Workplace Safety and Insurance Board
Appeals Resolution Officer Decision
Decision Number: 20100122
Objection By: Worker
Participants: Worker, Worker Representative, Employer
Hearing Date: N/A
Issue
The worker objects to the denial of full reimbursement for a Specialist’s medical report as outlined in the Nurse Consultant’s decision of October 21, 2009. The worker representative was reimbursed for a total of $23.54 for the medical report, and they request he be fully reimbursed for the $300.00 that they actually paid.
How the Issue Arises
The Workplace Safety Insurance Board (WSIB) case manager (adjudicator) had initially denied secondary entitlement to the worker’s right knee. In support of the worker’s position that entitlement should include the right knee, the worker representative wrote Dr. Luba, Orthopaedic Consultant, in order to request additional specific information and clarification regarding the worker’s condition.
In a letter dated March 14, 2006, Dr. Luba wrote to the worker representative indicating that the cost for this service is $300.00. His letter confirms that immediately upon receipt of payment, the requested information would be forwarded to the worker representative. Dr. Luba then provided a detailed response concerning the worker’s medical condition in a letter dated March 14, 2006. This information was used by the Appeals Resolution Officer (ARO) to render a decision dated November 7, 2006 allowing secondary entitlement to the right knee.
In a decision dated October 21, 2009 the WSIB Nurse Consultant acknowledged that the worker representative requested reimbursement of $300.00 for the medical report. However it was determined that the worker representative would be reimbursed for a doctor’s report, at a total of $23.54.
The issue before the Appeals Branch is the worker representative’s objection to the denial of full reimbursement for the fee paid to obtain the specific information from the Specialist.
Authority
Workplace Safety and Insurance Act:
Section 33(4)
Section 37(5)
Operational Policy Manual Documents:
17-02-03 -- Payment of Clinical Assessments
RESOLUTION METHOD AND PROCESS
Contact was made with the worker’s representative who agreed for the appeals resolution officer to proceed to a decision based on the information contained within the claim record, along with their submission of June 9, 2010.
A Participant Form was received from the employer and therefore they were contacted and advised of the objection issue and method of resolution.
Assessment of the Evidence
In arriving at a decision in this claim, I have had regard for the record, the applicable law and policy, as well as the interested parties’ view on the issue.
In considering a worker’s entitlement to WSIB benefits, a decision maker is mandated to have regard for WSIB legislation and related policy.
Policy 17-02-03 states in part:
The WSIB pays for requested clinical assessments or reports used solely to adjudicate claims. These assessments/reports are considered benefit expenses.
The WSIB pays the costs of clinical assessments used to adjudicate claims. This includes payment for assessments used for health care or return-to-work purposes.
If the WSIB receives reports not specifically requested, payment is made only if the information submitted is necessary and/or useful for making a decision. If the report repeats information already on file or, if it contains information that is of no value to the adjudicative process, no payment is made.
When I assess all of the pertinent information in the claim file, I find that the worker representative is entitled to reimbursement for the expenses paid for Dr. Luba’s medical report dated March 14, 2006. In reaching this conclusion, I had regard for all of the available information, however found the following details particularly relevant:
The ARO acknowledges in the decision dated November 7, 2006 that Dr. Luba’s comments and opinion were used in rendering a decision to accept additional entitlement in this claim.
I note that the Nurse Consultant’s decision of October 21, 2009 concludes that Dr. Luba’s report was used in the decision making process and hence has allowed partial reimbursement of the Specialist’s fee. The question remains as to the correct amount that is to be reimbursed.
The worker representative argues that the Specialist, Dr. Luba provided medical information of a complex nature, and in accordance with WSIB fee schedule, should be fully reimbursed for this expense.
In reaching a conclusion in this matter, I contacted one of the WSIB health care payment representatives and confirmed that if accepted, the Specialist would have been entitled to be reimbursed for the time it took him to review the chart and prepare the written response. The specialist is entitled to $56.05 for each 15 minutes, under code M651 AND $23.54 under code M650 to prepare a one to five page document reply. OR, the specialist would be entitled to a total of $112.10 under code M649 for a complex report.
In this case, I find that it is reasonable that the specialist has requested a total of $300.00 for approximately a one hour and 15 minute review of the worker’s records and to complete the response, as well as an additional $23.54 for the one page document reply.
The worker representative is therefore entitled to be reimbursed for a total of $300.00 that was paid for the Specialist report that was used to determine entitlement in this claim file. I note that the worker representative has been partially reimbursed. The balance owing is to be paid directly to the worker representative.
CONCLUSION
I conclude the worker representative is to be reimbursed for a total of $300.00 that was paid to obtain a specialist report that was used in the adjudication of this claim file. The worker representative has already been paid $23.54, as such the balance owing, $276.46, is to be paid to the worker representative.
The worker’s objection is therefore allowed.
DATED August 6, 2010
S. Bennett
Appeals Resolution Officer
Appeals Branch