WCB Procedures

Initial entitlement decision - Archived Nov 14, 2022

Procedure summary

Published On

Dec 10, 2019

Purpose

To determine if an injured worker is entitled to receive workers' compensation benefits.

Description

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.

Key information

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

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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 Act.Policy 06-01 , WC Act 1.1 (z) Whether the injury falls under the Workers’ Compensation Act.There 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.	Administrative tasks Review applicable forms: Worker report of injury or occupational disease (C060) [PDF, 0.24MB] Employer report of injury (C040) [PDF, 0.32MB] Supporting medical reporting Employer physical demands analysis (C545) [PDF, 0.21MB] Job description MVA request for information (CL020A) Automobile accident report (L054) [PDF, 0.11MB] 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: Right of election form (AB resident – out of province accident)(C169) [PDF, 0.14MB] Election to claim under the AB WCB form (AB accident - out of province resident) (C1040) [PDF, 0.06MB] Right to elect letter (CL058A) 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 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).	Administrative tasks 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. Attach release of medical information form (C463) for out-of-province cases. [PDF, 0.16MB] Worker's authorization of a representative form (C622) [PDF, 0.28MB] Employer's authorization of a representative form (C966) [PDF, 0.22MB] Confirm who is authorized on the claim to ensure communication takes place with all necessary representatives.
3. Make the initial entitlement decision Review all information on the file and determine if the claim is acceptable, referring to related policies and legislation. Once every effort has been made to contact the worker, employer and health care provider(s) to gather and review the required claim information, make the entitlement decision. Some injuries may require additional diagnostic testing or medical referrals to accept the claim. These include: Dental injury Fractures Hearing loss Occupational injury or disease Psychological injury Repetitive strain injury The initial entitlement decision has three outcomes: Accepted It is confirmed that the injury is work-related (it arose out of employment and occurred in the course of employment). Medical investigation 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. Denied/inactive 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.	Administrative tasks Complete/update the required eCO screens: Claim details - claim type and initial entitlement decision Injury details Treatment details (only required when surgery has occurred or treatment has been denied) Return-to-work screen Employment screen 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 Shift cycle 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.	Administrative tasks Follow the rate setting procedure.
5. Communicate the outcome/decision 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.	Administrative tasks Document verbal communication of decision in the claim file. 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 Monitor: 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. Transfer: 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. Inactivate: 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.	Administrative tasks 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: Fit for work - date-of-accident job (CL041C) Fit for work - modified duties (CL041X)

