APPEAL Processes

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Where to start

Earlier I mentioned how important it was to read and understand the ‘case plan letter’. This letter contains a description of every decision made on your claim. They do not title this as a Case Plan Letter but you will see how they are all just templates with information filled in each time. This is what is needed to begin the appeal process. The next group explains what a Request for Review is (commonly referred to as RFR), and how to properly fill it in without having to pay a consultant or lawyer!

This is the last and most important stage of the game! It's become quite apparent that claimants continually need to appeal decisions made on their claim due to case managers refusing to follow policy. If you chose not to do this, you are letting them win!  This is what I mean by needing to learn to play their game. When you learn the policies that relate to your claim, you can eliminate a lot of grief you are subjected to at the hands of these unscrupulous people that work for WCB!

NEVER hire an appeals advisor. These people work for WCB and very few appeals are won. I discovered through my experience with one, they purposely alter important wording so the DRB and Appeals Commission are unable to grant your win. They too have to follow policy & legislation.

Requst for Revew (RFR)

If you have proven that policy wasn’t followed and your case managers refuse to change anything, you have the option of filing a Request for Review. This is the form you need to fill out and submit when you want to appeal a decision made on your claim. You have the right to appeal any decision made on your claim. The form is very easy to prepare as there are only 3 sections on it. The first is the decision you want to appeal. This will come from the case plan letter your case manager sent stating her decision.

For example, if they say you are qualified to be a call centre agent and you know it is not a suitable position based on policy, you can simply put ‘I disagree with my case manager’s decision that says I am qualified to work as a call centre agent” The second section just needs the date of the letter that states the decision. For example:  April 5, 2017. The final section asks what your reasons are for this review. This is where you can state that you are not qualified because it is not suitable based on policy. Quoting the policy will help but is not needed at this point. It is very important to quote the exact policy applicable to your appeal. There is some that are similar but for different reasons.You can get a copy of the RFR form off WCB’s website from the following link: https://www.wcb.ab.ca/resources/for-workers/forms-and-guides.html

Then scroll down to the Request for Review and click on it. The list of forms is in alphabetical order. This opens up as a word document. If you do not have a printer or a computer with MS Word, you can call the contact centre and have one mailed to you. NEVER file this online! If they know you could win that appeal, the online one may disappear. I have also heard from other injured workers that the appeal issue wording gets changed. Always have your original copy! Once you have it filled in and signed, send it via fax or email. Always keep a copy of all documents!

Gathering Appeal Info

Once you have submitted the RFR, you can start putting information together to present to the DRDRB (decision review body organized to review appeals on your claim). This is not a hard process. Once you have the proper evidence and the applicable policy, the rest is easy. I will use the same example noted under the Request for Review section to give you the information needed to be gathered. I am also using this example because I was successful at proving this exact position was not suitable for me based on policy. I have also helped other claimants with the suitable employment appeals and they have also won.

Get as many job ads for a call centre agent as you can that show WCB’s information on this position from the database in inaccurate. This includes wages, experience, education and physical and critical job demands.  Once you have found at least 12 job ads that prove theirs is inaccurate, send every one of them to the contact centre and ask them to be scanned to your file. Look at your compensable work restrictions to see if they fall within the critical and physical job demands listed on the profile for a call centre agent. For example, if your restrictions say you can’t sit more than 66% of the day, this position is not physically suitable because the profile states you need to be able to sit 100% of day.

A call centre agent requires a person to have experience. If you have never worked in one you are not qualified and therefore it is not vocationally suitable as per policy. You also need to be proficient with computer programs like MS Office. If you do not have certificates stating you are, this is another example of not being vocationally suitable. Remember I stated in the vocational services section and proved with policy, that a job needed to be suitable at 4 levels in order for WCB to approve it.  Now that you have proven on many levels this position would not be suitable, find the applicable policies surrounding suitability and write them down or print them off (listed in Vocational Services stage). Now you just need to put this information together I suggest typing it up in report form. to present to the DRDRB.

DRDRB

This stands for Dispute Resolution and Decision Review Body. Once the supervisor gets your Request for Review, they make a decision on it. If they deny it, it gets sent to the decision review body. The info on the WCB website regarding this department is not always how this is handled. The case managers often stall these reviews because they know a claimant will win. There is no time frame for these reviews stated in policy.

A review specialist from the decision review body usually contacts you to ensure they understand your specific issues and concerns and to determine your understanding of the decision. They will also ensure you have a clear opportunity to outline your issue before the specialist makes an assessment on your case. Make sure the appeal issue on your form matches theirs. They tried changing the wording on mine and I caught it before it was too late. Other injured workers have experienced the same.

You have the right to present your case to them in a face to face meeting or by telephone conference. I prefer the face to face meeting because they tend to be more patronizing over the phone! This also gives you the opportunity to provide them with the applicable documents or evidence you collected. Make sure you have a copy as well. The fact sheet about questioning a decision can be found on WCB’s website by clicking on the following link: https://www.wcb.ab.ca/assets/pdfs/workers/WFS_Questioning_a_WCB_Decision.pdf

Once the DRB makes a decision, they will send a copy of this to your claim file and one to you. If you have lost your case with them, chances are you relied on an Appeals Advisor or consultant to file this appeal. You can’t lose if you have proven they did not follow policy. These people manipulate the wording on the Request for Reviews intentionally and make you believe you have a strong case. When this happens, they purposely urge you to file with the Appeals Commission because this is the last stage to take an appeal and is binding! The commission can only go by what’s worded in your appeal issue and apply it to policies and legislation. You will find information for the Appeals Commission further down on this page.

