What to Do If Your Workers' Compensation Claim Is Denied in Illinois

Learn about the deadlines and procedures in Illinois for appealing an insurance company's decision to deny or delay workers' comp benefits.

It can be discouraging if you were hurt at work and your employer’s insurance company has denied your workers’ comp claim or refused to pay some benefits. But Illinois law gives you the right to challenge the insurer’s decisions. Below, we’ll explain the main reasons insurers deny claims, as well as the process for filing appeals with the Illinois Workers’ Compensation Commission (WCC).

When Workers’ Comp Doesn’t Cover Your Injury

Insurance companies frequently deny workers’ comp claims if the injury doesn’t appear to be work related. To be eligible for benefits, you must have an occupational disease or an accidental injury that happened because of your job and while you were working. (To learn more about how this basic rule applies in different situations, like injuries during travel, see our article on when injuries or illnesses are work related.)

Under Illinois law, workers’ comp specifically won’t cover injuries under certain circumstances, including when:

  • you were hurt while participating in a voluntary recreational activity, like a picnic or softball game, or a drug or alcohol rehab program, even if your employer paid some of the costs,
  • the injury resulted from your own intoxication, or
  • you were committing a certain kind of crime when the injury happened.

How to Appeal a Denial of Benefits

If you want to get the WCC to help resolve a disagreement with the insurance company over your benefits, you must first file an “application for adjustment of claim.” The deadline for filing this form is the later of:

  • three years after your injury or after you were disabled because of an occupational illness; or
  • two years after the last payment you received for benefits.

You can download the application form, as well as all other workers’ compensation forms for Illinois, from the WCC’s forms page. Mail three copies of the completed form to any WCC office, or drop them off in person. You must also give a copy to your employer.

Requesting a Hearing

After you file the application for adjustment of claim, the WCC will assign an arbitrator to your case and schedule a status call every three months. Once you’ve gathered your evidence and are ready for an arbitration hearing, you can request a hearing date during any of these calls. If neither you nor the insurer asks for a hearing, the status calls will continue on the same three-month schedule. However, if there still hasn’t been a hearing request by the end of three years, the arbitrator will dismiss your case unless there’s a good reason for continuing it.

Except in emergency situations (discussed below), an arbitrator can’t resolve your dispute until your medical condition has stabilized and you aren’t likely to improve even with more medical treatment.

Arbitration Hearing

The arbitrator will conduct a hearing that’s similar to a trial. Both sides will present evidence, but it will be your responsibility to prove that you’re entitled to the benefits you’re seeking. When the disagreement is about medical benefits, this means proving that you need the requested treatment and that the costs are reasonable. After hearing the evidence, the arbitrator will issue a decision.

Expedited Hearings in Emergencies

You can request a relatively quick, expedited arbitration hearing if:

  • your medical or temporary disability benefits have been cut off (file a 19(b) petition), or
  • you can’t return to work and need medical or temporary disability benefits (file a 19(b-1) petition).

Administrative Appeals

In order to appeal the arbitrator’s decision, you must file two copies of a petition for review with the WCC within 30 days, along with an explanation of your objections to the decision. Within 35 days after receiving the decision, you must also file either a transcript of the arbitration hearing or a statement about the facts presented at the hearing (to which both you and the insurance company have agreed). The arbitrator’s decision will become final if you don’t file both documents on time, unless you’ve received an extension of the time to file the transcript.

A panel of three commissioners will review the evidence presented at the arbitration hearing, the arbitrator’s decision, and written arguments that you and the insurance company have submitted. If you or the insurance company requests a panel hearing, both sides will also present brief oral arguments supporting their claims. The panel will then make a decision within 60 days.

Judicial Appeals

If you’re unhappy with the decision of the WCC panel, you can work your way through the state court system. Start by appealing to the circuit court in the county where the insurance company or your employer is located, or where the accident happened.

Contact a Lawyer for Help With Your Appeal

The Illinois workers’ compensation dispute resolution process is complicated. But you don’t have to go through it alone. An experienced workers’ comp attorney can help you gather the medical records, doctors’ opinions, and other evidence needed to prove you’re entitled to benefits. A lawyer can also represent you and argue your case at arbitration and panel hearings. See more details on how a workers’ comp lawyer can help your case.

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