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Illinois Workers' Compensation Claims Unlikely to Match Fee Schedules

Posted on in Workers' Compensation

Illinois Workers' Compensation Claims Likely Limited to Amount NeededThe Illinois Workers’ Compensation Commission created fee schedules in order to establish the maximum amount of money that may be awarded for different medical expenses in a workers’ compensation claim. The commission determined the maximum amounts by using the fees that were in the 80th percentile for a medical service and taking 90 percent of that amount. The fee schedules are divided into geographic regions and annually updated based on the Consumer Price Index. Categories of medical expenses include:

  • Procedures and treatments;
  • Hospital inpatient and outpatient fees;
  • Emergency room fees;
  • Rehabilitation services;
  • Medical prescriptions;
  • Dental services; and
  • Professional services.

Though fee schedules establish how much a workers’ compensation claimant may receive, the IWCC is unlikely to award more than what is needed to pay for a claim.

Recent Case

In Perez v. Illinois Workers’ Compensation Commission, a workers’ compensation claimant was appealing an IWCC decision to not award the fee schedule amount of $37,767.32 to pay for her medical expenses. The claimant had slipped on a wet floor at her job and suffered a lateral meniscal tear in her left knee, requiring surgery and physical therapy. The IWCC order her employer to pay $17,857.96, based on payments made by the insurance of the claimant’s husband and out-of-pocket copayments. Circuit and appellate courts both ruled that awarding the fee schedule amount would give a financial windfall to the claimant that goes beyond what is needed for her medical expenses.

Negotiated Rate

In the recent case, the plaintiff claimed that the IWCC should not have allowed the employer to pay the lower rate that the plaintiff had negotiated with her husband’s insurance. The plaintiff said that the employer can pay a negotiated lower rate only when it or its insurance provider has negotiated the rate. However, the appellate court ruled that the law does not contain such limiting language in determining what an employer must pay. The Illinois Workers’ Compensation Act states that an employer must pay:

  • The negotiated rate;
  • The actual medical expenses; or
  • According to the fee schedule.

The negotiated rate may be reached with an employer or insurance carrier, but the law does not specify that it must be the employer’s insurance carrier. In any case, the IWCC will use a lower negotiated rate instead of the maximum fee schedule.

Receiving Appropriate Compensation

Employers and their insurers often try to avoid paying the proper compensation for a workplace injury. A McHenry County workers’ compensation attorney at Botto Gilbert Lancaster, PC, can help you obtain the payments you need for your medical expenses and lost income. To schedule a free consultation, call 815-338-3838.



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