Decision Making (POL-160)

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Chapter: 
CLAIMS

Subject: 
DECISION MAKING

Effective Date:
July 23. 2020

Last Updated: 
May 15, 2025

PURPOSE STATEMENT

This policy explains how the Workers Compensation Board makes decisions on claims.

REFERENCE

Workers Compensation Act R.S.P.E.I. 1988, Cap. W-7.1,Sec 6, 17, 32(3), 56(2), 59(1), 59(2), 59(3)

Workers Compensation Board Policy, POL-48, Internal Reconsideration

Workers Compensation Board Policy, POL-71, Conditions for Entitlement

Workers Compensation Board Policy, POL-87, Third Party Actions

Workers Compensation Board Policy, POL-90, Time Limit for Workers to File a Claim

DEFINITION

In this policy:

“New evidence” means information that is factual, new and relevant to a decision.

“Objective information” means information or evidence that can be quantified or measured.

“Person with a direct interest” related to a claim decision means the worker or dependants of the deceased worker, the accident employer where the decision has a direct financial, legal or operational impact on that employer, and the Workers Compensation Board.

“Subjective information” means opinions that are based on information that cannot be quantified or measured.

POLICY

  1. When a claim is filed for compensation, the Workers Compensation Board (WCB) has the legislated responsibility to make the decisions on the claim.
  2. The WCB makes its decisions based on the merits and justice of each case. In doing so, the WCB:
  • Gathers and considers sufficient relevant information to establish the facts and circumstances of the case. 
  • Applies relevant provisions of the Workers Compensation Act and Regulations.
  • Applies relevant WCB policies.
  1. The WCB is not bound to follow strict legal precedent when making decisions. This means that each matter is evaluated individually, and the outcome is not determined by previous decisions.

Gathering Information

  1. The WCB is required to gather sufficient information to make initial and ongoing decisions on the claim. Information is gathered throughout the duration of the claim as required and the WCB will determine when it has enough information to make a decision.
  2. Workers, employers and health care providers must provide the WCB with information related to the claim, but they are not required to prove or disprove a claim.
  3. If more information is required the WCB will work with the worker, employer, health care providers and other third parties, if applicable, to obtain sufficient information to make a decision.
  4. The WCB will make all reasonable attempts to gather sufficient information. If the attempts are not successful, the WCB must make a decision based on the information available.
  5. The WCB will analyse the information it gathers to determine whether it is evidence in the decision. To be considered evidence, the information must be reliably accurate and relevant to proving or disproving a fact in the decision.

Weighing Evidence

  1. The WCB will assess the evidence to determine the weight on either side of the issue. Weight is determined by the nature, credibility and quality of the evidence.
  2. Evidence that is factual and objective has greater weight than evidence based on subjective information.
  3. If there is conflicting evidence, the WCB will analyse and give weight to the evidence by considering the following:
  • Whether the evidence is based on objective versus subjective information. 
  • The accuracy, completeness and source of the information relied upon in the evidence. 
  • The timeliness and comprehensiveness of the evidence. 
  • The relevant expertise or degree of specialization of the person providing the evidence.
  • The relevance and credibility of any research referenced in the evidence. 
  • Any issues of bias or lack of objectivity by the person providing the evidence.
  1. The WCB will assess and weigh the evidence and base the decision on the balance of probabilities – a degree of proof which is more probable than not.

Benefit of Doubt

  1. If, after all of the evidence is weighed, the evidence for or against the issue is approximately equal in weight, the benefit of doubt will apply. This means that the decision will be made in favour of the claimant.
  2. The benefit of doubt is not used to make decisions:
  • When the decision can be made on the balance of probabilities.
  • As a substitute for lack of evidence.
  • Based on specific pieces of evidence without considering all of the evidence.
  • In a purely speculative sense.

Application of Legislation and Policy

  1. The WCB will apply the relevant provisions of the Workers Compensation Act and Regulations, as well as other applicable legislation, to the evidence to make a decision on the claim. All decisions must be in accordance with the legislation.
  2. The WCB will also apply the relevant WCB policies to the evidence to make a decision. To be considered relevant, the policy must relate to the issue being decided and be in place at the time of the decision.
  3. The factors that are considered to make decisions about entitlement to workers compensation benefits are explained in WCB policy, POL-71, Conditions for Entitlement.

Exceptional Circumstances

  1. There may be rare or exceptional circumstances where:
  • No policy exists that is applicable to the facts of the case.
  • Existing policy does not sufficiently cover the particular case.
  • Application of the policy would lead to a result that was unreasonable that the Act or the WCB never intended.
  1. In these situations, the decision will be made on its own particular facts, in accordance with the general provisions of the Act and the merits and justice of each case. In all cases, the WCB will clearly identify the exceptional circumstance and explain why policy is not applicable.

Communicating Decisions

  1. The WCB will explain the reasons for the decision, including the application of legislation and policies used in the decision making process. The WCB will also clarify the significance of the evidence used to make the decision.

Reconsiderations

  1. The WCB may reconsider previous decisions at the request of a person with a direct interest as set out in WCB policy, POL-48, Internal Reconsideration.

New Evidence

  1. If new information becomes available after a decision is made, the WCB will consider whether it is new evidence and, if so, whether the decision should be changed or reversed.
  2. Any information received will be reviewed to determine if further action is required.
  3. To be considered new evidence, the information must meet two basic criteria:
  • It is credible and relevant to the issue in question. 
  • It provides information not previously considered by the decision maker that could affect the outcome of the decision.
  1. If information is determined to be new evidence, the WCB will consider the new evidence and review the relevant decision.
  • If the new evidence changes the balance of probabilities, the decision will be changed or reversed.
  • If the new evidence does not change the balance of probabilities, the decision will not change.

Exceptions to the Consideration of New Evidence

  1. The WCB is unable to consider new evidence to change or reverse the following types of decisions:
  1. The WCB may refuse to consider a request to change or reverse a decision if the request is frivolous, vexatious or an abuse of process, or the decision is more than 20 years old.

New Evidence and Internal Reconsideration

  1. If a decision is under internal reconsideration – the first level of appeal – and information is submitted that was not on file at the time of the decision, the Internal Reconsideration Officer (IRO) will determine whether the information is new evidence.
  2. If it is determined to be new evidence, the IRO will consider the new evidence when making an internal reconsideration decision.
  3. If it is not new evidence, the information will not be considered in the internal reconsideration and the person who submitted the information will be advised in writing.

  4. If new information is submitted to the WCB after the internal reconsideration decision has been made, the IRO will determine if it is new evidence.

    If information is determined to be new evidence, the IRO will consider the new evidence and review the relevant IRO decision, as set out in this policy.

New Evidence and the Workers Compensation Appeal Tribunal

  1. If a decision is under appeal to the Workers Compensation Appeal Tribunal (WCAT) and WCAT receives new information at a hearing that may be new evidence, the matter will be referred back to the IRO to be considered under this policy.
  2. The IRO decision about whether the new information is considered new evidence can be appealed at WCAT. If WCAT determines that the new information is new evidence, they can apply the new evidence to the original matter under appeal.

HISTORY

May 15, 2025 – Amended to reflect new process for reviewing new evidence; addition of exceptional circumstance clause for situations not covered under current WCB policy.

December 10, 2020 - Non-substantive changes to reflect revised definitions in policy, POL-48, Internal Reconsideration.

Board of Director Approval Date: July 23, 2020.

This policy incorporates amended content from – and replaces – WCB policies POL-62, Benefit of Doubt, POL-68, Weighing of Evidence, and POL-83, New Evidence.