Managing Mental Distress Claims

“The reality of workplace stress is with all of us—at all times,” said Rhonda Shirreff, a labour and employment lawyer with Heenan Blaikie, speaking today at the firm’s 2011 Labour & Employment Seminar Managing Claims and Controlling Costs with the WSIB.

Stress is evident as employers place more demands on employees at work—and at home, thanks to smartphones. More often, stressed employees are turning to Ontario’s Workplace Safety and Insurance Board (WSIB), Shirreff said, to see if they can make a connection with stress and work, and claim benefits. Disability arising from stress is difficult to measure objectively. But the Workplace Safety Insurance Act (WSIA) explicitly addresses entitlement to work-related stress. Under Section 13(4) and (5) of the WSIA, an employee is entitled to benefits for mental stress caused by the following:

• an acute emotional response (a significant or severe reaction that results in a psychiatric or psychological response, which can be immediate or delayed);
• a sudden and unexpected traumatic event (under the WSIB’s policy, a “sudden and unexpected traumatic event” must be clearly and precisely identifiable, objectively traumatic and unexpected in the normal course of a worker’s employment or work environment—for example, witnessing a fatality at work, being the object of death threats or physical violence); and
• a reaction arising out of, and in the course of, the employee’s employment. 

However, there is no entitlement for mental stress related to general workplace conditions or arising from decisions made in the daily life of an organization (such as demotion, discipline, changes in productivity expectations, terminations).

But the Workplace Safety and Insurance Appeals Tribunal is taking a more liberal approach to work-related stress claims, Shirreff said. This is particularly notable in cases of harassment—for example, intimidation by co-workers, outbursts by management (bullying boss) or overzealous scrutiny by supervisors. The scope of claims allowed for mental stress is broadening, so employers need to be vigilant.

Be aware of potential mental stress triggers. “You want respectful behaviour in the workplace from everyone— even the owner,” said Shirreff.

Listen to and address workers’ concerns with interest. “Take all complaints seriously.”

Look for ways to improve employee well-being. “Many employers have EAP systems in place and on-site wellness programs.”

Be proactive and be prepared. 

“It’s law and policy, and it’s a very broad interpretation of this.”

Shirreff left the audience with a good piece of advice: “Head off these claims before you ever get them.”

Like Science, Dental Care is Always Evolving

Today, the “new normal” for benefits plan sponsors means trying to keep up with the rapid pace of research and development in dental healthcare while simultaneously making sure cost containment remains paramount. The goal for plan sponsors is to provide appropriate and relevant coverage for their members. But with new and exciting dental innovations coming down the pipeline, it can seem impossible to keep on top of what’s hot and what’s not and—more importantly—what should and shouldn’t be covered under your dental plan. More than ever before, plan sponsors need to rely on the experts for help regarding the latest developments in the dental world through open and ongoing dialogue. 

Appropriate, relevant dental 

There is a lot of buzz these days concerning new visualization aids for oral cancer screening known as adjunctive screening aids. Through innovative use of light, these aids are meant to enhance the type of hands-on oral cancer screening that the dentist already does during both initial and recall examinations, using sight and touch to look and feel for abnormalities. 

Some of the aids use what is known as reflectance. This works by having the patient rinse with a mouth solution; the dentist then uses a special type of glow stick light to examine the mouth. Normal healthy tissue appears dark, whereas abnormal tissue appears white. Other types of aids use what is known as auto-fluorescence by shining a special light into the patient’s mouth. In this case, normal healthy tissue appears green and abnormal tissue appears darker. 

Another development receiving attention is the use of locally delivered antimicrobial agents (LDAs)—also referred to as periodontal antibiotics— to complement scaling and root planing to prevent gum disease. Gum disease, or periodontal disease, can result in tooth loss when plaque and tartar build up around the tooth creating “gum pockets”—gaps between the tooth and gums. The deeper gum pockets become, the greater the chance of gum recession and bone loss, eventually resulting in tooth loss. 

LDAs make it possible to target individual pockets because the treatment is placed inside the infected pocket in powder form just after scaling and root planing. LDAs kill the bacteria associated with gum disease, possibly reducing the depth of the gum pocket and helping to prevent further deterioration. 

