body (DRDRB or AC) for review. If the new information relates to a request for a reopen, follow the 1-5 Claim Reopen procedure. Note: New information may not change a previous decision, but it may impact the worker's entitlement from the date of the new information onward. If an administrative review indicates a previous decision may need to be changed, continue to Step 3. See Policy 01-08, Part II, Application 3 - Reviews and Appeals.	Administrative tasks Refer the request to the appropriate appeal body, if required: DRDRB: Send a file note (Request for Review) to the DRDRB Intake, Team Desk. Reference the DRDRB Decision Memo, include the decision date and enter “New Evidence Determination Request” in the Description line. Appeals Commission: Forward the new information to the Hearing Chair responsible for the decision being reviewed.
2. Determine if the new information was obtained without reasonable delay, submitted within the time limit and meets the criteria for new evidence Review the new information to determine whether the information was obtained without unreasonable delay and submitted within the time limit. If either criterion is not met, the information is not reviewed to determine if it is new evidence and the decision is not reconsidered. Refer to the Policy requirements for reconsiderations not met section below. If the information was obtained without unreasonable delay and submitted within the time limit, review the new information and decide if it is new evidenceSee Policy 01-08, Part II - Reconsiderations (New Evidence). Determine if the new information is considered to be new evidence under Policy 01-08, Part II, Application 2: Reconsiderations (New Evidence), specifically Question 8. To be considered new evidence, it must meet all of the criteria. Further investigation is required If there is not enough information to determine whether the new information meets the criteria for new evidence, gather all relevant information until a decision can be made. This may include contacting the worker, employer, and/or physician or requesting assistance from an appropriate source (such as investigations, assessments, or an opinion from an internal consultant, etc.). Ensure all the relevant information is available on the file before making the referrals. For medical consultant referrals, refer to the medical consultant opinion section for more information. If the new information is a research paper the requester wants to have considered as new evidence, refer it to the Medical Services Librarian. Once the results of the investigation are received, determine if the information can be considered new evidence. Refer to the considerations at the beginning of this step. Policy requirements for new evidence are not met If the new information was not obtained without unreasonable delay, not submitted within the time limit or does not meet the criteria for new evidence, contact the worker and/or employer (and their representative, if applicable), to explain the decision and its basis (for example, the new information was not substantive or relevant to the previous decision, or it was reasonably available but not obtained without unreasonable delay and there was no exceptional or justifiable reason for the delay). Explain their right to request a review of the new decision. If other decisions will be reviewed, explain the next steps. Document the decision, the discussion(s) and send the appropriate letter(s). (Follow the appropriate procedure if the new information results in a new issue that must be adjudicated.) If the information was accompanied by a Request for Review (RFR) of the original decision that is outside the one-year time frame, send the appropriate letter to advise the requestor (and representative, if applicable) that the RFR is not in accordance with Section 9.4 (1) of the Act. Policy requirements for new evidence are met If the new information meets the policy requirements to be considered new evidence, contact the worker and/or employer (and/or their representative, if applicable) to confirm that new evidence has been accepted and outline the next steps to address the request for reconsideration. Document the discussion(s). If additional information is needed to make the reconsideration decision and assess the potential impact on benefits, send the appropriate letter(s) to communicate the new evidence decision and next steps. If no additional information is needed and a decision on the reconsideration and its potential impact on benefits is ready, proceed to step 3 and send the corresponding letter as detailed in step 4 outlining the new evidence decision, reconsideration and any impact on benefits.	Administrative tasks For additional information on the disclosure of information, go to internal Procedure 20.2 - Communication of Claim Information. Document the discussion(s) in a file note (Contact / Claimant Contact or Contact / Employer Contact). Follow the procedure: 11-2 Internal consultant referral 4-2 Medical testing, referrals and program support Internal Procedure 40.1A - Medical Referrals (Research paper requests) Send CL101D (New evidence denial) letter See Policy 01-08, Part II, Application 1: Reconsiderations (General) and Part II, Application 2: Reconsiderations (New Evidence). Follow the internal 3.1-3, Request for Review Outside One Year Time Limit procedure. Send the appropriate letter(s). Include information about the worker and employers right to request a review of the new decision: Claimant – Custom Letter (CL000A) Insured – Custom Letter (IN000A) 1 yr Time Limit Expired RFR (IN011C) 1 yr Time Limit Expired RFR (CL011C)
