When Illinois employees suffer workplace injuries, workers’ compensation benefits are supposed to provide medical care, wage replacement, and other vital support. Unfortunately, many valid claims are denied. As Illinois attorneys, we see firsthand how overwhelming this process can be when injured workers face delays or denials from insurance carriers. Workers’ compensation is not optional for most employers, it is a legal right under the Illinois Workers’ Compensation Act (820 ILCS 305). However, insurance companies often rely on technicalities, incomplete records, or disputed facts to deny benefits. Understanding the common reasons claims are denied is the first step toward protecting your rights and ensuring you get the benefits the law provides.
One of the most frequent reasons claims are denied in Illinois is the insurer’s argument that the injury was not caused by work. Under 820 ILCS 305/2, injuries must “arise out of and in the course of employment” to qualify for benefits. This means there must be a clear connection between your job duties and the injury.
Insurance companies may argue that an injury happened outside of work, during a commute, or as a result of personal activities. They may also point to pre-existing conditions to dispute that the injury was caused at work. For example, if an employee with a prior back issue suffers a herniated disc while lifting heavy boxes, the insurer may attempt to claim it was unrelated to job duties.
When this happens, medical evidence and witness testimony become critical. Without detailed medical records linking the injury to workplace activities, a denial is highly likely.
Illinois law requires injured workers to report their injuries to their employers within a certain timeframe. Under 820 ILCS 305/6(c), an employee must provide notice to their employer within 45 days of the accident. If this deadline is missed, the claim may be denied entirely, even if the injury is legitimate.
Insurance companies often rely on late reporting as grounds for denial. Employers may also argue that they were not given proper notice, which makes it easier for them to dispute liability. Reporting an injury promptly—and documenting the report in writing—can prevent this issue.
Medical documentation is the foundation of any workers’ compensation claim. Under 820 ILCS 305/8, employees are entitled to medical treatment for work-related injuries. However, if medical records are incomplete, inconsistent, or fail to clearly link the condition to workplace duties, insurers often deny claims.
A common issue arises when workers visit doctors who are not familiar with documenting occupational injuries. If the doctor’s notes omit mention of the injury being caused by work, insurers will argue that the injury is not compensable. This is why consistent, accurate medical documentation is critical to success in workers’ compensation claims.
Another common reason for denial is disagreement over how serious the injury is. Insurers may argue that an employee is exaggerating symptoms or that the injury is not as disabling as claimed. Under 820 ILCS 305/8(b), temporary total disability (TTD) benefits are owed when an injured worker is unable to work due to the injury.
When doctors disagree about work restrictions or treatment needs, insurance companies often deny wage replacement or medical benefits. Independent medical examinations (IMEs) arranged by insurers may downplay the severity of the injury. Without strong medical evidence from treating physicians, workers risk losing benefits they are legally entitled to.
Illinois law does not allow insurers to deny claims solely because a worker had a pre-existing condition. However, insurers frequently use this argument to avoid paying benefits. Under 820 ILCS 305/1(d), aggravations of pre-existing conditions are compensable if they are caused or worsened by workplace activities.
Despite this clear rule, insurance companies often argue that the injury was entirely pre-existing and not aggravated by work. For example, an employee with arthritis who suffers a flare-up after repetitive motion at work may face a denial. These cases often require medical testimony to prove that the work activity worsened the pre-existing condition.
Workers’ compensation benefits may also be denied if an employer or insurer claims the injury resulted from employee misconduct. Under 820 ILCS 305/11, no compensation is allowed for injuries caused by intoxication or illegal drug use. Similarly, injuries caused by horseplay or intentional misconduct may not be covered.
Employers sometimes use these allegations as a defense even when there is little evidence. For instance, an employer may allege intoxication without conducting proper testing. These situations often require aggressive legal representation to challenge unfair accusations.
Another common reason for denial is a claim that the worker is not an “employee” under the Act. Independent contractors are not covered by workers’ compensation in Illinois. However, many workers are misclassified by employers as contractors when, under the law, they should be considered employees.
The Illinois Workers’ Compensation Commission uses several factors to determine employment status, including control over the work, method of payment, and who provides the tools and equipment. Employers may dispute claims by labeling workers as independent contractors, but this is often challenged successfully in hearings before the Commission.
If your claim is denied, you have the right to file a claim with the Illinois Workers’ Compensation Commission (IWCC). Under 820 ILCS 305/19(b), you may request a hearing before an arbitrator to contest the denial. Acting quickly is important because delays can impact your ability to recover benefits. Gathering medical records, witness testimony, and other evidence can strengthen your case.
You must report your injury within 45 days of the accident under 820 ILCS 305/6(c). Failure to report within this timeframe can result in the denial of your claim. It is always best to notify your employer as soon as possible and provide written documentation of the injury and how it occurred.
Yes. Under Illinois law, aggravations of pre-existing conditions are compensable if they were caused or worsened by your job duties. For example, if repetitive lifting at work worsens a pre-existing back condition, you may still be entitled to benefits. Insurers often use pre-existing conditions as an excuse to deny claims, but medical testimony can establish that work activities contributed to the injury.
Workers’ compensation benefits include payment for medical treatment, temporary total disability (TTD) if you cannot work, temporary partial disability (TPD) if you return to light duty at reduced wages, permanent partial disability (PPD) for lasting impairments, and permanent total disability (PTD) if you cannot return to work. Death benefits are also available to surviving family members under 820 ILCS 305/7.
Employers sometimes misclassify employees as independent contractors to avoid paying benefits. If your claim is denied on this basis, the Illinois Workers’ Compensation Commission will look at the actual nature of the work relationship. If the employer controls your work hours, provides equipment, and pays you directly, you may be considered an employee and entitled to benefits.
You generally have three years from the date of the injury to file a claim, or two years from the last payment of compensation, whichever is later, under 820 ILCS 305/6(d). Missing this deadline can bar your claim entirely, so it is important to act quickly if your employer or insurer denies benefits.
At The Law Offices of Robert T. Edens, P.C., we know how frustrating and stressful it is when workers’ compensation claims are denied. Insurance companies often put profits ahead of injured workers, but Illinois law provides clear protections. Our team fights to ensure our clients receive the medical care and wage benefits they are entitled to under the Illinois Workers’ Compensation Act.
Contact our Illinois workers’ comp lawyers at The Law Offices of Robert T. Edens by calling us at 847-395-2200 to receive your free consultation. From our offices in Antioch, Waukegan, and Woodstock, we represent injured workers throughout Illinois. If your claim has been denied, do not wait—your right to benefits may depend on the actions you take now.
The Law Offices of Robert T. Edens, Personal Injury and Workers' Compensation Law Office, have offices in Antioch, Waukegan, Grayslake, Woodstock and Barrington. We represent clients throughout the communities of Antioch, Waukegan, Grayslake, Barrington, Woodstock, Buffalo Grove, Deer Park, Gurnee, Lake Zurich, Round Lake, McHenry, Cary, Crystal Lake, Libertyville, Lincolnshire, Mundelein, Vernon Hills, Wheeling, North Chicago, Zion, Inverness, Palatine, Wauconda, Island Lake, Fox Lake, Barrington Hills, Spring Grove, Lake Bluff, Lakemoor, Long Grove, Lake Villa, Kildeer, Wadsworth, Indian Creek, Fox River Grove, Lindenhurst and other cities within Lake and McHenry Counties Illinois.
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