Big Overview of Medical Benefits Under the Illinois Workers' Compensation Act

While I’ve discussed medical benefits countless times on this blog, it’s been a while since I’ve done a larger post on what you can and can’t get.  First off, it’s important to know that you are entitled to payment of 100% of any bills for medical care related to your work injury as long as the treatment is reasonable and related to your job accident.

Reasonable means that it’s not experimental and is generally accepted by the medical community. So MRIs, X-rays, physical therapy, etc. would be reasonable.  Healing stones, excessive chiropractic treatment, non-FDA-approved surgery, etc. would not be reasonable.

Related means that the treatment is related to your job accident. This is usually straightforward, but not always.  If you hurt your back then obviously physical therapy for your back problem would be related and covered.  If you also have a foot injury from falling at home, it likely wouldn’t be covered, unless you can show that something about the job accident made you fall at home. This usually happens when someone is on crutches or is otherwise having trouble getting around. The other unique scenario is if you need weight loss surgery before having back surgery.  Even though your weight isn’t likely job-related, it can be argued that the work injury made it worse and that you can’t recover without it. So at times, you can get that type of treatment paid for.

When we say 100% payment, this means no co-pays and no out-of-pocket expenses. It also means you can’t be billed for payments that aren’t made. If the bill is $2,000 and the insurance only pays $1,200, the medical provider can’t come after you for the remaining $800.  That’s illegal under Illinois law. In fact, there is a schedule as to how much each type of procedure should cost and medical providers can’t create their own prices.

I often get asked what are examples of specific treatments that are covered. Some are obvious and others aren’t.  This list includes:

• First aid on the scene of accident and EMT charges.
• An emergency room visit.
• Treatment in the hospital if you get admitted.
• Follow-up care with your doctor.
• Physical therapy treatment.
• Diagnostic tests such as MRI’s, CT scans, EMG’s, and others.
• Surgery and surgical center charges.
• Medications.
• Helpful devices such as crutches, knee scooters, and wheelchairs when needed.
• Gym memberships if prescribed by a doctor for strengthening or rehab.
• Modifications to your home if required such as putting in a wheelchair ramp.
• A car (usually for workers who become paralyzed) and need a special accommodation.
• Pain management.
• Vocational rehabilitation.
• Work hardening.
• Functional capacity examinations.
• Re-training for new jobs within your restrictions.

What you can’t do is doctor shop to as many doctors as you like.  The law changed in 2011 which allowed employers to set up what is known as a preferred provider program or PPP. Very few companies have done this, but when they do, you have to choose your doctor from a list that they created and has been approved by the Illinois Department of Insurance.  Everyone else, which is most workers, can choose any doctor they like, but there is one big thing to be aware of.

You are entitled to two “chains of referrals” for your medical care.  What that basically means is that if you go to your family doctor and they think you need to see an orthopedic doctor, you should get a written referral.  If the orthopedic doctor wants physical therapy, you also should get a written referral. As long as they are all making referrals, it’s considered one chain. If your orthopedic doctor wants you to have surgery, you are entitled to a second opinion. If he makes that referral for you, it’s still part of that first chain. If you do this on your own, it starts a second chain.  You can start treating with that doctor and as long as they make referrals, it’s still the second chain. But if you go on to a third chain, you are responsible for those bills.

So to be safe, always ask for a referral, and don’t be afraid to hurt your doctor’s feelings.  The people that get in trouble in these situations are usually those who are doctor shopping or get fired by their doctors for being difficult patients.  Going outside the two chains can really blow up a case and be a financial hardship.  It’s important to note that first aid and emergency treatment typically don’t count as one of your two choices. Also, if your employer sends you to a company doctor that also is not usually one of your two chains.

There is no time limit on how long you can treat for an injury. While most injuries plateau or get better, some can require a lifetime of care.  This is usually someone with a major injury who needs ongoing pain management or a worker who had hardware put in their body that may have to come out at some point in the future.

Under Section 12 of the Illinois Workers’ Compensation Act, your employer or their insurance company can schedule you for a one-time medical exam called an independent medical examination or IME. It’s a doctor of their choosing that is not there to provide you care or look out for you. They are there to offer an opinion as to whether or not your injuries are work-related and what treatment you need.  The employer/insurance company has to schedule this exam at a reasonable time and place and pay for your travel expenses to get there. I highly recommend that you talk with a lawyer before going to one of these exams. Many of these doctors are hired guns and write similar reports on a lot of their cases.

We encourage injured workers to focus on their health above all else when it comes to their cases. If their benefits are denied or delayed, you can use your group insurance if needed. We don’t like that route and if you do that we highly recommend that you keep receipts of payments. At some point, especially if the case goes to trial, we can get the group insurance reimbursed.

By Mike Helfand

Courtesy of Illinois Workers Compensation

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