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OFFICE OF THE OMBUDSMAN

Injured while working for a Self Insured Employer?   You may feel like you just joined the circus and are one of the animals forced to jump through flaming hoops of fire just to get your Workers Compensation benefits.

The state legislature agreed in 2007 that injured workers of Self Insured employers needed a safety net to protect them while walking the tight rope between their employer, the third party administrator and the Self Insurance Section Department of Labor and Industries.  This is how the Office of the Ombudsman for Self Insured Injured Workers (OSIIW) came to be.

Any of these three ring circus acts sound like you could be the performer?

ACT 1-
An injured worker becomes homeless with her children because she had not been paid time loss for almost a year.  Her long-term attending physician certified she could not work at her job of injury, she even had a second orthopedic specialist confirm she was unable to work, but the Claims Manager for the Self Insured employer choose to ignore these medical opinions. Instead they stopped paying her time loss benefits based on the two independent medical exams which the employer choose. 

ACT 2-
An injured worker is schedule for his fourth Independent Medical Evaluation by his employer’s claims manager.  He fell off a ladder and injured his knee.  Two of the prior IME opinions supported his claim together with his own physician, but one IME doctor disagreed so the claims manager scheduled a fourth exam.  Clearly the employer was not going to stop getting medical examinations until they had what they wanted, so they could deny his benefits.

ACT 3-
An injured worker is told by his doctor that he is being scheduled for surgery for his industrial injury.  The worker receives notice from his doctor that the surgery must be cancelled because they had not received authorization from the employer’s claims manager.  Injured worker calls the claims manager to ask what he needs to do to get his surgery authorized and receives no response, no explanation or return calls.

These are real cases investigated and resolved by the Ombudsman’s office.

Injured workers of Self Insured employers can seek help from the Office of the Ombudsman at anytime during their claim.  The Ombudsman can provide injured workers with many resources to address claims discrimination, claims suppression, unnecessary IME’s, delayed time loss payments and denied medical treatment.  

The Ombudsman can act as the ring master in this Workers Compensation circus to make sure everyone is performing properly, and to insure that benefits are paid to the injured worker without their having to jump through flaming hoops. 

Getting the Self Insured employer and their third party administrators to do the right thing is not easy.     The  2015 Ombudsman’s report showed through their investigations, Self Insured Employers only do the right thing a little over 1/3 of the time.  What happens to the other 2/3rds of workers seeking help from the Ombudsman: 22% of the claims investigated by the Office of the Ombudsman were resolved directly with the Self Insured Employer. However over 32% of the investigations required the Self Insured Section of the Department of Labor and Industries to intervene and order the employer to pay the benefits owed.

The office of the Ombudsman needs to hear from you if you have problems when dealing with these large self insured employers.  They need you to report problems with the claims management companies hired by the employer so they can work directly with the employer and their third party claims administrators to resolve the issues delaying proper payment of benefits.

Sometimes a knowledgeable advocate is all you need to push the Self Insured Employer to do the right thing and authorize your benefits.  Through the ombudsman, self-insured workers have access to  knowledgeable and effective advocates who are able to work in partnership with self-insured personnel. The Ombudsman’s office is there to help you, the worker receive appropriate benefits under the law.

The Ombudsman can be reached here, Office of the Ombudsman, or by calling 888-317-0493

More Information about Self Insured Employers is available here.

Whats Next? 

The Players
L&I Basics
Time Loss Benefits
Contact Us, Do I have a Case