WORKERS' INFORMATION KIT:  Health Care

Who Is Eligible For Health Care Benefits and Services?

You are entitled to claim for health care benefits if:

• you are an injured worker entitled to benefits under the workplace safety and insurance plan (formerly called workers' compensation), and
• you have a work-related injury for which health care is necessary, appropriate and sufficient as a result of the injury
  

What Are Health Care Benefits and Services?

WSIB defines health care as:

• professional services provided by a health care practitioner
• services provided by or at hospitals and health facilities
• prescription drugs
• the services of an attendant
• modifications to a person's home, vehicle and other measures to facilitate independent living which, in the opinion of WSIB, are appropriate
• assistive devices and prostheses
• extraordinary transportation costs to obtain health care
• such measures to improve the quality of life of severely injured workers which, in the opinion of WSIB, are appropriate.

Requirements of Health Care Practitioners and Health Professionals

There are two classes of "doctors" according to WSIB. The first class is called "health professionals." A health professional is a member of a college as defined in the Regulated Health Professions Act, 1991.

Health professionals include, but are not limited to:

• doctors and surgeons
• chiropractors
• dentists and oral surgeons
• massage therapists
• occupational therapists
• optometrists
• physiotherapists
• psychologists
• registered nurses
• registered nurses (extended class)
• speech therapists

The second class of "doctors" is called "health care practitioners". According to WSIB, health care practitioners belong to a college falling under the scope of the Regulated Health Professions Act, 1991 or the Drugless Practitioners Act, 1990.

Health care practitioners include, but are not limited to:

• all health professionals
• all drugless practitioners under the Drugless Practitioners Act, 1990 (i.e., persons who treat diseases of the human body by manipulation, adjustment, manual or electro-therapy, or by any similar method)
• social workers

WSIB will sometimes purchase services from non-regulated professionals. You should contact your adjudicator or nurse case manager before beginning any treatment or services.

Back to Top

Initial Choice of Health Professional

You have the right to choose the initial heath professional who will treat your work-related injury or illness. However, you are only allowed to choose from among four groups of health professionals provided that the treatment of the injury or illness is within that health professional's scope of practice, as defined by the governing legislation for that group of health professionals. The health professionals you are allowed to choose from are:

• chiropractors
• doctors
• physiotherapists
• registered nurses (extended class)

WSIB considers you to have made your initial choice of health professional when you obtain follow-up treatment after the immediate or emergency treatment of an injury. WSIB recognizes that, in most situations, you cannot choose the health professional that treats you immediately following an accident.

If you want to change the health professional that treats you (e.g., if you move or your doctor retires), then you must notify and get approval from your adjudicator. If you visit another health professional in relation to your work-related injury, then WSIB would deem only one health professional as responsible for the management of your health care. For example, if you initially see your family doctor in regard to your work-related injury and that doctor refers you to a specialist who treats your injury, then WSIB will select only one of these professionals as responsible for the management of your health care. The health professional selected by WSIB would be in charge of reporting your treatment.

Back to Top

Payment for Health Care Benefits and Services

WSIB pays health care practitioners for most treatments associated with the work-related injury. The payments can include, but are not limited to:

• treatment by health care professionals such as doctors, chiropractors,
  physiotherapists and dentists
• hospitalization, surgery and emergency care
• prescription drugs
• prosthetics, orthotics and other assistive devices such as glasses, hearing aids, crutches and wheelchairs
• contracted services, such as an attendant and other measures to help severely impaired workers live independently
• travel and accommodation costs related to the claim (such as those for medical appointments)

In some cases, you may need approval before receiving treatment. It is a good idea to get pre-approval to ensure that WSIB will pay for the health care you receive (e.g., hearing aids, dental care). Speak to your adjudicator or nurse case manager to find out which treatments need pre-approval. Generally, treatment from a health care practitioner not registered with WSIB must be pre-approved.

Health care practitioners bill WSIB directly for any treatment or services required for your work-related injury. The health care practitioner should not bill you or another insurer for any amount over and above the approved WSIB fee. If the health care practitioner charges you for the balance of the fee, contact your adjudicator or nurse case manager.

If WSIB refuses to pay for your treatment, then ask your health care practitioner to send a medical report to WSIB explaining why the treatment is necessary. Please see Appendix 1 for a sample letter that you may wish to use as a guide. Remember to provide a copy of the WSIB letter denying your treatment to your health care practitioner.

