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How Long Does a Workers’ Comp Investigation Take?

Written by Ankin Law Office

The duration of a workers’ compensation investigation depends on the facts of the accident and the severity of the injury. Injured workers seeking workers’ compensation benefits may find themselves navigating a complex and confusing process. The process becomes more complex when injured workers learn their claim is being investigated. It is illegal under Illinois State Law for an employer to retaliate or terminate an employee who makes a workers’ compensation claim. Instead, employers and insurance companies often prolong the workers’ compensation process by investigating claims.

How Does Workers’ Compensation Claims Process Work?

Pursuant to the Illinois Workers Compensation Act, a victim is eligible for workers’ compensation benefits if he or she suffered an injury at his or her workplace, or because of working for his or her employer. Illinois law requires employers to purchase and provide workers’ compensation insurance for their employees. Generally, independent contractors are not eligible for workers’ compensation benefits. 

An injured worker must file his or her claim with the Illinois Workers’ Compensation Commission within three years of the accident.  A failure to file a claim within three years bars the claim. However, prior to filing a claim with the Commission, an injured employee must make a written or oral report to his or her employer within 45 days of the accident. If a victim fails to report the injury, his or her claim may be barred.

Assuming a claim is accepted but cannot be settled, it must be litigated. The workers’ compensation proceeding is a two-stage process. Arbitrators appointed by the Commission decide claims that cannot be settled. If one party is satisfied, he or she can seek a review by a panel appointed by the Commission. If one party remains unsatisfied, he or she can appeal the case through the Illinois judicial system.

What Happens After a Workers’ Compensation Claim is Made?

After an employer is notified of an accident, he or she must provide the injured employee with a list of approved medical providers.  The employer must also inform his or her insurance company to begin the claims process.  An employer is also required to file an accident report with the Workers’ Compensation Commission within 30 days of receiving notice of the claim.

If a victim is unable to work for three days, the insurance company and employer must accept or deny the claim within 14 days. If the claim is accepted, the insurance company is required to begin paying the injured worker’s disability. If the employer or insurance company denies the claim, they must provide the injured worker a written notice explaining their decision to deny or investigate the claim.  

How Does a Workers’ Compensation Investigation Begin?

After an injured worker files a workers’ compensation claim, it is not unusual for the employer or insurance carrier to attempt to obtain a recorded or signed statement regarding the accident from the injured worker. An injured worker cannot be compelled to provide a written or recorded statement. Experienced Chicago workers’ compensation lawyers often suspect that an insurance carrier’s attempt to obtain a statement is an indicator that they intend to investigate a claim.

Why Are Workers’ Compensation Claims Denied Or Investigated?

Workers’ compensation insurance provides several benefits designed to help injured employees recover from their injuries and rebuild their lives. Workers’ compensation insurance is a form of no-fault insurance, which means a victim is still entitled to coverage even if his or her own negligence caused the injury.

Despite being a form of no-fault insurance, there are several reasons why workers’ compensation claims are investigated.  Investigations occur because insurance carriers or employers have reasons to believe the claim is fraudulent or that a defense can be asserted. Certain warning signs increase the possibility that employers and insurance carriers will investigate a claim, including:

  • Lack of witnesses to the accident.
  • The employee failed to obtain medical treatment in a timely manner.
  • The employee is unresponsive to contact attempts when not at work.
  • The accident occurred immediately after the employee received a poor performance evaluation.
  • The employee’s duties could not have resulted in the claimed injuries. 
  • The employee was possibly engaged in illegal activity at the time of the accident.
  • The employee was under the influence of alcohol or drugs at the time of the accident.

Additionally, the expensive nature of workers’ compensation benefits creates a strong incentive for employers and insurance companies to investigate claims with the goal of prolonging the process or to simply avoid paying the claims. Insurance companies utilize adjusters, investigators, and doctors to investigate claims. 

How Are Workers’ Compensation Claims Investigated?

Investigations usually begin with insurance carriers and employers reviewing claim forms in order to ensure that the accident was reported within 45 days and that the claim was filed within the statute of limitations period. Investigators then attempt to interview the injured employee and any individuals who may have witnessed the accident. Investigators will conduct interviews to obtain more information about the facts of an accident. If an injured worker underwent a test for drugs or alcohol following the accident, the results are likely to be reviewed.

Employers and insurance carriers investigate injured workers’ medical histories by obtaining copies of their prior medical records.  Insurance companies and employers also have the power to compel injured workers to be evaluated by medical doctors of their choosing. Investigations are often prolonged if an injured worker suffered prior injuries, even if they are unrelated. This is because insurance companies hope to find information, which can support a medical opinion, and argument, of an injury not being work-related or being caused by a pre-existing medical condition.

Does an Investigation End if a Workers’ Compensation Claim is Accepted?

Independent contractors, such as Uber drivers, face a relatively short claims review process when they ask “how long does an Uber investigation take”?  Workers’ compensation claims continue to be investigated by insurance companies and employers even after they are accepted.  Employers and insurance companies have the power to compel injured workers to submit to independent medical examinations throughout the claims process. This is because investigators are trying to obtain evidence that the injured worker exaggerated the extent of his or her injuries or no longer require medical treatment due to reaching maximum medical improvement. It is normal for investigators to covertly follow and conduct surveillance of victims for weeks or months. Investigators will attempt to photograph or film people while they are performing some type of strenuous physical activity despite being placed on a light duty, or no work medical status. Investigators also try to obtain evidence of other types of fraud, such as a person working at another job while collecting workers’ compensation benefits. Insurance companies and employers also investigate injured workers by searching through their social media. As with conducting live surveillance, investigators hope to find damaging posts, photos, or videos of injured workers. It is possible that investigators monitor the social media accounts of injured workers, and their friends and families, throughout the entire duration of a workers’ compensation case.