State News : Illinois

By: Kisa P. Sthankiya

The claimant in Aim National Lease v. Illinois Workers’ Compensation Commission, 2026 IL App (1st) 250494WC-U, ¶8, worked as a rental representative conducting “360 inspections” of trucks, which required walking around and climbing in and out of vehicles. On August 13, 2019, she tripped over a parking block during an inspection and fell, testifying that she felt throbbing pain in her left lower leg and shooting pain from her heel to her toes. 2026 IL App (1st) 250494WC-U at ¶9.

She was treated at Working Well Occupational Health, diagnosed with contusions and left foot and ankle sprains, and placed on light-duty restrictions. 2026 IL App (1st) 250494WC-U at ¶10. Although X-rays showed no fractures, she continued to experience swelling, antalgic gait, and pain and was referred to physical therapy. 2026 IL App (1st) 250494WC-U at ¶11.

Beginning in September 2019, Dr. James Hong, a podiatrist, treated her for persistent ankle pain, numbness, and tingling, diagnosing ankle sprain and neuritis, and prescribed therapy, medication, injections, and work restrictions. 2026 IL App (1st) 250494WC-U at ¶¶12 – 14. At subsequent visits in September and October 2019, the claimant continued to report sharp, shooting pain and neuritis-type symptoms, though some improvement was noted with gabapentin and therapy. 2026 IL App (1st) 250494WC-U at ¶¶13 – 14. Dr. Hong administered a steroid injection, adjusted medications, and maintained work restrictions while documenting ongoing nerve pain and reduced range of motion. 2026 IL App (1st) 250494WC-U at ¶14.

From October 24 through October 28, 2019, the claimant participated in a 30-mile cancer walk where participants had to walk 10 miles a day. 2026 IL App (1st) 250494WC-U at ¶18. The claimant testified that she did some walking during the event but spent most of the weekend riding around in a golf cart. Id.

On October 29, 2019, the claimant went to a physical therapy appointment and reported that she was slightly worse than the week prior due to being out of town but she felt 76-to-80-percent better and some improvements. 2026 IL App (1st) 250494WC-U at ¶19. The following therapy visit on October 30, 2019, she again noticed increased pain in the left heel since the weekend but also showed progress with strength, range of motion, flexibility, and function. 2026 IL App (1st) 250494WC-U at ¶20.

On November 21, 2019, the claimant followed up with Dr. Hong and complained of numbness, tingling, and shooting pain radiating from her ankle to her toes and calf. 2026 IL App (1st) 250494WC-U at ¶21. Dr. Hong’s examination revealed positive Tinel’s and Valleix’s signs in the tarsal tunnel, and he diagnosed neuritis/neuropraxia, left foot sprain, and possible plantar fasciitis. 2026 IL App (1st) 250494WC-U at ¶¶22 – 23. Because her symptoms were worsening and appeared structural, he ordered MRIs, increased medication, and modified restrictions. 2026 IL App (1st) 250494WC-U at ¶23.

MRIs of the left ankle were taken on December 14, 2019, and interpreted as largely negative, showing normal ligaments and tendons with only minor findings such as mild arthritis in the first MTP joint. 2026 IL App (1st) 250494WC-U at ¶24.

At the employer’s request, the claimant underwent an independent medical exam (IME) on December 18, 2019, with orthopedic surgeon Dr. Kamran Hamid. 2026 IL App (1st) 250494WC-U at ¶25. He diagnosed ankle sprain and instability related to the work accident and suggested the claimant may have had complex regional pain syndrome (CRPS) or sympathetic mediated pain, though evaluation was complicated by medication use. Id. Dr. Hamid considered prior treatment reasonable, found that the claimant was not at maximum medical improvement (MMI), and recommended further MRI imaging due to poor quality of the December 14 images. 2026 IL App (1st) 250494WC-U at ¶26.

On December 19, 2019, Dr. Hong expressed concern about early CRPS and referred the claimant for pain management, recommending possible dorsal root ganglion (DRG) treatment while maintaining work restrictions and agreed with new MRI imaging. 2026 IL App (1st) 250494WC-U at ¶27.

Additional MRIs of the left tibia/fibula, left ankle, and foot in January 2020 showed mild edema, fluid, and bursitis but no major abnormalities. 2026 IL App (1st) 250494WC-U at ¶28. Dr. Hong continued to suspect early CRPS and recommended pain management due to persistent nerve pain and limited relief from medication. 2026 IL App (1st) 250494WC-U at ¶¶29 – 30.

