State News

 
Readers of The Compendium may recall DWC’s launching two years ago of CompCourses. These free webinars are designed to benefit workers’ compensation professionals, including adjusters, employers, and healthcare staff, by providing essential education on the workers’ compensation system, delivered in free 1-hour webinars. Not only are participants able to stay informed on current trends and improve their professional skills, they are also able to earn free Continuing Education (CE) credits by watching the webinars and completing a short quiz.
 
DWC announced last month that its CompCourses webinars will now be available in an on-demand, self-study format, allowing participants to learn and earn CE credit whenever it fits their schedule by watching previously recorded CompCourses webinars and completing the short quiz to earn 1 hour of TDI self-study CE credit.
 
Earning on-demand credit could not be easier! Simply visit the CompCourses webpage here and select the course you wish to take. You will fill out a Microsoft form, watch the 1-hour webinar on YouTube, and take the quiz to test your knowledge.
 
Voila…..
 
DWC has announced that it will continue to offer live CompCourses in 2026, affording participants the opportunity to engage directly with subject-matter experts and earn CE credit.
 
CompCourses webinars for 2026 are planned as follows:

• Navigating the Top 10 Workers’ Compensation Disputes – Spring 2026.
• Texas Workers’ Compensation Income Benefits 101 – Summer 2026.
• Medical Fee Dispute Resolution – Fall 2026.
• Return to Work – Winter 2026.

Copyright 2026, Stone Loughlin & Swanson, LLP 

DWC is considering amending 28 Texas Administrative Code Chapter 152 concerning attorney fees and sought comments through last month on whether changes to the current hourly rate for attorney fees are necessary.
 
We note that when the Act was implemented in 1991, the approved hourly rate for attorney fees was $150. That rate remained in place for 26 years, until 2017, when it was increased to $200.
 
Per the Bureau of Labor Statistics Consumer Price Index Inflation Calculator, $200 in January, 2017, has the same buying power as $266.89 in December, 2025. Further, $200 in December, 2025, has the same buying power as did $149.88 in January, 2017. In other words, due to inflation, it’s as if the rate was never increased.

By comparison, the maximum weekly temporary income benefit in 1991 was $428, and the minimum was $64. By 2016, the maximum weekly benefit had risen to $895, and the minimum to $134. Today, the maximum weekly benefit is $1,271, and the minimum is $191. So, benefit levels have nearly tripled since 1991, while the attorney hourly rate has increased only once and remains at $200 nearly a decade later.  Meanwhile, that rate must cover the overhead required to operate and maintain an effective law practice which has increased in ways that were inconceivable in 1991.
 
Workers’ compensation now has the second lowest average hourly rate of any practice area at an average of $180, second only to juvenile law at $146, while the average hourly rate for all practice areas is $367. Hourly Rates in Texas. 
 
The overarching concern is that if the rate cap is not raised, the workers’ compensation bar will continue to shrink, as it is doing now, as older, experienced attorneys retire and new attorneys choose other practice areas over workers’ compensation law because it is more difficult to make the numbers work.  At that point, employees, employers, and carriers will no longer be able to obtain effective legal representation in this highly complex area of the law.

Copyright 2026, Stone Loughlin & Swanson, LLP 

by: Kisa P. Sthankiya

Stephanie Ringbloom, Esq.:

The Pennsylvania Supreme Court issued an unpublished opinion in the case of Yoder v. McCarthy Construction, Inc., et. al., No. 43 EAP 2024, 2025 WL 2981889 (Pa. Oct. 23, 2025). In this decision, the Court confirmed the applicability of the McDonald test for coverage of a subcontractor. The Court noted that “Under the Workers’ Compensation Act (Act), as  interpreted  by  this  Court  for decades, a general contractor that hires a subcontractor to perform work on a jobsite is deemed  an  “employer”  that  is  secondarily  liable  to  the  injured  employee  of  the subcontractor  for  the  payment  of  compensation  under  the  Act, provided  that  the subcontractor—the  one primarily  liable—fails  to  make  payment.” They cited to Section  302(b)  of  the Act, 77 P.S. § 462. A general contractor can thereby avail itself of the same tort immunity afforded to the subcontractor by way of this secondary liability.

There are five elements that must be met under the McDonald test for a general contractor to qualify as a statutory employer: (1) the existence of a contract with an owner or one in the position of an owner; (2) occupancy and/or control of the premises upon which the work is being performed; (3) the existence of a subcontract with the general contractor; (4) entrustment of part of the general contractor’s regular business to the subcontractor; and (5) the claimant is an employee of that subcontractor. The Supreme Court determined that McCarthy Construction had demonstrated all five elements in the claim filed by Yoder, thereby granting it statutory immunity for the civil claim that the injured worker had tried to file against McCarthy.