3. Reconsider the previous decision Review the claim and determine if and how the administrative review or the new evidence impacts the previous decision. Consider: Was the previous adjudicative decision consistent with the available evidence and a reasonable interpretation of legislation and policy in effect at the time of the decision? Is "benefit of doubt" (if originally used) still applicable? Is there now a shift in the weight of evidence or balance of probabilities? See Policy 01-03 Benefit of the Doubt. Was the original information deliberately misleading, or was the new information deliberately withheld from WCB? (In this case, determine if the information meets the criteria for deliberate misrepresentation or refer the claim to the Investigations Unit for possible legal action if fraud is suspected or confirmed.) See Policy 05-01, Part II, Application 1, Question #4. If the previous decision is supported and no changes are required, contact the worker and/or employer (and/or their representative, if applicable) to explain the decision. Document the discussion(s) and send the appropriate letter(s) to communicate the decision and next steps. If there is new evidence that supports the need for a reopen investigation, follow the 1-5 Claim reopen decision procedure. End this procedure.	Administrative tasks Follow the internal 20.6 - Investigation Unit Referrals procedure. Send the appropriate letter(s): Claimant – Custom Letter (CL000A) Insured – Custom Letter (IN000A)
4. Determine the impact to benefits and communicate the decision Determine the effective date for the decision change based on the available evidence and whether the change in decision results in an adjustment to benefits, services or medical aid costs. If the decision results in a change of benefits the effective date is the date the worker became entitled/not entitled to the benefits. Follow applicable procedure for the type of benefit. Increase in benefits If the decision results in increased benefits, request new benefits and/or action any held payments, if applicable. Decrease in benefits If the decision results in decreased benefits, adjust the benefits retroactively to the date the worker (or dependant) was not entitled to the benefits or was entitled to decreased benefits. An overpayment could be created when the effective date of certain eCO key dates such as date of accident or return to work is adjusted to an earlier date. If the new decision results in an overpayment to the worker or employer, determine if it should be cost corrected or recovered. See Policy 05-01, Part II, Application 1; Compensation Overpayments and follow the internal Procedure 5.2 - Diagnose a Cost Adjustment and Cost Correct / Forgive it or Collect it as an Overpayment. See Policy 05-01, Part II, Application 1; Compensation Overpayments when a claim was accepted and then denied and the injured party successfully recovers damages from a third party through a lawsuit (resulting in an overpayment to the worker). Medical Aid Costs If the changed decision impacts medical aid costs, notify the Medical Aid Department to create or monitor any medical aid payments. The Medical Aid team addresses all medical aid overpayments with service providers. The decision maker addresses worker medical aid overpayments (e.g., prescriptions paid to the worker). See Policy 05-01, Part I - Compensation Overpayments. Verbally communicate the decisions, its basis, any impact to benefits and next steps (if any) to the worker and/or employer and follow up by sending a letter. 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. Inform them of their right to appeal the decision. See the Request for Review (RFR) section.	Administrative tasks Document the new decision in a file note (Active Case Management, Case Planning) and complete the Description line as appropriate for the claim circumstance: New Evidence Appeal Request for Review Update relevant eCO screens, as required. When there is an increase in benefits: The system automatically recalculates benefits for rate-based payments that have an issued or request status when the system runs overnight, as long as the payments do not require a manual adjustment. (All adjusted payments are placed on hold for decision maker review and approval.) Payments that had not been requested or issued will still need to be requested. Adjustments to rate-based payments (e.g., AEL, ATP, ATL, TPD, etc.) that were manually set or adjusted by the Payment Unit in the past must be requested from the Payment Unit. Send a file note (Compensation Payments, Details) to the appropriate team desk in the Payment Unit, outlining the required changes, and asking for a review and adjustment. When we deny a sub-layoff after benefits have been issued: Change the decision on the Return to Work screen to Denied. Classify the overpayment to the worker by completing the Cost Adjustment Classification Script. Send a file note (Medical Payment Processing) to Medical Aid, Team Desk to process any "other provider" payments (such as taxi, bus, hotel and translation fees), if appropriate. To create and monitor any related medical aid payments, send a file note (Medical Payment Processing) to the Medical Aid, Team Desk. Send the appropriate letter(s): Claimant – Custom Letter (CL000A) Insured – Custom Letter (IN000A)
5. Determine if the employer is entitled to cost relief for an overpayment or other issues If a decision change results in an overpaymentSee Policy 05-01, Part I - Compensation Overpayments to the worker, cost relief is automatically applied to the claim. However, if the employer contributed to the overpayment by providing incorrect information, they are not entitled to cost relief and costs are to be applied back to the claim by notifying the Cost distribution team.	Administrative tasks Send a file note (Cost Distribution) to the Cost Distribution, Working Desk, requesting the employer be charged with the overpayment amount. Follow the 12-1 Cost Relief and cost reallocation procedure.