In contrast, Dr. Kenneth Candido, who conducted an IME on January 28, 2020, opined that the claimant did not have CRPS but instead had tarsal tunnel syndrome and that she could return to full-duty work without restrictions. 2026 IL App (1st) 250494WC-U at ¶31. Based on his opinion, the employer denied further pain management treatment. Id.

With the employer’s consent, the claimant started treatment with Dr. Hamid in March 2020. 2026 IL App (1st) 250494WC-U at ¶32. He expressed concern of CRPS versus sympathetic mediated nerve pain and recommended pain clinic consultation, which the employer refused to approve. Id.

In April 2020, during a telemedicine visit with Dr. Hamid, claimant reported an increase in nerve pain. He reviewed the January 2020 MRIs as showing ligament tears and recommended surgical reconstruction but cautioned that pain management was necessary first due to likely CRPS exacerbation. 2026 IL App (1st) 250494WC-U at ¶33.

A third IME was performed by orthopedic foot specialist, Dr. Anand Vora, in May 2020. 2026 IL App (1st) 250494WC-U at ¶34. He found no instability or CRPS and concluded the claimant had reached MMI with only a resolved contusion, releasing her to full duty without further treatment. Id. Dr. Vora questioned the claimant’s reported symptoms based in part on records referencing her participation in the cancer walk in October 2019. 2026 IL App (1st) 250494WC-U at ¶35.

Meanwhile, the claimant began treatment with pain specialist Dr. Thomas Pontinen, who disagreed with the tarsal tunnel diagnosis and supported a diagnosis of CRPS based on symptom distribution and examination findings. 2026 IL App (1st) 250494WC-U at ¶36. After a lumbar sympathetic block in May 2020 resulted in approximately 90-percent pain relief, Dr. Pontinen concluded that the improvement strongly supported CRPS rather than tarsal tunnel syndrome. 2026 IL App (1st) 250494WC-U at ¶38.

The employer scheduled claimant for a reexamination with Dr. Candido in June 2020 that the claimant refused to attend. 2026 IL App (1st) 250494WC-U at ¶37. A meeting was held by the parties with the arbitrator, and, according to the employer, the arbitrator opined during that meeting that the IME should not proceed. Id.

Dr. Candido performed a record review in August 2020 and opined that claimant had sustained a neuropraxia of the posterior tibial nerve. 2026 IL App (1st) 250494WC-U at ¶39.

Dr. Hamid maintained his CRPS diagnosis and recommendation for surgery after pain control. 2026 IL App (1st) 250494WC-U at ¶40. Throughout 2020 and 2021, the claimant, under Dr. Pontinen’s care, continued lumbar sympathetic blocks with temporary relief. 2026 IL App (1st) 250494WC-U at ¶41.

In April 2021, Dr. Candido reaffirmed his view that no CRPS was present and that no further treatment or restrictions were necessary upon an updated examination and reviewing surveillance video. Id.

In January 2022, Dr. Matthew Jaycox, a pain management specialist who agreed with the CRPS diagnosis and noted that although an anterior talofibular tear had been confirmed, surgery was not feasible due to CRPS. 2026 IL App (1st) 250494WC-U at ¶42. He recommended neuromodulation treatment and referred the claimant to Dr. William Landphair to consider a DRG stimulator. Id. After consultation, the claimant proceeded with a DRG trial in March 2022. 2026 IL App (1st) 250494WC-U at ¶43.

The claimant reported greater than 80-percent pain relief following the trial and elected to proceed with permanent implantation. 2026 IL App (1st) 250494WC-U at ¶44. The permanent DRG was implanted on March 23, 2022, and subsequent follow-ups documented 90-percent or greater relief, decreased swelling, and significant functional improvement. 2026 IL App (1st) 250494WC-U at ¶45. By August 29, 2022, her pain had decreased to two out of ten, she was active with walking and swimming, and she continued to report substantial improvement. 2026 IL App (1st) 250494WC-U at ¶46.

The arbitrator found that the conditional ill-being was related and awarded medical expenses and prospective medical treatment. 2026 IL App (1st) 250494WC-U at ¶3. The employer appealed the decision to the Commission. The Commission denied some medical bills due to no evidence of supporting medical records. 2026 IL App (1st) 250494WC-U at ¶4. They affirmed the arbitrator’s denial to admit certain documents offered by the employer and denying a fourth IME. Id. The Circuit Court of Cook County subsequently affirmed the decision on appeal. 2026 IL App (1st) 250494WC-U at ¶5.