    On December 3, 2025, an Arkansas Court of Appeals issued an opinion that further bolstered the supreme reign of the Arkansas Workers’ Compensation Commission (more commonly referred to as the “Full Commission”) as the deferential trier of fact and arbiter of credibility. One of the most noteworthy quirks of Arkansas workers’ compensation law is that Arkansas appellate courts and the Arkansas Supreme Court afford near-complete deference to the Full Commission’s credibility assessment of witnesses while completely disregarding the credibility determinations rendered by Administrative Law Judges that have had the opportunity to personally observe witnesses and their demeanor while testifying on the stand. The Full Commission is tasked with reviewing the decisions rendered by ALJs along with the evidentiary record of a claim once an ALJ’s decision has been appealed, but their review of the record is limited to transcripts of testimony, evidentiary exhibits, and briefs submitted by legal counsel for both parties. However, despite never getting to personally observe witnesses and their demeanor as they testify, it is well settled in Arkansas workers’ compensation law that the reviewing Court of Appeals or Arkansas Supreme Court will “give no weight to the ALJ’s findings whatsoever” and will instead defer to the credibility assessments and findings of facts rendered by the Full Commission even though it is the ALJ that presides over a claim for months (potentially even years), makes rulings on the admissibility of evidence, and personally observes claimants and other witnesses as they testify under direct and cross-examination. Dardanelle Pub. Sch. v. Ewton, 2025 Ark. App. 575, at 7, 728 S.W.3d 401, 405 (citing Clark v. Peabody Testing Serv., 265 Ark. 489, 579 S.W.2d 360 (1979)). 

    In the case in point, Claimant Andrea Ewton was employed as a substitute custodian for Dardanelle Intermediate School and was on the clock when she walked from the school’s office to her car and injured her knee and ankle when she stepped down from a curb in the parking lot. At issue was whether she was performing employment services when she went to her car or whether she had gone to her car for a personal errand (specifically to retrieve her water bottle). Mere hours after Ewton’s fall, she spoke on the phone with a claim supervisor and reported that she had gone to her car that morning to retrieve a water bottle when she slipped off a curb injuring her knee and ankle. In the recorded transcript of that call, Ewton was specifically asked if she had gone to her car for any purpose other than retrieving her water bottle, and she responded, “No ma’am”. The school nurse that iced Claimant’s injuries immediately after the accident also testified that Ewton told her she had been walking to her car to get a drink when she slipped off the curb. These reports made by Claimant immediately after her accident are noteworthy because she eventually changed her story and testified at the hearing in front of the ALJ that she had gone to her car to retrieve a set of keys that she needed to open school buildings. Ewton had also testified during her deposition that she went to her car to retrieve a set of keys; however, during her deposition, she testified that the school nurse had given her the wrong set of keys earlier that morning. In contrast, she testified in front of the ALJ that the school’s secretary had given her the wrong set of keys that morning (perhaps after she and her attorney realized that the school nurse only had keys that could open the nurse’s office rather than the various school buildings that Ewton needed to access that day). 

    After observing the demeanor of Ewton, the school nurse and the secretary while they testified, in addition to reviewing the Claimant’s deposition transcript and the transcript of her recorded statement made on the same day of her accident, the ALJ ruled that Ewton had failed to prove she suffered a compensable injury to her knee and ankle because she was not performing employment services at the time of her fall. In his opinion, the ALJ specifically found that Ewton did not provide credible testimony when she testified that she had gone to her car that morning to retrieve a set of keys to one of the school’s buildings. His credibility determination was based on Ewton’s inconsistent narratives regarding why she went to her car that morning as well as other instances of doubtful credibility in the record such as her testimony at the hearing that she hadn’t worked since her accident which was contradicted by Claimant’s unemployment application wherein she reported working for a nursing and rehabilitation facility for a period of four months after her accident at the school. 

    In spite of the ALJ’s personal observations of the witnesses throughout their testimony as well as his thorough opinion which cited to numerous inconsistencies in the evidentiary record in support of his credibility assessments, the Full Commission reversed his denial of the claim and found that Ewton had met her burden of proof in establishing that she was performing employment services at the time of her fall. The Full Commission noted in its decision that it specifically found Ewton’s testimony to be credible when she testified at the hearing that she had gone to her car to retrieve a set of keys rather than only going to her car for a bottle of water. Respondents appealed the Full Commission’s decision to the Court of Appeals arguing that Claimant had failed to prove she sustained a compensable injury within the scope of her employment because she provided inconsistent statements regarding her purpose for going to her car. However, the Court of Appeals abided by long-standing precedent in deferring to the Full Commission’s credibility determination and stating that Arkansas courts will affirm the Commission’s decisions when the issue on appeal comes down to the Commission’s assessment of the credibility of witnesses.  

    Given that the Court of Appeals is bound by the Arkansas Workers’ Compensation Act and decades of case law which designate the Commission as the ultimate factfinder, the Court of Appeals’ decision to affirm the Full Commission is certainly not surprising to those who are familiar with workers’ compensation law in the natural state. Ultimately, it is up to the Arkansas legislature to amend the law if they believe that the ALJs who have the opportunity to personally observe the demeanor of witnesses and to comb through extensive evidence should be given deference when making credibility determinations and other valuable findings of fact over the administrative and judicial bodies who are charged with reviewing the evidentiary record from transcripts and records alone. 

