In my practice, we treat patients with a wide range of orthopedic problems, from sports injuries to degenerative disorders to injuries sustained on the job. We have found that some of our patients have questions about various aspects of workers’ compensation. In addition, there are many common misunderstandings about how workers’ comp claims are administered.
First, let me share some basic statistics. According to The National Workers’ Compensation website, over 16,000 workplace injuries or illnesses occur each day in the United States. 98 percent of these are covered under workers’ compensation, a system that was designed to give injured workers access to medical care needed to treat job-related injuries and restore them to their workplace.
Workers’ Compensation Defined
Workers’ compensation, also referred to as workers’ comp or workmans’ comp is a state-mandated—but not state-provided—insurance purchased or self-funded by employers to provide coverage to an employee in the event that he or she is injured on the job. These benefits are paid regardless of fault. In Illinois, although the insurance is provided by the employer, the program is administered by the Illinois Workers’ Compensation Commission.
In addition to covering the employee’s medical expenses for the injury, workers’ compensation also provides for a percentage of your salary to be paid to you during recovery, and pays for related rehabilitative services, such as physical or occupational therapy.
What it Covers
In most instances, workers’ compensation covers injuries that are caused, in whole or in part, by the employee’s work. In some cases, an employee who has a pre-existing condition, and can prove his or her work aggravated that condition, may be eligible for benefits.
Generally, workers’ compensation covers medical expenses incurred as a result of an injury, a wage-loss replacement income (usually two-thirds) and, in some cases, vocational or rehabilitation benefits, such as on-the-job training, schooling or job placement assistance.
There is also the issue of Maximum Medical Improvement (MMI). MMI is a “treatment plateau,” which means the individual has either fully recovered from his or her injury or the condition has stabilized to the point where no medical change can be expected, despite continuing medical and rehabilitative treatment. At the time it is determined that you are at MMI and able to return to work, your compensation benefits will be terminated. If you are unable to return, you may be eligible for other types of partial or permanent workers’ compensation benefits.
How the System Works
Your initial responsibility is to notify your employer of your injury and complete the necessary paperwork. In most cases, this will be your direct supervisor or someone in the human resources department. You will fill out what is referred to as a “first report of injury,” which is required before any benefit payouts can begin. There may be limits on the time you have to notify your employer and file a workers’ compensation claim. A claim cannot be filed unless the employee makes the initial report, and it should be made as soon after the incident or injury as possible or you risk losing some of your rights within the workers’ compensation system. Note that an employer cannot penalize an employee for reporting an on-the-job injury!
Employees have the right to choose their own workers’ comp physician. Although a physician working for or under contract to the employer may examine the patient, the employee’s choice of physician to treat them must be honored. However, before any treatment, such as surgery, is provided, it must be approved through workers’ compensation in order to be covered. In most cases, the insurance company will abide by the physician recommendations, though this approval may cause a delay in your treatment. In addition, the insurance company may request a second opinion, but employees do have the right to seek treatment with their own physician.
Once the report is filed, your workers’ compensation carrier— not your employer or physician—will determine if the claim is valid under the policy. This may involve providing additional information, such as copies of medical records or employer and co-worker statements, if applicable. As the employee, you are responsible for gathering and submitting this information. It is also your responsibility to ensure that any surgery you undergo is pre-certified (if necessary), that the bills are processed in a timely manner and that the account is paid in full.
Remember, the bottom line is that employees have the right to choose the physician who will evaluate and treat them. However, the treatment must be approved by the workers’ compensation carrier. TPW
The content in this article is intended to serve as general information and is not a substitute for legal advice. Please contact your employer or the State of Illinois Workers’ Compensation Commission for specifics to your situation.