At trial, Arbitrator Amarillo found that the claimant proved her left foot and ankle condition was causally related to the August 13, 2019, work accident and credited the opinions of her treating physicians, concluding that the DRG implant’s success supported causation and the necessity of treatment. 2026 IL App (1st) 250494WC-U at ¶47. The arbitrator also found the claimant’s testimony credible and supported by objective findings, rejecting any suggestion that she was exaggerating her symptoms. 2026 IL App (1st) 250494WC-U at ¶48.

The arbitrator determined that the opinions of Dr. Candido and Dr. Vora were not credible or persuasive, noting inconsistencies with the medical evidence and treating physicians’ findings. 2026 IL App (1st) 250494WC-U at ¶¶49 – 50. The arbitrator specifically found Dr. Vora’s malingering theory unsupported, criticized his selective reliance on the record, and remarked negatively on his deposition demeanor. 2026 IL App (1st) 250494WC-U at ¶¶50 – 51. The arbitrator further rejected the employer’s experts’ assumption that the claimant had walked 30 miles shortly after cancer surgery. 2026 IL App (1st) 250494WC-U at ¶52.

The arbitrator held that the claimant’s medical treatment was reasonable and necessary and ordered the employer to pay the submitted medical bills paid by claimant’s private insurer pursuant to §§8(a) and 8.2 of the Workers’ Compensation Act, 820 ILCS 305/1, et seq. 2026 IL App (1st) 250494WC-U at ¶53. He also ordered the employer to authorize ongoing care, including Lyrica and maintenance of the DRG stimulator, but declined to award penalties or fees. 2026 IL App (1st) 250494WC-U at ¶¶54 – 55.

On appeal, the Commission modified the decision by disallowing certain unsubstantiated medical bills but otherwise affirmed, finding the remaining medical expenses reasonable, necessary, and causally related to the accident. 2026 IL App (1st) 250494WC-U at ¶56. The Commission also ordered payment for prospective care related to the DRG and Lyrica. 2026 IL App (1st) 250494WC-U at ¶57.

The Commission rejected the employer’s argument that it had been improperly denied a §12 IME, noting the employer had invited the arbitrator’s guidance and that the record did not support a finding of error. 2026 IL App (1st) 250494WC-U at ¶¶58 – 59. The Commission affirmed and adopted the arbitrator’s decision in all other respects. 2026 IL App (1st) 250494WC-U at ¶60.

The employer sought judicial review, and the Circuit Court of Cook County confirmed the Commission’s decision. 2026 IL App (1st) 250494WC-U at ¶61. The circuit court rejected the employer’s argument that it was not liable for group health insurer-paid “billed charged” on a “subrogation lien statement” because some of the charges were not substantiated by any medical bills from the claimant’s healthcare provider. 2026 IL App (1st) 250494WC-U at ¶62. The circuit court rejected the employer’s argument that it is liable to pay the lesser of the healthcare provider’s actual charges, the negotiated rate, or the amount identified in the fee schedule provided in §8.2 of the Act, 820 ILCS 305/8.2. Id. The employer maintained that such a determination cannot be made unless the healthcare providers’ bills are produced at the time of trial. Id.

1. Causation and Intervening Injury

The first issue the employer raised was regarding whether the October 2019 breast cancer walk that the claimant participated in was an independent intervening cause breaking the chain of causation.

The court noted that every natural consequence flowing from a work-related injury is compensable unless an independent intervening accident completely breaks the chain of causation between the original injury and the subsequent condition, as recognized in National Freight Industries v. Illinois Workers’ Compensation Commission, 2013 IL App (5th) 120043WC, ¶26, 993 N.E.2d 473, 373 Ill.Dec. 167. 2026 IL App (1st) 250494WC-U at ¶69. To relieve an employer of liability, the intervening cause must entirely sever the causal connection rather than merely contribute to the claimant’s condition, as explained in Global Products v. Workers’ Compensation Commission, 392 Ill.App.3d 408, 411, 911 N.E.2d 1042, 1046, 331 Ill.Dec. 812 (1st Dist. 2009). Id. A non-work-related accident that only aggravates a weakened condition does not break the causal chain, and other incidents that aggravate the claimant’s condition are legally irrelevant, as held in Teska v. Industrial Commission, 266 Ill.App.3d 740, 640 N.E.2d 1, 3, 203 Ill.Dec. 574 (1st Dist. 1994), and Vogel v. Industrial Commission, 354 Ill.App.3d 780, at 821 N.E.2d 807, 813, 290 Ill.Dec. 495. Id. So long as a “but-for” relationship exists between the original work injury and the subsequent condition, the employer remains liable, consistent with Global Products, supra, 911 N.E.2d at 1046. Id.

