Introduction to Compensation Claims for Injured Workers (7:III)

A. Introduction

Sections 96 and 113 of the WCA give the Board exclusive jurisdiction over workers’ compensation matters. The courts have generally respected this strong privative clause.

Section 96 specifically grants the Board the exclusive jurisdiction to inquire into, hear, and determine:

• a) whether an injury has arisen out of or in the course of an employment;
• b) the existence and degree of disability by reason of an injury;
• c) the permanence of disability by reason of an injury;
• d) the degree of reduction of earning capacity by reason of an injury;
• e) the average earnings of a worker, for the purpose of levying assessments, and the average earnings of a worker for purposes of payment of compensation;
• f) the existence of the relationship of a member of the family of a worker as defined by the Act;
• g) the existence of dependency;
• h) whether an industry is within the scope of the Act, and the class to which an industry should be assigned for the purposes of the Act;
• i) whether a worker is in an industry within the scope of the Act and entitled to compensation under it; and
• j) whether a person is a worker, a subcontractor, a contractor or an employer within the meaning of the Act.

Section 113 of the WCA gives the Board jurisdiction over compensation in relation to workplace health and safety.

Once an injured worker applies for compensation, the Board will begin to assess whether or not to accept the claim. Once the claim is accepted, the Board will then adjudicate the worker’s entitlement to the type of compensation benefits listed above.

B. Overview: Initial Acceptance or Denial of A Compensation Claim/Disclosure & Appeals

After a worker makes an application for compensation, a Board officer issues a decision (usually in writing) accepting or denying the claim. For a compensation claim to be accepted, the Board must generally find:

• a) STATUS: The applicant is a “worker” covered under the Act.
• b) DISABILITY: The applicant suffered a personal injury or an occupational disease, causing disability.
• c) CAUSATION: The worker’s disabling injury or disease was caused by work.
• d) TIME LIMITS AND PROCEDURES: The worker submitted a timely and proper application.

If a claim is denied by the Board, it is typically because one or more of the above conditions was not met. The Board decision typically sets out the reason why the claim was denied and cites the relevant policy from RSCM II. However, the evidence on which the decision is based may or may not be summarized in the decision.

All the evidence on which the decision is based will be in the claim file, which may also include memos from case managers (CMs) and clinical opinions from Board Medical Advisors (BMAs). The claim file may also contain detailed phone memos providing the CMs with a summary of the worker’s evidence. The claim file evidence as a whole provides the basis for the Board’s decision and is evidence which will be available and considered by the appeal bodies, RD and WCAT.

Workers are entitled to a copy of their claim file (paper or CD) on request and will also automaticallybe sent a copy of the claim file if they file an appeal. In addition, the worker may obtain online access to parts of their claim file by calling the Board. These matters are covered in the section below on Disclosure. Disclosure may be given directly to the worker’s representative if the disclosure request or appeal notice is accompanied by a valid authorization of representation, signed by the worker. [Authorization forms are available on the Board website].

If the worker (or the employer) disagrees with the Board’s decision, he or she may appeal the decision to the Review Division (RD) within 90 days of the Board decision. The RD is a review body internal to the Board; links to RD material, including RD appeal forms, are available on the Board website (through the link “Review and Appeals” on the left list of the home page). The RD must issue a decision within 180 days of the appeal being filed. The RD decision may then be appealed to an independent tribunal, the Workers’ Compensation Appeal Tribunal (WCAT) within 30 days of the RD decision. WCAT appeal forms are available on the WCAT website. See Section VI: Appeals for more details.