Workers Compensation FAQInformative Workers' Compensation Questions & AnswersWhat is workers' compensation? What is workers' compensation? Workers' compensation is a system of benefits provided by law to most workers who have job-related injuries or diseases. These benefits are paid regardless of fault. Each state has its own workers' compensation law. The Illinois Workers' Compensation Commission administers the program. As the administrative court system, the Commission must be impartial. Staff will explain procedures and basic provisions of the law, but cannot act as an advocate for either the employee or employer. Which employees are covered by the law? Almost every employee who is hired, injured, or whose employment is localized in the state of Illinois is covered by the law. These employees are covered from the moment they begin their jobs. What injuries and diseases are covered under the law? In most instances, the law covers injuries that are caused, in whole or in part, by the employee's work. A worker injured by the repetitive use of a part of the body is covered, as is a person who experiences a stroke, heart attack, or other physical problem caused by work. A worker who had a pre-existing condition may receive benefits if he or she can show the work aggravated that condition. Injuries suffered in employer-sponsored recreational programs (e.g., athletic events, parties, picnics) are not covered unless the employee is ordered by the employer to participate. Accidental injuries incurred while participating as a patient in a drug or alcohol rehabilitation program are not covered. Who should the injured worker notify? The employee should inform the employer promptly. The law requires the employee to notify the employer of the date and place of the accident, if known. Notice may be given orally or in writing. To avoid problems, we recommend the employee give the employer a written notice containing the following items: a) The date and place of the accident; Notice to a fellow worker who is not a part of management is not considered notice to the employer. What are the time limits for notifying the employer? Generally, the employee must notify the employer within 45 days of the accident. Any delay in the notice to the employer can delay the payment of benefits. A delay of more than 45 days may result in the loss of all benefits. For injuries resulting from radiological exposure, the employee must notify the employer 90 days after the employee knows or suspects that he or she has received an excessive dose of radiation. For occupational diseases, the employee must notify the employer as soon as practicable after he or she becomes aware of the condition. What should the employer do after receiving notice? The employer should promptly take the following steps: a) Provide all necessary first aid and medical services;
The law provides the following benefit categories: a) Medical care that is reasonably required to cure or relieve the employee of the effects of the injury; Are workers' compensation benefits considered income? No. Workers' compensation benefits are not taxable under state or federal law and need not be reported as income on tax returns. By law, the employer is responsible for the cost of workers' compensation. Most employers buy commercial workers' compensation insurance, and the insurance company pays the benefits on the employer's behalf. No part of the workers' compensation insurance premium or benefit can be charged to the employee. Other employers obtain the state's approval to self-insure. What does the law require of employers? Employers must: a) Obtain workers' compensation insurance or obtain permission to self-insure; What if the employer won't pay the worker any benefits? The worker or the worker's attorney should contact the employer directly to determine why benefits are not being paid. Poor communication often causes delays and misunderstanding. If the problem persists, the employee should file a claim at the Commission. Please note that an accident report does not trigger any action by the Commission. The Commission gets involved only if the worker files a claim and follows the procedures to request a hearing. Can a worker be fired for reporting an accident or filing a claim? It is illegal for an employer to harass, discharge, refuse to rehire, or in any way discriminate against an employee for exercising his or her rights under the law. Such conduct by the employer may give rise to a right to file a separate suit for damages in the circuit court. An employee with a pending workers' compensation claim may still be disciplined or fired for other valid reasons. What are the time limits for filing a claim? Generally, an employee who fails to file a claim within the time limits loses his or her right to claim future benefits. In most cases, the employee must file a claim within three years after an injury, death, or disablement from an occupational disease, or within two years of the last payment of TTD or a medical bill, whichever is later. Some cases have different deadlines including asbestos exposure, death, occupational disease, pneumoconiosis and radiation exposure. Does the voluntary payment of benefits affect a claim? If the employee accepts benefits, he or she does not give up any rights under the law. Similarly, if the employer pays benefits, it does not waive its right to dispute the claim. Even if a claim is filed with the Commission after some benefits have been paid, the employer still has the right to contest its liability to pay any compensation at all. Does the worker have to hire an attorney to file a claim? No, but in disputed cases, most employees and employers do hire attorneys. If the worker does not hire an attorney, it becomes the worker's responsibility to keep track of the claim, appear at hearings when