Injury-specific initial entitlement decision

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Dental injury A dental injury can occur on its own, as a result of another physical work-related injury or as damage directly caused by the treatment of a work-related injury. Review available documents to confirm the dental injury. This can include: A report of the dental damage A detailed dental history A report outlining the proposed treatment X-rays or photos If there are work-related TMJ concerns, obtain related medication history and assist the worker in determining their oral hygiene requirements, such as a special appliance or aid. A request for an opinion from a dental consultant may be required to determine the relationship between the dental damage and the work-related accident, or if there is anticipated severe or long-term damage as a result of the injury.	Administrative tasks Send the initial dental assessment request (SP001A) to the dental treatment provider. Send the appropriate decision letter: Dental treatment approved (SP001B) Dental treatment not approved (SP001C) Update the Dental treatment line in eCO with the appropriate benefit and approval codes. And to request a referral, if applicable.
Fractures Review the worker’s medical and x-ray reports on file to help confirm the details of the fracture.	Administrative tasks Add the initial treating physician, clinic, hospital or as a participant on the claim if available. Enter the correct fracture ICD code on the injury details screen in eCO and click "Calculate Best Practice" button in the injury duration best practice section to calculate and display best practice and assist with determining an initial estimated return to work date on the return to work screen. Enter the worker’s treatment information into the “Treatment details” screen in eCO.
Hearing loss (occupational noise-induced) Workers can be compensated for noise-induced hearing loss that occurs within Alberta and Saskatchewan, or if they were employed with the Government of Canada in Nunavut, Yukon or Northwest Territories. Review the available documentation and communicate with the worker and employer to gather: A history of the worker’s hearing loss and a medical history. Discuss symptoms and concerns with the worker. Records of the worker’s employment history and exposure to noise. An audiogram completed within the last year by a registered hearing aid practitioner (RHAP) or audiologist. Any additional audiogram readings or ENT (ear, nose and throat) reports. If appropriate, send the hearing loss factsheet [PDF, 0.15MB] to the worker for more information Review the reports to determine whether the pattern of hearing loss shown on the audiogram(s) is consistent with occupational noise-induced hearing loss. If required, obtain a medical opinion from a medical consultant to establish: The level of hearing loss The relationship between the hearing loss and occupational noise exposure The level of entitlement for tinnitus An indication of a permanent clinical impairment and recommendation for compensation. In some cases, the medical consultant may request further testing such as an auditory brain stem response test or an MRI. In order for a claim for occupational noise induced hearing loss to be accepted, the following criteria must be met: The worker’s audiogram(s) demonstrate the pattern shown in the noise-induced hearing loss chart below: The worker has been exposed to at least two years of noise levels equal to or greater than 85 decibels averaged over an eight-hour workday (the Alberta occupational exposure limit).	Administrative tasks Send the hearing loss package [PDF, 0.62MB] Hearing information form (C042) Worker's employment record form (C131) Employer’s information questionnaire (C139) Hearing loss medical release form (C583) If the worker has been employed through a union, a letter from the union can provide a history of employment. Send a dizziness/balance questionnaire to the worker if dizziness/balance problems are reported (traumatic injury) in consultation with the worker.
Occupational injury or disease Occupational disease may progress over time, and may involve multiple employers. A worker may experience symptoms immediately following exposure to a workplace hazard or many years later. Occupational injury or disease claims may require further information gathering to determine when the illness began and if it was a result of the worker’s workplace conditions. Obtain the worker’s health and employment history. Gather their previous health and/or dental records and any related diagnostic reports such as x-rays. The following information can also help guide the entitlement decision for an occupational injury or disease: The timeframe between the exposure and the onset of symptoms. Details on how the worker was exposed. The job description and if required, the brand name of the safety equipment used. Biochemical testing reports. Information detailed on workplace Materials Safety Data Sheets (MSDS). Air quality reports/industrial hygiene reports, Occupational Health and Safety reports and any other reports documenting substances within the work environment. If required, request a medical opinion to gain additional information or guidance on the relationship between the symptoms and work exposure, diagnosis, work restrictions, and whether a permanent impairment is anticipated.
Psychological injury Psychological or psychiatric injuries at work can happen suddenly, due to a traumatic situation, or can develop over time. They can also develop in response to being injured at work or undergoing treatment for a work-related injury. To accept a claim for a psychiatric or psychological injury, there must be a confirmed psychological or psychiatric diagnosis as defined in the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM). WCB will presume that a confirmed psychological or psychiatric injury arose out of and occurred in the course of employment in the following circumstances, unless there is evidence to the contrary: A first responder (as defined in section 24.2 of the Workers' Compensation Act) has been diagnosed with post-traumatic stress disorder (PTSD) or a worsening of an existing case of PTSD (for accidents/incidents that occur on or after December 10, 2012). First responders include firefighters, police officers, peace officers (sheriffs only), and paramedics (including emergency medical responders (EMRs), primary care paramedics and advanced care paramedics). For accidents/incidents that occur on or after April 1, 2018, correctional officers and emergency dispatchers are also covered. Effective April 1, 2018, this presumptive coverage also includes other psychological/psychiatric conditions that develop after a confirmed exposure to a traumatic event at work. A worker has been diagnosed with a psychological/psychiatric condition and had a confirmed exposure to a traumatic event at work (for accidents/incidents that occurred between April 1, 2018 and December 31, 2020). For any circumstances and time frames not specified above, WCB will accept a confirmed psychological/psychiatric injury when there is a link between the psychological/psychiatric diagnosis and the work accident/incident(s) or the injury/subsequent treatment. This includes: A traumatic event at work; it must be confirmed that the