APPEALS RESOLUTION OFFICER DECISION
DECISION NUMBER: 20230064
OBJECTING PARTY: worker
REPRESENTED by: WORKER REPRESENTATIVE
RESPONDENT: employer
REPRESENTED by: self
HEARING: HEARING IN WRITING
HEARD by: J.L. Hughson, appeals resolution officer
ISSUES
The worker objects to the Case Manager’s (CM) decision dated March 24, 2022, which denied the worker a time limit extension to make their claim for entitlement to benefits for a psychological condition.
BACKGROUND
On June 17, 2019, this Police Constable was overwhelmed by psychological symptoms which had developed gradually. The worker began to lose time from work on June 18, 2019, and sought medical treatment on June 19, 2019. Their claim was initially approved for short-term and then long-term disability benefits through their employer. The Employer’s Report of Injury (Form 7) was dated July 27, 2021, and the Worker’s Report of Injury (Form 6) was dated September 17, 2021, over two years after the onset of their symptoms.
In their decision dated March 24, 2022, the CM identified that the worker had not filed their claim with the WSIB within the six-month deadline mandated in policy, and denied the worker a time limit extension to do so.
The worker objects to the decision dated March 24, 2022, and this issue is now before me.
AUTHORITY
Operational Policy Manual
Published
15-01-03 Workers’ Requirement to Claim and Consent
April 9, 2021
ANALYSIS
I find the worker is entitled to a time limit extension in order to file their claim for benefits. I have carefully considered all of the available information, legislation and relevant operational policies in reaching this decision.
In their submission, the worker’s representative (WR) contended that a time limit extension should be allowed, as the worker met two of the exceptional circumstances criteria listed within policy 15-01-03, Worker’s Requirement to Claim and Consent. They stated the worker was experiencing serious health problems in relationship to their mental health issues as well as alcohol use disorder, and that the worker reported their condition to two health care professionals. They also noted the nature of the worker’s PTSD diagnosis includes the avoidance of difficult or stressful situations, and the stigma of making their employer and colleagues aware of their PTSD diagnosis was stressful for the worker. In support of contention, the WR referenced the Workplace Safety and Insurance Appeals Tribunal (WSIAT) decision number 3/13, which allowed a time limit extension for a worker who had delayed in filing their claim for benefits for seven years after the date of injury.
Although the employer indicated they were participating in this appeal, they did not provide a submission on this issue.
Policy 15-01-03, Workers’ Requirement to Claim and Consent, states in part that
A claim must be filed within six months of an injury or, in the case of an occupational disease, within six months of the worker learning of the disease. The WSIB may extend the six-month deadline, or waive the dual requirement altogether if in the WSIB's opinion it is just to do so.
Policy 15-01-03 goes on to state that if a worker fails to file a claim by the respective deadline, the WSIB allows the claim to be filed at a later date if the worker can show that exceptional circumstances existed at the deadline. Exceptional circumstances can include:
- compelling personal reasons, such as serious health problems or injuries (experienced by the party or the party's immediate family), or the party leaving the province/country due to the ill health or death of a family member
- the worker's ability to understand the time limit requirements and consequences of not meeting them (e.g., was the worker made aware at the workplace of the requirement to claim and consent; were language difficulties a factor?), and
- whether the worker reported the accident to the employer, health care professional, or co-workers.
I accept the worker was experiencing serious health issues at the time of the six-month deadline to file their claim. The family doctor’s chart notes, dated September 27, 2019, indicated the worker was shaking a lot in their fingers and legs, which increased with stress. In the psychologist’s report, dated February 15, 2022, they noted that when the worker began treatment in June 2019, the worker
…presented with the following symptoms: sad/depressed mood most of the day, nearly every day; diminished interest/pleasure in almost all activities; significant weight loss; sleep difficulties; psychomotor retardation; fatigue; feelings of worthlessness with a sense of hopelessness; memory/concentration issues; passive suicidal thoughts; increase alcohol consumption; and trembling/shaking.
These findings are supported by the same psychologist’s response to a questionnaire given to them by the short-term disability provider, dated September 24, 2019. In this document, the psychologist noted that the worker’s symptoms were considered to be chronic and severe, and the worker had difficulty functioning on a daily basis. They stated the worker was having severe limitations in
- Managing crisis
- Tolerating confrontation
- Motivation
- Initiative
- Time management
- Meeting deadlines
- Multi-tasking
- Memory
- Organization/Planning
- Problem-solving
- Decision Making
As part of their submission, the WR referenced the WSIAT medical discussion paper, Post Traumatic Stress Disorder, which stated that “one of the core features of the disorder is the avoidance of difficult and stressful situations.”
I find the exceptional circumstance of compelling personal issues in the form of serious health issues on the part of the worker has been met. The medical information supports that at the time of the deadline to claim, the worker was experiencing severe psychological symptoms, including but not limited to impaired cognitive function, difficulty in decision-making, initiative, problem-solving, and tolerating confrontation. I accept the WR’s statement that the worker initially did not pursue a WSIB claim as they were concerned about the shame and stigma of their diagnosis. While this does not negate the worker’s legal requirement to claim and consent, as outlined in policy 15-01-03, I accept that the worker’s ability to make the decision of filing a WSIB claim was significantly impacted by the severity of their symptoms.
The CM completed a reconsideration decision dated December 6, 2022, which addressed the WR’s submission with their Appeals Readiness Form (ARF). As part of their rationale in continuing to deny the worker’s entitlement to a time limit extension to file their claim, they noted that the worker reported their psychological issues were primarily related to relationship and financial issues, and that the worker had initially indicated they did not wish to file a WSIB claim. However, these issues are irrelevant to the matter before me. The claim file information supports that there were compelling personal reasons which impacted the worker’s ability to file their claim within the six-month deadline, and, as a result, a time limit extension is allowed.
Given the above, I find the worker is entitled to a time limit extension in making their claim for benefits, as provided in policy 15-01-03, and the operating area may now adjudicate the worker’s initial entitlement to benefits.
CONCLUSION
The worker’s objection is allowed.
A time limit extension is granted.
DATED March 30, 2023
J.L. Hughson
Appeals Resolution Officer
Appeals Services Division