Who Determines What Medical Care Should Be Approved?

Under the Illinois Workers’ Compensation Act, if you are injured on the job you are entitled to reasonable and necessary medical care that is related to your work injury. In other words, getting physical therapy for a work related back injury would be reasonable and necessary.  They’d have to pay for 100% of it at any medical provider you wanted to see (with very few exceptions). But if your appendix needed to come out, they wouldn’t have to pay for it as that treatment wouldn’t be related to your job at all.

Medical care under the Work Comp Act gives a glimpse in to what life could be like if we had universal health care in this country.  It doesn’t cost the patients anything and allows them to focus on their health. Of course though, because it’s still administered by insurance companies, there are challenges. It’s not unusual for a worker to get hurt on the job and have trouble initially getting medical care approved.

So who gets to decide what medical treatment should or shouldn’t be paid for.

Technically, per Section 16 of the Illinois Workers’ Compensation Act, it’s the Workers’ Compensation Commission that decides.  But that’s just technical talk for cases that are disputed and go to trial. In reality, it’s usually your doctor who decides what is reasonable and necessary. And they do it based on what is standard practice in the medical community.

So if you hurt your back, it would be reasonable to have physical therapy, a MRI if you don’t get better, epidural steroid injections and finally surgery if nothing else has worked.  In most cases that is a reasonable course of action and if an orthopedic doctor thinks it’s necessary, if the case were to go to trial, the Commission would likely agree.

On the other hand, if instead of seeing an orthopedic doctor, you go to one who wants to heal your back with crystals and herbal remedies, it’s not likely that the Commission would approve this treatment and make the insurance company pay for it.  That would be true even if your doctor sounds credible in saying why your treatment is reasonable and necessary.  That’s because it’s not accepted practice within the medical community to treat a back injury with crystals.

The same would potentially be true if the orthopedic doctor wanted to perform some surgery that happens in Europe but is not standard practice in the United States or if it involved a device not approved by the FDA. Generally speaking, it’s traditional procedures that are allowed.

For the insurance company to deny benefits, they are also supposed to have a doctor discuss your care. That means they’d need a doctor to state a MRI isn’t needed for example or more likely, that the need for treatment is not related to a work injury.

Ultimately, in most cases if your doctor and you are credible, the care will be approved. Sometimes insurance companies deny treatment without a valid reason at all just to see if they can get away with it.  The good news is that an experienced lawyer can almost always solve that type of problem.