30 Nov, 2023

How Many Workers’ Comp Claims Are Denied in Bloomington?

Author Todd A. Strong
3d illustration of a worker compensation claim with a stamp denied. How many workers' comp claims are denied
3d illustration of a worker compensation claim with a stamp denied. How many workers' comp claims are denied

Understanding Workers' Compensation Claims in Bloomington, IL

Employers in Illinois are required by law to provide workers' compensation insurance to almost all employees who are hired, injured, or whose employment is localized in Illinois. It is estimated that 91% of Illinois employees are covered under the Act.

The Purpose of Workers’ Comp

Workers in Illinois are entitled to receive benefits in case of injuries or illnesses that occur while on the job. This is made possible through workers' compensation insurance, which can cover medical expenses and compensate for lost wages. However, Illinois workers' compensation does not provide coverage for injuries or illnesses resulting from unknown causes. Furthermore, it's mandated by Illinois law that any employers with one or more employees must provide workers' compensation insurance for all their employees.

Benefits of Workers’ Comp

Compensation for work-related injuries is provided by workers' comp. In the event that an employee experiences an injury that is related to work, workers' comp will offer coverage for the following benefits:

Medical Expenses

In case any employees are affected by an injury or sickness that is related to their work, workers' compensation insurance can assist them in covering their medical bills. Medical expenses include the costs associated with hospital visits, surgeries, medications, and any other medical treatment and care required.

Missed Wages

Where employees sustain injuries that require them to take time off for recovery, they may not be able to earn wages during that period. However, workers' compensation can cover some lost wages if the employees miss out on them due to a workplace injury or illness.

Reduced Earnings Capacity

If an employee gets injured and is unable to perform his or her current job or has limited opportunities for future career growth, the worker’s earning potential will decrease. In such a scenario, workers' compensation will provide the employee with financial support to make up for the difference between his or her pre-accident wages and post-accident earnings.

Ongoing Care

If workers suffer injuries, they may require continuous medical attention to recover. Ongoing care expenses, then, could involve visits to the doctor, rehabilitation expenses, medication, surgeries, and other related costs.

Death Benefits

Death benefits are financial assistance provided to family members who have lost the support of the deceased worker. These are typically only available to close relatives, including spouses, children, blood relatives, and other dependents who lived with the deceased employee and relied on the deceased employee's financial assistance.

Disability

In some cases, an employee's injuries can be significant enough to cause partial or permanent disability. Workers' compensation claims typically utilize four different types of disability:

  • Permanent partial disability (PPD) refers to a permanent injury that impedes an employee's ability to perform some work-related tasks, while still having the capacity to perform others. In this case, workers' comp can pay a portion of the difference in wages between what the employee earned before and after the accident. Alternatively, the employee can receive compensation based on the loss of the use of a body part, with the compensation amount depending on the body part affected.
  • Permanent total disability (PTD) provides lifelong financial assistance to employees who have suffered a permanent injury or illness that prevents them from working.
  • Temporary partial disability (TPD) benefits are available to employees who are injured and working in a limited capacity, with the aim of assisting them during their recovery period. To qualify for TPD benefits, the employees must earn less than they would if they were working at their full job capacity. These benefits are provided until the employees can return to their regular job or until they reach maximum medical improvement.
  • Temporary total disability (TTD) allows employees to claim a portion of their weekly wage when they are unable to work entirely due to injuries and need time off to recover. This benefit is provided until the employees are fully healed and able to return to work.

Determining Claim Eligibility

Typically, there are four basic eligibility requirements for workers' comp benefits:

Employer Must Be Covered By Workers' Compensation

Under Illinois laws, all employers are required to provide workers' compensation insurance to their employees. This insurance serves as a compromise between the employer and the employee, which allows the latter to receive coverage for any workplace injuries in exchange for relinquishing the ability to hold the former liable.

You Must Be an Employee to Qualify for Workers' Comp

Not all workers are considered employees and eligible for workers' compensation benefits. Independent contractors, such as freelancers, and consultants, are typically not entitled to these benefits. The rules regarding eligibility can vary from state to state, but generally, courts will assess the level of control a worker has over their work and other details of their working relationship with the company or individual who hired them.

Injury or Illness Must Be Work-Related

If you were doing something for your employer and got injured or became ill, it is considered work-related. For instance, hurting your back while loading boxes at the warehouse, or developing carpal tunnel syndrome while typing. However, it can be challenging to determine if your injuries are work-related in some other situations, such as if you got injured during a lunch break, at a company-sponsored social event, or while playing with your co-workers.

You Must Meet Workers' Comp Reporting and Filing Deadlines

In Illinois, you must report a work-related injury in writing to your employer within 45 days to qualify for worker's compensation benefits. Waiting longer disqualifies you from receiving benefits.

Factors Impacting the Approval or Denial of Workers' Comp Claims

Pre-existing Conditions and Their Impact on Claims

A pre-existing condition refers to any health problem that existed before a work-related injury occurred. It’s important to note that these conditions may have occurred years prior to employment. Examples of pre-existing conditions include herniated discs, carpal tunnel syndrome, and heart conditions.

