INTERVIEW QUESTIONS - WORKERS' COMPENSATION COMPENSATION SERVICES ISSUES JURISDICTION: NOVA SCOTIA I. COMPENSATION SERVICES ISSUES

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1 INTERVIEW QUESTIONS - WORKERS' COMPENSATION COMPENSATION SERVICES ISSUES JURISDICTION: NOVA SCOTIA I. COMPENSATION SERVICES ISSUES 1. Is there a requirement, statutory or otherwise, requiring the regular review and potential readjustment of the rate of temporary wage loss benefit paid to an injured worker? If yes, what is the basis for adjusting the temporary wage loss benefit (i.e., a different basis for calculating the rate; a change in circumstances or level of disability)? And, are there any statistics or data regarding how often the rate is adjusted down or up? At 12 weeks the rate of Temporary Earnings Replacement Benefit (TERB) is reviewed. The basis for the review is to establish a more accurate calculation of the annual net earnings of the worker. For the first 12 weeks of benefits, the worker receives TERB on the basis of their earnings in the four weeks prior to the injury. After 12 weeks, a long-term earnings profile is established and the rate of TERB adjusted. [Policy ] At 26 weeks, the rate of earnings replacement (temporary or extended) moves from 75 percent to 85 percent of loss of earnings. It is estimated that less than three percent of claims exceed 26 weeks. 2. Are permanent disability awards, both partial and total, subject to review and readjustment? For example, is there a requirement, statutory or otherwise, requiring the regular review and potential readjustment of the rate of permanent disability award? If yes, what is the basis for adjusting the award (i.e., a different basis for calculating the rate; a change in circumstances or level of disability)? And, are there any statistics or data regarding how often the rate is adjusted down or up? Permanent benefits include a blended award: an Extended Earnings Replacement Benefit (EERB) and a Permanent Impairment Benefit. EERB is the difference between pre- and post-accident earnings actual or estimated. No EERB is paid if the economic loss is not greater than the Permanent Impairment Benefit (PIB) rate. A PIB is paid for life (though may be paid in a lump sum). The PIB calculation is: 30% multiplied by the Permanent Medical Impairment Rating, multiplied by 85% of preaccident net earnings. 8/18/98 Page 1

2 The PIB rate is reviewed a 16 months and subject to readjustment based on the Permanent Medical Impairment rating. The PIB is then only reviewed again if there is a reported change in the claimant's condition; however the rate will only be adjusted if there is a change in impairment of 10% or more. 3. Is there any prohibition in the workers' compensation legislation in your jurisdiction against topping up (i.e. purchasing private disability insurance which provides income in addition to workers' compensation payment?) Yes. A ceiling or top up form an employer (or employer funded source) is equal to 85 percent of the worker's net actual pre-injury earnings. This is being phased in and topping up is permitted if specifically provided for in a collective agreement that has not yet expired and was in effect when the new legislation was passed. 4. What factors, if any, other than earnings, are used to determine workers' compensation benefits (for example what impact does age, marital status, number of dependents, retirement, education and training have on the calculation of benefits)? None. [At age 65, EERB is replaced by an annuity equal to 5% of the total EERB. PIB is payable for life.] 5. Is deeming used in either 1) setting the duration of temporary benefits or 2) as the basis for calculating permanent disability awards (where "deeming" means deeming a worker ready to return to work, and/or as capable of earning income at a particular income level, though the worker may not have actually returned to work or may be earning income at a lower level)? And if yes, what are the prerequisites for applying deeming? And, are there any statistics or data regarding the frequency with which deeming is used? Yes deeming is used for calculating permanent impairment benefits. When setting the rate of PIB the board uses medical information to determine whether the claimant is physically able to work. Based on this assessment, the claimant's EERB amount is based in part on the claimant's estimated potential earnings ability (EPEA) -- what they are considered capable of earning. The estimated work must be reasonably available to a worker. EPEA is calculated by the claimant's rehabilitation counselor. 3/3/99 Page 2

