A workers’ compensation insurance company, third-party administrator or any other adjusting company in reality has a conflict of interest. Conflict exists because the company has received the premium from an insured employer or paid for a contract from a third-party administrator. In exchange for that, the carrier or administrator adjusts the claim for the injured worker. The third-party administrator or insurance carrier runs a business, and the goal of the business is to return profits to its shareholders; thus, they invoke all sorts of methods to control the costs of administering the claim.
One way for the insurance carrier to control the claim is to tell the injured worker that he or she must go to the insurance carrier’s selected occupational clinic. In reality, the occupational clinic is a gatekeeper for the insurance company. The doctors there typically have Masters degrees in Public Health, and some of these doctors generally understate the nature of the injury, and recommend an immediate return to work, either in full or restricted duty. These doctors also tend to take an incomplete history, take a simple x-ray—even if an MRI, for example, is needed for proper diagnosis—and fail to make a referral to a specialist, such as an orthopedic surgeon who specializes in sports medicine or in injuries to the specific body part. Instead of a prompt diagnosis, these occupational clinic doctors may prescribe physical therapy, medication, and tell the injured worker to return to their clinic in a few weeks.
The injured worker will then usually get a call from the claim adjuster seeking to take a recorded statement. Essentially, this is used to look for defenses to the claim and to determine whether there’s a history of prior injury to the specific body part. I never advise clients to give a recorded statement to a claim adjuster or any other investigator. In addition, the adjuster may forward an all-encompassing HIPAA authorization that allows them to obtain any records from birth up until the current time regarding any issue. This request is far too broad, and these authorizations should never be signed without the advice of an attorney.
Typically, the adjuster then assigns a nurse case manager whose role in this matter is not of a nurse, per se; she actually acts as a conduit between the doctor, the patient and the claim adjuster, and has been deemed a cost-containment person by the Supreme Court of Illinois. I typically do not allow nurse case managers on any of the claims that I handle because they seem to interfere with the patient-doctor privilege and relationship.
If your injury happened after the 2011 amendments to the Illinois Workers’ Compensation Act, then you should retain legal counsel experienced in workers’ compensation matters. You, as an unrepresented injured worker, do not stand a chance against your employer’s insurance carrier, lawyers and other professionals. With the aid of the right legal counsel, you’ll be able to be directed to healthcare providers who are not controlled by the occupational method of referrals to doctors who have made contracts, typically with the employer or insurance company, to work for less than the fee schedule. In fact, your employer may have what’s called a Preferred Provider Program; if they do, then you should receive a written notice of this fact at the time of your injury, and then this essentially removes one of your two choices of medical care under the law in Illinois.
There are many other sections of the new Illinois Workers’ Compensation Act that have been changed, and tend to favor the employer, giving them more control to determine what, if any, treatment the injured worker will receive, even if he is treating with his own doctor. One tool of control for the insurance carrier is called Utilization Review. This is the mechanism whereby your employer’s representatives will be able to deny, delay and not pay for further treatment or diagnostics being requested by your physician. The only way to cure this problem is to request a hearing before an arbitrator at the Illinois Industrial Commission. You should not do this without legal counsel. In fact, it would have been wiser to call a lawyer immediately after receiving your initial emergency first-aid care following your injury. Regardless of what stage you are in the process, it is in your best interest to at least obtain a free confidential consultation with an experienced Illinois workers’ comp attorney.
Finally, you should be aware that that carrier will attempt to diminish whatever permanent partial disability you have by application of the Sixth Edition of the AMA Guides to the Evaluation of Permanent Impairment. This is a consensus document, meaning that the doctors who wrote this edition reached a consensus on how they would evaluate impairment, which actually has nothing to do with permanent partial disability. An experienced workers’ compensation attorney will be able to guide you and advise you through the various provisions of the 2011 changes to the Illinois Workers’ Compensation Act. In addition, there are currently more changes being proposed by various factions at work in the Illinois Legislature, along with lobbyists, that would make it more difficult for an injured worker to qualify for benefits.