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WCB Procedures

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  • 1 - Claim entitlement decisions
    • 1-1 Initial entitlement decision
    • 1-3 Initial entitlement decision - hearing loss
    • 1-4 Benefits during a medical investigation
    • 1-5 Claim reopen (continuation or recurrence) decision
    • 1-6 Aggravation of a pre-existing condition decision
    • 1-7 Reconsider a previous decision (new evidence)
    • 1-8 Fitness-for-work decision
    • 1-9 Conflict of medical/psychologist opinion
    • 1-10 Additional entitlement decision
    • 1-16 Medical assistance in dying
  • 2 - Compensation rate setting
    • 2-1 Rate setting
  • 3 - Return-to-work and care planning
    • 3-1 Modified work
    • 3-2 Collaborative care planning
    • 3-3 Duty to cooperate
    • 3-4 Egregious conduct
    • 3-5 Obligation to reinstate employment
    • 3-8 Medical panel
  • 4 - Medical benefits and services
    • 4-1 Medical testing, referrals and program support
    • 4-2 Community treatments
    • 4-3 Psychological counselling
    • 4-4 Orthotics and prosthetics
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    • 4-8 Pharmacy direct billing and medication management
    • 4-9 Pharmaceutical cannabinoids and medical cannabis
    • 4-10 Externally-powered prosthetics
    • 4-11 Non-standard medical aid treatment decision
  • 5 - Claim-related expenses
    • 5-1 Travel and subsistence benefits
    • 5-5 Child and animal care
    • 5-6 Home and workplace modifications
    • 5-7 Vehicle modifications
    • 5-8 Initial hospitalization, treatment center and care facility benefits
    • 5-10 Special financial assistance
    • 5-13 Lump sum retirement (pre-retirement) benefit approval
  • 6- Permanent disability benefits
    • 6-1 Permanent clinical impairment
    • 6-3 Advances and lump sum commutation requests
  • 7 - Re-employment benefits and services
    • 7-1 Triage assessment referral
    • 7-2 Supported job search
    • 7-4 Retraining programs
    • 7-5 Training on the job, train and place, or work assessment
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  • 8 - Wage loss supplements
    • 8-1 Wage loss supplement final approval
    • 8-2 Retroactive wage loss supplement final approval
  • 9 - Claim information, access and privacy
    • 9-4 Authorizations: worker and employer representatives
  • 10 - Client inquiries and incidents
    • 10-1 Client inquiry resolution
    • 10-3 Critical incidents
    • 10-4 Address a fairness inquiry
  • 11 - Claim and file administration
    • 11-1 Requesting medical reports
    • 11-2 Internal consultant referrals
    • 11-4 Translation and interpretation services
    • 11-5 Claim entitlement Investigation Unit referrals
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  • 12 - Cost and entitlement adjustments
    • 12-1 Cost relief, cost transfer and cost reallocation
  • 13 - Claim decision review and appeal
    • 13-1 Address a resolution submission or letter

Benefits during a medical investigation

Procedure summary

Published On

Dec 16, 2024
Purpose

To determine if a worker is eligible to receive compensation benefits while entitlement is investigated. 

Description

WCB may carry out medical and/or non-medical investigations to determine entitlement. When a medical investigation is needed to determine entitlement, compensation benefits may be paid while the investigation is completed. Compensation benefits are not paid during non-medical investigations.

The WCB decision maker reviews the claim to determine if the worker is eligible for benefits during a medical investigation. If the worker is eligible, the decision maker pays benefits while the medical investigation is completed. Once the investigation is complete, benefits may continue if the entitlement is accepted or will end if the entitlement is not accepted. 

Key information
Medical investigations

Section 38(3) of the Workers' Compensation Act (WCA) gives WCB the authority to carry out a medical investigation if it's needed to determine entitlement. 

A medical investigation occurs when an entitlement decision cannot be made until the worker completes medical assessments. This includes assessments arranged by WCB (e.g., functional capacity examinations, independent medical examinations, comprehensive psychological assessment, etc.), and medical assessments completed in the community.

The following situations are not considered medical investigations:

  • No medical assessment is required but WCB has not yet received outstanding medical reporting or medical opinion necessary to make an entitlement decision.
  • WCB is carrying out a non-medical investigation (e.g., to evaluate the employment circumstances at the workplace, to gather additional information about the mechanism of injury) necessary to make an entitlement decision.