Supporting Information

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Obtain without unreasonable delay WCB expects that all interested parties will make all reasonable efforts to obtain (pursue) all relevant information as soon as possible without unreasonable delay. If new evidence was reasonably available to the party at the time of the initial decision, WCB will consider why the information was not provided at the time. In cases where there is a delay in obtaining the information, consider if the reasons for the delay are exceptional and justifiable. Some examples might include (but are not limited to): There are new clinical findings which were not available at the time of the original decision that led to a change in diagnosis The interested party relied on someone else that they trusted to seek and/or obtain new evidence on their behalf, it was reasonable for them to rely on that person and, once they became aware that the person had failed to obtain new evidence, they took reasonable and timely action. The interested party was unable to seek and/or obtain new evidence due to a diagnosed mental or physical incapacity or they were prevented from doing so because of some other valid reason. Unless there are exceptional and justifiable reasons for a delay in obtaining the new evidence, WCB will not review the information to determine if it is new evidence. The decision-maker should use reasoned judgement to determine if the information was obtained without unreasonable delay. In addition, the decision-maker should consider when the worker started pursing the new information rather than only when they were able to obtain the information. For example, if a worker disagrees with a decision and goes to their general practitioner requesting a referral to a specialist but, due to wait times, cannot get in to see the specialist for a year, the decision-maker should consider the date the worker went to see their general practitioner rather than the date the worker was able to see the specialist when considering whether there was an unreasonable delay.	Administrative tasks See Policy 01-08, Part I - Reconsiderations, Reviews, and Appeals and Part II, Application 2: Reconsiderations (New Evidence).
Submit within the time limit WCB expects that all interested parties will make all reasonable efforts to submit all relevant information as soon as the information becomes available. The time limit for submitting new information to support a request for reconsideration is one year from the date that the new information is discovered or becomes available. The time limit cannot be extended. If the information is not submitted to WCB within this time limit, WCB will not review the information to determine if it is new evidence. The decision maker should use reasoned judgement when determining the date the evidence became available or the worker/employer became aware of the information.	Administrative tasks See Policy 01-08, Part I - Reconsiderations, Reviews, and Appeals and Part II, Application 2 - Reconsiderations (New Evidence).
Medical consultant opinion WCB decision makers may seek a medical opinion to help them determine if new information is material, substantiveIt gives new information that was not previously available to the decision maker and could affect the outcome of the decision or probativereasonably capable of proving/ disproving a relevant fact at issue. A referral to a medical consultant may be required to determine if there are new, objective and/or relevant medical findings that could affect the outcome of a previously made decision. For example, if attempting to determine if what appears to be a new finding on an MRI was identified on a previous MRI, if a suggested new diagnosis is actually a new diagnosis based on new objective findings, etc. Ensure all the relevant medical information is available on the file before making the referral. The medical consultant will answer specific questions posed by the decision maker and will provide a rationale for their opinion. Not all new information requires a medical consultant opinion. An opinion from a medical consultant is not required when the new information restates information that was already available and considered at the time of the original decision or pertains to a different time period than the original decision. For example, if a worker disagrees that they were fit for work at a medium level 10 years ago and submits a recent Functional Capacity Evaluation that indicates they are only fit for work at a limited level, an opinion from a medical consultant is not required. Reporting about the worker's current functional abilities is not relevant to the worker's functional abilities 10 years ago and cannot impact the original decision regarding fitness. However, this information may impact the worker's current entitlement to benefits so the claim may be reviewed for a possible reopen.	Administrative tasks Follow the procedure: 11-2 Internal consultant referral Internal Procedure 40.1A - Medical Referrals (Research paper requests)
Request for Review (RFR) A decision regarding new evidence is subject to the same right of review or appeal as any other adjudicative decision made by a reviewing body. If there is concern or disagreement with a decision made by the WCB, both workers and employers have one year (from the date of the decision letter) to submit a request to have the decision reviewed. (If it has been more than a year since the decision was made the DRDRB may extend the time limit under certain circumstances.) An RFR can be submitted within one year of the following decisions: To accept or deny that information provided by a worker or employer to support a request for a reconsideration is new evidence. To change a decision based on new evidence or an administrative review. A decision not to change a previous decision is not considered a new decision for the purposes of RFRs. In this case, the worker and employer have one year from the date of the original decision to request a review.

Supporting references

Policies

Procedures

Workers’ Compensation Act

Applicable sections

Section 9.3 - Review Body
Section 9.4 - Reviews
Section 13.1 - Power of Appeals Commission
Section 13.2 - Appeals
Section 17 (3) - Jurisdiction of Board
Section 21 (1) - Compensation in place of action
Section 142 - Overpayments
Section 143 - Right of Set Off

General Regulation

Applicable sections

Related Legislation

Applicable sections

Procedure history

December 19, 2023 - July 2, 2024

Compatibility Warning

WCB Procedures

Reconsider a previous decision (new evidence)

Procedure summary

Detailed Business Procedure

Administrative tasks

Further investigation is required

Policy requirements for new evidence are not met

Policy requirements for new evidence are met

Administrative tasks

Administrative tasks

Increase in benefits

Decrease in benefits

Medical Aid Costs

Administrative tasks

Administrative tasks

Supporting Information

Administrative tasks

Administrative tasks

Administrative tasks

Supporting references

Policies

Procedures

Workers’ Compensation Act

General Regulation

Related Legislation

Procedure history