Excerpts from the Illinois Handbook on Workers' Compensation and Occupational Diseases
http://www.iwcc.il.gov/handbook.htm
SECTION 5: Medical Benefits
1. What medical benefits are covered under the Act for work-related injuries?
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 employee's home, such as a wheelchair ramp, the employer may have to pay those costs as well.
2. Who pays for the medical care?
If the employer does not dispute a medical bill, it will pay the medical provider directly. The employee is not required to pay co-payments or deductibles, unless the service is covered under a group health plan.
3. Can a doctor send the employee a bill for the medical care for a work-related injury while a case is pending at the Commission?
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. This is a practice known as "balance billing." The provider may send the employee reminders of the outstanding bill, and ask for information about the case such as the case number and 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.
4. Can the employee choose a doctor or hospital from which to receive treatment?
Generally, the employee may choose the provider where he or she seeks treatment. However, there may be some limitations both on the number of providers seen by the employee or on which particular providers that an employee may choose. The employee must choose carefully so that he or she does not end up becoming personally responsible for medical bills.
The employee's choice of provider will be limited to a selected network of providers if an employer has established what is called a Preferred Provider Program or "PPP." If there is a PPP, the employee has a choice of two physicians from the network within the PPP.
If an employer does not have a PPP, then the employee has a choice of any two providers. This does not include referrals from those two providers. First aid and emergency care are not considered to be one of the employee's two choices. Nonemergency care obtained before the employee reports the injury to the employer does not count as one of the two choices.
5. How will an employee know if their employer has a PPP?
If an employer has established a PPP, it must inform the employee about the PPP in writing on a form that is promulgated by the Commission.
6. Is an employee only allowed to choose providers from the PPP network?
The employee may decline participation in the PPP at any time by sending the employer a written statement. If the employee declines participation, it counts as one of the two choices of medical providers. If the employee declines participation in the PPP, the employee may choose any doctor or hospital, and go to any doctor to whom the employee is referred by that provider. If the employee wishes to see another chain of providers, however, the employer must approve.
7. What if the employee believes the PPP or the second choice of provider is providing improper or inadequate medical care?
In this situation, the employee may petition the Commission. If the Commission finds the provider's care is improper or inadequate, the employee may choose a provider at the employer's expense.
8. Where can employers obtain the form informing employees about its PPP?
This form is available on the Commission's website at http://www.iwcc.il.gov/forms.htm.
9. As long as the employee stays within the limits on their choice of provider, will the employer then pay for all medical care?
Employers may use other methods under the Workers' Compensation Act to evaluate or challenge the necessity of medical care sought by an injured employee.
An employer may perform what is called a "utilization review," which is a review of 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 the utilization review finding, along with all other evidence, when determining whether a treatment was reasonably necessary.
If the Commission finds that a medical treatment was not reasonably necessary, the employer will not be responsible for paying the bill. The employee is not responsible for any treatment the Commission finds to be excessive or unnecessary. The employee may be held responsible for treatment that is deemed not covered under the Act.
10. What are the employee's responsibilities regarding medical care?
The employee should take the following steps in terms of medical care:
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.
b) Cooperate with the doctors and make efforts to achieve a complete recovery and full return to work, if possible. An employee may lose their eligibility for 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. An employee 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 employee's medical status and fitness to work.
11. What if an injured employee has religious beliefs that prevent him or her from seeking medical treatment?
If an employee and employer agree in writing, and if the employee submits to all physical examinations required by the Act, the employee may, in good faith, rely on treatment by prayer or spiritual means alone in accordance with the tenets and practice of a recognized church or religious denomination. An injured employee who denies treatment in accordance with this provision will not suffer any loss or reduction of workers' compensation benefits.
12. Does an employee have to allow employer-hired case managers to manage his or her care?
No. An employee 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 an employee's medical care is confidential.
While case management is not mandatory, an employee may find the assistance of case management helpful.
13. Can the employer ask for an evaluation of an employee by its own doctor?
Yes. The employer may order a full medical exam by the doctor of its choice. The employer must provide notice of the exam to the employee and the exam must be at a time and place reasonably convenient for the employee. If submitting to the examination causes the employee loss of wages, the employer must provide reimbursement for the wages and also the expense of travel and meals.
14. Can the employee review the examiner's report?
The employer's doctor must give both parties the examiner's report as soon as practicable, but not less than 48 hours before an arbitration hearing.
15. How are prices for medical care determined?
Most treatments that are covered under the Act and were provided on or after February 1, 2006, are subject to a medical fee schedule. The employer shall pay the lesser of the provider's actual charge or the amount set by the fee schedule.
If, however, an employer or insurance carrier contracts with a provider for the purpose of providing services under the Act, the rate negotiated in the contract shall prevail.