Medical investigations may be required for any type of entitlement decision including:

  • Acceptance of a new claim (for example, an assessment is needed before claim acceptance can be determined).
  • Acceptance of a new injury or reopen on an established claim (e.g., a medical opinion or assessment is required to determine whether the new injury or the re-open is related to the original injuries accepted on the claim.
  • A new medical investigation is needed on a claim where a medical investigation was already conducted, and entitlement was denied.
Benefits during medical investigations 

Section 38 (4) of the WCA indicates that a worker may be eligible for benefits during a medical investigation. WCB will authorize benefits during a medical investigation when all of the following criteria are met:

  • The worker is not eligible for or receiving wage replacementWage replacement benefits cover the worker's loss of earnings when they are unable to work. Wage replacement is payable by WCB when the worker is missing time from work due to an accepted work accident or injury. Wage replacement benefits may be payable by other agencies when the worker is missing time from work for reasons unrelated to their WCB claim.  Wage replacement benefits cover the worker's loss of earnings when they are unable to work. Wage replacement is payable by WCB when the worker is missing time from work due to an accepted work accident or injury. Wage replacement benefits may be payable by other agencies when the worker is missing time from work for reasons unrelated to their WCB claim.benefits from another party or on another WCB claim (e.g., short-term disability benefits, Employment Insurance (EI), medical disability benefits, etc.). If a worker is being paid out by their employer for vacation pay, benefits may be considered during a medical investigation.
  • It is probable (more than likely) the entitlement will be accepted following the investigation and the worker would be entitled to wage replacement benefits if the claim was accepted.
  • The medical investigation is likely to take more than 14 days.
  • The worker is 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.

Benefits payable during a medical investigation may include:

  • Payment for medical assessments or investigations required to determine entitlement.
  • Payment for treatment such as physical therapy treatment or psychological counselling.
  • Payment of wage loss benefits.

See the Supporting information section for more information on the types of benefits payable.

The decision maker automatically reviews for entitlement to benefits during a medical investigation. A request from a worker or their representative is not required. 

Additional resources for medical investigation are available in the internal Procedure Resource Library.

Detailed business procedure

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1. Determine whether a medical investigation is required

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.

Administrative tasks

Follow the appropriate procedure:

  • 1-1 Initial entitlement decision for new claims
  • 1-5 Claim reopen decision procedure for existing claims.
2. Determine if the worker is eligible for benefits from another party and experiencing economic hardship

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.

Administrative tasks

Document the discussion in a file note (Contact/Claimant Contact) or (Contact Employer contact)

 

 

 

 

3. Make the decision and obtain approval, if required

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.

Administrative tasks

Send a file note (Entitlement Decision) to the supervisor using the Medical Investigation file note template. Document the request and the basis for approving or not approving payment of benefits during the medical investigation. The template is available in the internal Procedure Resource Library.  

4. Communicate and implement 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.

Administrative tasks

Document the discussion in a file note (Contact/Claimant Contact or Contact/Employer Contact).

To approve benefits during the medical investigation, set the compensation rate (when required).  

Update the following eCO screens:

  • (New claim only) Claim Details tab, Initial Entitlement Decision field: select Medical Investigation.
  • Return to Work screen: Add the layoff details, and set the Layoff Decision field to Medical Investigation. For a reopen claim, add a new layoff (do not extend an existing layoff sequence). Ensure an actual EOL Date was entered for the prior existing layoff.
  • Injury Details, Injury Decision field: select Medical Investigation for each injury being investigated.
  • Treatment Details if any treatment is pending.
  • Benefit Details tab for any lines (e.g., Authorized Treatment, Travel Expenses) added.

Note: eCO automatically applies cost relief when the Initial Entitlement Decision field is set to Medical Investigation. A system generated task is sent to the Cost Distribution team to manually apply cost relief for the subsequent layoff, when the layoff decision is set to Medical Investigation.

Action all pending payments. 

Send the appropriate letter:

  • Medical Investigation Approved (CL032A) 
  • Medical Investigation Denied (CL032C) letter 

Follow the 1-1 Initial entitlement decision procedure for new claims and the 1-5 Claim reopen decision procedure for existing claims.

Send an email to community supports when the medical investigation is not approved and the worker agrees with the referral. 

5. Pay benefits and obtain approval to extend benefits, if required

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.  

Administrative tasks

Send a file note (Entitlement Decision) to the supervisor. Document the dates of the original request and approval (if applicable) file notes, the reason continued benefits are required and the anticipated end date of the medical investigation. 

Follow the appropriate procedure:

  • 1-1 Initial entitlement decision for new claims.
  • 1-5 Claim reopen decision for existing claims.
  • 4-1 Medical testing, referrals and program support
  • 9-1 Conflict of medical/psychologist opinion 
  • 11-2 Internal consultant referrals
6. Conclude benefits being paid during a medical investigation

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.

Administrative tasks

Follow the 1-1 Initial entitlement decision procedure for new claims and 1-5 Claim reopen decision procedure for existing claims.

