More on Third Party Claims

I liked Dave’s last post about third-party claims. It’s not a topic we’ve talked about very much, but it can be an important avenue of recovery for someone severely hurt at work. So, what types of situations will result in a claim against a third-party?

We see a lot of third party claims involving injuries on construction sites. Just think of all the activity on your everyday construction project. The General Contractor has the overall duty to provide a safe work environment for all workers on the site. The General contracts with a number of specialty subcontractors.   It’s not unusually to have  subcontractors in charge of site preparation, framing, electrical, plumbing, mechanical work, roofing, cement and even landscaping. Each of these subcontractors hires their own employees, and must make sure those workers are performing their work safely, and just as importantly, not endangering any of the other workers on the site. So, if the framer leaves a hole in a floor uncovered and an employee of the electrician falls through it and is injured, there is a potential third-party claim against the framing subcontractor and maybe the General Contractor as well. A roofer who doesn’t tie off properly and falls off a roof injuring himself does not have a claim against his own employer, other than his workers compensation claim. But, the landscaper who is hit by the roofer’s falling ladder may very well have a third party claim against the roofing subcontractor. Any work injury which occurs at work site with multiple employers or subcontractors should be carefully evaluated for potential third party claims.

 If a product or piece of equipment being used by a worker, but not owned by the workers employer, fails or is defective there may be a third-party claim against the product manufacture or owner. For example, a metal ladder with a faulty weld or a rented back hoe with no functioning back up warning signal. If either of these defects proximately causes a work injury the product manufactory or owner may be held responsible.

 If the worker is driving as part of regular work duties and is involved in a motor vehicle accident, there may be a third party claim against the negligent driver. If a worker is assaulted by a customer, there may be a third party claim. A worker who is injured on physical premises not owned or maintained by his employer, may have a third party claim. For instance, the delivery driver who slips on ice on the loading dock while making a delivery, may have a claim against the company responsible for the property. Any number of situations can give rise to a potential third party claim. As a general rule of thumb, if a work injury involves some entity other than your immediate employer, some product or equipment that your employer does not own or control, you should explore your options. As Dave mentioned, third party claims involve proof of negligence, which worker’s compensation claims do not require, and they can take a long time to resolve. But they can also be an effective tool in making sure your recover for all your damages, not just the limited statutory benefits provide in our workers compensation laws.

Reducing Long Term Disability

Someone asked, “what are the benefits of having a light duty program?”  It’s a really good question, and I suppose you would get different answers depending on who you ask. While I fully realize light duty programs are a cost saving mechanism for employers, I don’t believe these programs are inherently evil.  I won’t bore you with the research, but it seems well accepted the longer an injured worker is away from employment, the more devastating the financial impact on that worker and their family. Staying connected to your work place, and returning to some type of daily work activity as soon as possible, can be much better than long-term disability. Those who have a strong work ethic and a sense of self which is closely tied to employment, can avoid the feelings of loss and hopelessness which come with losing that employment or ability to work.

 However, like everything else in life, light duty programs run the gambit from good, to bad, to really ugly. There are those which are designed and intended to do all the right things; keep the worker connected to employment, offer meaningful work at fair pay, while affording dignity, respect and security.  And, there are those whose main goal seems to be to create such a hostile work environment that the worker will quit, or be set up for termination. The question is, how do we create incentives for the former and discourage the latter? How do we create a culture where employers and employees both see the benefit of working together to insure quick, meaningful, and permanent return to work after an industrial injury or occupational disease?

 I don’t mean that to be a rhetorical question – I really am looking for ideas. I think we have an opportunity in this State to move forward with productive changes which improve return to work and reduce long-term disability, like the Vocational Improvement Project which is currently in year 2 of a 5 year pilot. I’m not talking about redefining what is or is not an injury, or allowing workers to settle claims for a lump sum rather than holding employers accountable. These maneuvers may reduce costs, but they do not address return to work or reduce long-term disability. We don’t need to shift the problem out of sight, we need to solve it.

