Most employers know that WSIB-related costs can be very expensive. However, not everyone knows about cost relief programs offered by the Board. We asked Anna Aceto-Guerin for some insights into successfully acquiring SIEF cost relief.

What is the SIEF program?

In order to encourage companies to hire workers with previous injuries or disabilities, the WSIB created a program called SIEF (Secondary Injury Enhancement Fund). SIEF provides financial relief to employers when an injured worker’s pre-existing condition either enhances or prolongs recovery from a work-related disability. Receiving SIEF cost relief does not impact the amount of benefits paid to the injured worker.

The amount of cost relief applied is based on the combination of the severity of the pre-existing injury against the severity of the workplace accident. For example, an injury that occurred as a result of a “minor” accident (one that would typically not cause impairment) due to a “major” pre-existing injury would receive the highest level of cost relief for the employer.

So what is the problem?

As part of its focus on cutting costs and eliminating its unfunded liability, the WSIB has become increasingly conservative in its allowance of SIEF requests over the past five years. Requests that would have been routinely approved in the past are now regularly rejected.

As WSIB consultants, we have noticed that approximately 95 percent of SIEF requests are being initially denied regardless of merit. This means that our team has needed to become much more persistent in our pursuit of cost relief for our customers. Even when one is lucky enough to get SIEF approved on first request, it is probably the minimum they can possibly award.  As a result, our basic rule of thumb is object, object, object.

Why object when you have received some SIEF

Objecting to a straight-out denial of your SIEF request may seem obvious to some, but what do you do if you did receive some level of cost relief? Should you be satisfied and stop there? Definitely no! Now you know that there has been some level of pre-existing condition identified to justify the allowance of cost relief and you must dig deeper. Your next step is to find out exactly why and with what information that decision was made by the WSIB.

Assessing both of the elements

As mentioned, approval of SIEF is built upon two criteria: severity of accident and the impact of a pre-existing condition that may have prolonged the recovery from said accident.

In requesting SIEF, each of these two elements must be tacked individually. Deciding the severity of the accident should be based on the facts you have uncovered. Determining the impact of the pre-existing condition can be more complicated. Obtaining the Access File is a key part of SIEF cost retrieval and it contains the relevant medical information on which the decision was based.

Subjectivity

Also, you must realize that making a SIEF decision can be a very subjective one for the WSIB. Determining the exact severity of an injury and precisely to what degree the pre-existing condition has affected recovery are not always easy to assess. Who can really measure those two criteria objectively? Are you able to say with certainty that a slip or a trip is moderate accident, likely to cause a disablement as opposed to minor accident, not likely to cause a disablement?

So we have discovered that SIEF case managers are just like us – human! They use their best judgment to decide and because the group of SIEF case managers is very small, less than 20 in total, getting to know which case manager making the decision will really help you to understand their logic.

Accessing the medical evidence

The other factor to consider is all based on medical evidence. The first trick is to ensure the right medical records get included in the file and that the claims manager actually reviews it.

In a recent file one of our consultants reviewed, the WSIB claims manager had based their decision on an operative report they said they had reviewed.  But when we objected to the denial and reviewed the access file ourselves, the said operative report was nowhere to be seen, it didn’t exist in the file.  In this case, we were able to make sure that the claims manager actually obtained the report from the treating physician and we used it to support our reconsideration request.  We would have never been able to do that if we were not persistent, objected to the decision and requested the access file.

Timing is everything

There is a lot to be said for timing of the request as well.  Too early, the case manager may rule that the recovery is not sufficiently prolonged to warrant SIEF. Too late in the game and they will tell you that the accident severity now is higher than previously determined due to the prolonged recovery.

Should you bring in the experts or try it yourself?

Think you would like to try your hand at pursuing cost relief?  We definitely encourage it, but with one word of caution. Be aware that you only get a few kicks at the can:

• Initial request,
• Reconsideration,
• Appeal to WSIB, and finally
• WSIAT appeal

Don’t squander your attempts trying to figure it out.

Our recommendation is if you want to try, put in the first request and then once you get denied (because you probably will) then object to the denial. You will then get the case file and can get an expert to review the medical to build a solid argument for reconsideration or appeal.

Benefits of third party independent medical opinions

Lastly, remember that you can only move to the other stages of appeal if you have something new to provide to the decision maker. We have had a lot of success in obtaining third party independent medical opinions on the case file to “connect the dots” with the medical evidence.

On a recent file we managed, after we first received a denial we provided further medical opinion (obtained by engaging the services of a third party independent medical provider) along with our reconsideration.

As a result, we were able to we obtain 75 percent SIEF cost relief! Minor accident and moderate pre-existing was determined after an initial denial for SIEF. That saved our client over $283,000 in NEER savings and decreased their pending actual surcharge for September 2014 by $283,000!  That deserves some applause!

The two keys to success

So what can we learn from all this? Being persistent is critical for sure. But also knowing how to “speak the WSIB’s language” is definitely another. Knowing WSIB policy and really understanding what their decision is based upon — so you can come back with a solid argument — is key to getting what you want.

Next steps

We would love to assist you and you organization in being more successful with your cost relief requests and reducing your WSIB costs. Remember that acquiring SIEF is the last resort, focusing on RTW and objecting to initial entitlement will ultimately get you further in the long run.

If you have any WSIB or SIEF related questions, feel free to contact Anna Aceto-Guerin directly at anna@clearpathemployer.com or (519) 624-0800.