I recently had the chance to speak to a group of workers' compensation professionals from around the nation. They are each involved with "self-insurance," a term that has evolved over the years that I have been involved in this community.
Some are surprised when they are reminded that the vast majority of obligations in the workers' compensation law are the employer's. There is habitual reference in this community to the "employer/carrier," and certainly, there are contractual obligations between employers and carriers. By this contracting, the employer's statutory obligations can become the carrier's as well.
This reminds me of the many discussions of "tripartite relationships" that arise in the realm of attorneys who defend insurance companies. I have heard many debate whether the insured (policyholder) or the insurer is "the client." The easy answer is "both," but there may arise instances in which the attorney will perceive conflict between the two clients' interests. Those may be difficult courses to tread.
Many in the community do not recall, but in the 1970s it became difficult to obtain workers' compensation coverage in Florida. There was a perception of risk and pricing that led to diminished coverage availability. Insurance carriers became selective in their selection of employers, and some left the market completely.
The solution was for employers to provide their own coverage, "self-insurance," which was realistic for some employers but financially beyond the reach of others. This is a simple thought; you might choose to buy insurance on your car or drive it without any. If you have an accident with insurance, you have less financial responsibility, but if you are without coverage, you are fully responsible. It is easy to see that the choice may be more available for those with large financial resources.
The solution to that inequity in 1970s workers' compensation was that employers banded together and formed "funds" to provide coverage to those in their group. They were still "self-insured," but not individually so. This started a new lexicon with phrases and abbreviations. There were "self-insureds," "individual self-insureds," and more.
There was soon a realization that the day-to-day of adjusting or managing a loss could be both time-consuming and complex. The logical path might be for a self-insured to hire adjusters and managers or to contract with a company that has such expertise on staff. Thus, self-insureds came to be referred to also as "self-administered" (expertise on staff) or not (contracting for that expertise).
The trend continued, and there were bumps. There had long been state funds as safety nets for insurance company financial failures (guarantee funds). Florida had the Florida Insurance Guarantee Fund (FIGA). The advent of self-insurance prompted a similar response in the Florida Self-Insurance Guaranty Fund (FSIGA).
And yet, as the 20th century drew to a close, the insurance markets were more accessible. Self-insurance began to lose adherents. Large companies abandoned the challenges of financial disclosure, regulation, and hiring/managing expertise. They shifted back to insurance, but with a twist.
Much as you might make a choice to self-insure your car, you might choose to reduce the cost of your auto policy with a "deductible." This merely lowers the insurance company risk and therefore lowers the policy price. If you have a $500 deductible, there are many minor events the insurance company will not have to pay for.
As the deductible increases, the volume of avoided risks also increases, and the policy price decreases accordingly. Those deductibles might be "per claim" or "per year." The "per year" model is popular today with many health policies.
In the 1990s, I had a client with a $5 million per-claim deductible. That meant that for any accident, the expenses had to reach $5 million before the insurance company owed a nickel. However, the adjusting and management (expertise) was included from dollar one, just like in the example of non-self-administered self-insurance above.
Complex enough? Well, stay tuned.
In the self-insured model, a customer might choose to limit risk by buying "excess insurance." This would pick up at some preset level. The effect is much like a deductible. Once the age of guaranty funds began, states started mandating that all self-insureds would have "excess insurance." That is, all self-insureds had to have insurance.
In the insurance model, a carrier may do the same. Having signed on for the risk of loss for an employer, the carrier may manage and finance that risk entirely, or it may likewise purchase excess insurance to limit its losses. In effect, the carrier takes some of the premium it receives and pays another carrier to assume some of the risk.
That brings us back to the "tripartite" relationship. The employer may be a client, with responsibilities and rights. The carrier may likewise have responsibilities and rights. And, there may be one or more excess carriers stacked up on top, each with responsibilities and rights.
Why would it matter? From the defense attorney's perspective, it may matter in terms of reporting, documenting, and discussing. It may be important in terms of representation, competing rights, and duties. And, for the worker, it may be important as regards the negotiation process (who is making decisions) and timing (how many layers, meetings, or committees will examine the decisions).
But, at the foundation, the main point is that whoever has a "self-insured" portion or a "deductible" is self-insuring some portion of the potential financial responsibility. They are at risk and therefore should be conscious of the decisions being confronted, the analysis process, and the recommendations. Despite being "insured," the responsibility may suggest some "self-insured" risk to be managed.
Despite the decreases in "self-insureds," there is a fair volume of self-insurance remaining in the marketplace, and those who would resolve or litigate claims would do well to understand the implications of it.







