Illinois Workers’ Compensation Claim Denied?

The Insurance Company Does Not Get the Final Word

By Dan & Shaun Cusack, Attorneys at Law

You got hurt doing your job. Now you are dealing with pain, medical appointments, lost wages, and uncertainty about how you are going to support yourself and your family.

Then the workers’ compensation insurance company denies your claim, refuses treatment, or stops your checks.

Do not assume that means your case is over. It does not.

The insurance company does not decide whether you are legally entitled to workers’ compensation benefits. In Illinois, disputed claims are decided through the Illinois Workers’ Compensation Commission.

An insurance carrier can refuse to voluntarily pay you. It can dispute your accident. It can deny medical treatment. It can send you to a doctor of its choosing. But the insurance company does not get the final word on your rights.

At Cusack & Gilfillan LLC, we represent injured workers throughout Central Illinois and the Midwest, including Peoria, Bloomington-Normal, Pekin, East Peoria, Morton, Washington, Metamora, Eureka, Pontiac, and surrounding communities.

Why Did the Insurance Company Deny Your Claim?

Insurance companies deny workers’ compensation claims for many reasons. Sometimes there is a legitimate factual or legal dispute. Other times, the carrier simply interprets the evidence in the way most favorable to its position.

Common reasons for denial include claims that:

• The accident never happened
• Your injury was not caused by your work
• You reported the accident too late
• Nobody witnessed the accident
• Your first medical records do not mention work
• Your problem was caused by a preexisting condition
• Your treatment or surgery is unnecessary
• You are capable of returning to work
• The insurance company’s doctor disagrees with your treating physician

The carrier may also accept part of the claim while fighting the benefits that matter most. It may admit that you were injured at work but refuse to authorize surgery. It may pay medical bills but cut off your temporary total disability (TTD) checks while your doctor still has you off work.

The important question is not simply whether your claim was “denied.”

It is: What exactly are they refusing to pay, and what evidence are they relying on to justify it?

A Denial Letter Is Not a Court Order

This is one of the most important things an injured worker should understand.

An insurance company denial is the insurance company’s position. It is not a ruling from an arbitrator or judge.

Do not automatically assume the stated reason is supported by the evidence. A denial may be issued before the carrier has obtained all of the medical records, spoken with witnesses, understood your actual job duties, or heard your side of what happened.

You have the right to challenge that position.

Do Not Let a Denial Stop Your Medical Care

A denied claim does not make your injury disappear.

Continue obtaining medically appropriate treatment. Make sure your doctors know how the injury happened, what your job requires, how your symptoms developed, and what activities you can and cannot perform.

Your medical records can become some of the most important evidence in your case.

If your doctor believes you cannot work, make sure your work restrictions are documented. If surgery or other treatment is recommended, make sure the medical records explain why.

One of the worst outcomes is allowing an insurance-company denial to force you into abandoning medically necessary treatment and then having the carrier later point to the treatment gap as supposed evidence that you were not seriously injured.

If the workers’ compensation carrier refuses to authorize care, talk to an attorney about your options.

Preserve the Evidence Before It Disappears

A denied claim is often won or lost on evidence.

Depending upon the dispute, important evidence may include:

• Accident reports
• Photographs and video
• Witness information
• Text messages and emails
• Communications with supervisors
• Work schedules and time records
• Job descriptions
• Medical records
• Work-status notes
• Wage statements and pay stubs

For repetitive-trauma injuries, evidence concerning how often you performed the work, how physically demanding it was, and how your symptoms developed over time can be especially important.

Do Not Let the Employer Rewrite the History of Your Accident

Illinois generally requires notice of a work accident as soon as practicable and no later than 45 days after the accident, subject to exceptions and special rules.

If you told a supervisor, manager, foreman, HR representative, or another appropriate person about the injury, write down:

• Who you told
• When you told them
• Where the conversation happened
• What you said
• Whether anyone else heard the conversation

Notice does not always have to be in writing. But when an employer later claims, “You never told us you were hurt,” documentation and witnesses become important.

