Filing a Claim Against
a Self-Insured Ohio Employer
When your employer pays its own workers' comp claims, the deck is stacked against you from the start. Knowing how the self-insured system works is the first step to leveling the playing field.
The self-insured system: what makes it different
Most Ohio employers participate in the state insurance fund — they pay premiums to the Ohio Bureau of Workers’ Compensation, and the BWC processes and pays claims from that fund. But under Ohio Revised Code § 4123.35, employers who meet stringent financial and safety requirements can opt out of the state fund entirely and pay their own workers’ compensation claims directly.
These are called self-insured (SI) employers. They include many of Ohio’s largest corporations, hospital systems, universities, and government entities. As of recent BWC reports, approximately 1,300 employers in Ohio are self-insured, covering hundreds of thousands of workers across the state.
The critical difference: when you file a workers’ comp claim against a state-fund employer, the BWC — a neutral government agency — processes and pays that claim. When you file against a self-insured employer, your employer itself decides whether to allow or deny your claim, authorize your medical treatment, and approve your compensation. The entity paying the bill is the same entity making the decisions about your benefits.
Third Party Administrators: the employer’s claims team
Most self-insured employers do not process claims in-house. Instead, they hire a Third Party Administrator (TPA) — a professional claims management company — to handle the day-to-day administration of their workers’ compensation program. The TPA investigates claims, communicates with injured workers, arranges IMEs, processes payments, and makes recommendations on whether to allow or deny conditions.
Warning: Never mistake a TPA for a neutral party. Despite the professional, seemingly impartial title, a TPA is hired by, paid by, and answers to the employer. Their contractual obligation is to the company that writes their checks — not to you. In Mike’s experience, TPAs are among the most aggressive adversaries injured workers face, precisely because they are financially incentivized to reduce claim costs.
Common TPAs in Ohio include Sedgwick, CompManagement, and Sheakley. When you receive correspondence from one of these organizations, understand that you are dealing with your employer’s representative — not an independent claims processor.
Why self-insured claims are denied more aggressively
In the state-fund system, an individual employer’s premiums may increase based on claims experience, but the employer does not directly pay each claim dollar-for-dollar. In the self-insured system, the equation is brutally simple: every dollar paid on your claim comes directly from the employer’s own funds. Every allowed medical condition, every TTD check, every PPD award, every dollar of wage loss — it all comes straight from the employer’s bottom line.
This creates an inherent conflict of interest that Mike has witnessed play out thousands of times over 49 years of practice. Self-insured employers and their TPAs are statistically more likely to:
- Deny initial claims or specific conditions on the First Report of Injury.
- Schedule aggressive IMEs designed to generate opinions that support denial of treatment or early return to work.
- Contest applications for additional allowed conditions, particularly psychological conditions.
- Delay payment of approved compensation, forcing injured workers to wait weeks or months for checks they are legally owed.
- Challenge Permanent Partial Disability (PPD) percentages with employer-friendly medical evaluations.
- Offer lowball lump sum settlements to close claims quickly and cheaply.
Your rights are the same — the fight is harder
It is essential to understand that your legal rights under Ohio workers’ compensation law are identical whether your employer is state-fund or self-insured. The same statutes — R.C. Chapter 4123 — apply. The same benefits are available: TTD, wage loss, PPD, PTD, medical care, and settlements. The same appeal process through the Industrial Commission applies.
The difference is not in your rights but in how vigorously those rights are challenged. A self-insured employer has every financial incentive to contest, delay, and minimize your claim. That is why representation by an experienced workers’ compensation attorney is even more critical when your employer is self-insured.
Critical: If your self-insured employer or their TPA denies any part of your claim, you have 14 days to appeal that denial to the Industrial Commission. This is the same deadline that applies in state-fund claims, but self-insured employers count on injured workers not knowing about it — or not acting on it in time. See critical deadlines for the full list of time limits.
How to verify if your employer is self-insured
Knowing whether your employer is self-insured should be the first step after any work injury. You can verify your employer’s status through the Ohio BWC’s online employer search tool, by calling the BWC directly, or by asking your employer’s HR department. Mike recommends checking this before you file, because it changes how you should approach your claim from the very beginning.
Key indicators that your employer may be self-insured:
- Workers’ comp paperwork comes from a TPA (e.g., Sedgwick, CompManagement) rather than directly from the BWC.
- Your employer has a dedicated workers’ comp department or nurse case manager on staff.
- You are directed to specific medical providers chosen by the employer rather than selecting your own doctor.
- The employer is a large corporation, hospital system, university, or government entity.
Common TPA denial tactics
Mike has seen every tactic in the book. Self-insured employers and their TPAs use a consistent playbook to deny, delay, and minimize claims:
TPA playbook — denial tactics
Retaliation is more common with SI employers
Because every claim dollar hits the employer’s bottom line directly, self-insured employers are statistically more likely to engage in retaliatory conduct against workers who file claims. Mike has represented numerous workers at SI companies who were terminated, demoted, or harassed after filing legitimate claims. R.C. 4123.90 protects you against retaliation regardless of whether your employer is state-fund or self-insured — but you must act within 90 days.
Why you need a specialist for SI claims
Every injured worker benefits from legal representation, but workers at self-insured employers need it more than anyone. The TPA on the other side of your claim is a professional claims management operation with experienced adjusters, nurse case managers, and retained defense attorneys. You are not in a fair fight without experienced counsel.
Mike has handled thousands of claims against Ohio’s largest self-insured employers. He knows how TPAs operate, which IME doctors they use, what their settlement strategies look like, and how to counter every move in their playbook. That experience is the difference between accepting what the TPA offers and getting what you are actually owed.
Work for a self-insured company? Mike knows their playbook.
Free consultation — no fee unless we win your case.
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