necessary, and present evidence at hearings that proves his or her eligibility under the law. Arbitrators and commissioners must be neutral. They cannot act as an advocate for the worker or for the employer. The Commission cannot recommend attorneys. What must the worker do to receive benefits? It is the worker's responsibility to prove he or she is eligible for benefits. The employer does not need to disprove a worker's claim. By law, the burden of proof rests with the employee. Some of the main issues in a workers' compensation case are listed below. The employee must prove all of them to qualify for benefits. a) Jurisdiction: on the date of the accident, the employer was subject to the Illinois Workers' Compensation or Occupational Diseases Act. If the worker prevails on these issues, he or she will generally qualify for some benefit, but there may be other issues in dispute: for example, the parties may disagree over the extent of the worker's disability, or the worker's average weekly wage, or whether the medical treatments and/or bills were reasonable and necessary, or whether the worker is entitled to penalties, etc. An arbitrator of the Commission will conduct a trial, relying on Illinois law, rules of evidence, precedents set by previous workers' compensation cases, and the Rules Governing Practice Before the Commission. A court reporter will make a record of the hearing. Except for emergency hearings, an arbitrator cannot resolve a case until the worker has finished healing. Once the worker has healed, the parties need to prepare the case for trial by obtaining medical records, doctors' depositions, and other paperwork. By the time everything is ready for trial, it is not uncommon for one to two years have passed. Once everything is ready for trial, the arbitrator will schedule a trial within the month that the parties request it. After the trial, the arbitrator will issue a decision within 60 days, stating the amount of benefits, if any, to which the employee is entitled. Is it possible to appeal the arbitrator's decision? Yes. The employee and the employer each have the right to appeal a decision if dissatisfied. A panel of three commissioners (usually called the Commission) will review the arbitrator's decision, as well as the evidence and transcript of the trial. Both sides may submit written arguments to the Commission. The Commission will then conduct a hearing (called an oral argument) at which the parties may present a brief, 5-10 minute argument for their position. Within 60 days of that hearing, the Commission will issue its decision. While an appeal is pending, the employer does not have to pay the benefits awarded by the arbitrator. If the case is ultimately resolved completely in the worker's favor, interest will be added to the award, based on governmental bond rates at the time of the decision. There is also a 1% per month interest charge on medical bills, payable to the medical provider. Commission decisions are final for cases involving employees of the State of Illinois. In all other cases, either party may appeal to the Circuit Court, the Appellate Court, and in some cases, to the Illinois Supreme Court. What medical benefits are covered under the law? The employer is required to pay for all medical care that is reasonably necessary to cure or relieve the employee from the effects of the injury. This includes but is not limited to first aid, emergency care, doctor visits, hospital care, surgery, physical therapy, chiropractic treatment, pharmaceuticals, prosthetic devices, and prescribed medical appliances. The cost of devices, such as a shoe lift or a wheelchair, may be covered. If the work injuries result in a disability that requires physical modifications to the worker's home, such as a wheelchair ramp, the employer may have to pay those costs, as well. Who pays for the medical care? If the employer does not dispute a medical bill, it will pay the medical provider directly. The worker is not required to pay co-payments or deductibles. If the employer disputes a bill, it must promptly give the worker a written explanation for its refusal. While a case is pending at the Commission, the provider cannot try to collect payment from the employee once the employee notifies the provider that he or she has filed a claim with the Commission to resolve this dispute. The provider may send the employee reminders of the outstanding bill, and ask for information about the case (e.g., case number, status of case). If the employee does not provide the information within 90 days of the date of the reminder, the provider may resume its efforts to collect payment. Can the employee choose the treating doctor or hospital? Yes, but there are limits. The employee is entitled to choose two medical providers and any other providers to whom the employee is referred. That means an employee may initially choose any doctor or hospital, even if the provider is outside the employee's regular insurance network, and go to any doctor to whom the employee is referred by that provider. If desired, the employee may then choose another doctor or hospital, and again go to any doctor to whom the employee is referred by the provider. Generally, if the employee chooses a third doctor without the employer's approval, the employer is not required to pay for those services. First aid and emergency care are not considered to be one of the worker's two choices. As long as the worker stays within the limits on choice of provider, will the employer then pay for all medical care? A utilization review organization may review the employee's past, present, and future medical treatments related to the work injury, and analyze the necessity of those treatments. The Commission will consider this utilization review findings, along with all other evidence, when determining whether