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WCB Procedures

Initial entitlement decision - Archived Mar 17, 2025

Procedure summary

Published On

Dec 12, 2023

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. The location of the accident. The permanent residence of the worker on the date of accident. 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. This information helps to set a pre-accident baseline and determine the impact of the injury to the 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. The worker’s permanent residence is in another province, and they are injured in an accident that occurred in Alberta. * In both cases, 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 months of the accident or date of initial medical attention.	Administrative tasks Review applicable forms: Worker report of injury or occupational disease (C060) Employer report of injury or occupational disease (C040) Supporting medical reporting Employer physical demands analysis (C545) Job description MVA request for information (CL020A) Automobile accident report (L054) Send a file note (Employer Account) to the Claims Charging, Working Desk when the employer charging is not done or the personal coverage amount is not showing on the eCO Claim Folder-Policy screen.
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? Have you received any medical treatment or testing related to this injury so far? If so, who provided the treatment? What are your recovery and treatment goals? What is your job and what are your duties? Were you able to return to work or are you still off? Are you in contact with your employer? Encourage them to maintain that contact and relationship. Explain their responsibility to make reasonable, good faith, efforts to cooperate in the return-to-work process. When speaking to the employer: Discuss the accident and injury and clarify any information that is inconsistent or missing. Educate the employer about the nature of the worker’s injury and the important role that they play in the worker’s recovery. Discuss what modified work is available to the worker, and when the date of accident is on or after September 1, 2018, up to and including March 31, 2021, explain their responsibility and obligation to provide modified and/or permanent employment. Explain their responsibility to make reasonable, good faith efforts to cooperate in the return-to-work process. 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. Confirm earnings information as required. 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, worker or employer representatives or 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 If unable to reach the worker or employer by phone and additional information is required to make the decision, send the Request missing information letter (CL004A and/or the appropriate IN004 letter). 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. Worker's authorization of a representative form (C622) Employer's authorization of a representative form (C966) 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 Consider referring the claim for a(an): Medical opinion if there are questions about the relationship of the injury to the work accident, or Entitlement investigation from the Investigation unit when all attempts to gather the information have been unsuccessful. Send the referral from the eCO Add investigation referral screen. 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. In some cases, the wage replacement benefits may be paid to the employer when they are continuing to pay the worker during their recovery.	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 wage replacement benefits will be paid, discuss the option to receive payment through direct deposit. 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. Send the appropriate initial entitlement decision letter. Send initial entitlement decision denial letters to the worker only. The system will automatically send the date-of-accident employer or their representative another version of the letter. 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 every two weeks and the employer every six weeks, or as soon as the worker has achieved the ability to return to either modified or full work in order to assist with facilitating their return to work. Together, discuss the worker’s progress, evaluate their fitness for work, and modified work opportunities. Also, issue the appropriate benefits and arrange services as required. If a permanent clinical impairment is suspected, the impairment may be assessed on the reporting on the claim file, or the worker may 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. For claims with a date of accident on or after September 1, 2018, complete the Claim Closure/CA Monitoring File note - Fit for Full Duties and advise the Case Assistant to monitor the claim for a period of 6 months following the worker's return to pre-accident work and to transfer the claim to a claim owner if there is a change in status (i.e., worker was laid off, terminated, etc.). 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/Claimant or Employer or Modified Work/Employer or Claimant) documenting the discussions. Update eCO lines as needed. Update eCO screens and add a transfer file note using the appropriate template, if applicable. 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 fit for work letter in the CL041 series. Otherwise, send a Care Plan Conclusion (CL041E) letter as required.

