Workers’ compensation works quite a bit differently in Canada than it does in the United States. This is primarily due to The Meredith Principles, a law that has resulted in no-fault workers’ compensation insurance between employers and their employees.
This translates into coverage where fault doesn’t matter: employees are guaranteed support regardless of the stability of the company. The employers, in turn, are protected from some of the costs associated with serious incidents through an accident fund, which is collectively funded by employers and managed independently by provincial Workers’ Compensation Boards (WCBs).
While this no-fault system simplifies things in some respects, it doesn’t mean that employers can just sit back and let compensation claims handle themselves. Claims management is still a complex process and without an effective approach it ends up taking too long, costing too much, and not being handled as well as it could be.
This article will cover the basics of claims management for Canadian employers. We’ll walk you through seven steps that will help you navigate the process with care and professionalism, while also mitigating costs and minimizing effort.
Step One: Take Care of the Employee
Before you start your investigation and file the paperwork, you should first get employees the care they need. Your first words should always be “Are you okay?” and “What can I do to help?”
Employees are often out of sorts after being affected by a safety incident. To combat the shock and make things easier for them, have a package ready that includes:
- Directions to the nearest doctor’s office (that accepts workers’ compensation)
- Directions to the nearest hospital
- A “dear doctor” letter that outlines your commitment, modified work program, and full contact information
- A functional ability form, and your commitment to reimburse the clinic
- Physical demand analysis for positions in your workplace
- Workers’ compensation documents
- A modified work brochure
- Offer of modified work, along with a refusal of modified work letter
On the front of this package, type a reminder to bring the employee’s healthcare card or number. Many clinics won’t care for patients without this information. When a serious injury occurs, time is of the essence. Having this ready to go will ensure you’re not wasting precious minutes printing or faxing documents to a clinic. It will also reduce costs and increase your chances of receiving properly completed documentation.
Step Two: Communicate the Details of the Incident
Once the employee has received the care they need, your next step is to communicate the important details of the incident.
Remember that there are limitations on the medical information you can share, so tread carefully. To play it safe and stick to the pertinent details, focus on three key points:
- Who was injured
- How this will affect their work (days away from work, duration of modified or restricted duties, and workplace abilities and limitation)
- End with a simple and direct “contact me if you have any further questions or concerns”
Always take care of your internal communications before engaging with external parties.
Internal Communication
Follow any internal reporting protocols that are in place. If you don’t have a flowchart for internal reporting, report to your direct manager and the employee’s direct manager. If the incident is severe enough, your direct manager is the one who should be responsible for escalating.
Serious Injuries
If the employee experienced a serious injury, your next call will be to the number listed as their emergency contact. This can be a difficult conversation, but it should be kept clear and straightforward. This statement works best:
“[Employee name] was seriously injured, they are currently in route to [name of the hospital]. My cell phone number is XXX-XXXX. Are you able to meet me there?”
Your company may have a specific response plan or a designated person responsible for reporting critical injuries. If so, follow that procedure.
Fatal Incidents
If the incident resulted in a fatality, you will instead need to contact the local police. They will be the ones who report the incident to the next of kin.
External Communication
Which department you report an injury to and how soon quickly you must do it will depend on provincial legislation and the severity of the injury.
In Alberta, for instance, employers have 72 hours to report an illness or injury to the Workers’ Compensation Board if it results in:
- Lost time
- Medical treatment beyond first aid
- Medical aid expenses
- A permanent disability or a potentially disabling condition
- A fatality
Moreover, Part 7, Section 33 of the province’s Occupational Health and Safety Act imposes its own reporting requirements for certain incidents, including injuries that result in hospitalization.
So, if an employee gets a cut on their finger while handling a glass pane but returns to work the next day after being cleared by a doctor, the injury will be reported to the Workers’ Compensation Board.
On the other hand, if an employee spends three days in the hospital after falling from a ladder, the injury must be reported to the provincial government’s Occupational Health and Safety department, as well as the Workers’ Compensation Board.
The specifics vary across provinces, so be sure to review the reporting requirements of your jurisdiction.
