Reconsider a previous decision (new evidence) - Archived Jul 2, 2024

Upon receipt of a request to reconsider a decision based on new evidence or completion of an administrative review that indicates a previous decision may need to be changed, review the file to determine if the decision in question was already reviewed by the DRDRB or the AC. If it was reviewed by the:

• DRDRB but not the AC, only DRDRB can consider whether new information meets the criteria for new evidence and/or reconsider the original decision. 
• The AC, only the AC can consider whether new information meets the criteria for new evidence and/or reconsider the original decision. 

This is the case even if it seems apparent the new evidence warrants a change of the original decision.  

Advise the requester the request has been forwarded to the appropriate appeal body (DRDRB or AC) for review. 

If the new information relates to a request for a reopen, follow the 1-5 Claim Reopen procedure.  Note:  New information may not change a previous decision, but it may impact the worker's entitlement from the date of the new information onward.  

See Policy 01-08, New Evidence. 

Review the new information and decide if it is new evidenceSee Policy 01-08, Part I - New Evidence.  

Consider:

• Is the evidence material (relevant) to the issue in question and a previous decision?
• Is the evidence substantive?  Does it provide new information that was not previously available to the decision maker and could affect the outcome of the decision?
• Was the new information reasonably available to the party who requested the reconsideration at the time of the original decision and, if so, whether there is a reasonable explanation for why it was not provided at the time. Examples of reasonable explanations for why the information was not provided at the time of the original decision might include (but are not limited to):
  • There are new clinical findings that were not available at the time of the original decision that led to a change in diagnosis. 
  • The interested party relied on someone else that they trusted to seek and/or obtain new evidence on their behalf, it was reasonable for them to rely on that person and, once they became aware that the person had failed to obtain new evidence, they took reasonable and timely action.
  • The interested party was unable to seek and/or obtain new evidence due to a diagnosed mental or physical incapacity or they were prevented from doing so because of some other valid reason.

Further investigation is required

If there is not enough information to determine whether the new information meets the criteria for new evidence, gather all relevant information until a decision can be made. This may include contacting the worker, employer, and/or physician, or requesting assistance from an appropriate source (such as investigations, assessments, or an opinion from an internal consultant, etc.). Ensure all the relevant information is available on the file before making the referrals. For medical consultant referrals, refer to the medical consultant opinion section for more information. 

If the new information is a research paper the requester wants to have considered as new evidence, refer it to the Medical Services Librarian.

Once the further investigation results are received, determine if it can be considered new evidence. Refer to the considerations at the beginning of this step.

Policy requirements for new evidence not met

If the new information does not meet the criteria for new evidence, contact the worker and/or employer (and/or the worker/employer representative, as appropriate), to explain the decision and its basis (for example, the new information was not substantive or relevant to the previous decision, or it was reasonably available but not provided at the time of the decision  and there was no reason for the delay).  Discuss with the worker and/or employer, or their representative's right to request a review of the new decision. 

If the decision will be reviewed for reasons other than new evidence or if other decisions will be reviewed, explain the next steps. Document the decision, the discussion(s) and send the appropriate letter(s). (Follow the appropriate procedure if the new information results in a new issue that must be adjudicated.)

If the information was accompanied by a Request for review (RFR) that is outside the one-year time frame, send the appropriate letter to advise the requestor (and representative, if applicable) that the RFR is not in accordance with Section 9.4 (1) of the Act.

Policy requirements for new evidence are met

If the new information meets the policy requirements to be considered new evidence, contact the worker and/or employer (and/or the worker/employer representative, as appropriate) to advise that new information has been received and outline the next steps to address the request for reconsideration. Document the discussion(s) and send the appropriate letter(s) to communicate the decision on whether the information meets the new evidence criteria and next steps.

Review the claim and determine if and how the new evidence or outcome of the administrative review impacts the previous decision.

Consider:

• Was the previous adjudicative decision consistent with the available evidence and a reasonable interpretation of legislation and policy?
• Is "benefit of doubt" (if originally used) still applicable? Is there now a shift in the balance of probabilities? See Policy 01-03 Benefit of the Doubt.
• Was the original information deliberately misleading, or was the new information deliberately withheld from WCB?  

If the previous decision is supported and no changes are required, go to the next step.

If there is new evidence that supports the need for a reopen investigation, follow the Claim Reopen procedure. End this procedure.

Reconsider the previous decision if:

• It was not consistent with Legislation or approved policy.
• The weight of evidence or balance of probabilities has changed.
• The decision was made based on misleading information. (In this case, determine if the information meets the criteria for deliberate misrepresentation).  See Policy 05-01, Part II, Application 1, Question #4.
• Fraud is suspected or confirmed, refer the claim to the Investigations Unit for possible legal action.

Determine the effective date for the decision change based on the available evidence and whether the change in decision results in an adjustment to benefits or medical aid costs.

If the decision results in a change of benefits the effective date is retroactive to the date benefits should be increased or decreased. Follow applicable procedure for the type of benefit. 

Increase in benefits

If the decision results in increased benefits, request new benefits and/or action any held payments, if applicable.

Notes:

• The system automatically recalculates benefits for rate-based payments that have an issued or request status when the system runs overnight, as long as the payments do not require a manual adjustment. (All adjusted payments are placed on hold for decision maker review and approval.) Payments that had not been requested or issued will still need to be requested.
• Adjustments to rate-based payments (e.g., AEL, ATP, ATL, TPD, etc.) that were manually set or adjusted by the Payment Unit in the past must be requested from the Payment Unit. 

Decrease in benefits

If the decision results in decreased benefits, adjust the benefits retroactively to the date the worker (or dependent) was not entitled to the benefits or was entitled to decreased benefits.

An overpayment could be created when the effective date of certain eCO key dates such as date of accident or return to work is adjusted to an earlier date. 

If the new decision results in an overpayment to the worker or employer, determine if it should be cost corrected or recovered. See Policy 05-01, Part II, Application 1; Compensation Overpayments and follow the internal Procedure 5.2 - Diagnose a Cost Adjustment and Cost Correct / Forgive it or Collect it as an Overpayment. 

See Policy 05-01, Part II, Application 1; Compensation Overpayments when a claim was accepted and then denied and the injured party successfully recovers damages from a third party through a lawsuit (resulting in an overpayment to the worker).

Medical Aid Costs

If the changed decision impacts medical aid costs, notify the Medical Aid Department to create or monitor any medical aid payments.  The Medical Aid team addresses all medical aid overpayments with service providers. The decision maker addresses worker medical aid overpayments (e.g., prescriptions paid to the worker).

See Policy 05-01, Part I - Compensation Overpayments.

Verbally communicate the decisions, its basis, any impact to benefits and next steps (if any) to the worker and/or employer and follow up by sending a letter.

Clearly express the rationale used to reach the decision (citing policy, medical information on the file, any important background information) during the conversation as well as within the letter. Explain to the worker, employer and/or the representative of their right to appeal the decision.  See the Request for RFR section.

If a decision change results in an overpaymentSee Policy 05-01, Part I - Compensation Overpayments to the worker, cost relief is automatically applied to the claim. However, if the employer contributed to the overpayment by providing incorrect information, they are not entitled to cost relief and costs are to be applied back to the claim by notifying the Cost distribution team.