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. WCB is committed to providing dental treatment to restore the worker’s dental damage to what it was prior to the accident if possible. Dental treatment providers need authorization from the Workers' Compensation Board before dental treatment can be performed. The exception to this is when a worker receives emergency treatment for work-related dental injuries (e.g., emergency extraction of a broken tooth, emergency surgery to remove foreign bodies from the oral cavity, etc.). 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 Request any missing information. In addition, if there are work-related TMJ concerns or the dental damage is caused by another work-related injury or treatment for the work-related injury, obtain related medication history and assist the worker in determining their oral hygiene requirements, such as a special appliance or aid. Obtain an opinion from a dental consultant 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. The entitlement discussion with the worker, and the dental treatment provider, if needed, should include what treatment (i.e., specific teeth/tooth) is approved or not approved, the payment schedule and that the approved treatment should be done within one year from the date of the approval letter, whenever possible. Confirm these details in writing.	Administrative tasks Send the initial dental assessment request (SP001A) to the dental treatment provider. Complete the MC Review – Dental/Ophthalmology Referral form (FM551Q) from the eCO Create Referral screen. Include additional information or questions not on the form, if needed. Send the appropriate decision letter: Dental treatment approved (SP001B) Dental treatment not approved (SP001C) Update the eCO Dental treatment line with the appropriate benefit, decision, as required.
Fractures Review the worker’s medical and x-ray reports on file to help confirm the details of the fracture. If the reporting is not available, call the worker to find out where they received treatment for the fracture. Once a fracture is confirmed Fracture injuries have standard best practice timelines for returning to pre-accident job duties. To achieve this, the Medical Services department has an active role in confirming the fracture, documenting it in the eCO system and providing an opinion on the best practice return-to-work date that is based on both industry best practice durations and the worker’s individual condition. Decision makers use this information to help set realistic goals and care plans for the worker.	Administrative tasks Enter the correct fracture injury code on the injury details screen in eCO and click the "Calculate Best Practice" button to calculate and display the best practice date and assist with determining an initial estimated return to work date on the return to work screen.
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 fact sheet [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) demonstrates the pattern shown for noise-induced hearing loss. 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.	Administrative tasks There are no administrative tasks for this section.
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 have 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, referrals and program support 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) 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. If additional information is still required after contacting the worker/employer, send: Worker's progressive injury questionnaire (C504) [PDF, 0.09MB] Employer's progressive injury questionnaire (C606) [PDF, 0.27MB]