The burial benefit under the Nebraska Workers’ Compensation Act will increase to $12,200.00 effective July 1, 2026. This benefit applies upon the death of an employee, resulting through personal injuries as defined in NEB. REV. STAT. § 48-151.

By: Jigar S. Desai

In a February 26, 2026, opinion, the Illinois Appellate Court, Fifth District, Workers’ Compensation Commission Division, addressed a question of first impression under the Workers’ Compensation Act (Compensation Act), 820 ILCS 305/1, et seq.: whether a claimant who sustains a single injury to one body part may receive concurrent awards under both the scheduled loss provisions of §8(e) and the person-as-a-whole provisions of §8(d)(2). Azcon Metals v. Illinois Workers' Compensation Commission, 2026 IL App (5th) 250301WC. The court held that a claimant must elect one remedy or the other for the same injury, and that an employer who made a voluntary payment under §8(e) is entitled to a credit against a subsequent award under §8(d)(2).

The court affirmed the Commission’s award of permanent partial disability benefits under §8(d)(2) but reversed the Commission’s denial of credit to the employer for benefits previously paid under §8(e).

The decision provides important guidance on the interplay between §§8(e) and 8(d)(2), the election-of-remedies doctrine in workers’ compensation, and the credit principles that apply when employers make prompt voluntary payments under the Compensation Act.

Factual Background

Tom Snyder sustained an injury to his right foot and leg while working for Azcon Metals on March 19, 2020. His right foot was crushed between two rail cars. Snyder initially underwent surgery that resulted in the amputation of four toes on his right foot. However, the following day, he underwent a second surgery that resulted in the amputation of his right leg at the mid-tibia, below the knee.

Following the surgeries, Snyder was fitted for a transtibial prosthetic and participated in physical therapy, work hardening, and a functional capacity evaluation. The evaluation indicated that he could perform work at the heavy physical demand level but had decreased tolerance for prolonged standing and walking on uneven surfaces. Snyder participated in vocational rehabilitation and expressed his intent to pursue employment in heating, ventilation, and air conditioning or in the construction industry, acknowledging that those fields may require traversing uneven ground but believing he could manage the slower pace of such work.

Following the work injury, the employer promptly paid Snyder $97,010.30 in permanent partial disability benefits for the scheduled loss of his right foot pursuant to §8(e)(11) of the Compensation Act. The payment was made in two installments: $60,716.19 on April 20, 2020, and $36,294.11 on April 28, 2022, calculated at 167 weeks using a stipulated minimum statutory amputation rate of $580.90.

Procedural History

On April 17, 2020, Snyder filed an application for adjustment of claim. The matter proceeded to an arbitration hearing on January 27, 2023. At the outset of the hearing, the parties stipulated that the employer had paid, and was entitled to credit for, $17,438.31 in temporary total disability benefits and $42,822.94 in maintenance benefits. The parties further stipulated that the employer had paid $97,010.30 in permanent partial disability benefits for the scheduled loss of Snyder’s right foot under §8(e)(11), but they disagreed as to whether the employer was entitled to a credit for that payment against any additional permanent partial disability award.

Snyder waived his right to a wage differential award under §8(d)(1). The arbitrator awarded all requested medical expenses and, after considering the factors set forth in §8.1b(b)(v) of the Compensation Act, found that Snyder sustained permanent partial disability to the extent of 65 percent loss of use of the person as a whole under §8(d)(2). The arbitrator denied the employer’s request for a credit for the §8(e)(11) payment against the §8(d)(2) award.

On review, the Commission unanimously reduced the §8(d)(2) award from 65 percent to 45 percent loss of use of the person as a whole, finding that Snyder was young and remained capable of physically demanding work. The Commission, however, agreed with the arbitrator that the employer was not entitled to a credit. The Commission characterized the credit issue as one of first impression, concluded that §8(d)(2) did not permit an offset for previously paid amputation benefits, and noted that the employer had paid benefits under the incorrect section — §8(e)(11) (loss of foot, 167 weeks) rather than §8(e)(12) (amputation below the knee, compensated as loss of a leg at 215 weeks).

The circuit court affirmed the Commission’s decision in its entirety. The employer appealed to the appellate court.

The Appellate Court’s Analysis

Framing the Issue

As a threshold matter, the appellate court corrected the framing of the employer’s first argument on appeal. The employer had argued that the Commission erred by awarding benefits under both §§8(e) and 8(d)(2). The court clarified that the Commission did not “award” benefits under §8(e); rather, the employer had made a voluntary payment under that section prior to arbitration. The Commission only awarded benefits under §8(d)(2) and separately considered whether the employer was entitled to a credit. Accordingly, the court reframed the central issue as whether the Commission erred by denying the employer a credit for its voluntary §8(e) payment against the §8(d)(2) award.

