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14 Signs of Trouble in Your Illinois Worker's Compensation Case

It is difficult to predict at the outset which cases will result in the injured worker having problems being treated fairly throughout the course of his claim and receiving his benefits, but there are some warning signs that have over time shown to be strong predictors that there will be problems over the course of the case:

• Employer does not have worker’s compensation insurance

Even though worker’s compensation insurance is mandatory, there are a small number of employers who do not carry the required insurance. This does not change the employer’s liability to pay benefits, including the ongoing medical care and TTD benefits. Many employers do not have ready cash set aside for these kinds of costs, especially the ones who do not pay for worker’s compensation insurance.

• Employer suggests that you lie about what happened

Some employers will suggest to injured workers that you tell the doctor that you were hurt in some way other than what actually happened so that your health insurance will pick up the tab for your medical care or to avoid problems with OSHA. The problem with going along with this plan is that you create a record which shows that you have an injury which is not work-related and therefore jeopardizes your rights to any worker’s compensation benefits.

• Employer claims that injured worker is an “independent contractor”

The only way that there is an obligation to pay worker’s compensation benefits is when there is an employer-employee relationship. Sometimes, there is a legitimate independent contractor relationship, but other times employees are called independent contractors mostly for the purpose of dodging obligations that employers owe to their employees such as Social Security and unemployment taxes. This does not bode well for benefits being paid in a timely way to people who are truly employees, but are called “independent contractors”.

• Worker has an “off the clock” injury

“Off the clock” injuries include those that happen while at lunch or on break, coming and going from work, in employee parking lots, or during business travel. These may actually be covered by worker’s compensation, but insurance companies commonly deny claims because where the injured worker is “off the clock.” The scope of coverage is much broader than injured workers realize, and sadly, many workers take these denials at face value.

• Injured worker has a repetitive trauma injury such as carpal tunnel syndrome

Some injuries are very clearly related to work such as when you fall and break and ankle. Repetitive trauma injuries such as a carpal tunnel syndrome are covered by worker’s compensation, but they are harder to prove and require good medical evidence to establish. Insurance companies frequently deny claims for repetitive trauma injuries or put the injured worker’s medical file through extensive investigation and evaluation in order to find a basis for denying the claim.

• Injured worker needs extended period of time off work

When an injured worker is required to be off work for an extended period of time, this is an expensive claim for the insurance company. This invites additional levels of scrutiny from the insurance company as it tries to find a way out of paying the benefits the injured worker is entitled to.

• Injured worker has prior injuries or claims

If you have been previously injured, especially to the same part of the body as the current accident, this raises the index of suspicion on the part of the insurance company and increases the chance that your case will be subjected to increased scrutiny and will have difficulty getting prompt payment of the benefits you are entitled to. If you have previous claims, even if the injuries were not your fault or involved a different body part, the adjuster may regard you as a “frequent filer” whose previous experience with worker’s compensation claims allows you to game the system to gain benefits you don’t deserve. The net result: problems, headaches, and difficulty for you.

• Treating doctor orders expensive care like injections, MRI, or surgery

When your doctor orders treatment or testing that carries a large price tag, that changes the game for the insurance company. It means that they are likely to end up paying more money over the life of your claim, and as a result, they are likely to try harder to limit the costs of your claim by denying or delaying the payment of benefits or the authorization to receive medical care.

• Errors in computing TTD checks

We discuss earlier how important the Average Weekly Wage was for your case: it determined the amount that you receive while you are off work as well and it also forms the basis for your settlement for permanency. If your TTD check is light, that means that there is a potential error in calculating your Average Weekly Wage which could cost you thousands of dollars over the life of your case.

• TTD checks arrive late

Late-arriving TTD checks are often a sign that the insurance company is having your file reviewed and are considering cutting off benefits. Even if they paid your benefits this time, it is likely that your file will be up for consideration again, and if your benefits get cut off, you need to be able to act quickly to get them reinstated.

• Refusal to authorize or pay for medical care

If your doctor has recommended that you receive medical care, it is for one reason: to help you get better. If the insurance company is refusing to pay for it, there is one reason for that also: to save them money. The decision is being driven by what is good for them, not you.

• Worker is sent for an IME

The most important thing to know is that an “independent” medical exam is anything but independent. The doctor that you are sent was selected by the insurance company. Prior to seeing you, the doctor has seen at least some of your medical records, and you be sure that that the insurance company has some idea what he is going to say. Odds are that it will not be favorable to you. Doctors who do these exams charge much more for the exam than a standard office visit, you have to believe that an insurance company would not put out that kind of money if they expected the doctor to deliver a report which helped you and not them. Often, the conclusion to the report is that you do not need surgery, you can go back to work unrestricted duty, or that you do not have a condition which was caused by your work accident. This provides the insurance company with justification for cutting off your benefits. The other item of bad news is that if you do not go to the exam, you will lose your benefits. It may be time to look for some help ….

• Nurse case manager is assigned to case

When an injured worker is off work for an extended period of time and needs ongoing, regular care, the insurance company may assign a “nurse case manager” to your case. The stated purpose of the nurse case manager is to assist you in making a recovery and getting back to work. However, few injured workers find them of any use and they frequently interject themselves in the worker’s medical care in ways which are neither helpful nor appropriate. A nurse case manager is a significant expense to an insurance company, and you can expect that she was hired because she has proven effective in limiting claim costs before.

• Worker needs vocational rehabilitation

There are a few things that are true about cases that call for vocational rehabilitation. One is that the worker has suffered a serious injury and the other is that this will be an expensive claim for the insurance company. Many insurance companies try to undermine the injured worker’s right to vocational rehabilitation by assigning counselors who push the worker into an occupation which they may not be interested in or suited for, and when the worker balks at pursuing a course of action suggested by the counselor, the insurance company cuts off benefits. The job that comes out of vocational rehabilitation will be your career, and you should give serious thought to protecting your future.

The Law Offices of
Barry G. Doyle, P.C.
5215 Old Orchard Road
Suite 710
Skokie, IL 60077
Phone: 312.263.1080
Fax: 312.263.0153

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