Advances such as these may hold promise and therefore warrant coverage. Or, further study may be needed before it can be determined whether the investment makes sense. It’s the responsibility of your health benefits provider and plan advisor to be “in the know” and, in turn, to pass this knowledge on to you, the plan sponsor, in the form of recommendations for coverage. “In the know” is a lot more than just being aware of trends. It also means assessing any potentially beneficial innovations using established scientific evidence on a caseby-case basis. 

In terms of the above The Insurance Insider Page 2 Like Science, Dental Care is Always Evolving Like Science, Dental Care is Always Evolving examples, a dental consultant might suggest that existing scientific evidence does not yet confirm the usefulness of visualization aids in oral cancer screening. Likewise, traditionally, gum disease is prevented and treated through a combination of self-care by regular brushing and flossing, as well as professional dental care through regular scaling and root planing. This raises an important question: Do LDAs offer significant clinical gains in terms of preventing tooth loss from gum disease? 

The beauty of science is that it is always moving forward—and knowledge is cumulative. As a result, although some of today’s dental trends may not quite be there yet in terms of warranting coverage, the future may unfold to tell a different story. As scientific evidence builds, what is deemed not deserving of coverage today may evolve into coverage worthy treatment tomorrow. To keep pace with today and tomorrow, your best bet is to rely on the experts to provide evidence-based recommendations for evidence based care. – Dr. Edward Zieba March 11, 2011

Employers Around The World And The Sharing Of Benefit Costs With Employees

Employers in Europe and the U.S. remain fair to their employees and avoid shifting costs—despite a sharp increase in healthcare costs and health-related benefits, according to Mercer’s 2010 pan-European survey on employee health benefits. 

The survey, conducted in 14 European countries with responses from 556 employers, revealed that the cost of providing healthcare and health related benefits to employees in Europe rose by 3.3% in 2010. For the same period, average health benefits cost per employee in the U.K. and the U.S. rose 4.9% and 6.9% respectively. Germany and the Czech Republic reported the lowest cost increases of 1.7% and 1.8%, respectively. 

Health benefits include private medical plans and a range of other healthrelated benefits, including income support, critical illness coverage, employee assistance programs, dental and optical benefits, health screening, gym membership, and wellness programs. 

“Despite the increases,” said Steve Clements, partner at Mercer, “our survey found that most employers remain unwilling to restrict eligibility or the scope of coverage or to shift more costs to employees. To keep costs down they are generally focusing on measures that don’t directly affect the employee, such as insurer negotiations and improved plan management and monitoring.” 

The reason behind reluctance to pass on this cost to employees is, most importantly, the attraction and retention of talent. 

“The ability to differentiate your company in the marketplace by providing staff and their family with good benefits is crucial, especially at a time when flexibility on salaries is restricted,” said Clements. “Companies are also aware that a healthy workforce is a productive workforce, so cutting back on this benefit may be counterproductive in the long term. It’s in their interests to give their staff good medical coverage.” 

Cost pressures

Cost pressures Governments are shifting the cost of healthcare to employers and individuals in the form of tighter tax deductions, reduced scope of public healthcare services, privatizations, higher cost sharing and eligibility restrictions or opting-out schemes. And, employers are under pressure from employees and trade unions to improve health benefits, he adds. 

The survey showed that private medical plans, which include both mandated and voluntary supplemental plans, are offered by nearly all respondents (93%) from countries with government model health systems, including Ireland, the U.K., Portugal, Spain and Italy. 

In contrast, private medical coverage is offered by only 74% of respondents in social insurance model countries, such as Austria, Czech Republic, France, Germany, Poland, Switzerland and the Netherlands. 

Employers operating under government health systems reported slightly higher increases, averaging 3.7%, in the peremployee cost of all health-related benefits, compared to those operating under social insurance models, with an average of 2.9%. 

What’s important to employers

Nearly two-thirds of respondents (63%) rated managing employee health risks as a “very important” or “important” objective in the provision health benefits. More than half (53%) cited improving productivity as an “important” or “very important” objective. Respondents from countries with stronger national health systems, such as Germany and the Netherlands, were more likely to place improved productivity above retention, because company-provided benefits are perceived as less vital in countries with better healthcare. 

“In almost every country, employers see opportunities in investing in benefit plans,” said Clements. “This is especially evident in national systems that already exhibit such shortcomings as long queues, poor accessibility, lack of medical staff, higher fees and perceived quality issues. Investments in benefit plans are still tax efficient for both the company and individuals and helps attract and retain talented employees. The challenge is to achieve a return on investment through improved productivity while still keeping benefit costs under control.”