Claim reopen decision

WCB staff member (who is not the decision maker)

Receive or review the information indicating a claim reopen needs to be investigated. Gather additional information from the worker and request outstanding medical reports as needed.

If the worker cannot be reached, send the appropriate letter requesting the worker contact WCB to provide the required information. Refer the claim for assignment to a decision maker, if required.

Decision maker 

Review the information on the file including any claim alerts; attempt to fully understand the difficulties the worker is currently having and what they may need to assist them in their recovery before contacting them.

Consider if the new information is related to a reopen decision, or to a previous decision and may be considered new evidence under WCB Policy.

Develop a plan for investigating and making the reopen decision. Determine what information may still be required to make the reopen decision, and anticipate questions that may arise during the conversations with the worker and possibly the employer (see Steps 2 and 3 for more details about these conversations).

When reviewing the claim file, consider:

• Whether the injuries and conditions are accepted, aggravated, and/or not accepted.
• Whether the part of body being treated is the same part of body accepted on the claim.
• Whether the worker has an upcoming surgery and layoff previously scheduled.
• Whether there are any changes between the new medical and previous medical reports (for example, is there a new or additional diagnosis, a change in the worker’s fitness, pain, or function level, an increase in medication, etc.).
• Whether the new report(s) are a duplication of previously reviewed reports.
• If there is another cause for the difficulties (for example, the worker has experienced another injury and/or incident).
• The worker's claim history and whether there are recent claims.

 Note: If claim is being monitored by a case assistant these questions can be asked prior to transferring the claim to a case manager via the team assign desk. The case assistant should also review the transfer file note and the last case manager letter on file to determine if there were ongoing work restrictions or an excepted re-open in the future for further treatment.

If the information indicates that a new work accident has occurred and a new claim should be created or the injury is related to an existing claim, refer to the Additional Information section to action.

If there was no answer or response from the worker after two attempts to contact them, send the Reopen/Recurrence Investigation – New Treatment (CL016D) letter (if not previously sent). Also, document the reason for the call(s) and describe the missing information. (This enables the contact centre to gather the required information if the worker contacts them.)

Gather information (for example, 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 last active, if needed. Explain the information-gathering process for the reopen investigation, when a follow up will occur, and an estimated date for when the reopen 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?
• 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 the WCB (for example, benefits, physiotherapy, re-employment services, etc.)?
• What are your current symptoms, needs, earnings information on the date of layoff, and other relevant investigation details?
• Can we contact your current employer? Permission is needed when the current employer is not the date-of-accident employer. (This is to ensure contact does not jeopardize the worker's employment.)

Discuss whether a decision can be made immediately (based on the information the worker provided) or the plan to support the worker in their recovery and return to work while the investigation is completed. Services that may be helpful and can be arranged or authorized during the investigation include:

• Negotiating modified duties with the employer, including a referral for a return-to-work planning meeting to confirm job duties and identify modified work opportunities
• Treatment (for example, physiotherapy, chiropractic care, psychological counselling, etc.)
• Medical services (for example, medical status exam, independent medical exam, etc.)
• Ergonomic assessment to identify possible workplace modifications
• Triage assessment for re-employment services.

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

Contact the date-of-accident or the current employer (if the worker has given permission), 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 status of the worker’s employment (for example, are they still working, details of the layoff, job duties or changes to duties or hours)?
• Were you or any of your employees aware of the worker’s symptoms or difficulties?
• Are you aware of any job duties the worker is unable to perform?
• Has the worker been performing modified work? If so, what modified duties are they performing? Can you provide a job description. If not, are modified duties available?
• To confirm earnings information (if needed).

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. If a reopen decision can be made, go to the next step.

If a reopen decision cannot be made within 14 days, consider:

• What information is essential to make the decision.
• How long it usually takes to get the information and what can be done if the information is not received by a certain date.
• Whether there is something that can be done to get this information or arrange for the service faster.
• Whether the worker’s authorization is needed to request any of the required information.
• Whether there is a WCB resource that can help (for example, clinical consultant, medical consultant, Investigation unit, etc.).

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

• The information and/or service needed to be able to make the decision, such as:
  • Medical reporting not currently on the claim file
  • An internal consultant opinion (for example, medical, psychological, etc.) if uncertain about a diagnosis or whether the current medical complaints are related to the original injury
  • Medical assessment such as a medical status exam, independent medical examination, functional capacity evaluation, etc.)
  • 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.
• Whether the worker meets the criteria to receive benefits on a medical investigation basis.

Communicate the reopen investigation plan in writing to the worker and a copy to the employer, 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 reopen decision. Determine if the reopen is a continuation or recurrence of disability.

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.

Determine if cost relief applies.

When the decision is to accept the reopen, determine the type of benefits and services the worker is eligible to receive (that is, reopen to temporary total disability benefits, medical treatment and/or re-employment benefits and services). Proceed to the next step.

When the decision is to not accept the claim reopen:

• End the benefits (paid on a medical investigation basis) or services provided during the reopen investigation period, if appropriate.
• Action pending payments and/or overpayments, as required.
• Based on the reopen decision, determine what remaining claims costs, if any, should be removed (that is, is the reopen decision to not accept any ongoing responsibility or the current time loss) or added back to the claim as they were removed automatically (but should not have been). Refer to the Additional Information section for details.
  
  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.

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.).

If the information indicates that a new work accident has occurred and a new claim should be created or the injury is related to an existing claim, refer to Additional Information section to action.

Review the compensation rate and determine whether it can be adjusted to reflect current earnings. The compensation rate may be adjusted to reflect the earnings at the time of a recurrence when the four conditions of Section 61See Policy 04-03, Part II, Application 1, General. are met.

Contact the worker and date-of-accident employer to discuss the reopen decision, the evidence considered in making the decision, and how that 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.

Send the appropriate letter documenting the reopen information and provide a detailed explanation of the decision. Outline concerns expressed by worker and/or employer and how they were addressed, when needed. Include information about the Section 61 rate, if applicable.

When the reopen is not accepted and the Reopen/Recurrence of Disability – Denied (CL016F) letter is sent to the worker. The employer should not be sent a copy of this decision letter. A separate letter (Employer Reopen Denial – IN016A) is automatically sent to the employer advising them of the reopen decision.

Notify the regular medical service providers (if reports continue to be submitted), that the reopen of the claim is not accepted and further reporting is not required.

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

If the claim requires a future layoff, consider transferring the claim to a case assistant to monitor until just before the scheduled layoff. Transfer to a case assistant only if the reopen decision is made, communicated verbally and in writing, and no further care plan is required at this time.

If the claim requires ongoing monitoring for other entitlement (for example, wage loss, Permanent Clinical Impairment, academic, overpayment, etc.), document the details and transfer the claim to the case assistant.

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