I'm hoping some of you HR experts or those familiar with self-insured employers can offer me some assistance. My brother was hurt pretty seriously at work. His pelvis was fractured & of course required surgery. He is a long-term employee at the company and is hesitant to ask questions, which I don't understand. Anyway...we were under the impression that everything would be covered through worker's compensation (hospital & dr bills, salary, etc.) but we are being told that because his employer is "self-insured" that he will be assigned a worker's comp. #..but due to the company being self-insured everything will be handled/paid by a 3rd party company, not workers comp.
We are so confused because the 3rd party sent him a release stating that they have the right to attend dr. appts, rehab appts, and make all decisions for him. The release is also for them to get all his medical records but it also says health care providers are NOT conditioning his treatment, payment, eligibility for benefits, etc. on whether he signs this release.
After surgery..they initially told us he would need to go to an in-patient rehab center that would offer 3 hr per day intensive rehab & they didn't want a nursing home rehab unit as he would only get about 1 hr. per day. So...you guessed it..after talking with this 3rd party payor, you know where he ended up, the nursing home rehab against the family's wishes/surgeon's recommendation but the response from the hospital was they had to go with what the 3rd party company was willing to pay. What!!?? So of course, it's a financial decision, not what is best for his rehab.
So, I'm looking for advice. Sign/don't sign this release? Have you ever heard of this about a self-insured company going through someone else to manage worker's comp claims? Am I being nervous for him over all this for nothing? Sorry so long!
Thanks for the responses, great info from all of you! Just to clarify, he was assigned a BWC claim # through the state of Ohio...but it won't be handled by the state at all. Instead handled by the 3rd party company the self-insured employer has hired to handle their worker's comp claims
Don't sign anything!!! Call an attorney that specializes in workman's comp claims. I son't know if law's differ from state to state, but here a person has the legal right to the doctor of their choice and HIPPA laws protect medical records.
I was a WC claim adjuster for several years (we are not evil) in AZ. I didn't have experience with self-insureds since I worked for an insurance company so can't help you there. Minor claims, 1-2 weeks time off, total treatment under 1-2 months, you don't need an attorney. Major claims like your BIL's I would highly recommend an attorney. You don't pay out of pocket, your BIL will get a disability settlement at the end of this and the attorney will take 1/3 of that (at least in AZ they did). There is so much complexity in a case like your BIL's that it is almost a full time job just keeping on top of it all, having an attorney helps with all that. I agree to not just get one from an ad, make sure you interview some and fid out what type of guidance they will give you throughout the course of the claim. You do need to keep in mind that if you get an attorney all communication with the insurance company will go through the attorney's office, the insurance company will not be allowed to contact you directly. That's why it's important to get an attorney who will be available and responsive as they are your intermediary with the insurance company.
I'm in HR and handle our workers comp claims. We have workers comp insurance. The employee get a WC#. Is their a wc insurance carrier involved?
I would recommend your brother contacting the state division of workers compensation. I would do that first to understand your rights and then talk to the 3rd party company. Also, have your brother contact the HR office of his company. They might be able to put some pressure on the 3rd party company. I know we do when we feel our workers' compensation carrier is not doing what it should for our employees. Matter of fact, I had someone for our previous carrier say I was "mean". Hell yeah I was. If you don't take care of our employees, I will be "mean" to you!!! If all else fails, I would contact a reputable workers' compensation attorney.
Unfortunately, the 3rd party does have a lot of say in the care and treatment of the injured party. They are paying the bills. While I sympathize with your brother, the 3rd party is looking to put the employee back together at the most cost effective price. We go to doctor visits with our employees and we get the summary if we don't.
Not sure what the laws are in Ohio. I'm in Texas. As an employer, we are very involved in our employees recovery. Again, I encourage you to have your brother contact the HR person at his company.
He should also be getting temporary total disability compensation, beginning on 8th calendar day after accident.
I'll tell you this much--it would benefit your brother to speak to an attorney and ask him about signing the release.
