Policy Name:	Complaints Against Self-Insuring Employers
Policy #:	SI-03-03
Code/Rule Reference	Ohio Revised Code (ORC) 4123.35 (G) and 4123.352. Ohio Administrative Code (OAC) 4123-19-09 and 4123-19-13.
Effective Date:	November 6, 2024
Approved:	Rex Blateri, Chief of Employer Services
Origin:	Self-Insured Department/Employer Services
Supersedes:	Self-Insuring Employer Complaint (SI-28) policy effective December 1, 2015.
History:	Revised effective June 12, 2023. New policy effective December 1, 2015.
Review Date:	November 6, 2029

 

I.       Policy Purpose

 

Provides guidelines for receiving and investigating complaints against self-insuring employers (SI employers).

II.     Applicability

The policy applies to self-insuring employers and their representatives, injured workers and their representatives, and medical providers.

III.   Definitions

A.      Complaint: An allegation that an SI employer is not complying with the requirements of self-insurance. Complaints may be formal or informal.

B.      Formal complaint: An allegation submitted on a Filing of an Allegation Against a Self-insured Employer (SI-28) or equivalent form, or similar format via fax, mail, or email.

C.      Informal complaint: An allegation brought to the attention of the Self-Insured Department (SI Department) by phone or other informal format that can be addressed in an expeditious manner without a formal complaint filed.

IV.   Policy

A.      The SI Department will investigate all formal and informal complaints. A complaint may be submitted by telephone, fax, email, or mail.

Ohio Bureau of Workers' Compensation

Attn. Self-Insured Department

30 W. Spring St., 22nd Floor

Columbus, OH 43215-2256

Phone: 614-466-8222

Fax: 614-621-1081

Email: BWCSelfInsuredComplaints@bwc.ohio.gov

B.      A formal complaint must be submitted using an SI-28 or equivalent form. The SI Department will assign a formal complaint for investigation within five business days of receipt.

C.      Anyone may submit a complaint for a specific claim. Complainants may withdraw a complaint prior to a decision from the SI Department. However, only parties or their representatives to the claim may request administrative action including defending the complaint, filing an appeal , or withdrawing the complaint.

D.     Informal complaints. Many complaints result from a misunderstanding or a miscommunication between the injured worker or medical provider, and SI employer. Therefore, the SI Department will attempt to resolve any complaint in an informal manner whenever possible. Informal complaints  that are not addressed expeditiously will be addressed as formal complaints if the complainant files an SI-28 or equivalent form.

E.      Formal complaints.

1.      Upon assignment for investigation, the SI Department will send the formal complaint to the SI employer and their representatives.

2.      The SI employer must respond to BWC, the injured worker, any injured worker representative, and any complainant not a party to the claim within fourteen (14) days of receipt of a formal complaint.

3.      The complaint may be found valid and unresolved if the SI employer does not respond within fourteen (14) days of receipt.

4.      The SI Department may consider information provided with the complaint as well as any other information available to the auditor. At the auditor’s discretion, additional information may be requested.

5.      The SI Department may address additional issues not included with the original complaint if uncovered during the investigation.

6.      The injured worker, the injured worker’s representative, or complainant may withdraw the complaint at any point before the SI Department publishes its finding.

7.      At the conclusion of its investigation, the SI Department will find the allegation to be invalid and dismissed, valid and resolved, or valid and unresolved.

V.     Resolution of Complaints

A.      SI employers must resolve any valid issues within seven days of receipt of the finding.

B.      The injured worker, employer, and their representatives may request a reconsideration of the initial finding. The request must be received within fourteen (14) days of receipt of the finding. The Administrator’s Designee will address the request for reconsideration.

C.      Parties may request a review by the Self-Insuring Employers Evaluation Board (SIEEB) within fourteen days of receipt of the Administrator’s Designee’s decision.

D.     The SI Department will maintain a copy of the complete record of the complaint.

E.      Three valid complaints in a twelve (12) month period will result in an audit by the SI Department auditing team and will be considered during renewal of the SI employer’s self- insured program.

F.      Any valid and unresolved finding against an SI employer, or appeals to the decision of the Administrator’s Designee, will be referred to SIEEB.