Step Three: Conduct an Investigation
This step is all about building a medical report, not looking for the root cause behind the incident.
Part of a building and maintaining a strong safety culture is advocating for employees and being factual in your work. To achieve that, you’ll need to thoroughly investigate and document every aspect of the incident.
Gather data right from the scene of the incident, including details about the current environmental conditions, measures of any relevant weights or distances, and testimonials from eye witnesses. Be thorough – even information that appears irrelevant should be included. Take several pictures and include them in your documentation.
Why do all these details matter? Well, let’s say you receive a report of an employee with a skin rash on their neck. Some of the things you’ll want to know include:
- The day and time the rash developed
- Signs and symptoms you observe and the employee shares
- A physical description of the affected area
- Any chemicals they came into contact with
- The last meal they had before the rash appeared
- Any medications they take
- Regular or recent hobbies they engage in
- Any allergies they have
- Previous medical conditions
- The tasks they completed leading up to the rash
- Whether any other employees developed a similar rash
- Recent hygiene reports
Many of those details would seem irrelevant during an investigation (how likely would you be to ask the employee what they had for lunch?) but can be highly pertinent when trying to get a full picture of the condition and what may have contributed to it.
The rash could have developed because of contact with a chemical the day before, or it could be a staph infection from their local MMA gym. Without asking all the questions, you won’t be able to build your case.
So be sure to document everything, no matter how small.
(Learn more in 10 Critical Steps for Investigating and Reporting Accidents)
Step Four: File a Report
If required, file a report with your jurisdictional Workers’ Compensation Board. Reporting requirements vary across Canada, from needing to report all incidents to only those requiring medical attention.
Raising Concerns About a Compensation Claim
Most provinces will ask on the report form if you have any concerns about the compensation claim or allow you to voice these in conversation.
If you do have concerns around the claim, it is best to talk about it with the employee first. Advise them of your concerns, let them know you will be notifying the WCB of your apprehensions, and ask them for their feedback. This is a tough conversation to have, but going straight to the Board without notifying the employee could tarnish your relationship with them and impact the claim costs.
When contesting a claim, be aware that the balance of probabilities is in the worker’s favor (if it comes down to your word against theirs, the WCB will likely side with the employee). This is especially the case when there is a clear cause-and-effect relationship between activities that took place on the job and the resulting injury. For example:
- The worker’s hand gets caught in a roller while operating machinery on the shop floor, resulting in an amputation
- The worker trips and falls on a nail, resulting in a puncture to the left leg
- The worker lifts a 32 lb. box and experiences pain in their lower back
When the causal relationship isn’t so cut and dry, you will need to gather evidence surrounding the incident to determine whether any external factors could have played a role. You might, for example, be able to build a case in response to the following situations:
- The worker arrived at work with a rash on their neck
- The worker developed a hernia in the lower abdomen over a prolonged period of time
- The worker arrived to work with a red eye and believes they have contracted pink eye
The investigation you carried out in Step Three should aid you in you in this process.
Next Steps
If you believe the injury or illness was not caused by work-related factors, try the following.
Speak openly with the employee about your concerns. Focus on getting them the help they need through provincial healthcare. Advise them that they can still open a claim at a later date if new evidence comes up.
Employees have anywhere from three months to two years to file certain claims. Make sure the employee is aware of the reporting periods that apply to their situation.
Always Remain Impartial
Part of building and maintaining a strong safety culture is accepting when something goes wrong. In every organization, there is the potential for an incident resulting in a claim (that’s why we have no-fault insurance to begin with). Your role isn’t to downplay these incidents but to mitigate costs and prevent similar events from occurring in the future.
This applies to non-occupational injuries as well. In Canada, we have the Canadian Human Rights Act, with each province having their own version of this Act. In each of these legislations, you will find something to the effect of a “duty to accommodate” (with Quebec’s legislation being slightly different). This means that even if someone has an injury or illness they did not acquire through their tenure as your employee, you are still required to make accommodations for them, up to the point of “undue hardship.” Undue hardship, in this case, means that providing the accommodation is either unsafe or far too costly.