 From a workers perspective, what will  encourage a return to work? From an employer perspective, what reduces the risk of retaining a worker who has sustained an injury? How do we reshape the trajectory of  our work lives so that as we age work duties become less physically demanding, thereby reducing the prevalence of injury and occupational disease? Our ageing work force has value, with skills and knowledge that can and should be used. How do we harness that skill and knowledge when their bodies start to fail them?

 Light duty programs are one tool which can be used to reduce long-term disability. The trick is to insure it is used for the right reasons at the right time. The bigger trick is to put more tools in the toolbox.

What if my employer is a Native American Tribe?

The number of workers in Washington State who work for a Tribe, or in a Tribal owned business, is growing every day. Just think of all the casinos and associated businesses you see opening in your area. If you are employed by a Tribe, and are injured at work, do you have a L&I claim?

There is not an easy answer to that question. But I do have an easy first step if you are injured – file a Washington State Labor and Industries claim AND file a claim with the particular Tribe as required by your employer.

Tribes are Sovereign Nations. As such, they are not bound by our State workers compensation law. By way of example, if you were injured working for an Australian employer in Australia, you would be entitled to whatever rights or benefits Australian Law outlined. The same is true if you work for a Native American Tribe on Tribal owned land. You are entitled to whatever rights and benefits are outlined by the Tribe. While some of those benefits may track what is provided by the State, the exact nature of the rights and the processes for filing a claim will be dictated by each individual tribe.

So, why file a State L&I claim? L&I will allow claims where the employer is a Tribe, but the business is not on Tribal Land, or where the business is on Tribal land, but is not owned by a Tribe. As an employee, you may have no way ascertaining who exactly owns a business, and whether the property is Tribal land or not. The Department will investigate and allow or reject the claim as appropriate.

There is another good reason to file a claim, even if you are fairly certain it will be rejected because the business is owned by a Tribe, and is clearly on Tribal land. The State has no way of gathering information about how many injuries are occurring in these situations. Tribes are not required to report on the job injuries to the State. As a result, the State has no way of tracking these injuries or documenting whether such injuries are increasing. If an L&I claim is filed, and rejected, the Department has been able to gather the information. With information on the number and types of injuries occurring in Tribal businesses, the State will be in a better position to understand how this growing sector of our economy is effecting workers injured on the job in our State.

Vocational Option 2

We are about a year and a half into the 5 year pilot Vocational Improvement Project (VIP) at the Department of Labor & Industries. The Vocational Subcommittee (which I am on) continues to meet regularly. This first year has been busy with issues surrounding how to implement the changes to the vocational system, and the Department has done a good job with an overwhelming number of changes, both anticipated and not anticipated.

 The VIP has a feature which was not present in our former vocational system, for shorthand we call it “Option 2”.  Because it is new, workers have a lot of questions. Let me explain what it is, and then try to walk through some of the considerations.

 If a worker is found eligible for vocational retraining (that is, further vocational assistance is both necessary and likely to assist the worker in returning to reasonable continuous gainful employment) he or she works with a vocational rehabilitation counselor (VRC) to develop a comprehensive retraining program. This program can cost up to $12,240.00 (as of 7/1/08) and take up to two years. The vocational plan is submitted to the Department for approval. Once approved the worker has 15 days to choose one of two ‘options’.  You will receive information about these options as you progress in the plan development process, so the 15 day window should not be a surprise. You can not elect an option until your retraining program has been developed an approved. In theory, this insures you have had an opportunity to fully explore the retraining possibilities open to you, and have an exact plan developed so you are aware of exactly what the consequences of the ‘option’ choice will be.

 Option 1 – the worker participates in the plan as outlined and approved. This is the easy one, you know exactly what you are committing to.

 Option 2 – the worker declines participation in the retraining program. Time loss benefits stop. The worker is entitled to the equivalent of an additional 6 months of benefits, at the same time loss rate. The claim is closed with the appropriate permanent partial disability award.  Any time within the next 5 years the worker may use the reserved vocational retraining costs (the $12,000 plus) to pay for training or classes at any accredited or approved school or program.

