If you have a Washington Labor & Industries claim, you may be wondering who exactly is managing your claim. Here’s a brief roadmap.
The majority of workers compensation claims in this state are insured by and handled by the Department of Labor & Industries. (L&I) This is the state agency which oversees all workers compensation claims, health and safety issues, and wage compliance issues. We call these State Fund employers. Your claim is being managed by a claims manager at the Department’s main location in Tumwater. You may have several claims managers over the life of your claim. Don’t take it personally. Claims which are more complicated are transferred to more experienced adjudicators. Claims managers may leave or be promoted, with someone else taking over their existing case load.
Some employers in this state are self-insured (SIE) These employers cover their own workers compensation costs and manage claims themselves. But remember, they must follow the same law, and you are entitled to the same benefits. Some of this state’s larger employers are self-insured; Boeing, Alaska Airlines, Costco and Weyerhaeuser come to mind. School Districts, some grocery stores, cities and municipalities are also self-insured. If your employer is self-insured your claim is being managed, in most cases, by a private third-party administrative.(TPA) Your claims manger will work for a company like Puget Sound Workers Compensation Trust, Broadspire or Sedgwick. The claims manager will likely have a closer working relationship with your employer then you might see with a State Fund employer. This may be helpful if you are dealing with early return to work efforts. Although your self-insured claim is managed by a private TPA, the Department of Labor & Industries still has authority to assist in resolving disputes or working out wrinkles. While the SIE has authority to issue some types of orders on your claim, on many issues the SIE has to provide documentation to the Department and request an order to be issued. You can always contact the self-insured section at L&I if you are having a problem with the claims manager from the TPA.
A growing number of employers in this state are what we call Retrospective Rated Employers, or Retro employers. These are still State Fund employers, they are not self-insured. Your claim is still managed by a claims manger with the Department in Tumwater. But this is where it gets interesting. These Retro employers receive significant refunds if they keep their claim costs below some set measurement. (Don’t ask me to explain the formula. I listened to an actuary try to explain it once, and my eyes glazed over . . ) Because these employers have an interest in keeping claim costs down they often hire ‘shadow’ claims managers. These are also third-party administrators (TPA) except these shadow TPA’s do not have the actual authority to make decisions about your claim. They represent the employer and may be aggressive in contacting your claims manager and pushing them into taking certain action. The State Fund CM is still responsible for management of the claim, but the Retro TPA is acting as an advocate for the employer, encouraging the CM to terminate TL and close the claim in a timely manner. In many ways, these Retro TPA’s are doing the exact opposite of the work being done by your attorney, if you have one. If the TPA is being overly aggressive, it may be time to involve an attorney on your behalf to insure the CM is getting a balanced picture of your claim.
If you are confused and do not know who is managing your claim, you can always call Labor & Industries, and they will get you the correct contact information.