Appeals – Claims
Effective date: January 1, 2014
Application: All appeals
Policy subject: Reconsiderations and appeals
To provide guidelines for appeals of claim decisions.
- Section 18 of The Workers’ Compensation Act, 2013 (the “Act”) allows the Board Members to delegate any of their powers or functions to WCB employees. Persons affected by delegate decisions can make appeals. This section also directs that the WCB must create policy to guide the appeals process.
- Section 20(5) of the Act states that the WCB can reconsider any matter that it has dealt with and any decision that it has made.
- Section 23 of the Act requires staff to base every decision on the merits and justice of each case. However, WCB recognizes that from time to time, workers and employers desire an independent review of a decision on an injury claim.
- Section 171 of the Act clarifies that oral hearings are not a right under the Act.
- The intent of the appeals process is to provide workers and employers with an easily accessible and independent process of review for a decision regarding a worker’s claim for entitlement to benefits.
- Employer appeals regarding decisions on employer accounts (e.g., assessments) are not covered by this policy (see POL 20/2013, Appeals – Employer Accounts).
Appealing WCB Claim Decisions (Workers or Employers)
- Workers and employers (and their approved representatives) may appeal any claim decision.
- WCB has established a four-level process for workers or employers appealing a WCB claim decision:
- Review of the original decision by the staff responsible for the decision.
- Review of the original decision by an Appeals Officer. Appeals Department staff are bound by WCB policy and have authority to confirm, change or reverse any claim decision, except a decision made by the Board Appeal Tribunal, and
- Final review by the Board Appeal Tribunal comprised of two or more members of the Board. The Board Appeal Tribunal is bound only by the Act and has full discretionary authority in all matters as delegated to it under the Act (POL 22/2013).
- Review by a Medical Review Panel (bona-fide medical questions only) (POL 18/2010, Medical Review Panels).
- All requests for appeals must be in writing to the Manager of Appeals. The request should specify the decision in dispute, why the appellant disagrees with the decision, and their expected resolution to the appeal.
- Access to the claim file is in accordance with the provisions of section 173 and 174 respectively and will follow the process outlined under PRO 06/2017, Authority for Disclosure.
- All appeals at the Appeals Department level will be acknowledged in writing, including an outline of the decision in dispute, to all interested parties (workers, employers and their representatives).
- At each level of appeal, the decision is made by the staff member(s) who review the documents and/or hear the evidence. The decision maker will ensure that he or she has obtained information that, in the staff member’s opinion, is required to provide the best available evidence upon which to make the decision. Decisions made by the Board Appeal Tribunal will only be reviewed by the Board Appeal Tribunal.
- The decision will be made in accordance with the Act, policies and the rules of natural justice, which require the decision maker to:
- Act properly, fairly and without bias.
- Provide an opportunity for each party to state their case.
- Inform each party of the case that they must respond to.
- Consider all of the evidence.
- Ensure that the decision is made by those who consider the evidence, and
- Provide the parties with meaningful and timely reasons.
- Where the worker or employer provides new information that was not available when the decision being appealed was made, this information must first be considered by the WCB staff member responsible for that decision (e.g., Case Manager, Appeals Officer), before progressing to the next level of appeal (e.g., the Appeals Department, Board Appeal Tribunal).
- Following each level of appeal, the decision will be communicated in writing to all interested parties. The written decision will comply with POL 05/2017, Privacy of Information, and will outline:
- The decision in dispute.
- The appeal decision now being made, and
- The full reasons for the appeal decision, including the applicable authority as set out in the Act or WCB policy.
Standard of Proof
- At all levels of appeal, all information relevant to the issue(s) under dispute is considered and given weight appropriate to its relevance and level of verification. Decisions are based in accordance with the conclusion that is more likely, considering the merits and justice of the appeal. Where the evidence on both sides of an issue is approximately equal, the issue is settled in favor of the worker; POL 02/2019, Decision Making, will apply.
Burden of Proof
- There is no burden of proof on the worker or employer submitting the appeal. However, the worker or employer is expected to provide a reason for disagreeing with the original decision, and to cooperate in providing the information required by the WCB. The onus is on the WCB to ensure that there is sufficient information to make the appeal decision.
Act Sec #
Act Sec #
14, 15, 18, 20, 21, 22, 23, 29, 73, 80, 100, 169, 171, 173, 174
References updated in accordance with The Workers’ Compensation Act, 2013
POL 31/2010 Appeals – Claims
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