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Credibility Concerns Sink Workers' Compensation ClaimIn the latest of a series of back-and-forth court rulings, an Illinois appellate court denied a woman’s workers’ compensation claim because it believed she had not sufficiently proven that her injuries arose from her work. The case of Rechenberg v. Illinois Workers’ Compensation Commission started with an arbitrator awarding the claimant more than 34 weeks of temporary total disability benefits and medical expenses. The IWCC reversed the decision, which the claimant appealed. A circuit court overturned the IWCC decision, saying it went against the manifest weight of the evidence. The appellate court ruled that the circuit court was mistaken in its decision. The case against the claimant came down to an accident that occurred outside of work and doubts about her credibility.

The Case

The claimant is a nurse seeking workers’ compensation benefits due to a torn shoulder tendon she claims arose out of her work. The woman cited a day at work when she first started feeling severe pain in her shoulder. As part of her job, she was required to reposition patients in their beds. However, she admitted that she first started feeling soreness and discomfort in the shoulder about a month earlier after falling down stairs at home. The woman claimed that the physical demands of her work caused the severity of her injury, even if she had suffered a prior injury. The physician who performed surgery on her shoulder said it is possible that the woman’s lifting motions at work caused an already damaged shoulder tendon to become fully torn. However, a medical examiner for the employer stated that the type of lifting that the woman performed at work could not have caused the injury she suffered.

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Extra Effort Towards Safety Can Reduce Workplace InjuriesFor all the ideas that employers and lawmakers have for reducing workers’ compensation costs, improving workplace safety would be the most effective. Not only would it help prevent the need for workers’ compensation claims, but it could also increase productivity and employee morale. The federal government created the Occupational Safety and Health Act to enforce and encourage greater safety measures in the workplace. In Illinois, the federal Occupational Safety and Health Administration oversees private-sector employers, while the state has its own OSHA to regulate public sector employers. Employers are required to maintain safe working environments for their employees, but further safety measures are often voluntary.

OSH Act Requirements

The OSHA conducts unannounced investigations at worksites in order to check compliance with OSH Act requirements. Employers must take several actions to provide a safe workplace for its employees, including:

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Suing a Third Party for a Workplace InjuryThe Illinois Workers’ Compensation Act was created in part so that injured workers would not need to file personal injury lawsuits against their employers. As long as the employer has workers’ compensation insurance, the employer can cover the worker’s medical expenses without a direct cost to itself. By collecting the workers’ compensation benefits, the worker is not allowed to sue the employer for additional damages. However, an injured worker can file a personal injury lawsuit against a third party who was responsible for the injury. The worker may seek the damages in addition to his or her workers’ compensation.

Benefits of Lawsuits

Workers’ compensation benefits are meant to pay for the medical expenses needed for a worker to reach maximum medical improvement. Workers may also be compensated for lost pay if they are disabled and unable to fully return to work. Workers can receive greater compensation with a personal injury lawsuit because they can also request money for:

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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

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How Utilization Review Affects Workers' Compensation CasesAfter employees are granted workers’ compensation for their workplace injuries, employers and insurance companies may still dispute what medical services the compensation should cover. Workers want treatments that can help them fully recover and regain a quality of life. Insurers want the most cost-effective option that will adequately treat the injury. The two sides may disagree upon which treatments are necessary and which are gratuitous. The Illinois Workers’ Compensation Act allows employers to seek a utilization review to determine whether the medical treatment an employee is receiving is necessary to recover from the injury.

Utilization Review

According to Illinois law, a utilization review evaluates whether the level and quality of medical care in a workers’ compensation case is efficient and appropriate, based on standard practices for treating the injury. When an employer conducts a utilization review, a medical professional can make his or her decision based on:

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