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Workers' Compensation and your right to medical treatment

If you've been injured, you deserve to get the best medical care available. In Illinois, we are very fortunate that injured workers are allowed to choose their own doctors. But you need to be aware of restrictions to this right. The most important is the "Two Doctor Rule." This rule states that you can make two initial choices of doctor, and that these doctors must then refer you to other health care providers for any additional treatment.

The easiest way to understand this rule is to picture two wheels with spokes. At the center of the wheel is each of your initial two choices for treatment. Radiating out from them along the spokes of the wheel are their referrals to other doctors.

You might start treating with Doctor "A", and he can then refer to you any number of doctors. But what if you have a falling out with Doctor "A". You can go see Doctor "B", and once again, he can refer to you any number of doctors. Doctors "A" and "B" are your two doctors under the Two Doctor Rule. If you now go to Doctor "Z" without a referral, you have violated the rule, and that doctor will not be covered by Workers' Compensation. In addition, any doctor that Doctor "Z" refers you to will not be covered. So be careful. The safest thing to do is go to Doctor "A" and get referrals for all other doctors and treatment. Keep Doctor "B" as your "plan B." Don't use the second doctor unless you absolutely have to.

But what happens if Doctor "A" refers you to Dr. Kutter, and now Dr. Kutter wants to refer you to Dr. Lafingas? Do you have to go back to Dr. "A" for the referral? Nope. Any doctor within the chain of referrals can now refer you to other doctors, and so on and so on. So Dr. Kutter can refer you to Dr. Lafingas, and Dr. Lafingas can refer you to Dr. Yurkidding, and so on.

If you chart this out you could end up with something looking something like a spider web:

The important thing to remember is this; always get a referral. If you don't know what doctor to start with, a safe bet is a general practitioner or family doctor. They are accustomed to referring people out to various experts, and will likely have your best interests at heart.

Now let's say your boss drove you from the accident to the emergency room. Does the E.R. doctor count as one of your choices? No, the E.R. doctor never counts as your choice. What if your boss drives you to the "company doctor." This is a little trickier. You might think this was your boss's choice, and your boss might argue, "hey, I would have taken you to a different doctor if you'd asked." Be on the safe side; consider this your first choice. If you like this doctor, great. If not, move on to Dr. B, your second choice. Bear in mind, if the doctor actually works for your employer, like a plant doctor that is always on the premises, it's unlikely anyone would consider this your choice. You're definitely best off seeing your own doctor than the plant doctor. You need to see someone without a bias or a financial incentive contrary to your interests.

What treatment is covered?

Your employer, through their Workers' Compensation insurance carrier, must pay for all "necessary first aid, medical and surgical services, and all necessary medical, surgical and hospital services . . . limited, however, to that which is reasonably required to cure or relieve from the effects of the accidental injury." Sorry. If this is your first dose of legalese, take two aspirin and call me in the morning. What you've just experienced (aside from a bit of vertigo) was part of Section 8(a) of the Act.

Here's what this section of the Act is trying to say. You have the right to all prescribed medical treatment if it helps you get better, or at least your doctor thinks it might. Now I know what you're thinking. Obviously, the doctor must think it will help or the doctor wouldn't have prescribed it. That's a good point, but what you need to know is that the insurance company might hire their own doctor to say the treatment your doctor wants is not "reasonable and necessary," and therefore they won't pay for it. There are ways to get around this problem, but that goes beyond the scope of this article. You'll want the services of an experienced Workers' Compensation attorney if your bills are not being paid or treatment is not being authorized.

In summary, you pick your doctor, your doctor prescribes treatment and refers you to other doctors. The Workers' Compensation insurance should pay the bills as long as the treatment is "necessary" and "reasonably required to cure or relieve from the effects of the accidental injury." Don't get bullied into getting treatment from a doctor you don't want to see. And don't let the insurance company push you around. Illinois workers have fought hand in hand with the lawyers who represent them to create a strong set of rights in our Workers' Compensation law. You deserve to have your rights protected and get the best medical treatment possible. If you're not being treated right, fight back!

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This article is a modified excerpt from Mark Weissburg's "How to Win a Workers' Compensation Claim in Illinois." You can receive a FREE copy by making an appointment to see a qualified Workers' Compensation attorney at Horwitz, Horwitz & Associates. Call 866-360-9310 for a FREE consultation and book today.

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