Once you know that your health care practitioner has sent the report to WSIB, contact your adjudicator to find out if WSIB will now pay for treatment based on the report. If WSIB still refuses to pay for treatment, you may appeal the decision.

There are strict time lines for appealing a WSIB decision. You have six months from the date of the WSIB decision to make an appeal. For more information on appealing a WSIB decision, see OWA Fact Sheets 24 and 25 called "Appealing to WSIB" and "Appealing to WSIAT".

Back to Top

Payment for Prescription Medication

WSIB will only pay for claim-related prescription medication. Most of the time, the pharmacist can bill WSIB directly online for your claim-related prescription medication. Simply provide the pharmacist with your claim number and request that your prescription be processed through the WSIB online system.

If for any reason the cost of your prescription cannot be approved electronically, then complete the WSIB Medication Reimbursement Form. Your pharmacist has this form or you can download it from the Worker Forms section of the WSIB website at: http://www.wsib.on.ca/wsib/wsibsite.nsf/public/FormsWorkers

Attach your original receipts to the completed form and sign it before mailing. Remember to keep a photocopy of the form and receipts for your own records.

If WSIB refuses to pay for your medication, then ask the health care practitioner who prescribed the medication to send a medical note to WSIB, explaining why the medication is necessary. Please see Appendix 2 for a sample letter that you may wish to use as a guide. Remember to provide your health care practitioner with a copy of the WSIB letter denying payment of your medication.

Once you know that your health care practitioner has sent the note to WSIB, contact your adjudicator to find out if WSIB will now pay for the medication based on the note. If WSIB still refuses to pay for the medication, you may appeal the decision.

There are strict time limits for appealing a WSIB decision. You will have six months from the date of the WSIB decision to make an appeal. For more information on appealing a WSIB decision, see OWA Fact Sheets 24 and 25 called "Appealing to WSIB" and "Appealing to WSIAT".

Back to Top

Payment for Assistive Devices and Special Needs

WSIB will pay for the necessary, appropriate, and sufficient assistive devices that you require as a result of your work-related injury. The types of devices and special needs that WSIB will pay for include, but are not limited to:

• wheelchairs
• artificial limbs
• hearing aids
• dentures
• eyeglasses
• canes
• orthopedic mattresses
• special shoes
• home visits by a nurse

In the case of a serious permanent disability, WSIB can pay for home renovations such as the addition of a wheel chair ramp, or the alteration of your car or van.

You should seek WSIB approval before buying any of the above listed devices as each device has its own eligibility criteria. WSIB may require a detailed explanation from a health practitioner before approving payment for any assistive devices or special care.

If WSIB refuses to pay for assistive devices or special needs items, then you may appeal the decision. There are strict time lines for appealing a WSIB decision. You have six months from the date of the WSIB decision to make an appeal. For more information on appealing a WSIB decision, see OWA Fact Sheets 24 and 25 called "Appealing to WSIB" and "Appealing to WSIAT".

Back to Top

Payment of Clothing Allowance

WSIB will pay a set annual allowance to replace clothing damaged by a brace, prosthesis, or other device worn because of a work-related injury.

To be eligible for initial entitlement to this allowance you must:

• be permanently disabled or impaired
• be in receipt of permanent disability benefits or non-economic loss (NEL) benefits
• have reached your maximum medical recovery
• wear a WSIB authorized or supplied assistive device
• have worn the device one full year after receiving permanent disability or NEL benefits

You must apply annually in writing to WSIB for this allowance. You are required to have your treating health professional submit objective clinical findings confirming your need for the device, and stating that you wear the device at the same frequency as you did in the past year. You may wish to include some of the following points in your letter:

• that WSIB supplied or authorized the device
• that you have worn your device for a full year since receiving your permanent disability pension or NEL award
• the number of hours you wear the device on a daily basis
• how wearing the device causes damage to your clothes

Please see Appendix 3 for a sample of a "Request for Clothing Allowance" letter that you may wish to use as a guide. For more information, see OWA Fact Sheet 19 called "Clothing Allowance".

