Explanation of benefits

A worker asked the Commission for help when he did not receive a reply to his requests for an explanation of the amount of benefits he was receiving.

He had sent letters to the claims adjudicator in February and May. In June, he wrote to the manager, again with no response. He received a telephone message from someone at the WSIB saying the information he had requested would be sent to him. When another month passed and he did not receive the promised information, the worker contacted the Commission.

The Commission spoke to the manager, who was unaware that mail addressed to her was in the claim file. After reviewing the file, the manager told the Commission she agreed there were service delivery gaps, which she was in the process of addressing with the adjudicator.

The manager also:

  • called the worker to respond to the questions in his letter and apologize for the delay
  • confirmed that she would review the payment summary before it was sent to the worker to ensure that it answered the worker’s questions.

From the Commission’s perspective, this manager’s response exhibited fairness best practices.