In this case, I would definitely get a lawyer that speciailizes in workers' comp cases. Do not go with one that you just happen to find an advertisement for or get a brochure. Interview a couple. Find out how long they have been in practice, their "record", what kind of injuries etc. In IL, they could only get 20% of a settlement, if there is one. Make sure your brother keeps really good records from the beginning--hopefully no too late. This includes MRI/Xray etc.
I would also look up the state workers' cop office and ask questions pertaining to the state laws. My husband was injured at work and the place his employer sent him for exam said he had a lumbar sprain. Turned out he had a herniated disc that broke after they sent him back to work. If we had retained images of his MRI, we would have sued them. My husband has pins in his back due to later slipped discs that resulted from being sent back to work. We did have an attorney that made sure my husband got his workers' comp while he could not work, as well as the treament he needed and that the bills were paid.
Attorney now. Don't let him say it's too expensive to hire an attorney. It may cost him much more in the long run financially and in terms of his health if he signs away his rights without consulting legal counsel.
Is he afraid of losing his job if he asks questions? If he doesn't go along with this third-party? It shouldn't be like that.
Don't take a chance. If he doesn't receive the care and treatment his doctors recommend now, he could be dealing with the repercussions for the rest of his life, such as constant pain and limitations on his ability to work (since it sounds like he may do physical work at his job).
He deserves to have the care and treatment his doctors prescribe. The third-party in this case only cares about the bottom line and not necessarily the optimal treatment your brother requires to recover fully.
Wishing him the best with this.
He needs to hire a lawyer ASAP. Definitely do not sign the release until you've spoken to a lawyer about it.
Is he in Ohio as well? Because Ohio is a monopolistic state for WC. I know in other states large self insured employers always utilize a 3rd party claim manager, it eliminates the need for them to manage it alone and helps them contain costs. So the 3rd party would ideally try to keep the overall cost of the claim down whether they will do that to your brothers benefit is the question. The 3rd party having access to his records and his appts is normal in my opinion from working in commercial insurance. NY state requires his and even makes injured employees get second independent medical exams if an injury is in question. Now whether your brother is getting taken advantage of I can't say not knowing anything further. Sometimes an attorney is not a bad idea but keep in my mind any settlement he would potentially receive will have a large chunk given away to an attorney. I'd be more likely to ask the state WC board for help, they don't cost anything and are impartial.
Okay, now I am confused. Most if not all employers have a workman's comp insurance company and they are the devil themselves. Depending on the laws in your state they can have full control over everything. Missouri is one of those states and I hated what they put me through but the cards are stacked in their favor. I couldn't see my orthopedic surgeon. They made me wait four weeks to see theirs, all the while I couldn't walk. Then they made me do rehab before they would do surgery. Since it happened a week before I switched jobs and I then had a desk job where I could work some hours they paid nothing in lost wages because my new job paid a lot more. So they were allowed to take what I was making, and since even with less hours I made more, they didn't have to pay me for the missed days.
They are evil but it sounds like in your state they are legal.
I also wanted to add attorneys that take on workman's comp cases will take your case if there is money to be made so it wouldn't hurt you to speak to one. Of course the flip side, they take 25 to 40% plus their costs from your settlement.
MamaR it is not the adjuster, it is the laws. We have an odd bunch of laws that harm the truly injured and reward the chronic claimer. In Missouri you almost cannot make a claim without an attorney. For me they never did the surgery and then a year later my whole knee gave out and I had to have the surgery. With a chance my insurance would fight with WC to cover it I had to hire an attorney. Here is where it gets odd. Five years later I have a hearing in July with the second injury fund. My attorney is hoping to get a piece of the action, I am considering not showing up.
Well, pretty universally, HIPPA does not apply to worker's comp cases and decisions are made by your worker's comp company.
I was paid in full for wages and all medical was covered completely. If I got hurt and it wasn't covered right I hired an attorney and won and got nice settlements. The one thing though that you have to pay attention to is when they want to close the case with the settlement. They often want to close the medical on it. That's not a good idea unless the person is completely healed and won't ever have pain or disability from the injury.
So tell him to go visit with a workers comp attorney, they are always advertising on TV if he doesn't know how to fine one on his own.
It is typical for a company that is self insured to hire a Third Party Administrator to handle their claims.
