If an injury is a work injury medical treatment should go through work comp insurance.
Gary A. Newland is an Illinois Trial Lawyer, Co Chair of the Northwest Suburban Bar Asssociation Civil Law Committee and has a perfect AVVO score of 10.This answer posted on Avvo is for informational and educational purposes only. There is no attorney-client relationship created or formed and you should not rely on this as legal advice. The suggestion is made that if you wish to protect your rights, you consult with an attorney immediately
It is not illegal, it's just not right. Very often the insurance carrier will deny authorization for some requested procedure or surgery. When this happens and you do have access to group health insurance, it only makes sense to get the care that you need through the group health insurance and worry about who pays the bill, later. In Illinois, as long as the group health insurance is provided through the employer, it is all seen as coming out of the same pocket.
You don't tell us when you're doctor and requested authorization for surgery. If that request was made last October or November, your attorney could have and should have filed a motion for immediate hearing with the Commission (under section 19 BU one) and you would have had a final decision no later than March. This is still an option. The reason that many clients who have access to group health insurance choose not to have their surgery through the group health insurance is that most surgeries require several weeks or months of convalescence during which they would not be able to work. If the injury is not being covered under Worker's Compensation, there is no entitlement to the TTD (temporary total disability) that the employee would receive if the injury were handled as a work injury, in addition to co-pays and deductibles.
I would remind you that this is not the end of the story. You still need to settle the matter on permanency or have a hearing for the Arbitrator to render a decision.
Depending upon the outcome of your surgery, this may be an injury where you would anticipate the need for further medical care throughout your life. If that is the case, you may choose to proceed to trial in order to retain open medical benefits.
Whatever you choose to do, please make certain that your attorney provides all available options to you. If you have no attorney or your attorney is not communicating with you or has not provided any options to you, I would strongly suggest that you speak with an attorney who is willing and able to explain your options as soon as possible. Good luck.
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If the reason for the denial is no accident or the injury is not related to the work injury, they have the right to deny you the benefits. The way to fight them is to file a 19 b and have your doctor testify that the surgery is related to the work injury and the basis for his opinion. If the arbitrator agrees with your doctor you will get an award for back TTD benefits and future TTD benefits untilll you reach MMI.If they deny the claim for no reason what so ever you can petition the arbitrator for an award of Penalties and attorney fees.
Please note that thes e-mail respoinse to your question does not consitiute an attorney client relationship. I am not your attorney. Only if a signed retainer agreement is entered into is an attorney client relationship formed. If you wish to pursue you claim you are required to file an application for ajustment for claim prior to the statute of limmitations add give your employer the required notice pursuant to statute.
I am not going to add substantively to the answers you have been given, but since the tone of your question suggests you have an attorney I suggest you approach your attorney to better explore your questions in the context of the case. If you do not have an attorney, then you should be arranging a consultation without delay. If you have an attorney and you are not receiving satisfactory answers, you can seek a second opinion, but understand that a new attorney would be hindered in having to work out a fee arrangement with the former attorney.
The scope of this space does not afford an opportunity to adequately advise you. The response provided is intended to be informative, but not final. You are advised to arrange a consultation at which all facts and documents can be explored and terms for representation agreed. An attorney-client relationship must be formally established.