I had a recent talk with an injured worker who had a very serious neck injury and has been off of work for two years. His medical bills have all been paid and the case has been accepted. He had one neck surgery that did not solve his problem so now his treating doctor and a pain management specialist are recommending that he have a cervical fusion.
This is an expensive procedure so of course the insurance company sent him to an IME doctor who looked at him for five minutes and determined that no additional neck surgery is needed. So now he’s stuck in limbo with two competing doctor opinions even though it’s obvious to anyone who is looking and unbiased that the treating doctor is the one to listen to.
So his question to me was, “Is there an appeal process that allows me to get a new opinion to decide which of these doctors should be believed.”
The answer is that you don’t “appeal” anything. You get your medical records, probably take your doctor’s deposition and then go to trial. The appeal process is going before an Arbitrator and letting them decide which opinion to go with. Sadly there is nothing else that can be done other than trying to reason with the insurance adjuster which in most cases does nothing.
If their IME doctor is clearly a hack (e.g. doesn’t practice medicine anymore, just does IME’s) or goes against a previous IME of theirs we can file a petition for penalties and fees which will punish them for their delay. Beyond that, it’s just a matter of getting your case ready for trial ASAP and going from there. Sometimes we’ll do a pre-trial before an Arbitrator and they will tell the insurance company lawyer that they are going to lose, but in most cases you don’t get results without following through with an actual trial.
For you this means a potential delay in medical care and a day in court. It takes 3-6 months usually for the trial to happen and then depending on the Arbitrator it can be a couple of weeks to a couple of months before they issue a decision. If you have group insurance we’d advise you to get the surgery if you can and we’d get them reimbursed for anything they spend.
Because you need a case already on file with the Illinois Workers’ Compensation Commission before you can get a trial date, this is why it’s a good reason to get a lawyer before you need one.
Bottom line is that disputes happen in work comp cases, even when they seem ridiculous. The way to solve those problems is a trial.