Claim-specific circumstances

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Delayed worker reporting of the accident (Section 26) Workers are required to file their claim within 24 monthsAs outlined in Section 26 of the Workers’ Compensation Act. from the date of the accident or the date on which the worker becomes aware of the accident. However, when a claim is not filed within the 24-month time limitation, the claim may still be reviewed for entitlement if: There are reasonable and justifiable groundsReview Policy 05-01, Part II, Application 1 for examples of reasonable and justifiable grounds for the delay, or The claim is a just claimA “just claim” means evidence exists that supports claim acceptance. It is probable that the available evidence supports the claim is compensable, in accordance with the Worker’s Compensation Act, and all statutory and policy criteria. When evaluating whether it is a just claim, the decision is determining probability of acceptance, rather than making an initial entitlement decision. and should be allowed despite the failure to report within the prescribed time frame. To extend (i.e., waive) the 24-month time limitation and allow the claim to be reviewed, the worker needs to show they either had reasonable and justifiable grounds or that they have a “just” claim; they do not need to show both. When speaking to the worker, find the reason(s) why they did not submit their claim within the 24-month time frame and gather information about the accident (as outlined in step 2). If contact is unsuccessful, send the worker a letter requesting the information. Explain the claim will remain active for 30 days, and then will be inactivated until the information is received. Once received, evaluate all of the information and decide if the 24-month time limitation can be extended before moving on to adjudicate the entitlement of the claim. Obtain approval from the supervisor for the decision to extend or not extend the time limitation. The decision to extended or not extend the time limitation is communicated in writing and includes how the worker met one of the requirements or didn’t meet either requirement. Note: When the time limitation is extended, the initial entitlement decision is communicated in a separate letter.	Administrative tasks Send the appropriate request for information letter (CL050 series). Indicate a time frame for the worker to submit their information. Generally, this is 30 days from the date of the letter. Send a file note to the supervisor (Entitlement) outlining the decision and reasons for extending or not extending the 24-month time limitation. Send the Section 26 Extended/Approved (CL019H) or Section 26 Not Extended/Denied (CL019G) letter.
Out-of-province accidents (Section 28) Workers injured in an accident that occurred outside of Alberta may be eligible to elect to claim compensation (right to election) in Alberta if the conditions outlined in Section 28 of the Workers’ Compensation Act and Policy 06-01 Part II, Application 5 – Coverage Outside of Alberta are met. To determine if the worker meets the conditions and is a considered a worker under the WCA, confirm the following information with the worker and employer: Is the worker a permanent resident of Alberta at the time of the accident? If not, was their usual place of employment in Alberta and the work out of Alberta a continuation of that employment with the same employer? Was the majority (greater than 50%) of the worker’s employment in Alberta? For Alberta residents, did the worker perform work both in and out of Alberta? Has the worker’s employment out of Alberta lasted less than twelve continuous months? After reviewing the information, decide if the worker meets all of the conditions of Section 28 (1). If they do not, confirm whether the employer has a waiver in place prior to the date of accident. If the worker is unable to claim compensation in Alberta, they may be eligible to claim compensation in the province where the accident occurred. However, they cannot receive benefits from both the Alberta and the other province or territory WCB. Discuss the outcome of the Section 28 review with the worker, and if they have the right to election in Alberta, ask where they would prefer to claim compensation. Worker elects to claim compensation in Alberta Send the Right to elect letter and the Election to claim under the AB WCA form to the worker and request they complete the form and return within 14 days. Return to the main procedure to continue the claim entitlement investigation but wait to make a final initial entitlement decision or release any benefits until the signed Election to claim under the AB WCA form is received. When the signed Election to claim under the AB WCA form is received, notify the other provincial board the worker is claiming compensation in Alberta. Worker is not eligible to elect or has chosen not to elect to claim compensation in Alberta Obtain the worker’s verbal or signed authorization to release claim information to the other Board. Once the authorization is received, send the appropriate letter based on the claim circumstances and a copy of the claim documents and file notes to the other Board. Return to the main procedure to communicate the decision and send the letter to the worker and employer.	Administrative tasks To assist in determining if the worker is a permanent resident of Alberta, consider what address they provide on their tax assessment. The employer may apply to have all or any one of the Section 28(1) conditions (i.e., a, b and c) waived or extended. A waiver means the worker may still be able to claim compensation in Alberta. To find out if the employer has a waiver in place at the time of accident, send a file note to the Employer Account Services, SPV Desk. The Right to elect (CL058A) letter requests the worker complete, sign and return to the Election to claim under the AB WCA (out-of-province accident) (C169) form to the WCB. Election to claim under the AB WCA (out-of-province accident)(C169) While waiting for the worker to send in the signed C169 form, the claim may be provisionally accepted, and initial benefits held at the counter if the worker has verbally advised they are electing in Alberta and it is clear the claim is acceptable. When the form is received, the cheque can be released. If the form is not received within 30 days, the provisional acceptance of the claim will be overturned. Send the Was incident reported to other board? letter (GE001B) to notify the other Board the worker chose to elect in Alberta. Send the out-of-province permission letter (CL025B) to obtain the worker’s written authorization, if verbal authorization is not provided. Once authorization is received, send the appropriate letter and copy of the claim information to the other board: Worker elected to claim with other board (GE001C) Worker is not eligible to claim with Alberta Board (GE001D) *When the worker was paid benefits from both Boards, discuss with the Interjurisdictional (IJA) team.