Back to Top

Payment for Wage Loss due to a Health Care Appointment

If you have to take time off your normal working hours to attend a consultation, examination or treatment from a health care practitioner due to a workplace injury or disease, WSIB will compensate you for lost wages. Other times WSIB will pay for lost wages include:

• when you are requested by WSIB to report to a WSIB office
• when you report to any practitioner, specialist or clinic for an interview, examination, or to complete a WSIB form
• when you arrange an appointment with a practitioner, providing that the appointment is medically justified, does not constitute an unauthorized change in health care practitioners, and is solely for the purposes of examination, with appropriate reports submitted
• when you are supplied by WSIB with an artificial appliance and are required to lose time from work because of the need for repairs, refitting, or the replacement of the artificial appliance
• when you undergo a practitioner's treatment requiring your absence from work provided that the appropriate reports are submitted.

You must inform your adjudicator of your appointment in advance because WSIB may require a report from your health care practitioner before it will pay for lost wages. WSIB only compensates workers for lost wages due to health care appointments in claims not yet allowed if the appointment is pre-authorized.

If WSIB refuses to pay, you may appeal this decision. There are strict time lines for appealing a WSIB decision. You have six months from the date of the WSIB decision to make an appeal. For more information on appealing a WSIB decision, see OWA Fact Sheets 24 and 25 called "Appealing to WSIB" and "Appealing to WSIAT".

Back to Top

Payments for Chiropractors

Although WSIB will pay for you to see a chiropractor, there are strict guidelines for the type and length of treatment that is paid. You must first see a chiropractor that treats clients with workplace insurance claims, as some chiropractors do not treat clients with workplace insurance claims. Chiropractic treatments are usually allowed for the first twelve weeks after an injury. WSIB health care staff will decide how long the treatments should last beyond the twelve-week period.

If your chiropractor believes you will need more than twelve weeks of treatment, (s)he should write to WSIB at about the eight week period of your treatment and request approval for additional treatment. In the letter to WSIB, your chiropractor should describe how the treatment has improved your condition and explain why additional treatment is necessary.

If WSIB refuses to pay for your chiropractic treatment, then ask your chiropractor to write WSIB and explain why you need the treatment. Please see Appendix 4 for a sample letter called "Note to Chiropractor - Requesting Report for Non-Payment of Chiropractic Treatment" that you may take to your chiropractor. Remember to give your chiropractor a copy of the WSIB letter denying your treatment.

Once you know that your chiropractor has sent a report to WSIB, you should contact your adjudicator to inquire if WSIB will now pay for treatment. If WSIB still refuses to pay, you may appeal the decision. There are strict time lines for appealing a WSIB decision. You have six months from the date of the WSIB decision to make an appeal. For more information on appealing a WSIB decision, see OWA Fact Sheets 24 and 25 called "Appealing to WSIB" and "Appealing to WSIAT".

For more information on chiropractic treatment, please see OWA Fact Sheet 18 called "Treatment by Chiropractors".

Back to Top

Payment for Travel and Related Expenses

WSIB reimburses your transportation costs and reasonable related expenses for all WSIB approved travel that is related to your claim. This includes appointments with health care practitioners. Your travel costs for routine job search activities are not paid. However, your travel costs for attending a WSIB-sponsored training-on-the-job program are paid.

Transportation expenses are paid based on the most direct route taken by the most practical, expedient, and clinically necessary mode of travel. Public transportation is fully reimbursed. If public transportation is not available, you may take your car. Mileage will be paid at set rates and parking will be fully reimbursed. Remember to keep your receipts.

If you have an impairment that prevents you from taking public travel, WSIB will pay for specialized transportation if:

• you are involved in a medical or labour market re-entry (LMR) program
• you do not have a vehicle
• you have an impairment that prevents travel by public transit, or when a prevailing work-related condition requires a specialized means of transportation
• travel is essential to the medical or LMR program established for your work-related impairment.

If you have additional travel costs, call your adjudicator in advance to request approval. Once you have been given approval, you can submit your travel claim to WSIB in writing. To assist you in completing your travel claim, please see the Worker's Health Care Travel Expense Form located on the WSIB website at: http://www.wsib.on.ca/wsib/wsibsite.nsf/public/FormsWorkers.