Your goal isn’t to side against the employee and try to have their compensation claims turned down or their accommodation requests denied. Instead, your goal should be to objectively assess the situation and help your employee get the assistance or care they need.
Even More Ways to Improve Claim Outcomes
The thing that makes claim management so tricky is that no two cases are the same and no two employees respond the same way. That’s why it’s so important to take a thorough approach to it. While it won’t smooth out every single wrinkle, it will make managing claims more predictable and reduce your overall costs.
Here are some steps you can take that aren’t strictly part of the claims management process but are closely related.
Appeal the Claim
If you believe the injury or illness did not arise from employment, you can appeal the claim through the Workers’ Compensation Board.
Appealing a claim is a long process for the employer. Submitting an appeal can also be costly and impact your relationship with the employee. As such, it pays to be fully prepared before appealing a workers’ compensation claim. Familiarize yourself with your provincial Workers’ Compensation Board, read and understand their policies, retrieve and review the entire case file and read through the case law. Some WCBs also offer formal training on how to appeal claims.
Not only will this help you navigate the appeals process, it will also help you decide whether it’s worth submitting an appeal for a claim in the first place.
Let’s look at an example to illustrate that point.
This appeal decision from 2014 centers around a worker who tripped and fell while carrying boxes, resulting in a shoulder injury. The Workers’ Compensation Board deemed the injured worker eligible for temporary total disability benefits. The employer, however, appealed the decision, informing the Board that the worker failed a drug test following the incident, indicating that they were working under the influence. Given these circumstances, the Board granted the appeal and determined that the employee was not entitled to the benefits.
But would the appeal have been granted if the worker had simply been distracted when they got injured? What if the worker had been completely sober but acted carelessly? Would it make a difference if they tested positive but the incident was partly due to negligence on the employer’s part?
Reading through these cases will give you a better sense of when and why appeals are granted. Knowing this can save you plenty of time and costs, while also helping you build a stronger case when appealing a decision.
Strengthen Your Return to Work Program
Having a robust return to work program can go a long way to reducing claim costs, while also providing several benefits to the injured worker.
The key here is to offer meaningful modified work. To understand why, picture the following.
You’re at work in a facility that manufactures molded PVC products. Some of the pieces come out with a strip of PVC that has to be sliced off before the piece can meet quality assurance standards. So you grab your utility knife and use it the same way you’ve used it hundreds of times before. Only this time, it doesn’t just cut through the PVC – it slices into your hand as well. The cut extends from your pinky to your wrist, so this isn’t something the first aid kit can handle on its own. You’re rushed to a medical facility where you receive stitches and clearance to return to work on modified duties.
You return the next day, your hand still throbbing with a dull pain. You can’t get back to your usual post, but your supervisor guides you to your modified work task. Instead of the complex, skilled work you were doing before, you will be stuck on entry-level assembly for eight hours a day for two weeks straight.
How would you feel about your temporary assignment?
Some workers would surely welcome the break from their usual job, even if the task is rather dull. But others might see it as a punishment or a way to chastise them for getting hurt.
When you have to find modified work for an injured employee, make sure that it’s a good fit for them. Look for tasks that would still allow them to use their skills. Avoid saddling them with all the repetitive tasks no one else wants to do. And definitely don’t invent busywork just to keep them occupied.
Better yet, get the worker involved in the return to work process. Go over a list of options for modified duties and ask them if there’s anything that interests them or if there is any specific skill they would like to work on while they recover from their injury.
This type of approach will be better for your company culture and will make the employee more positive about being at work.
Square Away All Payments
Some WCBs mandate employer payments following injury claims. Some leave it up to you. Others prohibit it.
Where possible, pay for lost wages, damaged items, travel, and other expenses related to the injury through the company.
Say an employee is off from three days after a fall from a ladder that broke their glasses and hurt their shoulder. Make sure they get paid at the jurisdictional wage (60% to 90% their annual salary, depending on the province) and buy them new glasses. This will also benefit you, since every dollar that doesn’t need to be processed by the Workers’ Compensation Board will keep the overall claim cost down, which in turn will keep your premiums lower.
