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Claims decisions: Could you put that in writing?

Some compensation boards use a combination of form letters that are sent out to employers and/or workers, as well as decision letters that are written and customized for each claim and decision within that claim.

Decisions should contain pertinent facts of the situation at hand, the rationale for the decision, including a reference to applicable sections of the compensation legislation or any applicable operational policy, and any applicable deadline for appeal.

The recipient should then have a full understanding of how the decision maker came to that particular decision, and can decide whether or not to appeal it.

I recently became aware of a claim where the compensation board had allowed health care benefits in the form of surgery, and wage loss benefits, in a claim that had previously been closed. The employer was not made aware of these decisions — either verbally or in writing.

In fact, the employer remained unaware of the decisions to allow additional entitlement until the costs appeared on the employer’s Accident Cost Statement issued by the compensation board. As this particular employer pays dollar for dollar for all accident costs, it was very surprised to see that additional entitlement had been allowed.

On the downside of this situation, the employer must now scramble to try to minimize those accident costs by offering suitable work to the worker in order to get the compensation board to stop paying wage loss benefits.

On the upside, however, because no decision was issued, they were not advised of an appeal deadline and will be able to appeal the decision.
As the financiers of the compensation system, employers must be aware of the decisions that are made in claim files. Those decisions impact claim costs and the ability to effectively manage the claim and appeal decisions in a timely manner.

Employers should monitor claim costs and question any unexpected costs that appear related to a specific claim. If a written decision was not issued, be sure to request one as soon as possible in order to have a full grasp on what is happening in a claim.

David Marchione

David Marchione is an occupational health and safety consultant and paralegal at Fasken Martineau DuMoulin in Toronto. He can be reached at (416) 868-3468 or dmarchione@fasken.com, or visit www.ehslaw.ca for more information.
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