Workers Comp and Self Insured Employers

A self insured employer is one who self insures their workers’ compensation liabilities. If you are one such employer, you are not alone: California has the largest workers’ compensation self insurance program in the nation. As of January 1, 2014, nearly 10,000 California employers were actively self insured.

Employers may choose to self insure their workers’ compensation liabilities because it can be cost effective, allow the employers greater control over the claims program, and increase safety and manage loss control. Many employers contract with a third party administrator to supervise claims and perform other tasks. The alternative to self insurance is purchasing a workers’ compensation policy. Learn more about workers’ comp basics here.

Workers Comp Insurance – Can An Employee See His Own Doctor?

If your California employee was injured, or claims to have been injured on the job, they may want to visit with their own doctor or medical professional. While they are welcome to do so, they generally must also visit with an in-network doctor. Indeed, many workers comp insurance carriers include a Medical Provider Network (MPN) in their provision of services to their insureds and the insured employees.  Unless an employee has specifically elected to be treated by their personal physician in writing, and only if the designated physician has agreed to provide medical care for worker’s compensation injuries and illnesses in writing and the designation was made prior to the injury or illness, an injured employee must treat within the medical provider network.

Not surprisingly, many workers’ compensation disputes arise because the injured employee disagrees with the treatment recommended or provided by the doctor in the medical provider network.  Often, the insured claimant will see another medical provider who may recommend a different treatment or disagree with the diagnosis altogether, causing a legal and medical dispute with the injured employee. The quality and accessibility of the medical provider network is a factor an employer should consider when selecting an insurance provider.

Timing and Insurance Bad Faith Claims

Bad things happen to good businesses and to good people. Most businesses and individuals carry insurance for this reason. But what happens when the insurance carrier denies payment on the claim without a reasonable basis for doing so? Or, what if the insurer fails to properly investigate the claim in a timely manner? Where can you turn for help?

Although most states have enacted statutes to prohibit bad faith claims practices and also elect insurance commissioners to regulate and control insurance claim practices probably the most effective means for policyholders to enforce their rights is to file a civil lawsuit with the help of an experienced bad faith insurance lawyer alleging “bad faith” against their insurance company for denial of the claim or failure to reasonably investigate the claim in “good faith”.

In California, the insurer’s duty to act in good faith means the investigation of the insured’s claim must be reasonable and requires that the insurance company give at least equal consideration to the insureds’ financial interest as it gives to own interest. This also means the carrier must do a thorough, complete, fair and unbiased investigation before it can deny a claim.

A Breakdown of Insurance Bad Faith

Businesses seeking insurance coverage most often have the short end of the stick when it comes to bargaining power in the negotiation of an insurance policy. Indeed, there is often no room for negotiation. Businesses need various types of insurance coverage to exist and operate and the insurance companies, with billions of dollars in their corporate pockets, largely dictate the terms of the policies and contracts that govern the necessary insurance coverage. Over the years, this disparate bargaining power led to insurance companies engaging in dilatory tactics, or “bad faith” cond

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