Don’t leave the company account open for the taking, however. You need to ensure that you are properly tracking, vetting, and managing these expenditures to prevent employees from abusing the program.
Remember that it is also against the law and unethical to discourage an employee from reporting a claim in exchange for the company covering the costs associated with their injury.
Request Cost Relief
Cost relief reduces your claims costs and lessens the impact on your insurance premiums.
Cost relief is typically granted when you can demonstrate that there was a pre-existing condition that worsened or prolonged an injury or illness that arose on the job. For instance, an employee with a tear in their ACL slipping and falling at work will sustain a work-related injury, but one that would likely be less severe if they hadn’t been injured before.
Each province has its own policies around this, so your opportunities for cost relief will vary. In British Columbia, for instance, you must hit 10 weeks and a certain dollar value before even being considered for cost relief. In Alberta, some industries are not even eligible.
If it’s an option that’s available to you, it’s certainly worth considering.
Request a Cost Transfer
A cost transfer reallocates some or all the claims costs to another employer.
This happens, for instance, when an injury takes place while a contractor is on site or when workers are sent out on service calls at a commercial establishment. If negligence on the part of the other employer (the contractor or the company running the facility where the injury took place) contributed to the injury, the Workers’ Compensation Board may shift some or all of the costs onto them.
As always, the details of how this works will depend on your province. Ontario, for instance, has a claim minimum that must be met before you can request a transfer.
No matter which jurisdiction you’re in, you will need to prove that negligence was a factor. This can be difficult to do and it can impact your business relationship with the client in question, whether the transfer is approved or not.
If you are going to apply for a cost transfer, it is a best practice to notify the other employer in advance. This lessens the blow and gives you a better chance at preserving a positive relationship with them.
Determine Whether There Was Willful Misconduct
In some cases, you will be able to make the case that the employee’s willful misconduct was the reason they got hurt, not the conditions on your worksite.
Willful misconduct, in this context, includes:
- Deliberate disregard for safety
- Breaking the law
- Personal conflicts taking place at work
If you can demonstrate willful misconduct, then the injury will be deemed unrelated to employment (even if it did technically occur while the employee was on the job) and, therefore, not a compensable injury (in other words, not eligible for workers’ compensation benefits).
This doesn’t mean that any willful misconduct on the part of the employee will render an incident non-compensable. Suppose, for example, that an employee deliberately ignores a policy that requires them to use the sidewalk when making their way to the facility, opting to take a shortcut instead. While taking that shortcut, they fall and hurt themselves. Now, you might think that this is a clearcut case of willful misconduct. In fact, it will likely be deemed compensable because, while the employee did intentionally circumvent the sidewalk policy, they didn’t slip and fall on purpose.
But if an employee takes a hammer and purposefully strikes their hand with it, this is far more likely to be considered willful misconduct.
What it takes to prove willful misconduct varies from province to province and it is often difficult to make an airtight case. Still, it is worth thoroughly investigating the incident before ruling out this possibility.
Aim for Employee Retention
Employers will sometimes breathe a sigh of relief when the injured worker decides to quit rather than return to work.
An employee’s resignation is a double-edged sword, however. It will relieve you of the fulfilling the wage loss requirements, but the outcome of the claim and the worker’s behavior will now be entirely out of your hands. All medical expenses will still be processed through your account and you will have little control over the claims process, which can result in higher costs on your end.
Because of this, it’s better to take steps that will encourage the worker to remain under your employment. These include some that we’ve already outlined above:
- Take care of internal communication first, and handle it tactfully
- Provide the employee with information and assistance in navigating the claims process
- If you will be contesting their claim, notify them ahead of time
- Get their input and offer them a meaningful position if they require modified work duties
- Approach the situation impartially, rather than treating your employee as an adversary
Understand Your Province’s Specific Approach to Claims
To properly manage claims, you need to understand the ways your province’s Workers’ Compensation Board approaches them.
