Claim reopen (continuation or recurrence) decision

The initial notification of a potential claim reopen may be received by the decision maker, a case assistant monitoring the claim or through the Customer Contact Centre. If the claim was being monitored by a case assistant, they may have already started the investigation process by gathering information from the worker and/or employer. Once the information is received, the case assistant determines if the claim needs to be transferred to the decision maker. Refer to the Case assistant reopen responsibilities and tasks section. 

Review the request to reopen the claim or the new information that prompted the claim to be reviewed. The request might be documented in a file note if the worker spoke with a customer service representative, case assistant, or another WCB staff member. It could also be documented in a letter. Additionally, new reports may have triggered the need for a review.

Review the claim file to understand the difficulties the worker is currently having and what they may need to assist them in their recovery.

When reviewing the claim file, consider:

• What injuries and conditions are accepted, aggravated, and/or not accepted on the claim.
• Whether the part of body currently being treated is the same part of body accepted on the claim. If not, review the worker's claim history to determine if there are any claims for the same part of body.
• Whether the worker has an upcoming surgery and whether the surgery was anticipated before the claim was closed or inactivated.
• The new medical reporting or other reporting (if applicable) and whether it provides new information that was not previously available on the claim at the time the claim was closed. Does the new information indicate the worker has an increase in physical impairment or disability related to the compensable injury (e.g., a new diagnosis, new treatment, change in the fitness or functional level, increase in medication, etc.)
• If there is another cause for the difficulties (for example, the worker has experienced another injury and/or incident).
• What work the worker was fit to perform at the time the claim was closed and what is their current level of fitness. If the worker:
  • is currently working, what are their job duties (including physical requirements)?
  • stopped working, what were their job duties (including physical requirements) and why did they stop working?
• If the worker is receiving a wage loss supplementA wage loss supplement is a benefit payable to an injured worker whose work injury results in compensable work restrictions that impairs their ability to earn. To determined if there is an impairment of earnings, WCB compares the worker’s annual net earnings at the time of the accident (calculated in accordance with the WCA and the WC Regulation), with the worker’s actual or estimated post-accident net earnings. See Policy 04-04, Part I and II., what job the WCB previously determined they were able to do (i.e., the position used to estimate earnings) and whether they could reasonably still perform that job based on the current medical information.

Not related to a reopen for a continuation or recurrence 

If it is determined that the worker's difficulties are not related to a reopen on the current claim, consider if the information supports investigating: 

1. The impact on previous decisions: Assess whether the new information affects any past decisions on the claim. If it does, review and reconsider those decisions. Follow the 1-7 Reconsider a previous decision (new evidence) procedure instead of this procedure.
2. A new entitlement decision: Decide if a new decision is required based on the new information, especially if it impacts the worker's entitlement from the date of the new information onward. Follow the relevant procedure for the type of entitlement decision being made.
3. A new work accident: Determine if the worker's difficulties are due to a new work accident, necessitating a new claim and request a new claim be created. Refer to the Request a new claim be created and/or documents be moved/copied to another claim section. Determine entitlement for the work injury on the new claim. Refer to 1-1 Initial entitlement procedure.  
4. The reopen on another existing claim: If the injury relates to another existing claim, reopen the other existing claim and make the reopen decision on that claim by following this procedure. Refer to the Request a new claim be created and/or documents be moved/copied to another claim section. 

Reopen for a continuation or recurrence investigation required

Develop a plan for investigating and making the decision to accept or not accept a continuation or recurrence of the worker's disability for their compensable injury. Determine what information may still be required to complete the investigation and/or make a decision and anticipate questions that may arise during the discussions with the worker and possibly the employer (refer to Steps 2 and 3 for more details about these conversations). 

Gather information (e.g., symptoms, needs, earnings information on the date of layoff, etc.) that is needed to understand what has happened with the worker’s compensable injury, treatment, and employment since the claim was closed, if needed. Explain the information-gathering process for the reopen investigation, when a follow up will occur, and an estimated date for when the decision will be made. 