Standard of Review

The court noted that while the Commission’s determination of whether an employer is entitled to a credit is ordinarily reviewed for abuse of discretion, the Commission in this case interpreted statutory provisions and concluded that §8(d)(2) did not permit an offset. Because the dispute involved statutory interpretation, the court applied de novo review.

Election of Remedies: Section 8(e) Versus Section 8(d)(2) for a Single Injury

The core of the court’s analysis addressed the interplay between §§8(e) and 8(d)(2). The court acknowledged the tension between the two provisions. Section 8(e) provides that a claimant who receives a scheduled loss “shall not receive any compensation under any other provisions of this Act.” 820 ILCS 305/8(e). Section 8(d)(2), on the other hand, states that compensation awarded under that subsection “shall not take into consideration injuries covered under paragraphs (c) and (e)” and that such compensation “shall not affect the employee’s right to compensation payable under paragraphs (b), (c) and (e) . . . for the disabilities therein covered.” 820 ILCS 305/8(d)(2).

The Commission had relied on the language of §8(d)(2) to conclude that recovery under §8(e) should have no effect on an award under §8(d)(2), and vice versa, effectively permitting concurrent awards and denying the employer any credit. The circuit court agreed, adding that any ambiguity should be resolved in the claimant’s favor under the principle of liberal construction.

The appellate court disagreed. In its view, the language of §8(e) clearly precluded a claimant from recovering under both sections for the same injury to one body part. The court interpreted the language of §8(d)(2) as permitting an election — not a concurrent award — for a single injury. Specifically, the court concluded that §8(d)(2) permits a claimant to elect an award under either §8(e) or §8(d)(2) for an injury to a single body part, while also permitting recovery under both sections when a claimant sustains injuries to multiple, separate body parts in the same work accident.

Consistency with Prior Caselaw

The court grounded its conclusion in several lines of precedent. First, the court analogized to established caselaw holding that a claimant who sustains a scheduled loss may elect between a scheduled loss award under §8(e) and a wage differential award under §8(d)(1), but may not receive both. Citing Payetta v. Industrial Commission, 339 Ill.App.3d 718, 791 N.E.2d 682, 274 Ill.Dec. 590 (2d Dist. 2003), and General Electric Co. v. Industrial Commission, 89 Ill.2d 432, 433 N.E.2d 671, 60 Ill.Dec. 629 (1982), the court noted that this election principle reflects the understanding that an injured party will choose the award most likely to approximate the earnings loss the Compensation Act is designed to compensate. The Commission had distinguished those cases on the basis that §8(d)(1) contains an explicit exclusion for §8(e) claims, whereas §8(d)(2) does not. The appellate court acknowledged the difference in statutory language but concluded that the exclusionary language in §8(e) itself — prohibiting compensation under “any other provisions of this Act” (820 ILCS 305/8(e)) — resolved the issue.

Second, the court observed that both wage differential awards under §8(d)(1) and person-as-a-whole awards under §8(d)(2) serve to compensate injured workers for reduced earning capacity under certain circumstances. Given this functional similarity, the court concluded that the rationale prohibiting dual recovery under §§8(e) and 8(d)(1) applies equally to §§8(e) and 8(d)(2) when a single injury to one body part is at issue.

Third, the court distinguished its prior decisions in Beelman Trucking v. Illinois Workers’ Compensation Commission, 233 Ill.2d 364, 909 N.E.2d 818, 330 Ill.Dec. 796 (2009), and American Coal Co. v. Illinois Workers’ Compensation Commission, 2024 IL App (5th) 230815WC, 248 N.E.3d 493, 478 Ill.Dec. 868. In those cases, the claimants had sustained injuries to multiple body parts during a single work accident, warranting additional compensation under the Compensation Act. In Beelman Trucking, the supreme court permitted concurrent awards under §§8(e)(18) (loss of legs) and 8(e)(10) (loss of arm), reasoning that denying compensation beyond two members would leave additional losses uncompensated. In American Coal, this court extended that reasoning to permit concurrent awards under §§8(e)(18) and 8(d)(2) for nonscheduled injuries sustained in addition to the scheduled losses. The appellate court found those decisions consistent with its holding in Azcon Metals, noting that the present case involved only a single injury to one body part, and that allowing concurrent awards would result in impermissible double recovery.

Employer Entitled to Credit for Voluntary Payment

Having concluded that the claimant was entitled to compensation under only one statutory provision for his single injury, the court turned to the credit issue. The court held that the Commission erred by denying the employer’s credit request. The employer had promptly and voluntarily paid benefits under §8(e) following the work accident, providing the claimant with immediate financial relief. When the claimant subsequently elected to receive benefits under §8(d)(2), the Commission should have credited the employer for its prior voluntary payments.

