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How Do Workers Compensation Claims Work?

Most people know that when they’re injured on the job, they can make a workers compensation claim to get their medical costs covered or payment for temporary or partial disability that leaves them unable to work or to perform the full duties of their job. But most people would probably scratch their heads in confusion when it comes to just how to go about making a workers compensation claim and getting the available benefits.

The process of making a claim can be complicated and steeped in bureaucracy. We offer this explanation in hopes of demystifying some of the claims process. If you’ve been injured on the job, you likely will have questions even after reading this. We recommend talking to an experienced Chicago workers compensation lawyer to get answers about your specific injury and how you should proceed with your claim.

Reporting Your Injury

The first step toward getting workers compensation benefits after your injury is to report your accident. In Illinois, the Workers Compensation Act, 820 ILCS 305, requires that an employee notify an employer of an accident within 45 days. However, the insurance company that provides your employer’s workers compensation policy may have its own notice requirements, so it’s best to report an injury as soon after it happens as is possible.

When you report the injury, your employer should make sure you get prompt first aid or medical attention. If you’re going to miss more than three days of work because of your injury, your employer is required to start paying you temporary disability benefits, ask in writing for more information needed before benefits are provided, or give you a written explanation why disability benefits are being denied.

Your employer is required to report your accident to the Illinois Workers Compensation Commission within a month if your injury causes you to miss more than three days of work.

Many work-related accidents are resolved between the employee and employer or employer’s workers comp insurance company without a workers comp claim being filed with the IWCC. If the employer or insurance company refuses to pay benefits, a claim may be necessary. Even if you think you won’t have to file a claim with the IWCC, it can be useful to have representation by a skilled workers compensation lawyer who can negotiate with your employer or the insurance company to get you a fair settlement.

Making a Claim

If you can’t reach a settlement with your employer or the insurance company, the next step for you would be to file a claim with the IWCC. You can find the forms you need to file a claim online. A claim typically has to be filed within three years after your injury.

When you submit the forms, the commission opens a case file, assigns a case number, and assigns an arbitrator. It’s your responsibility as the injured employee to prove you’re eligible for workers compensation benefits. Your employer does not have to disprove your eligibility.

While your case is active, you’ll have a status call once every three months so that all of the parties involved and the arbitrator can talk about what’s happening, or request a trial. A trial in this sense means an arbitration rather than the traditional notion of a trial in a courtroom. You have to have reached what’s known as maximum medical improvement — which means you’ve recovered from your injury as much as you’re going to — before an arbitrator can decide your case.

If no one is ready to request a trial, you can go through this cycle of status calls for up to three years. When that time is up, the arbitrator may dismiss the case unless there’s justification to keep it going. Basically, it’s up to you and your employer to make sure your claim moves forward. To avoid getting bogged down in the process, it’s a good idea to hire a workers compensation lawyer to make sure everything stays on track, especially if there’s a dispute involved.

While your claim is in process, you may engage in settlement negotiations with your employer or the insurance company to try to resolve your workers compensation claim without a trial.

Arbitration

Once the parties request a trial, the arbitration gets scheduled. Similar to a courtroom trial, you and your employer will gather evidence — medical records, witness testimony, and other documents — to prepare for the arbitration. At the arbitration, the evidence is presented and then the arbitrator issues a decision within 60 days. If the arbitrator decides that you are entitled to benefits, the decision will say what benefits you should get and in what amounts. You can have representation by a workers compensation lawyer at the arbitration. In fact, you probably stand a better chance at a favorable outcome if you have a lawyer than if you do not.

Appeal

The arbitrator’s decision can be appealed to one of the IWCC commissioners, and beyond that to a Circuit Court and then up the ladder in the court system.