If you become injured as a result of a work injury in Illinois, the first benefit to which you will be entitled under the Illinois Workers’ Compensation Act will be medical treatment. Immediately after an injury, an employee is usually taken to an emergency room or a clinic mandated by the employer, where an initial diagnosis and treatment recommendation are made and work restrictions are possibly given. What happens next is up to the injured worker. If you are not aware of your rights at this time, then your remaining medical benefits could be jeopardized.
The Workers’ Compensation Act allows for an injured worker to select their own medical provider for their treatment. The employer cannot dictate where this treatment occurs. Under the Act, medical treatment shall be paid by the employer with no expense, co-pay or deductible to the injured worker. Medical treatment is paid for by the employer for all medical treatment that is reasonable and necessary and causally connected to the work injury. Treatment is covered under the Act until the employee reaches maximum medical improvement or MMI. This happens when no further medical treatment would be of benefit to the injured worker and the worker is discharged from the treating doctor’s care.
An employer may attempt to limit the amount of medical treatment by denying requests from a treating doctor for certain treatment. An employer can only do this if it has a reasonable basis to do so. Absent an argument about the injury, this usually occurs if the employer obtains a medical opinion that the treatment is not causally connected to the injury or that the medical treatment is not reasonable and necessary. The first and quickest method to obtain such an opinion is to have a Utilization Review performed. In such a review, a doctor or nurse can review the medical record and make a determination that the recommended treatment is not certified. If such a determination is made, there is a mechanism under the Act by which the treating doctor and the reviewing doctor can conduct a peer-to-peer review to attempt to resolve any disputes.
A more in-depth examination can be requested by an employer if they choose to send the injured worker to an Independent Medical Examination (IME). In such an exam, the injured worker is sent to a doctor (paid for by the employer) for evaluation only. After this exam, the IME doctor will prepare a report and if the findings are favorable to the employer, then it will use this report to deny further treatment. If the IME doctor’s opinion is in conflict with the treating doctor’s opinion, then an emergency hearing might be necessary. Depending on the attorneys involved in the case, this may be resolved short of having to go through the hearing process, or the full hearing may be necessary. The individual facts and circumstances of each matter will dictate exactly how to handle the situation.
The bottom line is that the best outcome for an injured worker is to receive appropriate and timely medical treatment so that a return to work occurs as quickly and safely as possible. Decisions made by the injured worker from the beginning of medical treatment to the end are vitally important to make sure that all rights and benefits are protected. Unless the injured worker is well versed in the operation of the Workers’ Compensation Act, a knowledgeable attorney can be invaluable to provide advice and counsel throughout this process. If you or someone you know is injured and going through this process, we can help.
Brian Cichon has over 20 years of experience practicing law in northern Illinois. He and the attorneys of McNamara Phelan McSteen, LLC are ready to help you now.