Ask the worker:

• What has happened with your compensable injury, treatment, and employment since your claim was last active? Do you recall something specific that may have caused the flare-up in your symptoms?
• What are your current symptoms and how have you been coping at home?
• Did you seek medical treatment and if so, who did you see, when, and what treatment plan was recommended?
• What help are you looking to receive from WCB (for example, benefits, physiotherapy, re-employment services, etc.)?
• Are you still working? What job are you doing and who are you working for (date-of-accident employer, new employer, or the position WCB used to estimate your earnings)? If the worker is not working, ask:
  • Why did you stop working and when was your last day? What job were you doing at that time and who were you working for?
• What are your current earnings or your earnings at the time you stopped working? Can you provide documentation of your earnings (e.g., paystubs, Option C printout from the Canada Revenue Agency, etc.)?
• Can we contact your current employer/the employer you were working for when you last stopped working (other than the date-of-accident employer)? Note: Permission is needed when the current employer is not the date-of-accident employer to ensure contact does not jeopardize the worker's employment.

Based on the claim file review and the discussion with the worker, if it is clear:

• The worker's current difficulties relate to a review/reconsideration of a previous decision, a new entitlement decision, a new accident or one of their other claims, explain the current claim will not be reopened for a continuation or recurrence. Follow the appropriate procedure based on the claim circumstance.
• A reopen decision for a recurrence or a continuation can be made immediately (based on the information the worker provided), continue to step 5.
• Further investigation is required, discuss the plan to support the worker in their recovery and return to work while the investigation is completed. Discuss services that that may be helpful during the investigation, confirm the worker agrees to participate, and arrange the referral or explain how they can initiate treatment (e.g., physiotherapy, chiropractic treatment, etc.) If the worker has a fitness level, negotiate a return to suitable modified duties, as appropriate. Refer to the Services for worker support during a reopen investigation section.
• The investigation will involve medical assessments, and the worker indicates they will experience financial 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.  The 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.due to the length of time the investigation will take, explore if the worker is eligible to be paid benefits during the medical investigation.
• That there are services that would benefit the worker, and they agree to participate, explain that a referral will be made for the appropriate services and/or explain how they can initiate treatment for physiotherapy, chiropractic care, etc.

If the worker did not grant permission to contact their current (not date of accident) employer, continue to Step 4.

Contact the date-of-accident or the current employer (if the worker has given permission to contact them), to discuss the worker’s employment and difficulties they are currently experiencing. Gather the information needed to make a reopen decision.

Ask the employer:

• What is the current status of the worker's employment? (e.g., Are they still employed? What are their job duties, modified duties, or hours? If not employed, why and what are the details of the layoff? Is there a way to modify their job duties so they can return to work?)
• If not already available, request a job description or a physical demands analysis.
• Are you willing to participate in a Return-to-Work Planning Meeting (RTWPM) to confirm job demands, explore opportunities for modified work, assess whether the worker would benefit from any ergonomic equipment, and/or develop a gradual return-to-work plan?
• Were you or any of your employees aware of the worker’s symptoms or difficulties?
• To confirm earnings information (if needed).

If the employer is the date-of-accident employer and they have decided not to offer modified duties to accommodate the worker’s current restrictions or they have terminated employment, discuss their duty to cooperate or their obligation to reinstate employment (when the date of accident was between September 1, 2018, and March 31, 2021). Consider a referral to an Industry Specialist. 

If the most recent employer is a new employer who has decided not to offer modified duties to accommodate the worker’s current restrictions or they have terminated employment, consider whether it is reasonable to contact the date-of-accident employer about whether they have modified duties. This may be appropriate when the worker is open to returning to work with the date of accident employer and there was a good employment relationship. 

If further information is required or the employer cannot be contacted by phone, send the appropriate letter requesting contact.

Determine if there is sufficient information to make the reopen decision for a continuation or recurrence. Consider whether the missing information is essential for making the decision. 

If the evidence is sufficient to make a decision to reopen the claim for a continuation or recurrence, continue to the next step.

If the worker's current issues relate to a review/reconsideration of a previous decision, a new entitlement decision, a new accident or another existing claim, return to the Not related to a reopen for a recurrence or continuation section in step 1 and follow the appropriate procedure based on the claim circumstance. 

If additional investigation is required before a reopen decision can be made and the investigation will take more than 14 days, consider:

• What information is essential to make the decision.
• How long it usually takes to get the information and if there are other avenues to get the information sooner such as:
  • Calling the medical provider or asking the worker to call them.
  • Requesting assistance from another WCB resource (e.g., clinical consultant, medical consultant, Investigation unit, etc.).
• Whether the worker may experience financial 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. while waiting for the decision. If so, determine:
  • if the worker meets the criteria to receive for benefits during the medical investigation. Refer to [Section 38 (3) and (4)] of the WC Act.
  • if a partial decision can be made (e.g., Issuing a retroactive benefit if the evidence supports the worker is eligible, while investigating to confirm the worker's current entitlement), or
  • referring the worker to Community Support Services, if not eligible for one of the above.

