Preparing to appeal a workers’ comp denial
Generally, workers who are injured on the job in Illinois are entitled to benefits, including disability and coverage of required medical treatment, under the Workers’ Compensation Act. There are cases, however, in which an employer may refuse to pay for workers’ compensation benefits. Employers may deny workers’ injury claims for any number of reasons, including failing to prove that an injury arose “out of and in the course of employment” or failing to report the injury to the employer within 45 days of the accident.
Filing a claim
When an employee, who feels they are eligible for coverage, has their claim denied, they have the ability to file an appeal with the Illinois’ Workers’ Compensation Commission. The first step for many should be to determine the reasoning for the denial. The employer should provide a written explanation, but if they do not, the employee should contact the employer for clarification.
Next, an injured worker must file an Application for Adjustment of Claim with the IWCC. By law, this must be done within three years of the date of injury and include proof of service affirming that the employer has received a copy of the application. Once the application has been filed, the Commission will assign an arbitrator who will conduct service calls with both the employee and their employer every three months to monitor negotiations. During those calls, either side has the right to request a trial.
Going to trial
If the two sides are unable to reach a settlement and a trial is requested, the injured workers are responsible for proving that they are eligible to receive benefits. This may include proving the following:
- The employer was under the jurisdiction of the state’s workers’ compensation and occupational disease laws at the time of the incident.
- The worker was legally employed on the day the injury was sustained by the employer.
- The injuries resulted from a workplace accident, or an illness from exposure to an occupational disease, and the accident or exposure was either caused or resultant from employment.
- The accident or disease exposure either directly caused or aggravated the injury.
- The employee notified the employer of the injury within the time allowed.
Other factors that may be disputed include the average weekly wage, the necessity of medical treatments or the level of a worker’s disability. According to the Handbook on Workers’ Compensation and Occupational Diseases from the IWCC, the Commission’s arbitrator “will conduct a trial, relying on Illinois law, rules of evidence, precedent set by previous workers’ compensation cases and the Rules Governing Practice Before the Commission.”
The guidelines for filing a workers’ compensation appeal are strict and the process can be complicated. For anyone who has been injured in a workplace accident and had their claim denied by their employer, it could be helpful to obtain legal representation.