 Most of the questions I field about Option 2 are whether to take it or not. I will leave for another day the questions surrounding how, and for what, the reserved vocational funds are used.  I will admit to being surprised at the number of workers who have chosen Option 2, it’s running pretty steady at around 25%. When the Subcommittee discussed including a way to ‘opt out’ of vocational retraining in this new pilot, I had in mind those workers who were at or near retirement age, were already receiving Social Security either disability or retirement, had a work history in a single occupation and who were clearly not returning to the workforce.  This was my picture of who would choose Option 2. 

 Well, I was quite wrong. The stories behind who and why workers are choosing to opt-out of the vocational process have been interesting and varied.  One very young worker wanted to retrain in a occupation which just very slightly exceeded her physical limitations. Although she believed she could do the job, the Department would not approve the retraining plan. The alternative plan, which was approved, was not exactly what she wanted to do.  She choose Option 2, got a student loan to replace the lost stream of time loss, and immediately accessed the reserved training funds to enroll in her chosen program.  Who would have thought? Several workers have chosen option 2 because their time loss rate is not enough to pay the bills. They believed their families would be better off if they found a job immediately, rather than scraping by for two years in a retraining program. Several workers talk of taking their Option 2 payout and their PPD award and starting their own business. In the end, it will be interesting to see the results of the study which will track outcomes for workers in this new VIP, including those who have chosen Option 2.

 The lesson I have learned is there is no one answer or test which will help a worker decide whether to choose Option 2 or participate in their retraining program. Every situation is different, in ways I had not anticipated.  However, there are some basic considerations which will be common to all workers. First, I ask my clients if they have a way to pay the bills when the 6 months of Option 2 payments and the PPD award are paid out. If not, then participating in retraining will keep the flow of time loss coming for the duration of the program, will provide return to work skills, and will buy some time to decide ‘what’s next’.  To those clients who say they will just go look for work, we have a frank conversation about the state of the economy and the unemployment rate in the state of Washington. If you do not have a job absolutely positively lined up, taking a pass on retraining might not be the best choice.

 You should consider your age, and whether you want to, and are able to, retire.  If you honestly have no desire or need to work, and are financially secure, then participating in a retraining program might not suit you.  On the other hand, if a you are relatively young, with years of work life remaining, this may be a golden opportunity to receive additional occupational training or education opening an entirely new chapter in your career. Choosing Option 2 and passing up this opportunity might be a mistake.

 One of the hurdles for workers at this stage of their claims is actually picturing themselves back in the work force, in any capacity. This is not a swift moving system. By the time a worker is found eligible for vocational assistance in the form of retraining they are years into their claim. Their lives have been a revolving door of physicians, surgery, therapy, testing, medical evaluations and endless appointments. Being disconnected from the workforce for such an extended period of time makes imagining a return very overwhelming. For those workers struggling with this reality, I urge you to pass up Option 2 and give your retraining program your best effort.  Just like education and training after High School can bridge the divide into the real world, this opportunity for retraining during your adulthood can bridge the gap between injury and returning to enjoyable employment.  Maybe you will get to the conclusion of your program and decide to retire. But maybe, and I believe more likely, you will get to the end of your program enthused, re-energized and optimistic about your future, with a new skill set as an added bonus.

When should you be receiving Time Loss?

When should you be receiving Time Loss?

The obvious answer is, ‘When you can not work because of your injury’.  But as with most things in the workers compensation world, it is not always as easy as the obvious answer.  Several hurdles must be maneuvered before you are entitled to time loss payments.

 First, there must be medical certification that you are unable to work because of  your work related injury.  At the beginning of your claim this should come from your attending medical provider. Unfortunately, this is one of those areas where it does not matter if you think you can do your  regular work – it matters what a medical provider thinks. So, get yourself to a  Doctor as soon as you can.  The certification will address your ability to return to work at your job of injury. There is no magic time loss form for your doctor to complete. Although the claims manager may send your medical provider an Activity Prescription Form, this specific form is not required to collect time loss. The same information can be found in the providers chart notes or any other form used by the Doctor’s office.  You will not receive time loss for the day of injury, or the 3 days following the injury, unless you remain off  work for 14 days. 