The court upheld the Commission’s rejection of the employer’s argument that the claimant’s participation in a breast cancer charity walk constituted an independent, intervening cause of her subsequent left leg, foot, heel, and ankle conditions. 2026 IL App (1st) 250494WC-U at ¶72. They noted that the Commission found implausible the employer’s assertion that the claimant walked 30 miles one week after major breast cancer surgery, crediting her testimony that she did not complete the full distance and spent most of the event riding in a golf cart due to postoperative pain. Id. Because the Commission found the claimant credible, the court noted it was entitled to rely on her testimony regarding the extent of her activity. Id.

Although the employer pointed to therapy and treatment records reflecting a temporary increase in heel pain and new clinical findings after the event, the court concluded that this evidence did not compel a finding of an independent intervening cause. 2026 IL App (1st) 250494WC-U at ¶¶73 – 74. The post-event therapy records also documented substantial overall improvement, including increased strength, range of motion, ambulation tolerance, and decreased pain frequency and intensity. 2026 IL App (1st) 250494WC-U at ¶74.

The court further emphasized that neither the medical records nor expert testimony supported a finding that the charity walk broke the causal chain. 2026 IL App (1st) 250494WC-U at ¶75. The treating physicians consistently attributed the claimant’s lower extremity conditions, including CRPS, to the August 13, 2019, work accident. Id. The employer’s reliance on testimony that plantar fasciitis could be aggravated by prolonged standing was insufficient. Id.

Even assuming there had been a post-walk aggravation, the court held that such evidence, at most, demonstrated a contributing aggravation of a preexisting work-related injury — not a complete break in causation. 2026 IL App (1st) 250494WC-U at ¶76. The record contained no medical testimony establishing that walking alone was the sole cause of her disabling conditions. Id. To the contrary, citing Vogel the court held that the evidence supported a “but-for” causal relationship between the original work injury and the claimant’s subsequent condition, and thus the employer failed to establish an independent intervening cause. Id.

2. Medical Bills and Group Health Payments

The most important issue on appeal was regarding the medical bill award by the Commission.

First, the employer argued that the Commission erred in awarding the claimant medical expenses for physical therapy treatments related to her left shoulder. 2026 IL App (1st) 250494WC-U at ¶78. The employer correctly noted that the claimant’s case involved injuries to her left lower leg, foot, ankle, and heel — not her shoulder. Id. Nevertheless, the Commission awarded payment for several physical therapy sessions in November and December 2019 that appeared to involve shoulder treatment alone. Id. The court agreed that these shoulder-related expenses should not have been awarded. Id.

The employer also argued that the Commission improperly awarded certain medical expenses despite the absence of supporting medical bills in the record. 2026 IL App (1st) 250494WC-U at ¶79. After the employer refused to pay for pain management treatment following Dr. Candido’s January 2020 IME report, the claimant’s private group health insurer, Blue Cross Blue Shield (BCBS), began covering those treatments. 2026 IL App (1st) 250494WC-U at ¶80. The claimant introduced medical bills from her providers and a “Consolidated Statement of Benefits” from BCBS covering medical treatments from January 5, 2021, through November 1, 2022. Id. The employer asserted that BCBS prepared this document in connection with a subrogation lien claim. Id.

The “Consolidated Statement of Benefits” listed total amounts billed for each date of service but did not itemize the specific treatments performed. 2026 IL App (1st) 250494WC-U at ¶81. The document reflected that BCBS paid a total of $208,342.16 in benefits, including approximately $169,000 to Rush Surgicenter for services on March 23, 2022, approximately $30,000 to Rush Oak Park Hospital for services on March 10, 2022, and payments for anesthesiology services on both dates. Id. After determining that the claimant’s medical expenses were reasonable and necessary, the Commission awarded $204,559.62 — the amount identified in the BCBS statement — minus certain medical bills lacking corresponding treatment records. Id.