Out-of-province workers injured in Alberta accidents When a worker is injured in Alberta but resides in another province, they may be eligible for coverage under the Alberta Workers' Compensation Act. They may also be able to elect to claim compensation under the Workers' Compensation Board in the province where they reside. This depends on whether: their employer confirms they perform business and/or operations in the province of residency at the time of their accident, and they have an account with the other Board or the criteria for the out-of-province right to elect has been met. Contact the employer to determine if they performed (or planned to perform) any business and/or operations in the worker’s province of residency at the time of the accident which would require them to have an account with that Board. Employer does not have business or operations in the province of residency If the employer confirms they did not perform any business and/or operations in the worker’s province of residency at the time of accident, the worker does not have the right to elect in another province, only Alberta. The employer can remove the requirement for the worker to complete a right of election form by: Submitting a signed Employer confirmation of Interjurisdictional accounts form, or Verbally confirming the same information. Exception: When the employer has an account in the other province, but confirms the worker was hired solely to work in Alberta, an Employer confirmation of Interjurisdictional accounts form is not required. The requirement to complete an Election to claim under the AB WCB form can be waived as the worker would not have the right to elect outside of Alberta. Employer has business or operations in the province of residency* If the employer confirms they performed business and/or operations in the worker’s province of residency at the time of accident and have an account with that Board, contact the worker to discuss their right to elect to claim compensation options. Ensure the worker understands the process they are choosing and answer any questions they may have. If the worker elects to claim compensation in Alberta, send the Right to elect letter with an Election to claim under the AB WCB (C1040) form to the worker and request they complete the form and return within 14 days. Return to the main procedure to continue the claim entitlement investigation but wait to make a final initial entitlement decision or release any benefits until the signed Election to claim under the AB WCB (C1040) form is received. When the signed form is received, notify the other Board the worker is claiming compensation in Alberta. If the worker elects to claim compensation with the other Board, obtain the worker’s verbal or signed authorization to release claim information to the other Board. Return to the main procedure to communicate the decision and send the letter to the worker and employer.	Administrative tasks Confirm whether the worker is a permanent resident of Alberta at the time of the accident. Consider what address the worker provides on their tax assessment. Some federal government employees who reside in the Yukon, Northwest Territories, or Nunavut are considered to be Alberta residents. Employer confirmation of Interjurisdictional accounts form (C1137) Document the employer’s verbal confirmation on the claim. It must include the information that is required on the Employer confirmation of Interjurisdictional accounts form including that they do not have business and/or operations in the worker’s province of residency. The Right to elect letter (CL058A) requests the worker complete, sign and return to the Election to claim under the AB WCB (C1040) form to the WCB-Alberta. Election to claim under the AB WCB form (AB accident - out-of-province resident) (C1040) While waiting for the signed C1040 form, the claim may be provisionally accepted and initial benefits held at the counter awaiting release if the worker has verbally advised they are electing in Alberta and it is clear the claim is acceptable. When the signed C140 form is received, the cheque can be released. If the signed C169 form is not received within 30 days, the provisional decision to accept the claim will be overturned. Send the Was incident reported to other board? letter (GE001B) to notify the other Board the worker chose to elect in Alberta. Send the out-of-province Permission letter (CL025B) to obtain the worker’s written authorization, if verbal authorization is not provided. Once authorization is received, send the Worker elected to claim with other board letter (GE001C). Do not release claim information to the other Board until authorization is received. *When the worker was paid benefits from both Boards, discuss with the IJA team.
Third-party claims When a person who is not covered under the WCA (i.e., third partyPolicy G3 - Third Party Actions), causes or contributes to an accident, the WCB will investigate and determine if legal action will be taken against the third party. The Legal Services department administers all actions (i.e., cost recovery) related to third-party claims. However, decision makers need to notify the Legal Services department when there is possible third-party action on a claim. When the outcome of the third-party action is cost recovery, and the worker receives an excess payment amount due to the settlement (i.e., the balance of the funds paid to the worker after payment of legal fees, reimbursements to the WCB for claims costs and the 25% guarantee to the worker, the excess amount will be offset from future benefitssection 22(12) paid to the worker under the claim.) Medical aid and rehabilitation benefits should not be offset. Legal Services will add an alert on the file where an excess payment was made. The decision maker will ensure the excess amount is deducted from future periodic compensation or the equivalent (e.g., temporary total disability benefits) until the excess is recovered. Note: If a motor vehicle or third-party accident occurred at or because of the worker's employment obligations, but there is no information confirming an injury occurred, the claim should not be accepted. While the person may be a "worker" as defined in the Workers' Compensation Act, in order for the claim to be acceptable for compensation benefits, an injury must have occurred as a result of the accident.	Administrative tasks Send a task (Legal) to the Legal -Third Party, Team Desk. Use the role code of Consultant - Legal. Do not complete or clear the "Screen for Third Party Recovery" task. It will be completed or cleared by Legal Services. On the payment request, add the hold code MS to the cheque and add a file note (Finance) indicating the cheque is to be sent to Legal Services. The CL101C (Denial Letter) gives an example of a summary statement to explain the entitlement decision for motor vehicle or third-party accident claims with no injury. Legal Services requires confirmation the worker is covered under the Act. It is important the denial letter include this information.

Supporting references

Policies

Procedures

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)
Section 26 - Time Limits for Claims
Section 28 - Out of Province
Section 56(1)
Section 64
Section 140

Workers' Compensation Regulation

Applicable Sections

Related Legislation

Procedure history

November 15, 2022 - December 11, 2023

December 10, 2019 - November 14, 2022

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