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When it pays to dig deeper

Most claims management courses or articles provide information on how to either decrease the occurrence of claims (or try to have benefits denied) or decrease the duration of claims (through return-to-work programs). While those techniques do work, it is important to consider other mechanisms of limiting entitlement — such as having claims constrained to an acute period of injury.

In previous articles, I have stressed the importance of a thorough investigation when an injury is reported. A thorough investigation can help determine information that may help limit entitlement in a claim that is otherwise been allowed, thus reducing the impact to your experience rating and saving you money.

When conducting the investigation after a report of an injury, some things an employer should consider include:

• whether this worker had prior similar claims or injuries — work related or not;

• any pre-existing conditions (i.e. prior surgery);

• whether modified work was required in the past for similar issues.

This information can be gathered from the worker, any witnesses or co-workers and human resources documentation. These should be gathered when the employer learns about the injury. It should be provided to the compensation board with the initial report so it can be considered in the entitlement decision-making process.

When compensation boards allow claims on an aggravation basis, they generally accept that the person had a pre-existing condition or impairment that has been aggravated or become symptomatic because of the work-related incident or situation. Entitlement is generally limited to the acute period of injury and recovery. Entitlement ends when the person has returned to their pre-injury level. In these situations, full recovery has been achieved when only the pre-existing impairment or condition remains.

It is possible that a person may suffer a permanent aggravation of a pre-existing condition. This may happen when the workplace incident causes a person’s condition to worsen below their pre-injury level, and they never return to that level. In those cases, a permanent impairment is likely under that claim. However, that should be the exception and not the norm.

Employers should strive to give the compensation board as much information as possible about any pre-existing conditions or impairments, in order to either try to have entitlement denied or limited to the acute period of recovery.

If the claim is allowed as an aggravation, it should be monitored, through communication with the compensation board, to determine when the worker has reached their pre-injury level.

Claims management techniques that lead to cost savings make good financial sense. Employers should use all tools in their toolbox when reporting and managing claims to try to minimize claim duration, thereby keeping costs down and helping their experience rating—which ultimately results in workers’ compensation cost savings.

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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