The court cited World Color Press v. Industrial Commission of Illinois, 125 Ill.App.3d 469, 466 N.E.2d 270, 80 Ill.Dec. 818 (5th Dist. 1984), for the proposition that an employer may receive credit for overpayments absent a statutory bar, and Salisbury v. Illinois Workers’ Compensation Commission, 2017 IL App (3d) 160138WC, 78 N.E.3d 979, 413 Ill.Dec. 703, for the policy principle that encouraging prompt and voluntary payments of benefits furthers the purpose of the Compensation Act. The court emphasized that denying credit for good-faith payments would encourage administrative delays as employers attempt to resolve every ambiguity before paying benefits — a result inconsistent with the Compensation Act’s primary purpose of providing employees with prompt and definite compensation.

Practical Implications

This decision establishes several important principles for practitioners on both sides of the bar.

For employers and carriers, the decision confirms that when a single injury to one body part is involved, a claimant must elect between a scheduled loss award under §8(e) and a person-as-a-whole award under §8(d)(2). The employer who promptly and voluntarily pays benefits under §8(e) will be entitled to a credit against a subsequent §8(d)(2) award. This holding should encourage prompt payment of scheduled benefits, as employers need not fear that early payments will go uncredited if the claimant later elects a different form of permanent disability compensation. Practitioners should carefully document voluntary payments, including the statutory section under which they are made, the calculation methodology, and the dates of payment.

For claimants, the decision preserves the right to elect the more favorable remedy — but it forecloses the possibility of receiving both a scheduled loss award and a person-as-a-whole award for the same injury. Claimants and their counsel should carefully evaluate which remedy produces the greater benefit before making an election, particularly in cases involving amputations or other injuries that may qualify under both sections. The decision also reaffirms that concurrent awards remain permissible when a claimant sustains injuries to multiple, separate body parts in a single work accident, consistent with the rationale of Beelman Trucking, supra, and American Coal, supra.

Finally, the employer’s miscalculation of the scheduled loss payment in this case — paying 167 weeks for loss of a foot under §8(e)(11) when the below-knee amputation should have been compensated as a loss of a leg at 215 weeks under §8(e)(12) — serves as a reminder that correct classification of the injury under the appropriate subsection of §8(e) is critical. An incorrect classification may result in an underpayment that could affect the credit calculation or expose the employer to additional proceedings.

By: Jigar S. Desai

In a January 27, 2026, Rule 23 order, the Illinois Appellate Court, Second District, Workers’ Compensation Commission Division, addressed the compensability of injuries sustained by a traveling employee who was assaulted by third parties while making deliveries. Avila v. Illinois Workers Compensation Commission, 2026 IL App (2d) 250093WC-U. The court reversed the Commission’s denial of benefits and reinstated the arbitrator’s compensability findings, holding that the Commission’s application of the aggressor defense and its causation analysis were against the manifest weight of the evidence. The court further remanded the case for the Commission to consider whether penalties and attorneys’ fees should be imposed.

Although the decision is nonprecedential, it provides a detailed illustration of how courts analyze street-risk exposures, the aggressor defense, and intervening acts in the context of traveling employees.

Factual Background

Jose Avila worked as a delivery driver for Amazon. On August 1, 2023, while performing his delivery route in Aurora, Avila was driving his truck on a residential street when a black SUV abruptly cut in front of him at close range. The maneuver was sufficiently sharp that Avila had to brake suddenly. Avila testified that the SUV nearly struck a woman who was unloading groceries on the side of the road.

After the near-collision, Avila honked his horn and gestured toward the driver of the SUV. He then stopped his delivery truck and momentarily remained in the area. According to Avila, his purpose in stopping was not to pursue a confrontation with the driver of the SUV but to check on the woman who had nearly been struck and to ensure that she was not injured. The dash camera footage showed Avila stopping his vehicle while a pedestrian remained in the parkway near the truck.

While Avila was stopped, individuals associated with the SUV began yelling at him. The driver of the SUV exited his vehicle and walked toward Avila. Avila testified that he felt threatened because he was still seated and buckled in his truck with the door open, and the approaching individual was on the side of the open door. Avila unbuckled his seat belt and exited the truck. The video footage showed Avila and the SUV driver meeting briefly near the truck, at which point the driver of the SUV punched Avila. Others joined in the scuffle. The physical altercation was brief and partially out of camera view. The woman who was almost struck intervened and calmed the initial confrontation.

After the initial confrontation, Avila returned to his truck and drove away. As he was leaving, he yelled words and made nonverbal gestures to the individuals who had attacked him. Avila stated that he did this out of frustration, but not in a threatening manner.

The dash camera footage showed him continuing along his delivery route through a residential neighborhood for several minutes. Approximately four to five minutes later, and two to three blocks away from the location of the initial encounter, Avila parked his truck to make another delivery. As he walked toward the delivery location, a maroon sedan pulled up near the truck. Several individuals exited the vehicle, including the driver of the SUV from the earlier incident. Avila was attacked from behind, knocked to the ground, and beaten and kicked by multiple assailants. During the assault, one of the attackers took a chain from Avila’s neck.