A dispute over notice should be addressed quickly, but an employer’s denial that notice occurred does not automatically end your case.

What Benefits Could the Insurance Company Be Withholding?

An Illinois workers’ compensation case can involve much more than payment of medical bills.

Depending upon the circumstances, benefits may include:

• Medical treatment for the work injury
• Temporary total disability (TTD) while you are unable to work
• Temporary partial disability (TPD) while working reduced hours or at lower earnings
• Permanent partial disability (PPD)
• Permanent total disability (PTD)
• Vocational rehabilitation
• Wage differential benefits when you cannot return to your former occupation and suffer a loss of earnings

An insurance company may pay one category while aggressively disputing another.

That is why a worker should not assume, “They paid some of my bills, so everything must be fine.”

The Insurance Company’s Doctor Is Not Your Treating Doctor!!

The carrier may send you for what is commonly called an “independent medical examination,” or IME.

Understand what is happening: the insurance company selected and paid the physician to evaluate you for the claim. And they will get what they pay for…

Attend the examination when required. Be cooperative and truthful. Describe your symptoms accurately. Do not exaggerate them, but do not minimize them either.

The IME doctor may disagree with your treating physician about whether your condition is work-related, whether you need treatment, or whether you can return to work.

An unfavorable IME report can lead the carrier to stop TTD or refuse medical treatment.

But an IME report is still evidence—not a final decision.

Your treating doctors’ opinions, diagnostic studies, medical history, testimony, job duties, and other evidence can be used to challenge it before the Commission.

Be Very Careful What You Sign

After a work injury, you may be asked to sign documents that affect rights far beyond a routine workers’ compensation claim.

Be cautious with:

• Resignation agreements
• Severance agreements
• Settlement contracts
• Broad medical authorizations
• Light-duty documents
• Releases of claims

Do not sign away rights you do not understand.

Workers’ compensation can overlap with employment, disability, unemployment, and other legal issues. A document presented as routine may have consequences that are anything but routine.

Illinois law also prohibits an employer from retaliating against an employee simply for exercising rights under the Workers’ Compensation Act.

If your treatment at work suddenly changes after reporting an injury—discipline, threats, suspicious schedule changes, hostile comments, or pressure to drop the claim—document what is happening.

What If the Insurance Company Stops Your TTD?

A carrier’s decision to stop your temporary disability checks can put enormous financial pressure on you.

But stopping the checks does not necessarily mean the carrier was legally justified in doing so.

If your treating doctor continues to keep you off work or gives restrictions your employer cannot accommodate, the medical evidence supporting your disability needs to be reviewed immediately.

Do not simply assume the insurance company must be right because the checks stopped.

Workers’ Comp Benefits Denied or Cut Off? Talk to Shaun or Dan Cusack

If the insurance company denies your claim, refuses your medical treatment, or stops your disability checks, you do not have to accept its decision as the final answer.

Shaun Cusack and Dan Cusack of Cusack & Gilfillan LLC represent injured workers throughout Central Illinois, including Peoria, Bloomington-Normal, Pekin, East Peoria, Morton, Washington, Metamora, Eureka, Pontiac, and surrounding communities.

We represent injured workers—not workers’ compensation insurance companies.

We can determine why your benefits were denied, obtain and develop the medical evidence, challenge unfavorable IME opinions, preserve evidence, pursue unpaid benefits, and take the dispute before the Illinois Workers’ Compensation Commission when the carrier refuses to do what the law requires.

If your workers’ compensation claim has been denied, your treatment has been refused, or your TTD checks have been stopped, contact Shaun Cusack, Dan Cusack, or the attorneys at Cusack & Gilfillan LLC for a free consultation.

The insurance company has lawyers and adjusters protecting its interests. You should know who is protecting yours.

This article provides general information and is not legal advice. Workers’ compensation benefits and deadlines depend upon the particular facts of each claim. Reading this article does not create an attorney-client relationship.