The schedule is posted on the Commission's website. Please also refer to the law, rules, Instructions and Guidelines, and the "Medical: Frequently Asked Questions" web page at www.iwcc.il.gov/faqmed.htm.
SECTION 6: Temporary Total Disability (TTD) Benefits
1. What are temporary total disability (TTD) benefits?
TTD is the benefit that an injured employee receives during the period in which the employee is either: (a) temporarily unable to return to any work, as indicated by his or her doctor, or (b) is released to do light-duty work but whose employer is unable to accommodate him or her.
2. How long can an employee receive TTD benefits?
The employer pays TTD benefits to an injured employee until the employee has returned to work or has reached maximum medical improvement or "MMI."
3. How is the amount of the TTD benefit calculated?
The TTD benefit is two-thirds (66 2/3%) of the employee's average weekly wage, subject to minimum and maximum limits. The minimums and maximums for TTD are available in Commission offices and online at www.iwcc.il.gov/benefits.htm.
4. How is the employee's average weekly wage (AWW) calculated?
The calculation of AWW can be complicated and will depend on the facts of each case. Generally, AWW is based on the employee's gross (pre-tax) wages during the 52 weeks before the date of injury or exposure. However, the calculation of AWW may be affected by many different factors, including, but not limited to: if the employee had more than one job at the time of the injury, worked less than 52 weeks, or on a casual basis.
5. Is there a waiting period for TTD benefits?
TTD is not paid for the first three lost workdays, unless the employee misses 14 or more calendar days due to the injury.
6. When is TTD paid?
The employer should make the first TTD payment within 14 days after receiving notice of the injury. Since delays are common, to facilitate the prompt payment of benefits, we encourage the employee to give the employer a written demand for TTD benefits along with the doctor's note.
If the employer does not pay promptly and cannot justify the delay, the employee may petition the arbitrator to order the employer to pay penalties and/or attorneys' fees to the employee. The employer should pay TTD at the same interval the employee was paid before the injury (e.g., weekly or biweekly).
If an employer stops paying TTD before the employee returns to work, it must give the employee a written explanation no later than the date of the last TTD payment. If the employer fails to provide this explanation, the employee may petition the arbitrator to assess penalties and/or attorneys' fees.
SECTION 7: Temporary Partial Disability (TPD) Benefits
1. What are temporary partial disability (TPD) benefits?
TPD is the benefit that may be received during 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 employment. The employer pays TPD benefits to an injured employee until the employee has returned to his or her regular job or has reached maximum medical improvement.
2. How is the TPD benefit calculated?
For injuries that occurred before June 28, 2011, the TPD benefit is two-thirds (66 2/3%) of the difference between the average amount the employee would be able to earn in the pre-injury job(s) and the net amount he or she earns in the light-duty job.
For injuries that occurred on or after June 28, 2011, the TPD benefit is two-thirds (66 2/3%) of the difference between the average amount the employee would be able to earn in the pre-injury job(s) and the gross amount he or she earns in the light-duty job.
Example: An employee was earning $900/week at the time of injury. While the employee was off work and recuperating, the pay for the job increased to $925/week. The employee returns to a light-duty job and earns $500/week.
Pre-injury average weekly wage (AWW) = $900
Current AWW of pre-injury job = $925
Post-injury gross pay = $500
Wage differential = $925 - $500 = $425
TPD = $425 X 66 2/3% = $283.33/week
The minimums and maximums for TPD are available in Commission offices and online at www.iwcc.il.gov/benefits.htm.
3. Who is eligible for the TPD benefit?
Individuals whose injuries occurred on or after February 1, 2006 are eligible to receive TPD benefits.
SECTION 8: Vocational Rehabilitation/Maintenance Benefits
1. 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.
2. 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.
3. What benefit is the employee entitled to while participating in an approved vocational rehabilitation program?
An employee is entitled to maintenance benefits, plus costs and expenses incidental to the vocational rehabilitation program.
4. How is the maintenance benefit calculated?
The maintenance benefit shall not be less than the employee's TTD rate.
5. Who is eligible for the maintenance benefit?
Individuals whose injuries occurred on or after February 1, 2006 are eligible for the maintenance benefit.
SECTION 9: Permanent Partial Disability (PPD) Benefits
1. What is permanent partial disability (PPD)?
PPD is:
a) the complete or partial loss of a part of the body; or
b) the complete or partial loss of use of a part of the body; or
c) the partial loss of use of the body as a whole.
"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 employee has reached maximum medical improvement or "MMI." PPD is paid only if the job-related injury results in some permanent physical loss.