When required, adjust or delete payments and process any outstanding exceptions.

When entitlement is not accepted:

  • Click the Process Payment Changes button to add the Cost Adjustment Classification Script task to the task list.
  • Complete the Cost Adjustment Classification Script (answer No to the three questions) to classify the overpayment (cost correction or overpayment).
  • If required, send a file note (Cost Distribution/Cost Relief Required) to the Cost Distribution, Working Desk advising of any costs that should not be relieved. Identify the specific costs or services. 

To help determine a reasonable period of recovery following surgery, refer to the internal Duration disability resources or to a medical consultant for an opinion/review. Follow the 11-2 Internal consultant referral procedure. 

Notes:

  • A system task is sent to the Medical Aid, Team Desk advising that an accept / not accept decision has been made. 
  • Do not delete any Medical Aid Fee For Service or Report Fees payments (the Medical Aid team will address these overpayments). 

Supporting information

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Types of compensation benefits payable during a medical investigation

Any type of wage replacement or top up benefit can be paid during a medical investigation. Generally, temporary total disability (TD01) benefits are paid during the medical investigation period. Temporary partial disability (TD02) benefits can be paid if suitable modified work is available that is consistent with the worker's medical restrictions, as long as the worker meets eligibility criteria (refer to the Key Information section) Re-employment assistance (VR)vocational rehabilitation benefits can be paid if the worker is fit for work and involved in re-employment services.

There may be cases where it is appropriate to change the type of payment (i.e., TOP/NOPCode used to categorize the type and nature of the payment.) payable to the worker during the medical investigation. The TOP/NOP code can be changed during a medical investigation when there is a more appropriate TOP/NOP code given a change in the circumstances of the claim.

Example: It was determined that a worker was entitled to TD01 benefits during a medical investigation as a Medical Panel is required to make an entitlement decision. New medical reporting is received that indicates the worker is fit at a modified level while waiting for the investigation to be complete. Other benefits may be considered until the Medical Panel can be completed, such as a re-employment or temporary partial disability benefits.

Paying compensation benefits retroactively

When it is determined that a worker should be paid benefits during a medical investigation, the benefits are paid from the date that decision is made. The benefits are not to be paid retroactively, even if the worker was missing time from work prior to the date of accident of the decision. Once an entitlement decision is made, the claim will be reviewed for entitlement to any benefits that may be payable before the decision to approve benefits during the medical investigation was made.

Paying allowance benefits during a medical investigation

When benefits such as Housekeeping Allowance (HKA), Home Maintenance Allowance (HMA), Short Term Home Assistance (STHA) or Personal Care Allowance (PCA) are already in place, these benefits may continue during a medical investigation.  No new entitlement decisions regarding HKA, HMA, PCA or STHA benefits should be made until the medical investigation is complete. 

Agency care may be approved if a worker requires assistance with homemaking, wound care, post-surgical care, etc. during the medical investigation.

How long benefits are paid during a medical investigation

In general, benefits approved for a medical investigation should continue to be paid until an entitlement decision is made. 

However, in cases where the medical assessment required to make an entitlement decision is considered invalid, benefits may be discontinued in some circumstances. For example, if a worker has already had one assessment that is invalid and participates in a second assessment that is also invalid, it may be reasonable to discontinue benefits during the medical investigation even though an entitlement decision cannot be made. This is decided on a case-by-case basis and with input from the supervisor. If a decision is made to end benefits during the medical investigation, other services or resources for the worker are explored.

When to use the "Medical Investigation" option in the eCO system

Only select "Medical Investigation as an option in the Initial Entitlement Decision field and on the Return to Work screen when you are paying the worker compensation benefits during the medical investigation as per Section 38(4). This ensures that claim costs are accurately charged to the correct account (i.e., Employer, Industry, Special Account). If you are completing a medical investigation on the claim but not paying compensation benefits, select the Pending option.

Cost relief for medical investigation

If entitlement is denied after benefits were paid during a medical investigation, cost relief is provided for the costs of the benefits that were paid during the investigation.

If entitlement is accepted after benefits were paid during a medical investigation, cost relief is not applicable.

Administrative tasks

Refer to Policy 05-02, Part II, Application 1.

Follow the 12-1 Cost relief and cost reallocation procedure.

Supporting references

Procedures

  • 1-1 Initial entitlement decision
  • 1-5 Claim reopen decision
  • 1-9 Conflict of medical/psychologist opinion
  • 4-1 Medical testing, referrals and program support
  • 12-1 Cost relief and cost reallocation

Workers’ Compensation Act

Applicable sections

  • Section 38

General Regulation

Applicable sections

Related Legislation

Applicable sections


Procedure history

January 16, 2024 - December 15, 2024
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