POLICY PURPOSE
The Workers Compensation Act (the Act) establishes the right of a worker, a deceased worker’s dependants (worker), or a worker’s employer (employer) to request a reconsideration of a primary
A. POLICY
This policy defines and describes the:
A.Authority and mandate of the Review Office;
B. Principles for reconsideration;
C. Process for reconsideration; and
D.Scope of reconsideration.
I. Authority and Mandate of the Review Office
The Review Office will conduct an independent, de novo (new or fresh) review of a claim decision when it receives a request for a reconsideration of:
i. A decision for compensation or other benefits made at the primary adjudicative level;
ii. A decision on administrative penalties related to a claim for compensation;
iii. A decision for cost relief or cost allocation for an individual claim;
iv. A decision when new information is brought forward; or
v. Issues referred back to the Review Office by the Appeal Commission.
In its reconsideration, the Review Office will consider all information it considers relevant to the issue, and when necessary, conduct further investigation and request new or additional information.
The Review Office has the authority to confirm, vary or rescind any decision made at the primary adjudicative level. The Review Office may also return matters to the primary adjudicative level when it considers it appropriate.
Reconsideration at the Review Office is intended to be an informal process. Once the reconsideration is complete, the Review Office must communicate its decision in writing to the worker and the employer.
Any decision by the Review Office is binding unless that decision is changed by the Review Office or appealed to and changed by the Appeal Commission.
II. Principles of Reconsideration
The reconsideration process recognizes that many workers’ compensation claims require the evaluation of complex issues, weighing conflicting evidence, interpreting technical and medical evidence, as well as an in-depth understanding of WCB legislation, regulations and policies. In undertaking a request for reconsideration, the Review Office will apply the WCB inquiry model of investigation and will endeavour to provide timely decisions as well as employ the service standards and quality performance measures of the WCB. The Review Office will apply the following principles when a request for reconsideration is received:
i. Follow a fair process in decision making;
ii. Give the worker or employer the right to provide relevant evidence and arguments;
iii. Inform the worker or employer of new issues under reconsideration and allow them the opportunity to respond;
iv. Provide reasonable time limits for submissions and responses to submissions;
v. Ensure that there is sufficient information on which to base a decision; and
vi. Act fairly and impartially when making decisions.
A primary adjudicative decision will stand until reconsideration by the Review Office is concluded or the primary adjudicative level changes or rescinds its original decision before the reconsideration is concluded. The WCB will then implement a decision of the Review Office if the reconsideration results in changes to or rescinding of an original decision.
III. Process for Reconsideration
The reconsideration process begins when a worker or employer submits a written application for reconsideration, and is complete on the date when the Review Office provides a written decision to the worker and employer.
Collection of Additional Relevant Information
In order for the Review Office to provide a meaningful reconsideration of the matter, it will solicit all information it considers relevant. If a review of the file suggests that more information is required, the Review Office may either send the matter back to the primary adjudicative level or proceed with the collection of information needed for the review. In deciding which course to follow, the Review Office will consider the amount of information that is required, the complexity of the matter under review and the amount of time that a worker has already waited for a decision.
Responsibility for Communication with Workers and Employers
When undertaking a request for reconsideration, the Review Office has the responsibility to:
i. Provide written notification to the worker and employer that a request for reconsideration has been submitted and indicate the issue or issues being appealed;
ii. Offer the worker and employer the opportunity to respond to the request when they indicate interest in the review, and provide a reasonable time frame for the response;
iii. Notify the worker and employer when expanding the scope of the reconsideration. The Review Office is not restricted to consider only the issue put before it and may expand the scope of the reconsideration. However, when doing so, the Review Office must provide the worker and employer the opportunity to make a submission on the new issue within a reasonable time frame; and
iv. Provide a final opportunity, when there is new information or evidence, to the worker or employer that initiated the reconsideration, to consider the responding person’s position and reply or provide a further submission within a reasonable time frame.
Timelines for Submissions
A worker or employer may file a request for reconsideration at any time after the primary decision is made. Once the request is filed, the Review Office may set reasonable time limits for awaiting written submissions and provide a time-defined opportunity to respond to new information or evidence.
In setting time limits, the Review Office will notify the worker or employer that he or she has:
- 30 calendar days from the date of the request to provide the Review Office with all information or submissions they feel necessary for reconsideration of the issue; and
- 30 calendar days to respond from the date the WCB has sent the requesting person’s submission or file copy.
In addition, when the worker or employer makes subsequent submissions that include new information or new evidence, the Review Office will promptly provide that new information or evidence to other persons participating and provide them with 15 calendar days to respond with a final written submission.
When the worker or employer fails to submit material within a reasonable time frame or does not ask for an extension of time, the Review Office may make a decision based upon the available information.
Further Reconsideration
At the time the Review Office issues a decision, it will inform the worker or employer of their right to take the matter to the final level of appeal, which is the Appeal Commission. However, prior to proceeding to the Appeal Commission, the worker or employer may request the Review Office to readdress its own decision when new evidence relevant to the decision has become available since the review was concluded.
The Review Office will not reconsider one of its own decisions if the worker or employer has already submitted an appeal on the same issue to the Appeal Commission, unless:
· The worker or employer withdraws the appeal submitted to the Appeal Commission; or
· The appeal is referred back to the Review Office by the Appeal Commission.