You will also be required to sign a Worker Verification Form to certify you have not worked, and to let the Department know if you have applied for any public assistance. (note – self-insured claims may not use this particular form)  The Department may send you this form, or you can complete it on-line in the Claim and Account Center. You can mail it, fax it, or drop it off at a service location.  If you have an attorney, your attorney will make sure you get one to complete when necessary.

 Time loss can be paid even before the Department issues an order formally allowing your claim. If there is medical certification and worker verification, provisional time loss benefits should be paid pending the Department’s review of the claim and allowance or rejection of the claim.  Of course, if the claim is ultimately rejected, these provisional benefits will need to be repaid. (in limited circumstance, the Director may waive repayment if recovery would be against equity or good conscience.)

 As the claim progresses, your medical provider may be asked by your employer to release you to light duty or modified work of some type.  (see previous posts on light duty work) The Employer should provide a specific job description which allows your medical provider to assess whether you can perform the work described. If your physician releases you to this work, you will not be entitled to time loss benefits. However, if this temporary light duty work pays less than your regular work, you may be entitled to Loss of Earning Power benefits to make up some of the wage loss. If this light duty work interferes with your recovery and your physician again certifies you are not able to work, your time loss should resume. Likewise, if the employer no longer has light duty work available, time loss should be paid.

 If you leave your employment, and take another job with another employer, you may still be entitled to time loss if your physician subsequently indicates your injury interferes with your ability to work at either your job of injury or your new job. I had a worker call the other day who had changed employers several months after her injury. About a year later she had surgery for her work related injury. The claim was open and the surgery was approved treatment. She wanted to know if she should have received time loss while she was recovering from surgery and unable to work at her new job. Absolutely, yes! It does not matter that she was working for a different employer, she should have received time loss, and we will be following up on her claim to make sure she does.

 If you move out of state you are still entitled to time loss benefits. There is no rule or law which requires that you reside in Washington to continue receiving benefits under your claim. We have clients in a lot of different states, and several foreign countries. While medical treatment may be a challenge, there is nothing about a move, in and of itself, which limits the payment of time loss benefits.

 If your injury is serious and permanently prevents a return to work at your job of injury a vocational assessment will be conducted. You should receive time loss during this process. If the vocational assessment concludes you are employable, your time loss benefits will stop.

 This is really only a very basic outline of when time loss should be paid. As a general rule, if you have an open claim, are not working because of your injury and are not receiving time loss benefits, you should talk to an attorney about your specific circumstances. There may be some arguments to be made that benefits should be paid. It is always worth taking a look, and may result in the payment of significant back due benefits.

Independent Medical Exams or IME’s

Perhaps it comes from reading hundreds of them. While medical exams arranged  by the Department of Labor & Industries or a self-insured employer may be called “independent”, they seem to be anything but “independent”. I generally refer to them as panel exams or defense medical exams. Whenever a dispute, question, concern or confusion arises in a claim, a medical exam is scheduled. The reports are often boilerplate, the same physicians show up time and time again. They seem to stall medical treatment rather than facilitate it.  

 

Be that as it may, if you are scheduled for such an exam, you need to go. Failure to attend will likely result in some negative action being taken on your claim. The Department or the self-insured employer has the right to have you evaluated by a physician or physicians of their choosing. These exams can be scheduled for any reason, and pretty much as often as they want. That said, I do have some suggestions.

 

If the date or time of the exam is inconvenient, it is ok to reschedule. Just call the phone number on the notice and reset the exam for a better time.  Despite what a frustrated claim manager may tell you, you are allowed to go on vacation, make plans, and have appointments unrelated to your claim. You are not at the beck and call of your claim manager 24/7. While your personal activities can not completely prevent your cooperation with reasonable claim management requests, they may make you temporarily unavailable, necessitating an exam be rescheduled.

 

If you have an emergency and need to cancel the exam at the last minute, call. It happens. Hopefully, not to the same worker over and over again, but it does happen. It could be the weather, or car trouble, or a sick child. Whatever the reason, call the facility and your claim manager as soon as possible. Unless you have a pattern of last minute missed appointments, it will not be grounds for suspending benefits. Although, you may be asked to write a short statement about the reason for the last minute cancellation for your file. The exam will be rescheduled.