However, if an employee’s pre-existing condition, such as knee, back, or shoulder injuries, are worsened by a work-related injury, he or she is eligible to file a workers’ compensation claim. The worsening of the condition can be proven using pre- and post-accident medical records, employment records, and witness testimonies.

Importance of Witness Testimonies and Medical Evidence

When it comes to workers' compensation claims, substantial evidence is crucial in determining claim approval. Evidence can include medical or witness testimony.

Medical Evidence

In workers' compensation claims, medical evidence plays a crucial role. It provides essential proof to support the worker's occupational illness or disease claim. Medical evidence can come in various forms, such as diagnostic tests, scans, physicians' reports, and medical records.

Medical evidence can help link your injuries to the workplace accident. Without it, your claim may be denied on the basis that your injuries were due to some other cause or a pre-existing condition.

Witness Testimonies

Witnesses provide testimony or evidence to support an injured worker’s claim, including describing the injury, its nature and treatment. Credible, firsthand witnesses can be vital in establishing the facts of a case, particularly when an insurance company is denying the claim. A workers’ compensation lawyer can help identify witnesses who can support a claim.

Potential Red Flags or Fraudulent Activities Leading to Denial

Fraudulent workers' comp claims can be filed by employees who either claim fake injuries, exaggerate less-serious injuries, or file a claim on an old injury. It's important for employers to be vigilant and identify such fraudulent claims. Some of the red flags that can indicate fraud include:

  • When a workplace injury is reported by the claimant alone, with no witnesses
  • Injuries that supposedly happen just before a weekend, holiday, or on a Friday, but are only reported on the following Monday
  • When the descriptions of the incident leading to the injury conflict with each other
  • Employees with a previous record of making injury claims, especially those who have made several claims across different jobs
  • Injured employees who are difficult to contact when they are supposed to be at home recovering
  • Employees who refuse medical treatment, specifically diagnostic evaluations, to determine the severity of a workplace injury.

Reasons for Workers' Comp Claim Denial

It is not uncommon for workers' compensation cases in Illinois to be denied after the initial application for benefits. Claim denials can be distressing for workers, but it happens quite often. Common workers' compensation denial reasons are failure to seek medical attention, lack of witnesses and evidence, waiting to report the injury, and pre-existing conditions. If you are wondering, “what if my workers’ comp claim is denied?” There is an appeal process.

Tips for Avoiding Workers' Comp Claim Denial

It is essential to know some common mistakes that people make when filing a workers' compensation claim, so that you can avoid them.

Keeping accurate, consistent, and detailed documentation can support your claim and verify your account of the events, ensuring that there is no doubt about what happened.

If you are injured or become ill, seek medical attention promptly. This shows that you take your health seriously. It also creates medical records that can tie your injuries to the workplace accident, preventing insurers from claiming that your injuries were caused by something else.

Both the employee and the employer should thoroughly document and investigate the incident, as well as evaluate the circumstances that led to the employee's condition. You should also collect contact information of witnesses who can corroborate your story.

Above all, it is important for employers and employees to communicate with their insurer and ensure that all parties understand the workers' compensation process, including state laws, statutes of limitations, filing deadlines, and other details that may affect the claim.

Questions to Ask a Workers’ Compensation Attorney

If you're looking for an attorney who knows how to apply for workers’ comp, there are several questions you should ask to make sure he or she is the right fit for your case.

Has He or She Handled Cases Similar to Yours in the Past?

Every compensation claim has unique facts, and a small detail in your case can make it significantly more complicated than others. Knowing if they have handled similar cases will help you judge competence levels. If he or she was successful, there's a high chance yours will be successful too.

Legal Fees and Payment Options

It’s important to know the legal fees and payment options before hiring an attorney. While a law firm may offer you a free consultation, litigation, and other legal services aren't free. Some lawyers charge by the hour, and some others charge on a contingency fee basis. Knowing the legal fees will enable you to determine if you will be able to meet the financial obligations.

How Likely Are You to Succeed in Your Claim?

Sometimes, you may start a claims process only to discover that you were not eligible for workers’ comp benefits. To avoid such situations, it's critical to know your chances of success.

Who Will Handle Your Case?

Sometimes, the lawyer you consult with may pass your case on to another associate to handle. To avoid unpleasant surprises, ensure that you speak with the right attorneys and are satisfied with them.

When considering workers’ comp lawyers to hire, you may also ask those you consult with how many workers’ comp claims are denied. You may find it helpful to work with an attorney who helps you understand your rights, as well as manage your expectations and know how best to move forward in the event your claim for work injury benefits is denied in Bloomington.

About The Author

Photo of Todd A. Strong
Illinois workers’ compensation and personal injury lawyer Todd A. Strong is the founder of Strong Law Offices in Peoria, Illinois. Todd brings considerable legal knowledge, experience, and skill to the table to ensure injured victims throughout the state are treated with respect, dignity, and fairness.