psychological/psychiatric injury was caused, at least in part, by the traumatic event/situation at work. An accumulation of work stressors over time or a stressor that exists over time; it must be confirmed that the stressor(s) is the predominant cause of the psychiatric/psychological injury. A psychological response to being injured and/or undergoing treatment for that injury; it must be confirmed that the psychological/psychiatric injury was caused, at least in part, by the injury or treatment. An event/incident(s) at work is considered to be traumatic when it involves direct personal experience of an event or directly witnessing an event that is sudden, frightening, shocking, specific and involves actual or threatened death or serious injury to oneself or others or threat to one’s physical integrity. For the period of April 1, 2018 to December 31, 2020, a traumatic event can also include workload or work-related interpersonal incidents that are excessive and unusual in comparison to the pressures and tensions experienced in normal employment. Effective January 1, 2021, interpersonal relations between a worker and coworkers, management, or customers may be traumatic when they result in behaviours that are aggressive, threatening or abusive. Excessive workload alone would not be considered traumatic but may be considered as a chronic stressor. Review the information on file to determine if there is evidence that the worker experienced a traumatic incident at work or an accumulation of stressors over time. Also review whether there is a confirmed psychiatric or psychological diagnosis made by a physician (including psychiatrists) or psychologist using the criteria in the most current edition of the DSM. Contact the worker and the employer to obtain information about the traumatic incident or workplace stressors. Ask questions to get an understanding of the worker’s injuries, how they’re coping and progressing and any initial or ongoing medical treatment they’ve received. If a decision to accept the claim or injury cannot be made immediately and the worker advises they are not yet receiving any treatment, offer up to five sessions of psychological counselling so they can receive support until the review is complete. If the information is unclear or there is no confirmed DSM diagnosis, contact the worker’s physician or psychologist using the appropriate letter to obtain additional information or clarification. If appropriate, send the related psychological injury fact sheets to the worker and/or employer for more information: Bullying and harassment in the workplace worker fact sheet [PDF, 0.07MB] Presumptive coverage for traumatic psychological injuries worker fact sheet [PDF, 0.07MB] Psychological injuries as a result of stressors that occurred over time at work (chronic onset) worker fact sheet [PDF, 0.06MB] Psychological injuries as a result of traumatic event(s) at work worker fact sheet [PDF, 0.06MB] Psychological injuries—frequently asked questions worker fact sheet [PDF, 0.07MB] Bullying and harassment in the workplace employer fact sheet [PDF, 0.07MB] Presumptive coverage for traumatic psychological injuries employer fact sheet [PDF, 0.07MB] Psychological injuries as a result of stressors that occurred over time at work (chronic onset) employer fact sheet [PDF, 0.06MB] Psychological injuries from traumatic event(s) at work employer fact sheet [PDF, 0.06MB] Support your employee as they recover from a psychological injury employer fact sheet [PDF, 0.06MB] When additional information is required to make a decision on acceptance or the injury, obtain an opinion from a medical consultant or psychological consultant or consider referrals for additional investigation(s) such as a Psychological Injury (PI) assessment, a Comprehensive Psychological Assessment (CPA) or an Independent Medical Examination (IME – psychiatric). A CPA may be helpful in establishing if the work stressors are the predominant cause of the psychological injury diagnosed. See the medical testing and exam referrals procedure for more information on making a referral. Additional information may be needed to make the initial entitlement decision, such as interviews with other stakeholders or witness statements. The decision maker may request assistance from the Investigation unit to help gather the information they are having difficulty obtaining.	Administrative tasks Request medical - physician (SP006A) Psychological report request (SP021D) Request med-psychiatrist (SP006H) Chronic psych intro (CL026B) General information questionnaire for emotional injuries (C844) [PDF] DSM confirmation physician (SP026J) DSM confirmation psychologist (SP026K) The claim can be accepted under presumptive coverage when there is a confirmed traumatic incident and a confirmed psychological/psychiatric diagnosis of: Acute stress disorder Post-traumatic stress disorder (PTSD) Adjustment disorder with depressed mood Adjustment disorder with anxiety Adjustment disorder with mixed anxiety and depressed mood Adjustment disorder with disturbance of conduct Adjustment disorder with disturbance of emotions and conduct Specific phobias related to the traumatic event (for example, a fear of heights after a fall from a significant height or a fear of driving after being involved in a major motor vehicle accident). Psych IED accept (CL041H) Psych IED deny (CL026G)
Repetitive strain injury Contact the worker and employer and discuss whether there was a specific task that led to the injury. Ask additional questions related to the worker’s job duties: Describe the typical tasks you perform each day. How long does it take to complete each task? How many times per day do you perform them? What are the typical movements required to complete those tasks (such as twisting, lifting or reaching)? How long has this been your typical workday? Have there been any recent changes to your job? Do you rest between tasks? When are your scheduled breaks? Do you take them? When did you first notice symptom(s) and have they become worse? What were you doing at the time? Are there any other factors that may have contributed to your injury? Also consider: Whether the worker has previous injuries or pre-existing conditions. Knowledge of the worker’s job and industry. The medical provider’s opinion.	Administrative tasks Ensure physical demands analysis (C545) [PDF, 0.21MB] and job description forms are on file. Worker's progressive injury questionnaire (C504) [PDF, 0.09MB] Employer's progressive injury questionnaire (C606) [PDF, 0.27MB]

Supporting references

Policies

Procedures

2-1 Rate setting

Workers’ Compensation Act

Applicable Sections

Section 1(1)z - Definitions - Interpretations
Section 14(1) - Application of Act
Section 24 (4): Statutory Presumptions
Sections 25(2) 56(1) 64 and 140
Section 26 - Time Limits for Claims
Section 28 - Out of Province

Workers' Compensation Regulation

Applicable Sections

Compatibility Warning

WCB Procedures

Initial entitlement decision - Archived Nov 14, 2022

Procedure summary

Detailed business procedure

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Injury-specific initial entitlement decision

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Administrative tasks

Supporting references

Policies

Procedures

Workers’ Compensation Act

Workers' Compensation Regulation

Related Legislation