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City looks into workers’ compensation complaints

OCEANSIDE — Councilman Chuck Lowery requested that city staff look into whether Oceanside’s workers’ compensation provider is meeting city needs.

He said his request was sparked by complaints from all categories of city employees.

“It’s all over the board, it’s not simply one group, elected officials, department heads, and staff have complained about the lack of responsiveness on the part of the company,” Lowery said.

Mayor Jim Wood said he has also heard complaints from city staff and employee union representatives. Issues include poor communication, lack of concern for employees, and delayed responses in having claims reviewed and paid.

“I heard about it too, and want to have it looked into,” Wood said.

Wood added city employees have repeatedly complained that they are dealing with a company that does not care.

“The one thing in common in the feedback is that it’s a joke working with TRISTAR,” Wood said.

The City Council unanimously voted to direct staff to report back on the provider’s service history, how it handles complaints, and the number of ongoing claims on March 4.

Wood said he would like an independent outside party to review services, and added a staff report would be a good first step in determining where a problem might lie.

The city hired TRISTAR to handle workers’ compensation claims three years ago, after the city staff member who performed the job retired.

There were attempts to fill the city position, but complex workers’ compensation laws, and demands of 900 full time employees, 200 hourly workers and 500 volunteers resulted in continuing with TRISTAR services, which cost the city $223,000 annually.

Human Resources Director Pat Nunez said communication between TRISTAR and the department has been good.

A company supervisor has met face to face with department staff to iron out any issues.

Six months after services started a third claims adjuster was added to better serve the city. Each adjuster is assigned to a specific category of claims, which streamlines responses.

Nunez said another improvement in service is that a claims adjuster, whose communication style did not match the city’s, was replaced at the city’s request.

Nunez said immediate care of injured employees is the city’s first concern.

To ensure that, human resource staff has arranged for MRI scans to be given without prior approval at plan approved medical facilities, and personally contacts workers who file a claim.

“We do everything we can to help that person, and get them back to work,” Nunez said.

Currently there are hundreds of ongoing workers’ claims that range from long term open claims, to serious injuries, and minor scratches.

Nunez said she has seen delays when employees wait weeks or months to file a claim.

She added the only complaints she had heard are employees’ disagreements with adjusters’ determinations on approved care or coverage.

Still, some employees have obtained lawyers to help them get results. Unfortunately, this adds more steps to the line of communication, and causes holdups.

City staff will return to council with a report within 30 days.

1 comment

Deborah Cahill August 3, 2015 at 10:08 am

All the workman comp problems trace back to one place
Sedgwick Claims They are taking over the workman comp business, they have what they call cut/off doctors. There is an article in First Coast News, Jacksonville, Florida where the city of Jacksonville, Florida paid one physician 1.4 million dollars to deny workman comp claims. Sedgwick is now getting into the self insurance business, where, for a price they can set up corporations like Target, AT&T etc… to handle their own workman comp, commercial liability, and even handle the regulations (illegally presenting false insurance information with state insurance commissioner to meet regulations which their “teams” handle for the corps.” They even provide legal services, should the claims go to court. Currently, this physician, Rogozinski, works denying workman comp claims for the STATE of FLORIDA, our governor formerly ran the corporation that was just charged with the biggest Medicare Fraud ever, SCOTT. If you track this “little Memphis based company” worth billions, and look carefully at their website for offerings, and also their advertisements and postings for jobs, they recently took over the State of Texas workman comp business. They deny workman comp, they deny long term and short term disability, and now they are denying and paying 0 for liability where people are hurt in stores or on premises of stores. They were purchased by Stone Point, they’ve been traded and acquired and merged, numerous times, they avoid SEC and Federal oversight, and they are acquiring and merging with all USA Third party administrators, they bought CIGNA. ETC. its hard to track and wrap your head around. North, moved this company from Chicago. This company is connected to ACE Global Insurance, they have a gazillion shell corps and companies in the US and globally. They are all connected and you can trace them back to ZURICH Banks. Ace is affiliated with ACE check cashing/ services, avoiding banking. These people are taking over insurance and finance, and moving the money to Switzerland. It’s hard to track, with all the shell companies, that look legitimate, like Sedgwick, which looks like a small company,. flies under the radar of all regulations, you never see their name on any lawsuit, even though they hire the lawyers. I have a lawsuit in Florida, Cahill v Target. I have recorded a lot of stuff “on the record” of court, now the judge is removing my motions, completely from the court records.
Sedgwick has had 3 cases before this Federal Judge, Schlesinger, utilizing this same attorney, Stone, Jacobs, and done the same thing 0 for all three people, hurt in Target accidents
Williams V. Target, Case 3:10 cv-00367-RBD JRK Ordonez V Target with JR Koch, Case 13:14425-CIV Martinez Lynch, Hernandez v Target 3:11 CV 00970-MMH-JBT; Chewning V Target 3:12 CV 01086 HWM JBT; Jane Haney V ACE Sedgwick 2:13-CV-02429 DCG;l
5:12 CV 10176 JCO RSW; Case 2:12 CV 03048 JFW MRW There is a pending case in Mass. 2:11 CV 12129 GAO, there have been cases trying to get them on “racketeering” but nothing has stuck yet, they are too good and have connections, the affordable care act is really upsetting them, Sedgwick has went into the Medicare Federal System CMS Conditional Payment Recovery and changed my account from 79K owed back to Medicare to 30K. I reported it, they got it corrected back to 79K. Sedgwick went back in again and changed it from 79K to 19K. I have reported it to the inspector General of HHS, for Medicare Fraud. Sedgwick has done this for years, and is now hiring “nurses” to inspect workman comp and track which drugs and prescriptions are given to patients, controlling what the physicians write for paid med,s branching out into controlling the prescription business. They are promoting the fact that people don’t return to work as soon if they are given “opoids” and this is a new position for Sedgwick, the pharmacy division and the liability division. This is a monopoly and is bigger than the banking bust. Its impossible to track and find the culprits, but these big med companies, like HCA, and Romneys companies, were directly involved in this same kind of thing. Its very big. Its very well connected politically from the local level to the top. However, no one has really put it all together yet. Insurance is not federally regulated, so it is easier to fly under the regulations radar, and these cases with workman comp are handled through different legal systems, with judges that are administrative judges, and they have these physicians “parked” with these judges, paid by Sedgwick to deny workman comp. Seems to me like they are taking over insurance, making sure the government gets nothing, cheating medicare and Medicaid (but under the disguise of cutting out federal welfare, however, I pay 145 per month for Medicare, 52 per month for drug coverage, I pay 1500 deductible for every hospitalization, I pay 147 per month for hospitalization. Medicare is not free. Sedgwick is cheating me, and America. and moving the money to corporations and holding companies out of Zurich. This is very big and very complicated I have looked at it for 8 months, and I cant track it all , its like an onion, everytime you get one thing, you stumble on something else.

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