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The Board Has Stopped Paying
Background
If the Board was paying in the claim and then stopped, usually it is because:
- the Board feels that the worker has fully “recovered” from the compensable injury, or
- the compensable injury is no longer the source of the ongoing loss of wages, or
- the Board thinks that, although the worker still has problems doing the regular job, the injured worker is not accepting suitable work offered by the employer that would eliminate any wage loss, or
- the injured worker is not cooperating in the Labour Market Re-entry process
It is vital that the injured worker whose benefits have been stopped know that they must not just “sit around”. They must be in active health care treatment or be in contact with their employer trying to return to work, or looking for work elsewhere or be engaged in some activity aimed at returning to work (eg. Taking courses on their own). Failure to take such actions will severely limit the amount of potential retroactive benefits. The worker should be documenting these efforts.
6. The adjudicator says that I am completely able to go back to my old work and has stopped paying me.
Usually this is because:
- the medical evidence on file leads the adjudicator to believe that there is no continuing problem that impacts on the ability to work.
You need to know:
- gather medical evidence as to the extent of the continuing problem
- have the doctor comment on why the continuing compensable injury would prevent the worker from returning to regular work
- the doctor must be supplied with accurate version of “regular” work duties in order for the medical opinion to carry any weight, so injured worker needs to get “physical demands analysis” from work or the worker needs to write out description in as much detail as possible of the work that they were performing
- the worker could also consider getting a Functional Abilities form completed if one had not been done recently
7. The Board isn't going to continue to pay me for my back injury because they say my remaining problems are the result of the back injury I had when I was a kid.
Usually, this is because:
- there are not enough details in the medical record or in the worker’s report of injury about what the worker was like before the injury and how the work impacted on that condition
You need to know:
- pre-existing conditions are not a bar to entitlement
- if worker was asymptomatic prior but something about the nature of the work caused the symptoms to appear, is entitlement on aggravation basis
- even if there were pre-existing symptoms, can still have entitlement if something about the nature of the work made those symptoms worse
- this will require medical records review - what was level of disability before injury and after injury - to show causal link
- need evidence as to how the work was performed
- may need evidence about changes in workload (pace, quota etc)
- once return to level of pre-injury symptoms and/or functioning, benefits will cease
- if never return to pre-accident state, can ask for permanent impairment award (Non Economic Loss)
8. I am in retraining now after my injury, but I had to stop because I got in a car accident and am unable to travel to school for a few weeks. The Board says they are going to cut my benefits off.
Usually this is because:
- post-injury non-compensable conditions can affect level of benefits
You need to know:
- benefits depend on “co-operation” in health care and return to work/labour market re-entry plans
- the Board is only concerned with the impact of the compensable injury on your ability to cooperate
- benefits should restart with the resumption/continuation of Labour Market Re-Entry/Return To Work plans once ready to return
- may be possible to be successful on appeal
9. My doctor says I can not go back to work at all right now but my adjudicator says I am fit to go back to the modified work my employer is offering and is going to cut me off.
Usually this is because:
- the Board considers that the employer has made an offer of work that is suitable and that will eliminate any wage loss
You need to know:
- refusal of suitable modified work has impact on benefits
- in order to get back on benefits, worker must show either that:
- no offer was made by the employer (eg. was the offer in writing?), or
- that the work offered will not restore the wages (eg. does the work offered pay the same as the pre-injury job in terms of wages, bonus, shift premium, etc.), or
- that if an offer was made, the job is not suitable
- in the meantime, need to be proving “co-operation” in health care and other return to work measures
- the Board doctor is telling the adjudicator about whether this offered job is “suitable” so need medical opinion to oppose this view
- medical differences of opinion (Board doctor vs. worker's physicians) are usually only resolved through appeal
- be sure worker's doctor understands what all is involved in the modified work (get a job description) and that the doctor is specific in outlining restrictions
- will need evidence as to how the modified work exceeds those restrictions
- unless worker has medical evidence that he is totally disabled from all jobs, the worker must continue to be in contact with the accident employer offering to come in to work that the worker feels is within the restrictions for the injury (and documenting those contacts)
- if there is no such modified work that the worker thinks is or may be made to be suitable, the worker needs to start looking elsewhere for jobs/training etc. (and keeping track of those efforts)
- the Board has a “return to work mediator” and an ergonomist that may be of assistance in resolving minor differences in opinion as to suitability: contact the return to work adjudicator
10. I didn't sign my Labour Market Re-entry Plan and now I was cut off benefits.
Usually, this is because:
- co-operation obligations affect ability to get benefits
You need to know:
- is not necessary to sign plan in order to be seen to be co-operating
- but is necessary to co-operate with the elements of the labour market re-entry plan itself, while appealing (eg. go to upgrading as outlined in the plan in the meantime)
- this type of appeal has a 30 day deadline to appeal
- worker needs to call his adjudicator and Labour Market Re-entry provider to ask to get back into the program
- if can not get back into the program and back on benefits, must take own steps to get back to work or school (eg. through Ontario Student Assistance Program or Employment Insurance for financing)
- see LMR section
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