Create the plan for making the decision, including the actions to be taken and the estimated date for the decision. Include:

• The information needed to be able to make the decision:
  • Medical reporting not currently on the claim file.
  • An opinion from an internal consultantFor example a medical or psychological consultant, etc. or from the treating doctor or specialist if there is uncertainty about a diagnosis or the relation of current medical difficulties/surgery to the original injury.
  • Medical assessment such as a medical status exam, independent medical examination, functional capacity evaluation, etc.
  • A return-to-work planning meeting to confirm job demands.
  • Investigation by the WCB Investigation Unit to help gather information that has been difficult to obtain.
• The services to be provided during the investigation period to promote a safe and sustainable return to work, and to minimize the impact of delays in obtaining authorization for required treatment. Refer to the Services for worker support during a reopen investigation section.
• Whether the worker meets the criteria to receive benefits during the medical investigation. Refer to [Section 38 (3) and (4)] of the WC Act.

When the investigation will take more than 14 days, communicate the reopen investigation plan in writing including the next steps in the investigation, a target decision date and the return-to-work plan.

Send requests for the missing information and referrals for any required services and/or assistance. Ensure all necessary information is on file before sending the referral.

Repeat Steps 2, 3 and 4 until the reopen decision can be made. It is important to maintain contact with worker and employer and to keep them up to date on the investigation.

Review the claim information and relevant policies and procedures and make the decision. Determine if there is a relationship between the worker's current difficulties and their original injury. If there is a relationship, determine if the difficulties are:

• A continuation.
• Due to a recurrence. If so, ensure the requirements of policy are met.

When the decision is to accept the continuation or recurrence, determine the type of benefits and services the worker is eligible to receive (e.g., temporary disability benefits, medical treatment and/or re-employment benefits and services, etc.). Proceed to the next step.

Determine if benefits need to be paid for a retroactive period. Consider whether:

• Medical evidence supports the worker was unable to perform their date-of-accident duties or modified duties for the retroactive period and no other suitable duties were available during this period. If so, determine the effective date for retroactive benefits based on the date of the medical report.
• An appeal decision directs that  retroactive benefitsRetroactive benefits may be paid as temporary total disability or a partial disability wage loss supplement such as an Economic Loss Payment (ELP), Temporary Economic Loss (TEL), Earnings Loss Supplement (ELS) or Temporary Partial Disability (TPD)).  Retroactive benefits may be paid as temporary total disability or a partial disability wage loss supplement such as an Economic Loss Payment (ELP), Temporary Economic Loss (TEL), Earnings Loss Supplement (ELS) or Temporary Partial Disability (TPD)).be paid or that an existing wage loss supplement be adjusted.

When the decision is to not accept the continuation or recurrence:

• End the benefits (paid on a medical investigation basis) or services provided during the reopen investigation period, if appropriate. Follow step 6 in the 1-4 Benefits during a medical investigation procedure.
• Action pending payments and/or overpayments, as required.
• Determine if there are any remaining claims costs that should be removed or if there are any claims costs that were automatically removed but should be added back. Refer to the Reopen not accepted - eCO screen completion and adjusting claim costs section.
• Consider additional resources that may be available to the worker as they recover (such as Employment Insurance benefits, long-term sick leave through Canada Pension Plan, sick benefits through an employer plan, WCB’s Community Support Program, etc.).
   

Determine if cost relief applies.

Note: Costs related to the reopen investigation will remain on the claim because this information was required to make the decision. However, costs associated with the services provided during the investigation can be removed as it has been determined they are not related to the compensable injury.

