L&I Claims are Either State Fund or Self Insured
- L&I claim administrative management come in two varieties. State Fund and Self Insured.
- State fund claims are managed by L&I.
- Self Insured claims are managed by the self insurer, with oversight by the L&I Self Insurance Section.
- In theory both types of claims should be handled the same. However it doesn’t work that way.
Self Insured Employers- May Not Be Fair
Employers with sufficient assets can self insure their L&I claims. These self insured employers manage their L&I claims in house or with the help of a service company. Employers self insure to save money. One way they save money is by not paying it to injured workers. If you have a self insured claim and a serious injury, you are already at a disadvantage.
L&I Self Insured Section – Should be There To Help You
It is the job of L&I’s self insured section to oversee self insurers and make sure that they are following the law. However L&I is too busy to look at every self-insured decision. As a result self insured employers often do bad things knowing that L&I is not looking. If you should get a bad decision do something. If you don’t complain, protest or appeal, then they get away with their unfair claims management.
What You Can Do if the Self Insured is Unfair – Self Insured Complaints
Don’t put up with bad treatment from your claims manager.
If you don’t like how your self insured employer is handling your claim, you need to take action. Become involved, get vocal, do something! Don’t let your self insured employer push you around. Here is what you can do:
- Talk to your self insured claims manager. This is your employer’s HR department or a service company such as Sedgwick, Gallagher Bassett, Pinnacle Risk Management, Eberle Vivian, Penser North America or Matrix. Ask them for an explanation of what they are doing. Tell them what you think. If they are wrong then tell them so and ask for what you want.
- Communicate with the L&I Self Insured Section about your self insured employers behavior. This is L&I. You have a claims manager at L&I, in the self insured section. It is the job of the L&I self insurance section to help you if you are being unfairly treated by your employer and their claims manager.
• Call them at 360-902-6901. Encourage them to do their job and help you with your claim.
- L&I Audit. If your self insured employer is completely despicable and has repeatedly denied your access to the benefits you deserve then you can also ask for an L&I audit of your employer’s compliance with self insured employer requirements.
- Talk with an L&I lawyer. If you want someone else to do the dirty work for you, talk to a lawyer. We eat self insureds for breakfast. L&I Lawyer.
Washington L&I Penalties to the Self Insured Employer
Self Insured Employers Must Follow the Law
Some employers are self-insured and manage their own workers compensation claims.
They choose to self insure because they wish to save money. Some self insurers will try to save money by not paying it to you. Don’t let them do this to you. Stand up for your rights and insist the self insurer treat you fairly. If they will not treat you fairly than request a penalty.
Penalties and the amount of the penalty for refusing to pay or delaying benefits are authorized by RCW 51.48.017. This law assesses a penalty of the greater of $500 or 25% of the amount due. Payment is to the injured worker.
Penalties are for Unreasonable Delay Paying Benefits
These self-insured employers are required to pay workers compensation benefits on time. If the self insured employer delays benefits they can be penalized.
The department of Labor and Industries will consider assessing a penalty for unreasonable delay of benefits under the guidelines of WAC 296-15-266.
Delayed benefits subject to penalty include time loss, loss of earning power, coverage of medical conditions, payment of medical bills, authorization of emergency medical care and permanent partial disability.
It is Difficult to Get L&I to Order a Penalty.
Unfortunately in their administrative regulations, L&I allows the Self Insured employers to get away with delayed payment if there is any legal or medical doubt that payment is due. Said another way, if the self insured gets a bogus IME it is difficult to get a penalty. This isn’t right. The opinion of the attending doctor should prevail. See: Clark County v McManus
Penalties which can be assessed against Self Insured employers for certain prescribed conduct:
Some penalties are payable to the injured worker, others to L&I.
- Unreasonable delay: RCW 51.48.017; WAC 296-15-266
- Failure to comply with a CRSSA: RCW 51.04.063
- Failure to conspicuously post required information: RCW 51.14.100(1)
- Failure to keep and or furnish compensation records: RCW 51.14.110
- Failure to timely provide the claims file: RCW51.14.120(1); WAC 296-15-420(7)
- Failure to timely notify L&I: RCW 51.14.120(2); WAC 296-15-480; WAC 296-15-420(1)
- Failure to submit a medical report of closure: RCW 51.14.120(3)
- Failure to timely act on a filed claim: RCW 51.14.130; WAC 296-15-350
- Failure to keep and allow inspection of payroll records: RCW 51.48.040
- Failure to follow L&I rules RCW 51.48.08
How to Make a Penalty Request
A penalty request is made by sending a written request to Labor and Industries. The director of L&I is required to issue an order within 30 days of your request. Some penalties are payable to the injured worker and some are payable to L&I.
Frequently asked questions about self insured penalties and more insight about how a court, the Board of Industrial Insurance Appeals, looks at penalties see : Penalties (RCW 51.48.17)
Ombudsman for Self Insured L&I Claims. Who are they?
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.
Getting the Self Insured employer and their third party administrators to do the right thing is not easy. The Ombudsman’s knows this and is there to help you. It is their job to get involved and to make Self Insured Employers do the right thing.
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