Avila reentered his truck after the second assault. Dash camera footage showed visible blood on his face and head. He appeared to photograph the fleeing assailants and then stumbled near the passenger side of the vehicle. Emergency medical services transported him to the hospital, where he was treated for facial fractures, dental injuries, head trauma, and related symptoms. He later received follow-up dental treatment and medical care for headaches and psychological symptoms related to the assault.

Procedural History

The case proceeded to arbitration. The employer argued that Avila was the aggressor and his recovery was therefore barred. The arbitrator disagreed and found that Avila’s injuries arose out of and in the course of his employment as a traveling employee and were causally related to the assaults. The arbitrator concluded that the risks of street encounters were incidental to his job duties and that, in any event, the second assault occurred while he was actively making a delivery. The arbitrator awarded temporary total disability benefits, medical benefits, prospective care, penalties, and attorneys’ fees.

On review, the Commission unanimously reversed. The Commission found that Avila was the aggressor in the first incident based on his gestures, conduct, and decision to exit his truck. The Commission further concluded that the second assault would not have occurred but for Avila’s conduct during the first encounter, thereby negating the causal connection to employment.

The circuit court reversed the Commission, finding that the aggressor determination as to the first incident, and the conclusion that the second assault was merely a continuation of the first, were against the manifest weight of the evidence. The employer appealed to the appellate court.

The Appellate Court’s Analysis

The appellate court affirmed the circuit court’s decision. The court began by reaffirming that an injury must arise out of and in the course of employment in order to be compensable. The “in the course of” element concerns the time, place, and circumstances of the injury, while the “arising out of” element requires a causal connection between the employment and the injury. The court noted that injuries sustained by traveling employees are analyzed under more liberal standards because such employees are exposed to the risks of the street as an inherent aspect of their work.

In the Course of Employment

With respect to the “in the course of” requirement, the court had little difficulty concluding that Avila satisfied this element. At the time of the second assault, Avila had resumed his delivery route and was actively engaged in making a delivery. The evidence showed that he had disengaged from the earlier confrontation, driven away, and returned to his work duties. Accordingly, the court found that Avila was within the time and space boundaries of his employment when the injury occurred.

Arising Out of Employment

The court then turned to the “arising out of” element. The Commission had concluded that Avila’s injuries did not arise out of his employment because the assaults stemmed from a personal dispute initiated by his conduct during the traffic encounter.

The appellate court rejected that characterization. It emphasized that Avila’s job as a delivery driver required him to travel public roadways and interact with traffic and members of the public. The risks inherent in street travel, including the possibility of confrontations with other motorists, are risks to which Avila was exposed by virtue of his employment. The court cited established precedent recognizing that assaults on traveling employees by third parties may be compensable when the employment places the employee in a position of increased exposure to such risks.

The Aggressor Defense

The appellate court devoted significant attention to the Commission’s application of the aggressor defense. The court reiterated that an employee who becomes the aggressor in a physical altercation may be found to have departed from the course of employment, thereby breaking the causal connection between employment and injury.

However, the court emphasized that aggressor status is a fact-intensive determination that must be evaluated based on the totality of the circumstances. The mere fact that an employee exchanges words, gestures angrily, or exits a vehicle does not, by itself, establish that the employee became the aggressor in a subsequent physical confrontation.

Reviewing the dash camera footage and testimony, the court found that the Commission’s conclusion that Avila was the aggressor in the first encounter was against the manifest weight of the evidence. The video did not show Avila initiating physical violence, and the evidence showed that the other driver approached Avila’s truck and struck the first blow. While Avila’s conduct may have contributed to a tense encounter, the court concluded that the record did not support a finding that he escalated the encounter into a physical fight so as to forfeit the protections of the Workers’ Compensation Act (Compensation Act), 820 ILCS 305/1, et seq.

Causation and the Second Assault

The court further rejected the Commission’s conclusion that the second assault was merely a continuation of the first encounter and therefore remained personal in nature. The appellate court emphasized that there was a meaningful temporal and spatial break between the two incidents. Avila had left the scene of the initial confrontation, driven several blocks, and resumed performing his delivery duties. The second attack occurred at a different location, several minutes later, and involved assailants who pursued Avila and initiated a new, unprovoked assault while he was making a delivery.

In addressing causation, the court explained that the Compensation Act does not require that employment be the sole cause of an injury. It is sufficient that the employment be a contributing cause. The court rejected the Commission’s “but for” reasoning that the second assault would not have occurred but for Avila’s earlier conduct. The court noted that such a broad conception of causation would improperly transform many workplace injuries into noncompensable events whenever a claimant’s prior conduct could be traced as part of the chain of events. Instead, the proper inquiry is whether the injury can fairly be traced to a risk of employment, as opposed to a purely personal risk. Here, Avila’s exposure to public street risks as a delivery driver, combined with the fact that he was engaged in work duties at the time of the second assault, supported compensability.