If WSIB does not approve payment for your travel expenses, you can appeal this decision. There are strict time lines for appealing a WSIB decision. You have six months from the date of the WSIB decision to make an appeal. For more information on appealing a WSIB decision, see OWA Fact Sheets 24 and 25 called "Appealing to WSIB" and "Appealing to WSIAT".

Back to Top

Serious Injury Program (SIP)

The WSIB SIP may administer your claim if you are considered severely impaired by WSIB or were diagnosed with one of several prescribed conditions. These conditions include, but are not limited to:

• hemiplegia, paraplegia, quadriplegia, or paraparesis
• major amputations (NEL award of 60% or greater; generally more than one limb)
• blindness
• major burns (2nd or 3rd degree burns involving both hands or feet, or face, head or neck area; or burns that required you to be transferred to a major burn unit)
• brain injuries that require major cognitive interventions, prevent you from living independently or handling your own affairs
• serious crushing injuries to the chest, abdomen, or pelvis, such as those requiring transfer to a major trauma hospital

You may be considered severely impaired by WSIB if you are:

• permanently impaired or disabled and your permanent disability (PD) benefits have been rated at 100%, or
• permanently impaired or disabled and have been rated for non-economic loss (NEL) benefits totaling at least 60%, or
• likely to be permanently impaired or disabled, in the opinion of a WSIB medical consultant, and are likely to meet one of the criteria above (at least 100% PD, or 60% NEL).

When you have your claim administered under the SIP, all aspects of your claim are handled by a support team consisting of: an adjudicator, occupational therapist or independent living consultant, advanced practice nurse case manager, nurse case manager, and a healthcare or LMR payment representative. The purpose of this team is to aid and monitor your healing.

For a complete guide to benefits specific to the SIP, you can visit the Independent Living Guide on the WSIB website. This guide will explain how to apply for a benefit or service, how that benefit or service will be paid for, and when reviews of your benefit or service will take place.

Back to Top

Independent Living Allowance

You may be considered severely impaired if you are:

• permanently impaired or disabled and your permanent disability (PD) benefits have been rated at 100%, or
• permanently impaired or disabled and have been rated for non-economic loss (NEL) benefits totaling at least 60%, or
• likely to be permanently impaired or disabled, in the opinion of a WSIB medical consultant, and are likely to meet one of the criteria above (at least 100% PD, or 60% NEL).

If you are a severely impaired worker that does not live in an institute, then WSIB will pay you an annual allowance to help you live independently and improve the quality of your life. The allowance is meant to offset the cost of services (regardless of cost) and devices or other items costing under $250 each. The following is a list of the types of services you may spend your allowance on, although this list is not exhaustive:

• indoor or outdoor maintenance of principle residence, which includes: snow shoveling, lawn maintenance, yard maintenance, cleaning (including eaves, pools, etc.), housekeeping, painting, house repair and general maintenance.
• taxi service to participate in social or community events
• supportive therapy, physical fitness, or recreational therapy, or recreational programs (e.g., art/music therapy, fitness center membership)
• non-vocational instruction such as "help line" support for computer programs
• internet access

The allowance is reviewed annually and paid as a lump sum. The allowance can be spent in any way you wish and you are not required to provide receipts. However, you cannot claim separately for any independent living service or device that is already paid for by the allowance.

You may be entitled to an additional reimbursement for devices that cost more than $250 if those devices are covered by the WSIB Independent Living Devices policy, as detailed below.

Back to Top

Independent Living Devices

If you are a severely impaired worker you may be entitled to this benefit. It pays for devices that cost more than $250 and help to restore your ability to:

• communicate
• be mobile
• engage in self-care
• avoid further injury
• prevent future health complications due to the work-related injury

WSIB will also reimburse you for devices that:

• are not intended to accomplish any of the objectives of the services covered by the Independent Living Allowance (if the worker is receiving the allowance)
• meet a permanent long-term need
• are appropriate, given the nature of the worker's impairment and functional limitations (e.g., the device can be used safely and effectively)
• are prescribed or recommended by a health care practitioner
• are reasonable in terms of cost and anticipated benefits
• are cost-effective considering the alternatives on the market
• meet performance standards generally accepted by medical or clinical rehabilitation specialists and certified by the Canadian Standards Association International (C.S.A.I.) or meet other applicable safety standards

If you receive the Independent Living Allowance, the devices must not be covered by that allowance. If you are not in receipt of the Independent Living Allowance, you may claim for the devices regardless of cost.

