Reasonable and Necessary Treatment

Medical Benefits

Doctor

Injured workers with compensable Illinois workers’ compensation claims are entitled to reasonable and necessary medical treatment.

The Illinois Workers’ Compensation Act provides:

The employer shall provide and pay … for all the necessary first aid, medical and surgical services, and all necessary medical, surgical and hospital services thereafter incurred, limited, however, to that which is reasonably required to cure or relieve from the effects of the accidental injury…

The employer shall also pay for treatment, instruction and training necessary for the physical, mental and vocational rehabilitation of the employee, including all maintenance costs and expenses incidental thereto.

820 ILCS 305/8(a) Illinois General Assembly | IWCC PDF. This provision also applies to claims made under the Illinois Occupational Diseases Act. 820 ILCS 310 Illinois General Assembly.

Medical Necessity

Whether medical treatment, such as a particular therapy or surgery, is reasonable and necessary is a frequently contested issue even in claims that are initially accepted by employers and their insurance companies. “The claimant bears the burden of proving, by a preponderance of the evidence, his or her entitlement to an award of medical care under section 8(a).” Dye v. Illinois Workers’ Compensation Commission, 2012 IL App (3d) 110907WC Google Scholar.

Similar to personal health insurance claims, the treating physician may be required to write a letter of medical necessity to convince the insurance company to authorize the recommended course of treatment.

To defend claims, employers and insurance companies may require the claimant to undergo an independent medical examination, also referred to as an IME, pursuant to section 12 of the Workers’ Compensation Act. 820 ILCS 305/12 Illinois General Assembly | IWCC PDF.

Additionally, employers and insurance companies can require requested medical treatment to go through a process called utilization review pursuant to section 8.7 of the Workers’ Compensation Act. 820 ILCS 305/8.7 Illinois General Assembly | IWCC PDF.

When medical necessity is disputed and a claim goes to hearing, the Illinois Workers’ Compensation Commission must decide between the competing medical opinions. It is “the function of the Commission to judge the credibility of the witnesses, determine the weight to be given their testimony, and resolve conflicting medical evidence.” Tower Automotive v. Illinois Workers’ Compensation Commission, 407 Ill. App. 3d 427 (2011) Google Scholar | Illinois Courts PDF.

If an injured worker is asked to submit to an IME, or has already been denied medical treatment recommended by their doctor, they should consider consultation with an Illinois workers’ compensation attorney.

Further reading:

Beelman Trucking v. Illinois Workers’ Compensation Commission, 233 Ill. 2d 364 (2009) (affirming as medically necessary section 8(a) award of voice-activated home computer system that allowed claimant to communicate with family and friends) Google Scholar | Illinois Courts PDF.

Zephyr, Inc. v. Industrial Commission, 215 Ill. App. 3d 669 (1991) (finding awards for home modifications are allowed if medically necessary under section 8(a) of the Act) Google Scholar.

Plantation Manufacturing Co. v. Industrial Commission, 294 Ill. App. 3d 705 (1997) (finding the Commission is allowed to award prospective medical treatment: “Specific medical procedures or treatments that have been prescribed by a medical service provider have been ‘incurred’ within the meaning of the statute, even if they have not yet been paid for.”) Google Scholar.

This article does not provide legal advice and does not create an attorney-client relationship. If you need legal advice, please contact an attorney directly.