3 6. Does the jurisdiction have an electronic claim files system in place? When was it introduced? What are the perceived advantages and disadvantages of electronic claims files? No imaging or electronic file management system is in place in Nova Scotia (except for a computerized payment system). 7. Have any research or studies been undertaken on the adequacy of benefits provided by the jurisdiction? Any research or studies on the issue of equity of benefits? Are these studies available to the Royal Commission? No studies have been undertaken to date. However, it is recognized that, particularly under the former legislation, there are some inequities in the benefit framework which was based on clinical rating only. A tri-partite committee has recently been struck to review the legislation and the Auditor General is to undertaken a systems review of the workers' compensation system n the 1998/99 fiscal year. 8. Claims Statistics: In 1996: 30,671 claims registered 7,995 compensable time loss about 89% less than 12 weeks; 11% less than 26 weeks; and only 3% of claims greater than 26 weeks. Breakdown of Total Claims Cost in 1996 (of total of $99 million): 50.9% long-term 27.3% short-term 5.1% survivor benefits 2.5% rehabilitation costs 14.0% health care costs II. ADJUDICATION 1. How would you describe the basic approach to adjudication in your jurisdiction (for example, inquiry based approach or adversarial)? Nova Scotia's approach to adjudication is based on early intervention and treatment. 3/3/99 Page 3

4 2. In your jurisdiction is the function of adjudicators, at the first stage, similar to an insurance adjuster? At in-take the claim is assessed and streamed into different processes (triaged). If the claim is medical only it is dealt with in a straightforward fashion by front-line staff; if the claim involves time loss is immediately assigned to one of the regional units. Adjudicators manage time loss claims of less than 12 weeks; if the claim is considered to be more serious it will be assigned directly to a case manager. 3. If new evidence is presented on a particular claim, is the claim sent back to the adjudicator for reconsideration? When new evidence is presented it is considered by the final decision maker, or the decision maker of record. 4. Are board policies binding on adjudicators? To what extent are adjudicators entitled to exercise discretion? Is discretion applied by an initial claims adjudicator reviewable? Board policy is binding on adjudicators and case managers, but adjudicators and case managers may use their discretion in arriving at a determination because board policy in some instances is written as a guideline for the decision maker. This discretion is subject to review. What, if any, mechanisms are in place to promote consistency in decision making? Adjudication Advisers perform a quality assurance function at the board. There is an Adjudication Adviser in each region who is available to decision makers to discuss issues and decisions. 5. Do workers and employers have access to their information in board files? If yes, is this because of a provision in the workers' compensation legislation or a result of the Freedom of Information and Protection of Privacy Act? Is further information found in sub-files which do not form part of the claim file? And if so, are the sub-files disclosed? Is relevancy of material in a board file a prerequisite to its disclosure to the affected worker or employer? If so, who determines whether the information is relevant and on what basis? Does the worker or employer have the right to object to the relevancy of the information after it has been disclosed? Workers have complete access to their claim file. An employer has complete access to their corporate file. 3/3/99 Page 4

5 An employer only has access to their worker's file if there is a decision under review or appeal and then is only provided with information under that file that relates to the issue under appeal. 6. Is there any informal review process for workers and employers regarding claims adjudication or assessment decisions (i.e. review by supervisor or manager prior to the formal internal reconsideration or review process and external appeal process, if any)? If yes, are there any statistics available on the total number of issues reviewed and the allow/disallow rate for this informal review process (are there any statistics kept on the number of issues reviewed, and the allow/disallow rate broken down by type of issue for example, assessment decisions, compensability, level of benefits)? There is an internal reconsideration process. All negative decisions must be reviewed by the decision maker of record. As result of these process about 95% of issues reconsidered are denied and about 5% accepted (95% of reconsiderations are dealt with in under 30 days). 7. Is there a formal "complaints" review process in your jurisdiction, distinct form any internal review or external appeals process, to deal with complaints from clients of the board regarding the conduct of board officers and staff or service issues? If yes, is this process independent of the board? There is no independent complaints process. However there is an established internal process for dealing with complaints under the quality assurance area. 3/3/99 Page 5