Two-Doctor Rule


Two-Doctor Rule

More often than not, we will be contacted by an injured employee who’s employer has already reported their accident to the company’s work comp insurance carrier, and they have already begun treatment with a doctor. One of the first concerns they report to us is that their employer chose their doctor for them, either by “suggestion” or under the misrepresentation that the employee had no choice.

What we make them aware of, is that under Illinois Worker’s Compensation law, if a person is injured in a work-related accident, they have the right to choose their doctor, as well as any other doctors they are referred to, for treatment. Injured workers actually have the right in Illinois to choose up to two doctors. This is commonly known as the “two doctor rule.” Many employers will try to force injured workers to receive their medical care at “company clinics” as part of an effort to keep medical costs down, telling them this is required.

Three points to keep in mind when determining whether or not you are in line with the two-doctor rule:

  1. An emergency room physician is never considered an initial doctor for the purposes of the two-doctor rule;
  2. A doctor on the company premises will rarely be considered an initial choice of doctors;
  3. Doctors at company clinics may be considered an initial choice, but it depends on the degree of “choice” you had in seeing this doctor. If, as noted above, your employer tells you it is required, the company clinic doctor should not be considered one of your choices.

However, if an individual goes to the emergency room following their work-accident, and they are given a referral to a doctor for follow-up, or are referred to their family physician, that first doctor is considered the first choice, or initial doctor. If that doctor then refers them to another doctor for more or different treatment, that second doctor is not considered the second choice, because it is within the “chain of referral.” The “chain of referral” means that the initial doctor can refer him to as many specialists or therapists as necessary to evaluate or treat the injury, as long as it is reasonable and necessary, and those doctors can also refer him elsewhere.

Now, let’s say he disagrees with his family physician, or initial choice, of doctors. He wants to go straight for an MRI, but his doctor wants to refer him to physical therapy first. If he goes to another doctor for a second opinion and without a referral, this second doctor will be considered his second choice. If he goes yet for a third opinion, and without a referral, this will violate the two-doctor rule, and any treatment or evaluation provided by this doctor will not be paid for. He will have to pay out of his pocket or through his private health insurance.

Another thing to keep in mind is that the Illinois Workers’ Compensation Act authorizes employers to create what is known as “Preferred Provider Programs,” sometimes known by “PPP” or “PPO’s.” A Preferred Provided Program is an organization of health care providers such as hospitals, clinics, and medical doctors, who are contracted with the insurer or company to provide health care to the insurer’s or employer’s employees. Under the two doctor rule, if an employer sets up a Preferred Provider Program, then the injured worker only has one choice of doctor and the chain of referrals will stem from this initial doctor.

With Preferred Provider Programs, the injured employee and his attorney should be wary. In an effort to keep insurance costs down, since on the job accidents naturally increase work comp insurance rates, employers very likely could choose a network of medical providers they know will make favorable decisions for them. Translated, this means that a doctor the injured employee chooses from his list of available medical providers may very well tell him his current medical condition doesn’t stem from his work-related injury, that it is caused by something else. If this happens, this could be hazardous, if not life-threatening, to your worker’s compensation claim. Likewise, the network of medical providers will want to keep the employer or insurer happy with their services, and in an effort to do so, “assist” them with their worker’s compensation claims.

This last piece of information is not intended as an encouragement for an employee to distrust his treating doctor if they are under a PPP or PPO, however, they should be aware the potential for this exists. They should also be aware that they may opt-out of the Preferred Provider Program in writing, and to their employer, and then choose his own two doctors.

If you have been injured at work, please contact our office immediately with any questions.