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When the Doctor Says Your Injury Is not Work-Related

Posted On January 20, 2020

When workers’ compensation doctors in Illinois tell injured workers their injuries are not work-related, victims have a right to seek another opinion under the two-doctor rule. To keep costs down, it is common for physicians to tell patients their current medical problems don’t stem from a work-related injury, especially when Preferred Provider Programs are involved.

Preferred Provider Programs

When workers suffer workplace accidents and injuries, they are often referred to physicians in Preferred Provider Programs. Physicians who handle workers’ comp injuries are commonly listed as preferred providers. They have an obligation to examine a worker and designate the injury as work-related or non-work-related. In some cases, employers may choose a network of medical providers with a history of making favorable decisions for them to keep insurance costs down.

Under the Illinois Workers’ Compensation Act, employers are authorized to create Preferred Provider Programs, referred to as PPPs or PPOs. A Preferred Provider Program is an organization of health care providers including physicians, hospitals, and clinics contracted with the employer or the insurance company to provide medical care for employees. Because of contracted services, most medical providers in Preferred Provider Programs try to assist employers and insurers with keeping insurance costs down as much as possible.

Choice of Doctors

Illinois law allows injured workers to see a doctor of their own choice. However, if the employer is part of a Preferred Provider Program the worker is pushed towards a doctor from that group. Under the two doctor rule, an injured worker must choose one physician from a list of preferred providers. He/she acts as a primary care physician who handles all injury-related exams, diagnoses, treatments, prescribed medications, and medical reports. If a specialist is needed for occupational illness or disease, all referrals must go through the preferred primary care physician.

If a worker does not want to see a physician within the PPP network, he/she can choose one physician outside the network. If the employer is not part of a PPP network, the worker can choose any two doctors of choice. However, if a third doctor or specialist is needed, the employer may not have to pay for the visits to the third doctor.

If the employer chooses a doctor to evaluate a work-related injury, the worker must accept the examination but can refuse medical treatment from that doctor. If a doctor diagnoses an injury as a non-work-related injury, a workers’ compensation lawyer can assist with claim denials and appeals.

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