WSI Fact Sheet #3
Workplace Safety and Insurance Appeals Assistance
How the Pensions & Benefits Unit Can Help You
If you disagree with a WSIB decision denying any entitlements or benefits, the first step is to complete and submit a WSIB Intent to Object Form. You should follow the directions for appealing your WSIB denial outlined in Fact Sheet #2 – Appealing a Workplace Safety and Insurance Decision. Please take notice of the appeal time limits in the letter sent to you by the Board decision maker. It is your responsibility to meet any time limits to appeal. Failure to submit the Intent to Object form by the appeal deadline will result in the loss of your right to appeal.
Often, the reason for the denial of a benefit can be as a result of a lack of information or insufficient medical documentation. It is helpful if you contact the WSIB decision maker to determine what is needed. You should still appeal the decision and can submit additional information in support of your claim at a later date.
Benefit Counsellors in the Pension and Benefits Unit of OPSEU represent members in their WSIB and WSIAT appeals. If you have decided to appeal the denial of any WSIB entitlement or benefit and would like OPSEU to represent you, the Benefits Unit will require a complete and up to date copy of your claim file for review. A copy of your claim file should be sent to you if the negative decision remains unchanged after the WSIB decision-maker has reviewed the Intent to Object form and any other information submitted. If you do not receive a copy of your file you can request one under the Freedom of Information and Protection of Privacy Act. You will find a WSIB Access Request form in our WSIB Appeals Package.
Your Role and Responsibilities
Meeting the Appeal Deadline
It is your responsibility to meet all deadlines to appeal. To do this you must complete and submit an Intent to Object Form to the WSIB within the time limits specified in the WSIB decision. You should indicate on the Intent to Object Form the issue(s) you are objecting to and clearly indicate the date of the WSIB letter which contains the decision on that issue.
Additional Intent to Object forms must be completed and submitted within the prescribed timelines for any subsequent decision letters that may deal with additional issues. If you disagree with decisions made in more than one claim, an Intent to Object Form must be submitted under each claim number in order to meet the time limits. Once again you will need to identify the issue(s) under dispute in each claim and the date of the decision that addressed those issues. Any additional information or medical documentation that supports your appeal should be attached to the completed Intent to Object Form. If you have no further information to provide, the Intent to Object form should be submitted to meet the time limits to object. You have now met the deadline to object and any additional information or medical documentation can be submitted for review at a later date.
Please check “I will represent myself in the objection process, or I am currently seeking representation” in section 4 (Representation) of the Intent to Object form. OPSEU will not go on record as your representative at this stage as a Benefits Counsellor has yet to review your file. A Benefits Counsellor will complete and submit the required direction of authorization form when the decision to act as your representative has been made and a Retainer Agreement has been signed.
The WSIB decision maker will review your Intent to Object form, arguments and any new information and reconsider the original decision. If the decision remains unchanged, or you did not submit any new information, the WSIB will send you a copy of your claim file along with an Appeal Readiness Form. Do not complete the Appeals Readiness Form. This form should only be submitted when the frontline decision-maker has had the opportunity to review and consider any additional information and/or medical documentation that is or may become available. Should OPSEU undertake to represent you, a Benefits Counsellor will complete and submit the appeals readiness form on your behalf.
Once you receive this package, forward the complete original copy of the claim file, in the order it was received, along with the blank Appeals Readiness Form to the Pensions and Benefits Unit. You can drop it off at the nearest OPSEU regional office and it will be sent to OPSEU Head Office via internal mail. You can locate the closest OPSEU office to you by visiting www.opseu.org and clicking on the Contact Us button or by calling 416-443-8888 or toll free at 1-800-268-7376. Alternatively you can send your file directly to: Pensions and Benefits Unit, OPSEU, 5757 Coopers Avenue, Mississauga, Ontario L4Z 1R9.
You will receive written confirmation from the Pensions and Benefits Unit that your file has been received and a brief outline of the process to follow. Your file will be assigned to a Benefits Counsellor for review to determine whether it meets our case prioritization criteria. The appeal must also have a reasonable chance of success based on the information in your WSIB file and any additional information you submit. If there is not a reasonable likelihood of success based on the current information, the Counsellor will outline the reasons in writing.
When the decision has been made to represent you, you will be sent a Retainer outlining the issue(s) we will represent you on. We cannot begin to represent you until you have signed and returned the Retainer to our office.
While receiving or appealing WSIB benefits, injured workers have an obligation to co-operate in the Work Reintegration process. Please refer to WSI Fact Sheet #4 for more detailed information on the WSIB Work Reintegration principles.
Although not specifically addressed under WSIB policies, applying for WSIB benefits brings with it a duty on your part as the injured worker, to mitigate your circumstances while awaiting or appealing benefits. This means you are expected to try and take whatever measures you can to recover and get yourself back to work at the earliest opportunity.
You should work with your union, employer and health professional to return to work with proper accommodations, if possible. If you are having difficulties with return to work/accommodation issues, please contact your Local’s union representatives or an OPSEU staff representative for assistance.
If you are having difficulties with your working duties, you should ask for appropriate restrictions from your treating health professional and ask your employer to accommodate them. If you feel your employer has discriminated against you on the basis of your disability (e.g., by not accommodating you), you may wish to file a grievance within the time limits prescribed in your collective agreement. Contact your steward, local president or OPSEU staff representative for assistance. If your WSIB claim is approved, you and/or your Employer may seek the assistance of a WSIB Return to Work Specialist.
Reporting a Material Change in Circumstances
Please also remember to inform your caseworker at the Workplace Safety and Insurance Board (WSIB) of any changes concerning your claim such as healthcare status, earnings/ income and return to work status. The Board refers to this as a “material change in circumstances”. You are required to inform the WISB of any material changes within 10 calendar days.
If you wish to contact the Pensions and Benefits unit, please email us at [email protected]
This publication contains general information and is intended as a reference only. It is not intended as a substitute for independent legal advice regarding your particular situation.