 

If your injury makes driving difficult, you can ask that transportation be provided. Usually, the Department or self-insured will arrange a taxi pick-up. If you are traveling from out of  Washington State, travel will definitely be provided, as well as hotel accommodations if necessary. If you do drive, keep track of your mileage and submit a travel reimbursement. You can get a form here.

http://www.lni.wa.gov/FormPub/Detail.asp?DocID=1631

  

Take someone with you. If you have an attorney, they can not go with you. But, you can certainly take a friend or family member. Not only will this give you some piece of mind, it will be an extra set of eyes and ears.  Your companion may sit through all parts of a physical exam. They will not be permitted to sit through a psychiatric or psychological evaluation.

 

Report any misconduct or inappropriate action by the physician who examines you or any other person associated with the facility where you have the exam. The Department will take action if they receive a number of valid complaints involving a particular provider or facility. If you have a concern about your exam, put it in writing right away and send it to your claims manager. It is perhaps human nature to view complaints made only after the report is received as a bit less credible. Complaints can be sent to:

IME Quality Assurance
Provider Review & Education Unit
Labor & Industries
PO Box 44322
Olympia, WA 98504-4322
360-902-6818

Do not rest up before your exam. I tell my clients to go about their normal activities before an exam, so the provider can see them in their normal state. Keep in mind it is important to be honest with the examiner. Not every test will cause symptoms, and you should be straight up about what does and does not effect your condition.

 

You are entitled to a copy of the exam report, although, the examiner will not send a copy to you. If you have an attorney they will get a copy of the exam and send it to you and your medical provider and request any necessary response. If you do not have an attorney, send a request for a copy of the exam in writing to your claim manager. While there is no law which says the request has to be in writing, I find it harder to ignore or forget about if it is in writing. When you get a copy of the report, take it to your attending medical provider. While the claims manger should send the report to your doctor, it does not always happen. Ask your physician to review and forward any comments directly to your claims manager.

 

You may find a second medical exam is scheduled shortly after  a report is received from the first exam. This is an unfortunate outcome of claim mangers looking for a “preponderance” of medical opinion. Many claim managers seem to feel this means the number of opinions on a particular issue, completely ignoring the quality or credibility of those opinions.  There is not much you can do about it.  If you have an attorney they will make the appropriate arguments, and work with your physician to obtain helpful information to forward to the claim manager.  However, to avoid being found uncooperative and having your claim or benefits suspended, you will need to attend the follow up exams.

 

The Department is currently drafting new Rules defining who can conduct these “Independent Medical Exams” and what those exams should look like. There is some hope these new Rules will serve to improve the quality of the exams themselves and make them more objective and fair.  I suppose we’ll see. In the meantime, these exams are a necessary part of your journey through the workers compensation system. Understanding them, and following a few common sense suggestions will  improve the experience.

How and When to Reopen your Claim

A L&I claim may be reopened within 7 years from the date the first closing order becomes final, for full benefits. That means, time loss, medical benefits, vocational services, disability awards, all benefits that are available under the law. If it has been more than 7 years since the claim was first closed, the claim may be reopened for medical benefits only. The Director of the Department has discretion to provide full benefits in certain circumstances in these ‘over 7’ reopenings.

 

Keep in mind, the time limit is 7 years from first claim closure, not the date of injury, not the date you returned to work, not the date the final installment of  any PPD was paid.  If a closing order was protested or appealed, and ultimately set aside, that is NOT the first claim closure. You are looking for the first final claim closing order. That is the start of the 7 year clock.

 

In a nutshell, a claim will be reopened only where there is medical evidence, based on objective medical findings, that the industrially related condition has worsened, or become aggravated, since the claim was closed.  Your own subjective descriptions of increased pain, loss of function, or inability to work are not enough. A claim can not be reopened solely for vocational services. The Department is looking for increases in objectively measurable findings. Worsening in measures of atrophy, nerve damage, degenerative changes, muscle wasting, range of motion, sensation. Worsening which is evident on MRI, CT scan, EMG. I tell clients, we are looking for concrete, objectively measurable changes in their work related condition.