Standard of Review

Finally, the appellate court underscored the standard of review applicable to Commission findings. While the Commission’s factual determinations are entitled to deference, they will be reversed when an opposite conclusion is clearly apparent from the record. The court concluded that the Commission’s findings regarding aggressor status and causation were contrary to the clear weight of the evidence presented.

This decision highlights the importance of carefully separating multiple incidents when analyzing causation. When an employee disengages from an initial confrontation and later sustains injuries in a separate encounter, the later event may be deemed an independent intervening act rather than a continuation of the earlier dispute. Practitioners should analyze temporal separation, geographic separation, and whether the claimant had resumed job duties at the time of injury.

For employers and carriers, the aggressor defense remains viable, but it requires a close examination of the totality of the circumstances. Evidence of verbal provocation or angry gestures may be insufficient, standing alone, to establish that a claimant was the aggressor when the other party initiates physical violence. Video evidence should be reviewed carefully, and the absence of audio may limit the ability to draw firm conclusions about verbal threats or provocations.

For claimants, the case underscores the significance of the traveling employee doctrine and the street-risk doctrine. Employees whose jobs place them in public settings are exposed to risks that may be deemed incidental to employment, including assaults by third parties. Demonstrating that the employee was engaged in job duties at the time of injury remains central to compensability.

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.

By: Kisa P. Sthankiya

In Safeway Scaffolding/Safeway Services, LLC v. Illinois Workers’ Compensation Commission, 2025 IL App (5th) 250298WC-U, the claimant sought benefits pursuant to §19(b) of the Workers’ Compensation Act, 820 ILCS 305/1, et seq., for injuries sustained to his low back. The claimant was employed as an insulator and sustained an undisputed low back injury on October 26, 2018. He underwent an L4 through S1 lumbar spine fusion surgery on February 11, 2019, and was authorized to return to work on May 17, 2019, with a 20-pound lifting restriction and to avoid repetitive bending, stooping, or twisting.

On June 6, 2019, a light duty assignment was made commencing on June 10, 2019. The claimant testified that he did not appear on June 10, 2019, due to a flood that caused bridge and ferry closures causing a 4-hour drive to work, and he had a 30-minute sitting restriction. He also testified that the job was a sham offer based on his situational experience. The respondent’s witness testified that the light duty job assignment was within the claimant’s restrictions and consisted of necessary tasks and was not a sham. He also testified that the position required making and trimming bandings. The job did not require any lifting.

Dr. Coyle amended the restrictions on July 2, 2019, to include 30 pounds lifting and intermittent sitting, standing, and walking every 30 minutes.

On July 7, 2019, the claimant contacted the employer and left a voicemail that he would return to work in a light-duty capacity. The employer did not respond to this call.

The claimant continued to treat thereafter until October 14, 2019, when he was released to maximum medical improvement by Dr. Coyle. He recommended the claimant seek physiatrist treatment if necessary.

Thereafter, the claimant was examined by Dr. Wayne at respondent’s request. He opined that the claimant could have returned to work light duty on May 17, 2019, and full duty as of October 14, 2019.

On January 10, 2020, the respondent sent an email offering to bring the claimant back to work full duty consistent with Dr. Wayne’s opinions. There was no restriction on driving, and they believed the claimant could pull over if he had issues driving to work.

The claimant testified that he wanted to proceed with additional treatment as recommended by Dr. Coyle. He understood he had been offered a job to return to work full duty. However, he did not believe he would be able to perform the job of an insulator and requested vocational rehabilitation services.

The arbitrator determined that the claimant had sustained a compensable accident and that his condition was causally related but that no further treatment was necessary. Medical benefits were awarded through the date of maximum medical improvement (MMI) of October 14, 2019. The arbitrator believed the petitioner could return to work full duty based on both Dr. Coyle and Dr. Wayne’s inability to find any explanation for the claimant’s alleged low-back pain when sitting. He also found significant Dr. Wayne’s findings of symptom magnification and Dr. Coyle’s opinions that the claimant did very well after surgery, could walk seven miles a day, and was in excellent health and physical condition. Prospective medical treatment was denied. Additionally, the arbitrator denied the claimant temporary total disability (TTD) after his refusal to return to work in a light-duty assignment after July 8, 2019. The arbitrator also denied vocational rehabilitation benefits.

The Commission affirmed and adopted the arbitrator's decision with certain modifications. On review, the circuit court of Madison County found that the Commission’s award of TTD benefits and its denial of maintenance benefits and vocational rehabilitation were against the manifest weight of the evidence. The court concluded that the claimant had not declined the light-duty job offered by the respondent.

On appeal, the respondent raised two principal issues. First, the Commission’s finding that the claimant’s refusal for light-duty work restrictions was not against the manifest weight of the evidence. Secondly, the Commission’s decision to deny maintenance and vocational rehabilitation services should be upheld.