To access this benefit you must get approval from WSIB before you purchase a device. If approved, you must purchase the device and submit your original receipt or vendor invoice directly to WSIB to be reimbursed.

Back to Top

Guide and Support Dogs

If you are a severely impaired worker, you may be entitled to a guide or support dog, provided that the dog is necessary to enhance your quality of life or to assist you in gaining employment, and is recommended by your health care practitioner.

If you are a severely impaired blind worker, your treating health professional or the Canadian National Institute for the Blind must recommend to WSIB the use of a guide dog for you.

If you are a severely impaired deaf worker who is completely deaf or suffers a significant immobility, support dogs must be recommended by your treating heath professional before WSIB will approve the expense. If you are a completely deaf worker, but not severely impaired and have less than 60% NEL or less than 100% permanent disability for hearing loss, you may still be entitled to a support dog if your treating health professional recommends one.

WSIB pays for the dog, training for the dog, mobility training for you, veterinary care, and maintenance of the animal.

Back to Top

Personal Care Allowance

If you are severely impaired and need assistance with the activities of daily living such as eating, maintaining good personal hygiene, grooming, or being mobile, then WSIB may pay an allowance for a personal attendant to assist you. There are three types of attendants. These include:

• a skilled attendant to handle your complex health care and hygiene
• a personal attendant to handle routine personal care
• a general attendant to handle basic supervision

WSIB determines your needs using an Activities of Daily Living Scale (ADLS) form.

In addition, WSIB differentiates between "non-agency" attendants such as your spouse, same-sex partner, or friend and "agency attendants" such as a nurse. An allowance is paid to you for non-agency attendants and the amount is related to the 3 levels of care. Payments for agency attendants are negotiated and paid directly to the agency. WSIB will review your need for a personal attendant on an annual basis.

If WSIB refuses to pay the allowance for an attendant, you may appeal the decision. There are strict time lines for appealing a WSIB decision. You have six months from the date of the WSIB decision to make an appeal. For more information on appealing a WSIB decision, see OWA Fact Sheets 24 and 25 called "Appealing to WSIB" and "Appealing to WSIAT".

Back to Top

Payment of Escorts

If you need assistance in traveling to healthcare or WSIB arranged appointments because of your injury, then WSIB will pay for you to have an escort. WSIB recognizes two types of escorts. These include:

• professional qualified escorts (e.g., a registered nurse) if you need assistance to travel to appointments because of serious clinical problems
• non-professional escorts, if you must be accompanied for legal or basic clinical reasons. A non-professional escort can be a spouse, parent or friend.

Sometimes, WSIB will pay for both types of escorts. Escorts are paid a set daily rate by WSIB. You should get advanced approval for an escort by contacting your adjudicator.

If WSIB refuses to pay for an escort, you may appeal the decision. There are strict time lines for appealing a WSIB decision. You have six months from the date of the WSIB decision to make an appeal. For more information on appealing a WSIB decision, see OWA Fact Sheets 24 and 25 called "Appealing to WSIB" and "Appealing to WSIAT".

Back to Top

Resources for Further Assistance

The Office of the Worker Adviser (OWA) can provide summary advice on appeals in which the value of the benefit being sought is worth less than eight weeks of loss of earnings (LOE) benefits. If the healthcare benefit or service you are seeking is worth more than eight weeks of loss of earnings (LOE) benefits, the OWA may be able to represent you in your appeal. For more information, see OWA Fact Sheet 1(b) called "Getting Help from the Office of the Worker Adviser".

This information kit is designed to help you to represent yourself. If you feel unable to deal with the claim or appeal process yourself, then you should seek help from your union, your community legal-aid clinic, or the office of your Member of Provincial Parliament (MPP).

For more information on health care benefits, please visit the following web links:

• The WSIB Operational Policy Manual, section on Health Care policies is a great resource in understanding your entitlement to health care benefits.
  
  
• Industrial Accident Victim's Group of Ontario (IAVGO) is a community legal-aid office that provides free legal services to injured workers.
  
  
• Community Legal Education Ontario (CLEO) is a community legal clinic that provides plain language publications on workplace insurance issues (formerly called workers' compensation).

OWA Workers' Kit 2 - March 2006