Benefits during a medical investigation

Review available information to determine if a medical investigation is required.

Consider the following:

• Is a medical investigationFor more guidance in determining whether a medical investigation is required see Section 38(3) of the Workers' Compensation Act. required to make an entitlement decision?
• Is the medical assessment (including the time it will take to receive the reporting from the assessment) likely to take more than 14 days?

If the answer to both of the above questions is yes, go to step 2. However, if a medical investigation is not required or will be completed within 14 days, follow the appropriate procedure to make the decision.

Contact the worker and explain what medical investigation benefits may include and determine if they are eligible for or are receiving benefits from another party (e.g., short-term disability benefits, EI medical disability benefits), and whether a delay in determining entitlement will create economic hardshipThe worker is unable to meet reasonable and necessary living expenses (such as rent, mortgage, utilities, food, transportation, health care) needed for the survival of the worker and their spouse and/or dependents and/or they are unable to keep up with debt payments and bills. Documentation is not needed to support that the worker will experience financial hardship.. When applicable, request the worker provide documentation that benefits from EI, short-term disability, etc. have been denied. 

If required, contact the employer to confirm the worker’s eligibility for short-term disability benefits.

Determine if the worker has other WCB claims and, if so, review the claim(s) to confirm the worker is not eligible for benefits under the other claim(s).

Notes:

• For EI or other disability benefits, the worker should provide a copy of a letter confirming they are not entitled to the benefit or that there will be a significant delay in payment of benefits. However, if the worker is unable to obtain documentation of an anticipated significant delay, payment of benefits may still be considered. 
• Documentation is not needed to confirm the worker will experience economic hardship.

Review available information to determine if the worker is entitled to compensation during the medical investigation. 

Consider: 

• Is the worker eligible for or receiving wage replacement benefits from another party or on another WCB claim (e.g., short-term disability benefits, Employment Insurance medical disability benefits, etc.)?
• Is it probable (more than likely) the entitlement will be accepted following the investigation?
• Is the worker experiencing economic hardshipThe worker is unable to meet reasonable and necessary living expenses (such as rent, mortgage, utilities, food, transportation, health care) needed for the survival of the worker and their spouse and/or dependents and/or they are unable to keep up with debt payments and bills. Documentation is not needed to support that the worker will experience financial hardship. as a result of the delay in determining entitlement?

Notify the supervisor of the decision or request approval for the decision. When the decision maker: 

• Has determined the worker is not entitled to benefits during the medical investigation, no supervisor approval is needed but the supervisor must be notified of the decision.
• Has determined the worker is entitled to benefits during the medical investigation, supervisory approval is required for all recommendations made by adjudicators, and all case manager recommendations when benefits is expected to be paid for more than 90 days. The case manager does not require supervisory approval when the period of benefits is expected to be less than 90 days but the supervisor must be notified of the decision.

Review the supervisor’s decision file note, if approval was required.

Call the worker (or their representative) and employer (when required) to discuss the decision to approve or not approve payment of benefits during the medical investigation. When approved, explain that the worker will not be required to pay back any benefits issued if entitlement is not accepted after the investigation is completed and that benefits will end the day the entitlement is not accepted; explain to the employer that cost relief would be applied in this situation.

When benefits during the medical investigation have not been approved, offer to make a referral to Community Supports for the worker, when appropriate. 

Send the appropriate letter to the worker (and their representative, if applicable) outlining the decision.

Continue to authorize benefits until the medical investigation is complete and the entitlement decision is made. 

If the medical investigation period will exceed the period approved by the supervisor or will extend beyond 90 days, obtain approval from the supervisor to continue paying compensation during the medical investigation.

When there is a conflict in medical or psychological opinion, or a medical exam is invalid, continue to pay benefits until the conflict or the invalid exam has been addressed.  

Once the decision is made to accept or deny entitlement, update the claim to reflect that the medical investigation is concluded and refer to the appropriate procedure to communicate the entitlement decision.  

When the entitlement is not accepted: 

• Conclude all benefits including wage loss and/or any medical aid benefits paid to the worker.
• Notify the Cost Distribution team and clearly identify the specific costs that should be relieved, if required. Include any costs that should not be relieved.
• Offer to make a referral to Community Supports for the worker, when appropriate. 

Notes:

• The Medical Aid team will review and address medical payments to service providers and adjust, if required based on the provider contract and will send letters to the providers as required.
• Medical aid benefits payable to the worker are addressed by the decision maker.

Surgery is non-compensable

If the worker undergoes surgery while being paid benefits during the medical investigation and the surgical procedure reveals a non-compensable cause for the worker's disability, pay benefits for a reasonable period of recovery following the surgery (i.e., until the worker returns to their pre-surgical state) when the WCB arranged for or facilitated the surgery (e.g., through the Visiting Specialist Clinic). However, if the WCB did not arrange for or facilitate the surgery (e.g., was already scheduled in the community), end benefits once it is determined the condition is not compensable. 

In the rare case where the surgery results in permanent disability, consider paying for that disability, when it is related to the surgery and not solely due to the underlying (non-compensable) condition.