Generally speaking, your medical care in an Illinois workers’ compensation case should be guided by your doctor. For most cases like back, leg, hand, shoulder injuries, etc., that doctor would be an orthopedic. Typically they’ll start with physical therapy for you, then maybe try pain injections and if that fails they might suggest surgery.
Work comp insurance companies usually won’t put up much of a fight for physical therapy, assuming there is no dispute your injury is work related. They will at times scoff at paying for a MRI and quite often try to prevent a surgery from happening due to the cost.
The reality though is that it shouldn’t be up to them. It should be up to your doctor assuming that they are credible which most orthopedic doctors are. Unfortunately, that’s not how work comp cases usually go down. Insurance companies will make you jump through hoops because they don’t care if you get better, they just care about their bottom line.
Two recently decided cases show how to get a surgery approved.
In case number 1, an assistant manager at a retail store was transferring 50 pound bags of dog food and felt pain down her leg. She got physical therapy and eventually had a lumbar discetomy. That didn’t fix her problem and her doctor recommended a lumbar fusion. Due to her pain she wanted this surgery. The case was denied with help of an IME doctor who on cross examination admitted he hadn’t reviewed any of her medical records. That shows you what a real hired gun doctor is about. They’ll say whatever the insurance company wants.
This worker won her case for a bunch of reasons. First off her doctor was credible. Second, the IME doctor was not credible. Third off the Arbitrator found she had exhausted all other options. She did additional therapy after the first surgery and had pain injections yet continued to have symptoms. Because of all of that, the plan for another surgery was reasonable.
In case number 2, a worker suffered a crush injury to his thumb when it got stuck in a machine. Eventually his doctor recommended a surgery. That was denied in part because the IME said that it was unlikely that the surgery would offer any improvements. Prior to the surgery the worker did physical therapy and other means to improve his pain. Nothing worked. And while there was no guarantee the surgery was help, there was also no indication that it could in any way be harmful. Because of that and the reasonable course of treatment, the doctor’s recommendation for surgery was approved by the Arbitrator.
In both cases the workers did important things that helped them win approval for surgery. First off they immediately sought medical care after getting hurt. Second is that they got referred to good orthopedic doctors. Third, they listened to the recommendations of their doctors including trying less expensive options like physical therapy. In one of the cases the IME doctor was credible in the other, they weren’t. But in the end it was the treating doctor who was listened to because everything else made sense and showed a good course of treatment.
It’s insane that it has to come to this, but this is the reality of how Illinois work comp cases take place. Even if the insurance company is nice at times, I assure you that they are trying to reduce their costs even if it’s at the expense of your health.