a treatment was reasonably necessary. If the Commission finds a medical treatment was not reasonably necessary, it will not order the employer to pay the bill, and the employee may be responsible for it. What are the worker's responsibilities regarding medical care? The worker should take the following steps: a) Seek first aid or medical attention immediately after the injury or the point at which gradual symptoms first begin affecting physical activities at work or at home. (Under some circumstances, the employee may rely upon treatment by prayer or spiritual means alone.) b) Cooperate with the doctors and make efforts to achieve a complete recovery and full return to work, if possible. A worker may lose benefits for injurious or unsanitary activities. c) Tell the medical providers that the treatment is for a work-related condition. This lets the providers know that the employer is responsible for the medical bill. d) Give the employer the name and address of the doctor or hospital chosen. If the employee changes providers, the employee should again notify the employer. The employee must also give the employer enough medical information for the employer to determine whether to accept or deny the claim. This includes all medical records relevant to the condition for which benefits are sought. A worker is not required to give anyone free access to his or her doctor or medical records, however. The employer is not required to provide benefits if it does not receive the medical information necessary to determine the worker's medical status and fitness to work. If the employee's doctor does not send medical records to the employer, benefits may be delayed. Does a worker have to allow employer-hired case managers to manage his or her care? No. A worker may, without penalty, refuse or limit the involvement of nurses or case managers hired by the employer. The employee is obligated to provide medical records that are relevant to the case, but otherwise a worker's medical care is confidential. Can the employer ask for an evaluation by its own doctor? Yes. On occasion, the employer may request a full medical exam by the doctor of its choice. When the employer gives the employee notice of the place and time of the exam, it must at the same time give the employee money to cover travel expenses, meals, lost wages, etc. The exam must be held at a reasonable time and place. The worker must undergo the exam, but he or she need not accept any treatment from the employer's doctor. The employer's doctor must give both parties the same report of the exam as soon as practicable, but not less than 48 hours before an arbitration hearing. The worker is also entitled, upon request, to a copy of all relevant medical records in the employer's possession. What is temporary total disability (TTD)? TTD is the period in which an injured worker is either temporarily unable to return to any work, as indicated by his or her doctor, or is released to do light-duty work but whose employer is unable to accommodate him or her. The employer pays TTD benefits to an injured employee until the worker has returned to work or has finished healing. What is temporary partial disability (TPD)? TPD is the period in which an injured employee is still healing and is working light duty, on a part-time or full-time basis, and earning less than he or she would earn in the pre-injury job(s). The employer pays TPD benefits to an injured employee until the worker has returned to his or her regular job or has finished healing. What is permanent partial disability (PPD)? PPD is: a) The complete or partial loss of a part of the body; or "Loss of use" is not specifically defined in the law, but it generally means the employee is unable to do things he or she was able to do before the injury. The Commission cannot make a PPD determination until the worker has finished healing. PPD is paid only if the job-related injury results in some permanent physical loss. What is permanent total disability (PTD)? PTD is either: a) The permanent and complete loss of use of both hands, both arms, both feet, both legs, both eyes, or any two such parts, e.g., one leg and one arm; or b) A complete disability that renders the employee permanently unable to do any kind of work for which there is a reasonably stable employment market. What is vocational rehabilitation? Vocational rehabilitation includes but is not limited to counseling for job searches, supervising a job search program, and vocational retraining, including education at an accredited learning institution. When is the employee entitled to vocational rehabilitation? If the employee cannot return to the pre-injury job, the employer must pay for treatment, instruction, and training necessary for the physical, mental, and vocational rehabilitation of the employee, including all maintenance costs and incidental expenses. The employee must cooperate in a reasonable rehabilitation program. The employee may choose the provider of such reasonable vocational rehabilitation services or may accept the services of a provider selected by the employer. Can a PTD recipient ever work? Generally, no. If an employee who experiences a complete disability (see 1(b) above) returns to work or is able to return to work, the employer may petition the Commission to terminate or modify the PTD benefit. Can an employee receive both PTD and Social Security? Yes, if the employee qualifies under the terms of each program. If an employee receives both benefits, the Social Security Administration will apply a formula that may result in a reduction in the Social Security benefit. These questions, and answers to other workers' compensation questions can also be found at the Illinois Workers' Compensation Commission website: http://www.iwcc.il.gov/. |
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