IV. Scope of Reconsideration by the Review Office
The scope of a request for reconsideration is generally limited to a matter or specific decision of an individual claim. The Review Office will normally review decisions for which a request has been received, but may include any issue if in its opinion it is reasonable and necessary to undertake a fair and impartial review. For example, it may be that a decision appears to be in error or the request for reconsideration implicitly involves another decision.
Before reviewing a decision for which reconsideration was not sought, the Review Office will notify the worker and employer of the new issue and provide them an opportunity to make a submission regarding the issue.
Withdrawal or Dismissal of a Request for Reconsideration
A worker or employer may ask to withdraw a request for reconsideration before the Review Office completes its review. The Review Office will normally agree to the request. The Review Office may refuse a request for withdrawal when it considers that not proceeding with a review would leave in place a decision which is inconsistent or conflicting with, or contradictory to WCB legislation, policies and procedures.
B. REFERENCES
The Workers Compensation Act subsections 19.1(3); 60.1(2); 60.1(3); 60.1(4); 60.1 (5); 109.7(1); 109.7(1)(h)
Subsection 11(2)(a) and 11(3) of Regulation 279/91 Appeal Commission Rules of Procedure, December 31,1991.
The Freedom of Information and Protection of Privacy Act;
The Personal Health Information Act;
Policy 21.50.10, Disclosure of File Information;
Policy 21.50.40, Disclosure of Information – Employer Access
Policy 21.10.10, Requests for Reconsideration Under Section 60.9, January 22, 1994
C. HISTORY
The WCB Review Office was established by Board Order No. 163/89, Appeal Hearings – Expedited Oral Hearings/Non-Oral (Paper) Hearings of December 12th 1989 replacing the existing Review Committee. Until that date, appeals on primary compensation, medical aid or assessment decisions were considered by a number of internal committees. Policy 21.00 Review Office established by Board Order No. 20/07 on April 26, 2007. The policy is effective May 1, 2007
ADMINISTRATIVE GUIDELINES
1. Review Office Goals
The Review Office is guided by the following goals:
a. To provide workers and employers with a process that is accessible, timely, simple and flexible for requesting a review of decisions made under The Workers Compensation Act, Regulations, Board Policies;
b. To conduct an independent and impartial file review to reconsider prior decisions made at the primary level of adjudication and case management;
c. To complete a comprehensive review of primary level adjudicative decisions in a manner that gathers and weighs all facts found relevant to the issue;
d. To decide on issues reasonably and consistently by weighing the merits of each individual case on balance;
e. To communicate in writing, reconsideration decisions which provide workers and employers a clear and concise description of the issue, decision and reasons for the decision or decisions; and
f. To support consistent, fair and quality claims decision-making by informing the WCB periodically on general outcomes, effectiveness and timeliness of decision-making by the primary level and the Review Office.
2. Requests for Reconsideration
a. A request for reconsideration by the Review Office usually occurs when:
i) A worker or employer disagrees with a written decision made by the primary level of adjudication regarding entitlement to a compensation benefit; or
ii) New evidence is presented that may affect a previous Review Office decision regarding entitlement to a compensation benefit.
b. A request for reconsideration will not be accepted where:
i) A written decision on the issue is still pending from primary adjudication;
ii) A decision on the issue has been rendered by the Appeal Commission;
iii) An appeal on the issue has been registered by the Appeal Commission; or
iv) The issue is other than a benefit entitlement or administrative penalty.
3. Filing a Request for Reconsideration
In facilitating the reconsideration process, the WCB will:
i) Inform the worker and employer at the time an initial decision is reached (at the primary adjudicative level), of their right to appeal the decision;
ii) Notify the worker and employer on how to file a request for reconsideration including a requirement that a request be made in writing indicating the issue for appeal, date of decision and reasons for disagreement with the decision;
iii) Provide the worker and employer with relevant forms and information on how to communicate their request;
iv) Clarify or acknowledge the issues for the worker and employer in writing;
v) Inform the worker and employer of their respective rights to relevant claim file information as defined in WCB policy and legislation; and
vi) Ensure access to file information as soon as possible after a request for reconsideration is filed and file access is requested
4. Timelines for Submissions
i) A worker or employer may file a request for reconsideration at any time following the primary level decision.
ii) Once the request is filed, Review Office may set reasonable time limits for awaiting written submissions and provide a time limited opportunity to respond to new information or evidence that it considers substantial and material to the decision.
iii) In setting reasonable time limits, Review Office will notify:
a) A worker or employer requesting the review has 30 calendar days from the date of the request to provide Review Office with any and all information or submissions they feel necessary for the proper reconsideration of the issue.
b) A worker or employer responding to a request for review may have 30 calendar days to respond after WCB has sent the requesting person’s submission or file copy.
c) If any subsequent submission includes new information or new evidence Review Office finds likely to be significant in its decision reasons, the Review Office will promptly provide that new information or evidence to other persons participating and provide 15 calendar days to respond with a final written submission.
iv) The WCB may establish service standards for Review Office decisions (e.g. the majority of decisions are anticipated within 60 calendar days following the date of initial request.)
v) If a worker or employer does not respond with written submissions within a time limit, Review Office may consider a request withdrawn or proceed with a decision. If in the opinion of the Review Office an injustice may result from application of a time limit, extensions may be granted.
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