Some provinces have caps on claim costs for certain injuries and illnesses. Alberta, for instance, has a threshold of $1,800. If a no time loss claim costs less than that, there will be no impact for the employer’s premium.
Other provinces like Quebec use a low cost / high cost threshold for claims. If it falls under a certain dollar amount, it is considered minor and will have minimal impact on your premiums. If it exceeds that dollar amount, however, it will have a much more drastic impact.
It’s important to dig deep. While provinces largely handle claims the same way, the devil is in the details. Small differences between provincial policies can have a big effect on your outcomes.
Tracking Claim Progression
One theme you’ve likely gathered from this is that the best thing you can do to reduce claim costs is simply to genuinely care for your employee, help them get the care they need, and make them feel valued. This is easier to accomplish if you have a system for tracking the progression of a claim.
Here’s one you can follow:
- Create a Medical File for the Employee: This should be stored securely on your computer or under double lock and key within an office. It should include the following information:
- Name
- Date of birth
- Date of incident
- Date of report
- Location of the incident
- Level of pain related to the injury (use an approved method of ranking pain to keep it consistent)
- Establish a Check-in Schedule: You can meet with the employee once a week, twice a month, or monthly in the case of a long-term claim. The meeting can be in person, on the phone, or over video conferencing, depending on the employee’s preference and what works best for both of you (remember to notify them that the line could not be secure if meeting remotely).
- Check the Status of the Injury or Condition: During each of these meetings, ask permission to check the area where the individual was injured or where an illness manifests. Do not, however, ask them to remove clothes or request to inspect private areas beyond the point of administering first aid. Alternatively, you can ask the employee to check it the day before the meeting and provide you with an update. The point is to look for signs that the condition is worsening, such as an infection, an increase in size, or swelling. Document your findings on your report. Then ask about their symptoms and document those as well. Ask about any obstacles to recovery, such as a supervisor assigning tasks that push the limits of the modified work duties or challenges with caring for the injury at home.
- Have the Employee’s Supervisor Complete Scheduled Check-ins: The goal of these additional check-ins is to show the injured employee that they are valued in the workplace. Update them on things going on at work, including any changes to personnel, workplace design, or working procedure. Let them know you want them to stay in the loop to make their return as smooth as it can be.
- Document Facts, Not Your Perception: It’s normal to embellish a statement when writing it down or relating it to someone else, but that is an instinct you should resist when documenting the progress of an employee’s condition. Document the employee’s words, not your paraphrase. For instance, write down “I changed my tires over the weekend, they were about 40 pounds each, and I felt a dull ache after it was done” rather than “Worker outlined that they changed tires, each one weighing approximately 40 pounds, which they would have lifted a total of eight times when removing and installing, resulting in pain to the injured area and a worsening of the condition.” While much of the facts are the same in both statements, only one accurately reflects what the worker said, without any additional details being snuck in unconsciously.
- Remove Obstacles for the Employee: For example, if the employee suffered a foot injury that makes it difficult for them to drive to medical appointments, offer to pay for a transit pass. You can also inform them of any support programs they might qualify for or resources that might be useful for them. This will help speed up their recovery, demonstrate care, and show empathy for the injured worker.
- Set Reminders for the Employee’s Appointments: Doing this will ensure that you ask about significant appointments, get updated information, and verify that the employee is attending medical appointments. This also ensures that you provide the things like a blank functional abilities form for the doctor, which will encourage them to assess the worker’s ability to return to work on modified duties. Have the employee or the doctor fax the form to you after each appointment and document the findings in your medical file. If an employee has frequent appointments (such as physiotherapy three times a week), keep these requests to every second week or once per month.
Do the Work, Lower Your Costs
Managing claims can be complex and intricate. Having a thorough and well-designed claims management system in place will make the process much easier, ensure that you gather all the information you need for a fair claims process, and reduce your overall costs.
It takes time to dig through your province’s policies, study previous cases, and figure out the best procedures for submitting and contesting claims. But reducing your expenses and keeping premiums low will make it worth the effort.