The Industrial Insurance Act governs every workers’ compensation claim in Washington State. This act provides benefits to workers and their dependents for disabilities or death after a work injury or occupational disease. Therefore, every L&I claim or self-insured employer claim must follow this law.
The Department of Labor and Industries (L&I) is a Washington State agency. The agency is responsible for administering all L&I claims under the act. With every work injury claim, L&I must decide which claim benefits are appropriate. Benefits include medical treatment, monetary compensation, vocational services, and more.
For payments, there are two sources of funding. The first is the Accident Fund. L&I manages this fund directly. The money in the fund comes from workers’ compensation insurance premium that Washington State collects from employers and employees. Then, there’s also private insurance for self-insured companies. If you work for a self-insured employer, then benefit payments come from your employer and their insurance company. Not sure if your employer is self-insured? You can find all self-insured employers on the L&I website.
What is a self-insured claim?
L&I qualifies and certifies employers to become self-insured. Employers wanting to be self-insured must apply with L&I. In fact, the qualification requirements are significant. Therefore, it doesn’t make sense for all employers in Washington State to become self-insured. Overall, self-insured employers have long term obligations. They must pay benefits for the lifetime of their workers’ claims. Moreover, this obligation remains the employer’s responsibility even after they surrender their self-insurance certification.
What is a third-party administrator or TPA?
Self-insured employers may elect to manage their own workmen’s compensation claims. Alternatively, they can have a third-party administrator (TPA) manage their claims. Most self-insured employers utilize TPA companies to manage workers’ comp claims. Every TPA in Washington State must carry a license from L&I. For that, to receive the license, a TPA must follow the requirements below:
1) Have a current Washington State business license
2) Demonstrate they meet the WAC 296-15-350 requirements for handling claims
3) Comply with reporting requirements under the Industrial Insurance Act
4) Complete and submit an application to L&I
5) Provide a list of employers with whom the TPA is contracted
6) Submit a list of certified claim administrators working for the TPA
7) Provide a list of claim administrators in the process of obtaining their WAC 296-15-360 certification.
TPA licensing and reporting requirements
Once licensed, every TPA must still submit an annual renewal application. Furthermore, they must update all information concerning employers they serve, as well as claims administrators that they employ. Any person making claim decisions must be a certified claims administrator. This is described in WAC 296-15-350. Moreover, to obtain certification you must participation in a 72 hour series of courses.
These courses cover:
i. Claim validity
ii. Medical management
iii. Compensation management, and
iv. Work disability prevention.
The course includes basic, intermediate, and advanced learning in each subject area. Once certified, claim managers must participate in continuing education, in three-year reporting cycles.
Work injury while working for a self-insured employer
Self-insured employers have many obligations to the state. However, despite these obligations, the TPA requirements, and claim manager qualifications, self-insured claims are often complicated. They are also very frustrating for the injured worker. For example, unlike L&I claims, the details and history for self-insured claims are not available online. Therefore, it can be very difficult to keep up with developments in the claim.
Self-insured employers and their TPA frequently hire or consult with attorneys. They do so regularly during the claim administration process. Hence, claims can progress very slowly and take a long time. Work injury claimants are often left in the dark about the progress of their claim. Many don’t really know what is happening in their claim. If that’s your case, then it’s probably a good idea to talk to a workers’ compensation attorney.