If a recurrence is accepted and temporary disability benefitsTemporary disability benefits includes temporary total (TD01), temporary partial (TD02) disability benefits or re-employment assistance benefits (VR01, VR02 and VR04). are payable, review the compensation rate and determine whether it can be adjusted to a Section 61When a worker experiences a recurrence of the same disability more than 12 months after their date of accident, a new compensation rate may be set, effective the date of the recurrence. This rate is known as a Section 61 rate and is based on a worker’s earnings at the time of their recurrence. All the criteria outlined Policy 04-03, Part II, Application 1, General must be met to be eligible for a Section 61 rate. rate to reflect the worker's earnings at the time of the recurrence. The compensation rate may be adjusted to reflect the earnings at the time of a recurrence when the four conditions outlined in Policy 04-03, Part II, Application 1, Question 3 are met. 

If the worker recovers to their pre-recurrence injury state (i.e., they return to their same level of fitness prior to the recurrence) the Section 61 rate ends. Any wage loss supplement payable will be based on the Section 56The section 56 rate is based on 90% of a worker's net earnings. It is the initial rate set on a claim and the rate is set using the worker's earnings at the time of their workplace injury/accident. rate. 

If the recurrence results in increased permanent work restrictions requiring re-employment services, any liability calculated is based on the Section 61 rate.

In rare circumstances, if the worker is in receipt of an ELP at the time of the recurrence and information confirms their actual earnings are higher than the section 56 rate (used for the existing ELP), the worker's ELP would end. This is because the worker's actual earnings are higher than their date of accident earnings. However, a section 61 rate will be set to reflect the worker's earnings at the time of the recurrence for the new layoff period.  If the recurrence results in increased work restrictions requiring re-employment services, any liability calculated is based on the section 61 rate.

Notes: 

• A Section 61 rate is not applied when it is determined that the worker's difficulties are due to a continuation of their injury (i.e. the compensable injury was not resolved and/or the worker was not at medical plateau).
• An accurate Section 56 rate must be in place before adding a Section 61 rate. A worker is eligible for a Section 61 rate when the earnings at the time of their recurrence of disability lay-off is greater than the Section 56 rate plus cost-of-living increases (COLAs).
• A new Section 61 rate may be set for each future recurrence of disability.

Contact the worker and date-of-accident employer to discuss the reopen decision, the evidence considered in making the decision, and how the evidence does or does not meet policy. If the worker and/or employer disagrees with the decision, discuss their concerns and collaborate to resolve them. Consider if there is any information that is missing that may change the decision.

If the reopen is accepted and:

• the rate was adjusted for a recurrence (Section 61 rate), explain to the worker what earnings (i.e., salary, shift cycle, overtime, etc.) were used to adjust the rate. If they disagree with the rate, ask them to provide documentation of their earnings (e.g., paystubs, tax returns, etc.).
• the date of accident employer has indicated they cannot provide modified duties to accommodate the worker’s restrictions, talk to the employer about their duty to cooperate. Consider whether the date-of-accident employer continues to have an obligation to reinstate for claims with a date of accident on or after September 1, 2018 to and including March 31, 2021. If so, explain the employer’s obligation. When warranted, consider a referral to an Industry Specialist if not already completed in Step 3.

When the reopen is not accepted:

• Explain to the worker that any services offered to them during the investigation will end. Outline additional resources that may be available to the worker (such as Employment Insurance benefits, long-term sick leave through Canada Pension Plan, sick benefits through an employer plan, WCB’s Community Support Program, etc.). Offer to make a referral for the Community Support Program and make the referral if the worker accepts the offer.
• If medical providers continue to submit reporting, notify them that the reopen was not accepted and further reporting is not required.

Send the appropriate letter documenting the reopen decision and the reasons for accepting or not accepting the reopen. Outline concerns expressed by worker and/or employer and how they were addressed, when needed. If the rate was adjusted, include information about the Section 61 rate.

If the reopen was not accepted, do not send the employer a copy of the decision letter. A separate letter is automatically sent to the employer advising them of the reopen decision.

If the claim requires ongoing case management, follow the 3-2 Collaborative care planning procedure.

If the worker is currently working but will need to lay off in the future (e.g., for a planned surgery or other treatment) and the claim does not require ongoing case management until then, consider transferring the claim to a case assistant to monitor until just before the scheduled layoff. A transfer is appropriate only if the reopen decision has been communicated verbally and in writing, and no ongoing case management is required until the worker lays off.  

If it is appropriate to transfer the claim to a case assistant, document the plan for future layoff and any monitoring required for approved or planned benefits (for example, wage loss, Permanent Clinical Impairment, retraining, overpayment, etc.) and transfer the claim.

If the claim does not require monitoring, close the claim.