2. What types of PPD benefits are awarded by the Commission?
There are four types of PPD benefits:
a. Wage differential (Section 8(d)(1) of Workers' Compensation Act)
If, due to the injury, the employee obtains a new job that pays less than the pre-injury employment, he or she may be entitled to receive a wage differential award. The wage differential award is two-thirds (66 2/3%) of the difference between the amount the employee earns in the new job and the amount he or she would be earning in their prior employment.
For injuries that occur before September 1, 2011, benefits shall be paid for the life of the employee. For injuries that occur on or after September 1, 2011, benefits shall be paid for five years after the date of the award or until the employee reaches age 67, whichever is later.
An employee may be compensated for either the loss of wages or the permanent disability related to the same injury, but not both.
b. Schedule of injuries (Section 8(e) of Workers' Compensation Act)
The Act sets a value on certain body parts, expressed as a number of weeks of compensation for each part. (See the chart at the end of this section). The number of weeks is then multiplied by 60% of the employee's AWW.
If a body part is amputated or if it cannot be used at all, that represents a 100% loss, and the employee is awarded the entire number of weeks listed on the chart. If the employee sustains a partial loss, the benefit is calculated by multiplying the percentage of loss by the number of weeks listed.
d. Disfigurement (Section 8(c) of Workers' Compensation Act)
An employee who suffers a serious and permanent disfigurement to the head, face, neck, chest above the armpits, arm, hand, or leg below the knee, is entitled to a maximum of 162 weeks of benefits at the PPD rate. The number of weeks is then multiplied by 60% of the employee's AWW.
A scar must heal for at least six months before a hearing to assess the disfigurement can be held. An employee may not collect compensation for disfigurement and the loss of use for the same body part. For example, a person who undergoes carpal tunnel surgery and is found to have experienced some loss of use, may be awarded a benefit based on the body part or on the disfigurement from the surgery scars, but not both.
4. Is an employee eligible for compensation for pain and suffering for a work-related injury?
Employees are not compensated for past pain and suffering, only for the residual pain that is part of the permanent disability.
5. What if the employee's condition changes?
For wage differential benefits where the injury occurred on or after February 1, 2006, if the employee's physical condition changes during the 60 months after the award becomes final, either party may ask the Commission to adjust the award. For all other PPD categories: if the employee's physical condition changes during the 30 months after the award becomes final, either party may ask the Commission to adjust the award.
SECTION 10: Permanent Total Disability (PTD) Benefits
1. 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.
2. What is the PTD benefit?
A claimant who is found to be permanently and totally disabled is entitled to a weekly benefit equal to two-thirds (66 2/3%) of his or her average weekly wage, subject to minimum and maximum limits, for life.
The minimums and maximums for PTD benefits are available in Commission offices and online at www.iwcc.il.gov/benefits.htm.
3. Can a PTD recipient ever work?
If an employee experiences a complete disability that renders the employee permanently unable to do any kind of work, and returns to work or is able to return to work, the employer may petition the Commission to terminate or modify the PTD benefit.
4. Does the PTD benefit amount stay fixed for life?
If a case is decided by an arbitrator, an employee will be entitled to cost-of-living adjustments.
Beginning on the second July 15th after the award became final, the recipient will receive an cost-of-living payment from the Commission's Rate Adjustment Fund that reflects the increase in the statewide average weekly wage during the preceding year. These payments are made monthly.
5. 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.
SECTION 11: Death/Survivors' Benefits
1. What is the burial benefit?
For injuries resulting in death that occurred before February 1, 2006, a benefit of $4,200 is provided to the survivor or the person paying for the burial. For injuries resulting in death occurring after February 1, 2006, the benefit is $8,000.
2. How is the amount of the survivors' benefit calculated?
The benefit is two-thirds (66 2/3%) of the employee's gross average weekly wage during the 52 weeks before the injury, subject to minimum and maximum limits.
The minimums and maximums for the survivors' benefit are available in Commission offices and online at www.iwcc.il.gov/benefits.htm.
3. Who is entitled to the survivors' benefit?
The primary beneficiaries of the survivors' benefit are the spouse and children under the age of 18. If no primary beneficiaries exist, benefits may be paid to totally dependent parents. If no totally dependent parents exist, benefits may be paid to persons who were at least 50% dependent on the employee at the time of death.
4. If the surviving spouse remarries, does this have an effect on eligibility for survivors' benefits?
If there are eligible children at the time of remarriage, benefits will continue. If there are no eligible children at the time of remarriage, the spouse is entitled to a final lump sum payment equal to two years of compensation. All rights to further benefits are extinguished.
5. Does the benefit amount stay fixed for life?
If a case is decided by an arbitrator, recipients of the survivors' benefit will be entitled to cost-of-living adjustments. Beginning on the second July 15th after the award became final, the recipient will receive an amount from the Commission's Rate Adjustment Fund that reflects the increase in the statewide average weekly wage during the preceding year. These payments are made monthly.
