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Adjudication of Chronic Mental Stress Injuries by the WSIB: A Farce, But We’re not Laughing

by / Monday, 10 December 2018 / Published in Uncategorized

The WSIB recently released a number of documents to IAVGO through a Freedom of Information request.

Among the most alarming was a recent audit the WSIB conducted of its adjudication into chronic mental stress entitlement claims. This audit was covered by The Toronto Star,with a focus on how the WSIB’s policy may have pushed it towards a 90+% denial rate of chronic mental stress claims.

The audit reveals a number of troubling realities about the current adjudication of mental stress at WSIB. It suggests that the WSIB is essentially auto-adjudicating mental stress claims, with a heavy focus on fast adjudication and a heavy de-emphasis on investigation or evidence gathering.

This is bizarre because chronic mental stress claims are likely among the most complex claims the WSIB is tasked to consider, right up there with occupational disease. Mental stress cases usually arise out of long-term exposures, with contested facts, and complex medical-legal issues.

Triage

A significant number of chronic mental stress cases (20%) are being adjudicated by a “Triage CM”. These “Triage CMs” denied 100% of the claims they adjudicated. Triage CMs are expected to issue a decision within 20 days of claim registration.

In most cases, the Triage CM got the case before the Worker’s Form 6 was even on file. In most cases, the Triage CM failed to ask the worker anything about their medical treatment, or any questions about possible witnesses or investigations:

In 94% of Triage CM adjudication cases, the Triage CM didn’t ask for any medical information at all before denying the claim.

The most common cited reason for Triage CM denial was a finding that the workplace event or events were employer decisions or actions. A large number of cases were denied based on a finding the work events were not a substantial work-related stressor. One case was denied based on the predominant cause test.

Eligibility adjudication

The remainder of chronic mental stress cases were adjudicated by an Eligibility CM, with a targeted time to decision of 49 days from claims registration.

Eligibility CMs did slightly better in terms of basic information gathering, but still did remarkably little in way of investigations and evidence gathering. Most did not discuss witnesses or other investigations with the worker, and 30% didn’t discuss medical information with the worker.

Despite the complexity of mental stress claims, 91% did not obtain even one witness statement. 78% didn’t request any additional medical information. And only 4% of cases involved the use of an actual investigator.

Eligibility CMs denied 92% of mental stress claims. The most common cited rationale for denial was that the workplace events were not a substantial work-related stressor, closely followed by a finding that the employer’s decisions or actions were the cause of injury. 4% of cases were denied because of the predominant cause test, and 3% because of the (possibly lack of) DSM diagnosis.

The Board also almost uniformly failed to provide help to workers in the form of psychological assessment or return to work. In only 1% of cases did the Eligibility CM facilitate psychological assessment or return to work.

Conclusions

The WSIB is not treating chronic mental stress claims as real injuries. It is failing to do basic investigations, gather documents, or investigate complex workplace risk factors for mental health injuries. The result is the near-total exclusion of workers with mental stress injuries from health care, return to work and compensation support when they are hurt on the job.

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