WORKPLACE SAFETY AND INSURANCE BOARD
APPEALS RESOLUTION OFFICER DECISION
DECISION Number: 20150012
DECISION DATE: April 8, 2015
OBJECTING PARTY: Worker
REPRESENTED by: Self Represented
RESPONDENT: Employer
HEARING: In Writing
HEARD by: N. Glyn-Williams, Appeals Resolution Officer
ISSUE
The worker is objecting to the Nurse Consultant’s (NC) decision of April 29, 2014 that reimbursed the worker’s physiotherapy treatment according to the WSIB fee schedule.
BACKGROUND
This Senior Public Servant worked for the employer for seven years. On February 25, 2014, at age 51, the worker was picked-up by a car service and while entering the vehicle, the driver did not realize she was not fully in the car and started driving. The worker immediately sustained a back injury and reported it to her employer. The worker did not lose any time from work.
A claim was registered with the WSIB on March 3, 2014. I note there are no medical reports on the record; however, the worker reported attending physiotherapy treatment at a clinic. The worker’s claim was allowed for a back injury for Health Care Benefits only. The record shows the worker continued to work and received nine treatment sessions of physiotherapy from March 3, 2014 until April 4, 2014.
The worker contacted the NC on March 27, 2014 to discuss reimbursement of her treatment expenses. The record shows the NC contacted the physiotherapy clinic to request direct billing to the WSIB for the worker’s treatment; however, she was advised that they were not a clinic registered with the WSIB and therefore could not direct bill the WSIB for the worker’s treatment.
On March 27, 2014 the NC left a message for the worker advising her that it would be necessary to submit the bills directly to the WSIB for reimbursement noting they were not a registered clinic and also advised the worker of the WSIB fee schedule used to pay for treatment.
On March 28, 2014 the worker spoke to the NC who recommended the worker change physiotherapy clinics noting the worker’s clinic was not registered with the WSIB. The worker confirmed she was unaware of this and was also unaware of the requirement to obtain pre-approval before starting treatment. The worker advised that it was likely that there were only two treatment sessions left and therefore she advised the NC that she preferred not to change clinics, at that point. The NC instructed the worker to submit the receipts for review.
The worker submitted the physiotherapy treatment receipts totalling $632.50 to the WSIB for reimbursement. In a letter dated April 29, 2014 the NC advised the worker that her treatment from March 3, 2014 until April 4, 2014 was reimbursed; however, adjusted to the approved WSIB fee schedule.
The worker objected to the NC’s decision requesting full reimbursement of her out-of-pocket physiotherapy expenses. This is the issue currently before the Appeals Services Division.
AUTHORITY
- Operational Policy
17-01-02 - Entitlement to Health Care
11-01-03 - Merits and Justice
- Section 33 of the Workplace Safety and Insurance Act (WSIA) states in part:
Arrangements for health care
(2) The Board may arrange for the worker’s health care or may approve arrangements for his or her health care. The Board shall pay for the worker’s health care.
(3) The Board may establish such fee schedules for health care as it considers appropriate.
Questions re health care
- (7) The Board shall determine all questions concerning,
(a) the necessity, appropriateness and sufficiency of health care provided to a worker or that may be provided to a worker; and
(b) payment for health care provided to a worker.
ANALYSIS
The worker completed an Appeals Readiness Form on September 15, 2014 and attached a submission arguing that following her injury she attempted to obtain clarification from the employer regarding seeking immediate treatment and was advised she could begin treatment and simply keep her receipts. The worker argued by seeking immediate treatment with the physiotherapy clinic that had previously treated her, it helped her back injury heal faster and it helped avoid any lost time from work. The worker argued by the time she spoke with the NC and was made aware that the physiotherapy clinic she had been attending was not a WSIB registered clinic she was almost at the completion of her treatment. The worker stated she advised the NC that she thought she would only need one or two more treatments and preferred to remain at the same facility. The worker argued the NC stated reimbursement of her expenses would be considered. The worker stated that she should receive full reimbursement for her out-of-pocket physiotherapy expenses that she incurred from March 3, 2014 to April 4, 2014, as it was her position that she had taken reasonable checks before acting and attending treatment at the physiotherapy clinic, further stating she was at that time focusing on her physical recovery and maintaining her job performance.
The employer submitted the Respondent Form and has requested a further review of the circumstances of this case.
I have carefully considered the information on the record, the worker’s position, the employer’s position and the applicable legislation and operational policies. Based on the evidence and circumstances of this case, I find the worker is entitled to full reimbursement of her physiotherapy treatment expenses from March 3, 2014 to March 28, 2014, as I find it reasonable to conclude that the worker during this time was unaware of her requirement to attend a treatment facility registered with the WSIB and was also unaware of the WSIB’s approved fee schedule, noting she had no prior claims and noting the employer provided her with no real guidance when asked.
I however also find the worker’s physiotherapy expenses beyond March 28, 2014 were appropriately reduced by the NC to the WSIB’s approved fee schedule. In coming to this conclusion, I note that as of March 28, 2014 the worker was fully aware of the requirement to attend a registered WSIB treatment facility for a compensable injury and was also made fully aware of the WSIB fee schedule for payment of treatment and the requirement to obtain pre-approval for treatment at a non-registered facility.
While I appreciate that the worker has expressed concern that she has out of pocket expenses in the amount of $632.50 for the treatment received, I must also note that she acknowledges in her letter of September 14, 2014 that she did not carefully review all the materials sent to her by the WSIB by mail or contact the WSIB directly after her claim was approved to discuss reimbursement of her expenses. As per Memorandum #3 dated March 28, 2014, the worker was at that time clearly informed by the NC of the established fee schedule for the payment of physiotherapy treatment, as well as advised of a worker’s requirement to get pre-approval to attend a non-WSIB registered clinic. Although I can extend benefit of doubt for the initial period the worker attended treatment and was unaware of the approval of her case and also unaware of the WSIBs fee schedule and reimburse her physiotherapy expenses in full, I find there are no exceptional circumstances in this case for the worker to be reimbursed for treatment in full beyond March 28, 2014. At that time, I find the worker made the informed decision to continue with her physiotherapy treatment at a non-WSIB registered treatment facility knowing she would not likely be reimbursed in full for the cost of that treatment.
Based on the facts of this case, I conclude the worker is not entitled to full reimbursement for her physiotherapy treatment beyond March 27, 2014 and any receipts submitted beyond this date were appropriately reduced, as per the WSIB fee schedule.
CONCLUSION
I conclude the worker is entitled to be reimbursed for the full cost of her physiotherapy treatments for the period of March 3, 2014 until March 27, 2014 inclusive.
I also conclude the worker’s physiotherapy treatment expenses beyond March 28, 2014 were appropriately reduced to the approved WSIB fee schedule.
The worker’s objection is allowed-in-part.
DATED: April 8, 2015
N. Glyn-Williams Appeals Resolution Officer Appeals Services Division