The central issue before the court was whether the Commission’s denial of TTD benefits after July 8, 2019, was against the manifest weight of the evidence. Relying on Gallentine v. Industrial Commission, 201 Ill.App.3d 880, 559 N.E.2d 526, 147 Ill.Dec. 353 (2d Dist. 1990), and Presson v. Industrial Commission, 200 Ill.App.3d 876, 558 N.E.2d 127, 146 Ill.Dec. 164 (5th Dist. 1990), the court emphasized that the dispositive inquiry is whether the claimant’s unemployment results from medical incapacity or from a voluntary refusal of available work. Safeway, supra, 2025 IL App (5th) 250298WC-U at ¶27. They noted that the record supported the Commission’s conclusion that the claimant never intended to return to work for the respondent, notwithstanding repeated offers of light-duty and, later, full-duty employment. The claimant’s failure to report to work on June 10, 2019, his characterization of the position as a “sham,” and his lack of response to subsequent job offers collectively undermined his claim for continued TTD. They noted that the record supported that the job offer was not a sham given the respondent’s testimony. They noted that despite the offer that light duty work continued to be available, the claimant never presented for a light duty assignment.

Significantly, the court rejected the claimant’s argument that the absence of MMI was dispositive. While MMI often marks the natural endpoint of TTD, the court reiterated that it is not a prerequisite to the termination of TTD benefits. An employee who is medically capable of working within restrictions and who declines an offer for light duty work is not temporarily totally disabled within the meaning of the Workers’ Compensation Act, even if additional treatment is contemplated. 2025 IL App (5th) 250298WC-U at ¶54, citing Interstate Scaffolding, Inc. v. Illinois Workers’ Compensation Commission, 236 Ill.2d 132, 923 N.E.2d 266, 276, 337 Ill.Dec. 707 (2010) (TTD benefits may be “suspended or terminated if the employee refuses work falling within the physical restrictions prescribed by his doctor”).

The court also gave substantial deference to the Commission’s credibility determinations. The Commission reasonably discounted the claimant’s explanations for failing to report to work, particularly where certain restrictions were imposed only after the job offer was made and where medical evidence contradicted the claimant’s assertions regarding his inability to drive or sit. The Commission’s rejection of the “sham job” characterization was likewise supported by detailed testimony regarding the job’s duties and its consistency with the claimant’s restrictions.

Viewed collectively, the decision reinforces the evidentiary burden on claimants to demonstrate not only ongoing medical need but a genuine inability to work. It also confirms that well-documented, bona fide light-duty offers that have been declined can serve as a defense to a claim for TTD benefits.

The second issue concerned whether Commission’s original decision denying maintenance and vocational rehabilitation benefits was against the manifest weight of the evidence. The claimant argued that vocational rehabilitation was necessary because he could not return to his pre-injury job as an insulator and that the respondent failed to accommodate his restrictions. The court rejected this argument, holding that the Commission’s decision was not against the manifest weight of the evidence.

The court began by reiterating that vocational rehabilitation and maintenance are not automatic entitlements under §8(a) of the Workers’ Compensation Act. The claimant may only receive maintenance benefits while engaged in a prescribed vocation rehabilitation program. Rather, they are awarded where a work-related injury results in diminished earning capacity and where rehabilitation is reasonably likely to restore or increase that capacity. 2025 IL App (5th) 250298WC-U at ¶65, citing National Tea Co. v. Industrial Commission, 97 Ill.2d 424, 54 N.E.2d 672, 676, 73 Ill.Dec. 575 (1983). Importantly, maintenance benefits are incidental to participation in an approved vocational rehabilitation program and are payable only while the employee is actively engaged in such a program. Safeway, supra, 2025 IL App (5th) 250298WC-U at ¶65, citing Euclid Beverage v. Illinois Workers’ Compensation Commission, 2019 IL App (2d) 180090WC, ¶29, 124 N.E.3d 1027, 429 Ill.Dec. 517.

Here, the Commission found that vocational rehabilitation was neither necessary nor appropriate because the claimant was capable of returning to work within his restrictions and had been offered suitable employment by the respondent. The record demonstrated that the claimant’s skills and physical abilities were sufficient to obtain employment without additional training, particularly given medical opinions supporting a return to full duty. Moreover, the claimant’s failure to accept light-duty work supported the conclusion that he lacked the requisite intent to return to work — a factor that independently weighs against an award of vocational rehabilitation.

The court also distinguished this case from situations in which an employer refuses to provide suitable work after an employee expresses a willingness to return. Unlike cases such as Otto Baum Company, Inc. v. Illinois Workers’ Compensation Commission, 2011 IL App (4th) 100959WC, 960 N.E.2d 583, 355 Ill.Dec. 701, the evidence in this case showed that the respondent consistently maintained the availability of work within the claimant’s restrictions and communicated that availability through counsel as documented in an email. Safeway, supra, 2025 IL App (5th) 250298WC-U at ¶65. The claimant’s failure to respond to or pursue those offers precluded a finding that vocational rehabilitation was necessary.

The Commission’s original decision was reinstated and the matter remanded with directions.