The employer contended that this award was improper because the BCBS statement showed only amounts BCBS claimed to have paid for unspecified services and was unsupported by the medical providers’ actual bills. 2026 IL App (1st) 250494WC-U at ¶83. The employer argued that without the providers’ actual medical bills in evidence, there was a failure of proof and no basis for liability for the bill. Id. The employer further maintained that, even if it were liable for some treatments, the actual bills were necessary to determine the correct amount owed under §8(a) of the Act. 2026 IL App (1st) 250494WC-U at ¶84. According to the employer, §8(a) requires payment at the lesser of the negotiated rate, the provider’s charge, or the statutory fee schedule rate under §8.2, and such a comparison could not be made without the actual bills. Id.

The court rejected these arguments. 2026 IL App (1st) 250494WC-U at ¶85. It explained that §8(a) requires payment at the negotiated rate if applicable, or otherwise at the lesser of the provider’s charge or the fee schedule rate. Id. Because BCBS had already paid the providers, the amount BCBS had paid constituted the “negotiated rate” under §8(a), which the employer was required to pay. Id. The court noted that analysis of actual charges versus the fee schedule is only necessary when the medical bills have not yet been paid by a third-party insurer. Id.

However, the court identified a discrepancy between the BCBS “Consolidated Statement of Benefits” and a separate BCBS spreadsheet that itemized charges and payments. 2026 IL App (1st) 250494WC-U at ¶86. Although both documents reflected the same amounts billed by providers, they listed dramatically different amounts paid by BCBS. Id. For example, while both documents showed Rush Surgicenter billed $169,119.60 on March 23, 2022, the Consolidated Statement recorded a payment of $168,526.34, whereas the spreadsheet listed only $50,059.40 as paid. Id. The Commission did not address this discrepancy, and the claimant did not explain it. Id.

Accordingly, the court remanded the matter to the Commission to resolve the discrepancy and determine the actual amount BCBS paid for the services at issue. 2026 IL App (1st) 250494WC-U at ¶87. The court held that only the amount actually paid by BCBS should be awarded. Id.

3. Arbitrator’s Actions Regarding the Employer’s Fourth IME Request

The employer contended that the arbitrator improperly interfered with its statutory right to obtain a fourth IME on June 23, 2020, by ruling that the examination should not proceed. 2026 IL App (1st) 250494WC-U at ¶89. The court rejected this argument, noting that the employer itself invited the arbitrator’s involvement by requesting guidance after the claimant refused to attend the scheduled IME. 2026 IL App (1st) 250494WC-U at ¶90. In an email to the arbitrator, the employer’s counsel expressly asked for a prompt discussion and indicated that “if that is what you decide,” thereby submitting the issue to the arbitrator for determination. Id. Having requested the arbitrator’s opinion, the employer could not later claim error based on that involvement. Id.

The court further observed that no transcript of the discussion existed and as a result, the record did not permit meaningful review of the alleged procedural error. 2026 IL App (1st) 250494WC-U at ¶91.

The court remanded the case back to the Commission to disallow any charges for treatments to the claimant’s left shoulder and to determine the amount that BCBS paid the claimant’s healthcare providers for medical services relating to the claimant’s work-related injuries, and to award the claimant that amount. 2026 IL App (1st) 250494WC-U at ¶93. The remainder of the Commission was affirmed.

PRACTICE POINTER: Proving and Defending Medical Bills When Group Insurance Has Paid

Ultimately, the significance of this case is the second issue the court addressed on appeal. This case reinforces that in group-health-paid claims, the dispositive figure is the actual negotiated amount paid. Additionally, the record should be clear to either sustain or defeat a medical expense award.

This case underscores the evidentiary and strategic importance of properly substantiating medical expenses when a claimant’s group health insurer has made payments for medical bills. For petitioner’s counsel, reliance on a consolidated insurer statement alone may be insufficient if discrepancies exist between the consolidated statement of benefits reflecting a paid amount and the actual medical bills. Practitioners should ensure the record clearly establishes (1) the services rendered via medical records, (2) medical bills, and (3) the actual amount paid for medical treatment when a group health insurer has made payments.

For respondent’s counsel, it is important to scrutinize the medical bills to the actual medical treatment records for discrepancies to determine what they are obligated to pay under the award. Further, this decision highlights that once a group health insurer has paid medical providers at a negotiated rate, the employer is obligated to pay the actual amount paid for the medical service and not the amount paid listed on the Consolidated Statement of Benefits in the lien itemization. If the medical bills remain unpaid, the fee schedule would apply. Respondent’s counsel should scrutinize the Consolidated Statement of Benefits and the actual medical bill to determine the accurate amount paid. If the petitioner fails to admit this information into evidence, the respondent should present the evidence to determine the actual amount paid and clearly raise the issue to preserve it for review.