Many employers in Washington State pay workers’ compensation insurance premiums to the Department of Labor and Industries (or L&I in short). Washington State supports and backs L&I. However, some employers choose to go with private workers’ compensation insurance provider. Such an employer is referred to as a self-insured employer.
Who manages self-insured workers’ compensation claims?
If you were injured at work or developed an occupational disease while working for a self-insured employer, then your claim is administered by a third-party. However, L&I still oversees the entire claim administration process. L&I often uses administrative codes to help its employees govern and oversee self-insured claims.
New rules help L&I oversee workers’ compensation claims
Effective today, July 1, 2019, the administration code WAC 296-15-425 governs self-insurer communication standards. What does that mean? It means that under this WAC code, self-insurers are now required to communicate with injured workers about certain decisions in writing using L&I templates.
Self-insurers must use L&I templates to communicate with injured workers within 5 days of taking action to:
1. Calculate an injured workers wage rate (form F207-227-000);
2. Start, stop or deny compensation benefits (form F207-224-000 and form F207-225-000);
3. Accept or deny a contended condition (form F207-220-000 and form F207-221-000);
4. Authorize or deny treatment (form F207-226-000); and/or
5. Assess an underpayment or overpayment of benefits (form F207-223-000 and form F207-222-000).
Why is this important? Is it good for injured workers?
This step is incredibly helpful because templates are designed to ensure timely and accurate delivery of claim decisions. The templates also promote efficient claim processing to protect injured workers and streamline L&I’s regulatory oversight. The templates inform injured workers of the action being taken and provide them with information about their right to dispute decisions. If an injured worker disputes a self-insurer decision within 60 days, L&I will intervene and issue an order to resolve the dispute. However, the Department’s decision may always be appealed to the Board of Industrial Insurance Appeals (BIIA) if either party disagrees with it.
If a self-insurer makes a decision and there is no dispute, then L&I will not intervene. While WAC 296-15-425 changes the process for how self-insurers communicate with injured workers, it does not change the reactionary process for injured workers. Just like any claim-related decision, it is important for injured workers to review claim decisions carefully. After that, it is extremely important to dispute any decision with which they do not agree in a timely manner.
My employer is apparently self-insured and was direct depositing my time loss check without my knowing it. At same time I was receiving time loss from L&I. Now 3 months later I realized that employer was paying me and I ask them why and they said only that they were required to. Shouldn’t I have been notified by employer that they were going to be paying me not L&I?
You should have been, however these mistakes happen all the time. I’m sorry to hear about your situation.
My employer is self insured and I have been receiving regular payments from Sedgwick since my surgery. This month my health insurance was canceled because my employer won’t send in the paperwork to allow the medical insurer to waive work hour requirements and today I was told I have to fill out Leave of Absence paperwork. I don’t understand what is going on.
Hi Terrie. There’s no easy answer to this question. Please call our office and set up a free consultation and we can go over the details. It’ll help us understand what is going on and provide some advice.
tuve una lesión laboral y se me de tuvieron los beneficios de la seguranza sedgwin y estoy en tratamiento médico mi teléfono [removed]
I work for a self insured employer. I had two Independent medical examinations and my employer didn’t like their reports so they hired a third IME that would give them the report they wanted but the letter they sent me didn’t say what the IME appointment was for and I was told that is illegal. I have called the ombudsman’s office but they never answer. I need just this question clarified please.
It is hard to say without more information. It depends on the timing of the IMEs and contents of notices. If you feel it is improper, you can always file a complaint with the L&I claim manager overseeing your self insured employer’s third party administration.