WSIB Required to Provide Explanation of Benefits Calculations

IAVGO made a complaint to the Fair Practices Commission regarding the Board's lack of co-operation in providing an explanation of benefits calculations, particularly in complex retroactive awards. Many worker representatives have battled with the Board over the years, trying to get individual claims adjudicators to provide an explanation for benefits in cases where the injured worker received retroactive benefits on appeal. As a result of the Fair Practices Commission's intervention, a protocol has been established within the Board for dealing with such explanations.
In a letter dated January 31, 2008 to Judy Kondrat of IAVGO, Fair Practices Specialist Janice Sandomirsky outlined the following:

" Claims Adjudicators have been reminded that they are expected to be proactive in providing payment explanations in all cases. All verbal payment explanations are to be followed up in writing. A detailed written explanation should always be provided in cases involving a complex payment. Examples of complex payments include:

• Retroactive payments


• Reviews/adjustments of benefit payments


• Minimum or maximum benefit payments


• Partial benefit payments


• Recalculations of average earnings


• CPP/QPP offsets

The written explanation will identify the type of benefit included in the payment(e.g. loss of earnings, interest, arrears, diversion for assignments, court orders), the average earnings basis and the payment period of each benefit paid.

Where there is a request for clarification of the benefit payment calculation, the Claims Adjudicator is expected to contact the Payment Specialist who will place a memo on the file outlining the calculation of the benefit payment in question. It is anticipated that the Claims Adjudicator will respond to the clarification request within three days. In exceptional cases, such as pre-1990 or non-imaged claims, it may take up to two weeks for the Payment Specialist to produce the memo. The Claims Adjudicator will advise the requester in writing about the delay and provide a time frame for a response.

If there are questions that require additional assistance/clarification, the Claims Adjudicator is expected to obtain guidance from his/her Manager, and , if necessary, the Payment Specialist Manager. "

The complex payment review also involved the creation of documents on payment terms and definitions, some sample letters, suggested payment criteria paragraphs, effective writing tips, plain language advice, grammar and spelling tips, and clear language reference tools.

This article has been reproduced with permission from Judy Kondrat of the Industrial Accident Victim's Group of Ontario (IAVGO). Kudos go out to Judy and IAVGO for their great work!