Canlii Database

Canlii.org is a public website that contains decisions from the Appeals Commission. They are posted because it’s a legal document the same as a decision from a court case. They all pertain to laws. The purpose of me telling you this is like a court case, you can use previous case decisions to support your appeal.

This site is very easy to use. You only need to type in applicable words and all case decisions with those words come up. For example, if you type in call centre agent in the document name box, all appeals involving a call centre agent come up. I used 4 different appeal case wins to support mine. The link I am providing below takes you right to the Appeals Commission decisions in Alberta but you can use cases from other provinces. I advise you to stay with Alberta as job and wages vary in other provinces. However, there may be different appeal issues where the other decisions would be applicable. Include the information and case decision number in your argument.  https://www.canlii.org/en/ab/abwcac/

Appeals Commission

Once you have had your RFR denied by the DRDRB, you are not out of options. You can send your RFR to be seen before the Alberta Appeals Commission.  The following link will take you to the Appeals Commission Practise Guideline which explains how to file your appeal with the commission. https://www.appealscommission.ab.ca/Appeals%20Commission%20Publications/2017%20Practice%20Guidelines%20(20170215)/01.%20Practice%20Guideline%201-Filing%20an%20Appeal_Feb-15-2017%20(20170215).pdf Submit your Request and they will contact you within 2 weeks acknowledging that they have received the request and will attempt to schedule the review with you. Things that you will need to know going into this is, what happens in this appeal is binding and will affect the outcome of your claim – for better or worse. Be Prepared! This is actually a simple process if you are prepared.

After these steps are completed, the Appeals Commission will go into your claim file and prepare what is known as an “All Documents Package” (ADP). This will be all documents they feel are relevant and pertinent for your appeal issue. For example, submitted job ads that prove your appeal issue would likely be added to the ADP. This package will also have a detailed list of the documents and are numbered for reference. You will need this when making reference to these in your appeal report you present to the panel. Once this document package is put together, they will send you a copy of this. These can be quite large and patronizing. Once you have this copy, you need to go through it to see there are any other documents you feel are applicable and they have missed. You have up until one week prior to the appeal hearing to get them added to the ADP. I strongly advise against waiting that long to submit them, because your employer is also entitled to all the documents being considered. If the employer does not receive these in a reasonable time period, giving them the opportunity to put together their arguments, the commission will refuse to allow them.

You will need to organize your report with the arguments you want to bring up in the appeal for them to consider when making a decision. Have a beginning, middle and end (your closing arguments). Role play what you are going to say and how you want these submissions to be brought out in the appeal. Remember, it is intimidating to sit in front of a board like you are on trial fighting for your rights. If there is any negative information in your file that relates to it, address it in the middle of your appeal and why it should not be used as consideration in a deciding factor on your claim, or what you have that is contradictory in your favour.

When you show up for appeal hearing, come early! Have copies of your appeal report to provide to all 3 members of the panel. If not, then leave time for your documents to be copied so you can provide copies to each panel member. You will be directed to wait in the lobby until someone comes to get you. Once in the appeal room, there will be a person typing notes of the appeal and recording everything that happens. You will sit at a table with a recording device in front of you. The 3 member panel will sit directly across from you.  It’s basically like court with 3 judges, it can be very intimidating so just mentally prepare yourself for that ahead of time and remember that YOU Practiced this, YOU Prepared, YOU know what you are talking about and YOU are injured. The only reason that you are there is because you innocently got injured while you were working and believe that a decision was made on your claim that was incorrect.

Once you have finished your appeal hearing, it will take approximately 21 days to grant a decision on your claim and each board member will have a say. The appeals commission will give you a docket number to type into the Canlii website so you can check and see if a decision has been rendered on your appeal. They will also mail you a copy of the decision report. A copy is also sent to your claim file.

Once you get your decision back and you have lost your appeal, read through it carefully to understand why. If the appeal issue was worded properly, and the applicable policies and legislation were applied, you have one of 4 options to proceed with this decision. These options are explained in the Practise Guideline I provided the link to above. If you notice on this list of options there’s the right to file a reconsideration application. Please read the guideline for this before proceeding. If you have an appeals advisor or consultant and you have lost main appeal, chances are you would lose the reconsideration. I lost mine! The following link will take you to the practise guideline about reconsidering appeals. https://www.appealscommission.ab.ca/Appeals%20Commission%20Publications/2017%20Practice%20Guidelines%20(20170215)/10.%20Practice%20Guideline%205-Reconsideration%20Package%20Including%20Application%20Form_Feb-15-2017%20(20170215).pdf

At this point I believe claimants need to file a complaint with the Alberta Ombudsman. You can have your claim file reviewed as well as the appeal. Alberta legislation has recently hired a new Ombudsman which was long overdue. In my opinion, the former one helped WCB with their injustices. You can find the information on how to proceed with filing a complaint to the Ombudsman under the Alberta Ombudsman tab on the top right.