 

Reopening requests, or aggravation applications as they are sometimes called, should be forwarded directly to the Department, even if your employer was self-insured. There is an actual form, which you can get here:

http://www.lni.wa.gov/FormPub/Detail.asp?DocID=1591

However, an informal written requests, with or without supporting medical information, will start the ball rolling. If there is such an informal request, the Department will forward you the reopening application to complete.  There is a portion of the form for you and a section for your medical provider to complete.

 

You can go to any medical provider to complete a reopening application. If you had a good relationship with the physician who treated you while your claim was open, that is a great place to start. Your primary care provider is ok, an appropriate specialist may be even better. If you have a copy of the closing medical report, take it with you. This will help the physician in comparing your current findings on exam to those at the time your claim was closed.  The medical provider will be paid by the Department for performing the exam and completing the paperwork, whether the claim is ultimately reopened or not. If the physician recommends a diagnostic study to complete the exam, the request should be forwarded to the Department along with the reopening application. The Department will approve many diagnostic procedures in order to gather all the medical information necessary to review the reopening application. Again, if the Department authorizes such a study, they will pay for it. The Department will likely schedule you for a medical exam, called an Independent Medical Exam, or IME. (We can discuss some other time whether there is anything ‘independent’ about these exams)

 

When in this process should you talk to an attorney? There is no hard and fast rule, although I tend to be in the ‘earlier is better’ camp.  The Department will issue an Order either reopening the claim or denying the application. You can protest or appeal a denial, and an attorney will most definitely be helpful, if not indispensable. However, earlier involvement has its up side. An attorney with a good relationship with the Department can nudge a claims manager in the right direction, help make sure all necessary diagnostic studies have been done (on the Department’s nickel), help the attending physician articulate the objective findings which have worsened or respond coherently to an IME report. It is, of course, quicker and less expensive if your claim can be reopened without having to litigate the matter. Getting an attorney involved early in the process will only serve to make sure all possible avenues are being examined before the Order is issued.

Light Duty Trap

In a previous post I encouraged you to have an open mind if your employer offers light duty work while you are recovering from your injury. It is generally a good thing to remain connected to your employer and the work force.

 

I touch on this topic again to alert you to the down side of  light duty work. If you are working light duty, your employer can still fire you for cause. If you are fired for cause, you do not receive time loss benefits. The employer will argue light duty work was available for you, but because of your own actions you are no longer working. Time loss is not payable, since it is not your injury which is preventing you from working and receiving a paycheck.

 

The most common scenario is a worker who does not call in to report an absence while on light duty. Most employers have a call in policy of one sort or another, some less strictly enforced then others. But I promise, if you violate these internal company polices while on light duty, you will find yourself out of a job, light duty or otherwise.

 

There is also the occasional horror story of an employer and co-workers treating a worker on light duty so poorly, that the light duty worker gets fed up and quits the job. Again, no time loss is payable, as the reason the worker is not collecting a paycheck has nothing to do with the work injury. I often tell my clients, your employer does not have to be nice to you.

 

The lesson here is to mind your P’s and Q’s. Follow company rules to the letter, even if no one else does. Walk away from taunts and mocking. Enforce the written restrictions from your medical provider. If your employer is one of the good guys, light duty work will be a valuable bridge during your recovery. If your employer is not on the up and up, the light duty job will evaporate just as quickly as it materialized. If the employer indicates they no longer have light duty work for you, at least your time loss benefits will immediately restart.

COLA

If you are receiving Time Loss or Pension benefits under a Washington State Labor & Industries claim, your July check will reflect an increase. Cost of Living Adjustments are effective July 1 each year. This year’s increase is 5.018%. Pension payments, which go out the 15^th of each month, will reflect the increase. Time loss for periods on or after July 1 will also reflect the increase. Your time loss check may cover periods both before and after the COLA,  the daily rate will reflect the difference.  You can read the press release from the Department here;

http://www.lni.wa.gov/news/2008/pr080626a.asp 

 

 

Who is managing your claim?

 

 

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.