Appealing an Illinois Workers' Compensation Denial
Updated By Beth Laurence
If you are an injured worker in Illinois who has been denied workers’ compensation benefits, you can submit a claim to the Illinois Workers’ Compensation Commission (IWCC) and request a hearing in front of an arbitrator. If you've given notice of your injury to your employer (see our article on filing a workers' comp claim in Illinois), but your employee or the employer’s insurance company refuses to pay you medical benefits or compensation for lost-time wages, it’s time to file a claim.
At the arbitrator hearing (which is like an informal trial), the arbitrator (who acts like a judge) can hear both sides of the case and make a decision on whether the employer must accept your workers’ comp claim. (If you've already taken the matter to you’re the IWCC and the arbitrator didn't force the employer to accept your claim, you can appeal this decision to a panel of commissioners—see below.)
Why Workers’ Compensation Claims Are Denied
If your employer is refusing to pay benefits, it must send you a written explanation of why workers’ comp benefits are being denied to you. If it hasn’t, the first thing you should do is contact your employer to find out why it is denying your claim. Or, if you received the notice from your employer but you don't understand it, or you believe that some of the information it contains is incorrect, call your employer. Lack of communication at the beginning can lead to problems.
Employers and their workers’ comp insurance companies deny claims for a number of reasons. If your employer believes that your injury wasn’t work-related (that is, wasn’t caused by activity on the job or didn’t happen during work-related duties), or that your injury doesn’t warrant medical treatment or time off work, or you didn't notify the employer within 45 days, it will deny your claim.
How to Fight a Denial of Your Workers’ Comp Claim
To get your employer to accept your workers’ comp claim after a denial, you’ll need to request a hearing before an arbitrator of the Illinois Workers’ Compensation Commission (WCC). Before you petition for a hearing, however, you need to have filed an Application for Adjustment of Claim, along with a proof or service, stating that you’ve given or mailed a copy of the application to your employer. This form is what files your workers’ comp claim officially with the commission; it can be mailed to dropped off at any commission office. After you have filed the form, you are assigned an arbitrator and case number. (After that, every two months, your case is reviewed in a status call, during which you can either request a trial or state that you are still in settlement negotiations.)
You must file the Application for Adjustment of Claim within three years after your injury (or within two years of the last compensation payment you received, if this date is later), or your denial will be permanent and you will be precluded from getting workers’ comp benefits permanently.
If you haven’t returned to work after your injury, and your employer or its insurance company has not paid you lost-time benefits (temporary disability payments) or medical benefits, you can petition for an expedited hearing (called a Section 19(b) hearing). (820 ILCS 305/19(b).) You do so by filing a Petition for Immediate Hearing, and you will get a final decision on whether your claim is denied or accepted, including whether your employer has to pay lost-time or medical benefits, within 180 days of the date of the petition (hopefully sooner). However, if you've already returned to work, and you are owed less than 12 weeks of temporary total disability payments, you are not entitled to an emergency hearing.
You should be aware of the fact that your employer will most likely be represented by an attorney at this hearing. Staff at the Illinois Workers Compensation Commission can answer general questions and provide information, but they cannot provide any advice specific to your case, and they can’t accompany you to a hearing. If you want to be represented at the hearing, you’ll need to hire a workers’ comp attorney.
Before a hearing, you’ll likely need to see a doctor to have your injury or illness evaluated. If either you or the employer disagrees with the evaluation of your treating physician, ether of you can request an independent medical exam (also called a Section 12 examination) by another doctor. (820 ILCS 305/12.)
For all other issues, such as the extent of permanent disability, you request a hearing and a commission arbitrator will set a trial date, which should be within 30 days of the request for a trial. At the trial, the workers’ comp arbitrator will help you and your employer resolve the issue over whether your injury claim should be accepted or denied. The arbitrator will issue a decision within 60 days of the trial.
Appealing the Arbitrator’s Decision
If your workers' comp case went to an emergency hearing or trial at the IWCC, and you’re not happy with the decision made by the arbitrator, you can appeal the decision to try to overturn the arbitrator’s decision. (Note, however, that only 24% of injured workers who appeal an arbitrator’s decision get an increase in benefits on appeal.)
You request an appeal by filing a Petition for Review, which needs to be filed within 30 days of the arbitrator’s decision. The appeal goes to a panel of three commissioners from the Workers’ Compensation Commission (which is also called the Commission). The panel reviews the arbitrator’s decision and sets a hearing date.
Before the appeal hearing, you can submit an argument for your side in writing to the Commission. At the hearing (also called an oral argument), you may argue your case for five to ten minutes. The Commission must issue a decision within 60 days of the hearing.
If you disagree with the Commission’s decision, you can appeal the decision to the Circuit Court, then the Appellate Court, and possibly even to the Illinois Supreme Court. (However, for Illinois state employees, the Commission’s decision is final (that is, no further appeal is allowed). You’ll need the help of an Illinois workers’ comp attorney to file an appeal past the initial petition for review.