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How do self-insured workers’ compensation programs work?

On Behalf of | Jun 2, 2023 | Workplace Accidents

When you get injured or contract an illness while on the job, workers’ compensation is there to help pay for any medical treatment you need. In Ohio, the state Bureau of Workers’ Compensation (BWC) handles most aspects of the compensation process, from reviewing the claim to paying benefits.

But employers in the state also have the option to self-insure, which means they can administer their compensation programs. What does this mean if you’re an employee of a self-insuring business?

The basics of self-insuring workers’ compensation programs

If a company is self-insured, its employees must file their workers’ compensation claims with their employer instead of the Ohio BWC. The employer is also responsible for making any determinations and decisions over the claim, the medical treatment needed and any benefits the employee receives.

A self-insuring company will pay for the health care services of an employee. Typically, prior authorization from the employer will be needed before an employee can receive medical services, except in emergencies. You (or the health care provider) must submit the medical bills to the employer within one year of the service date for coverage consideration. In addition, self-insuring employers must pay medical bills within 30 days of receiving them unless they need additional information or the claim is denied.

What happens if your self-insuring employer denies your claim?

Your employer could deny your claim for several reasons, the same way Ohio’s BWC turns down claims. Perhaps your employer believes your illness or injury resulted from something outside of work. Or maybe you sought medical services from a health care provider not part of your employer’s network.

When this happens, you can file a motion to request a hearing from the Ohio Industrial Commission. These appeal hearings, while having the same procedures as other workers’ compensation courts, occur in a small hearing room with only a few people present.

Representing yourself in a hearing might be tempting if only a few people attend, but appealing a claim denial is a lot more difficult than you think. You need to prove that your employment circumstances put you at greater risk of getting an injury or disease. You’re also going against your employer, who not only holds your employment but also your compensation – it can be intimidating to be in this spot. You might need the experience of an attorney who can represent you in the hearing and negotiate a deal with your employer.