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Home > Health Plan > Work-related Injuries
WORK-RELATED AND ON-THE-JOB INJURIES Some plans do not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your plan.
One of the most common reasons that medical benefits are delayed or denied is that there is a question as to whether or not
the condition is related to an injury at work.
The Health Plan includes an exclusion that is found in virtually all group health plans. It states that the Plan does not cover
medical expenses for accidental injury or sickness arising out of or in the course of employment (or self-employment) or for
which the patient is entitled to benefits under any Workers’ Compensation Law.
By excluding work-related injuries from the Plan, the Fund is recognizing the appropriate responsibility for medical costs: We
cover injuries that are not work-related; the Workers’ Compensation system covers medical costs for conditions that do result
from work.
If You are Injured at Work
Tell your immediate supervisor or employer right away. This is very important, as it sets the Workers’ Compensation benefit
process in motion.
In case of emergency, you will probably be sent to a hospital or clinic first and asked questions later. However, if possible,
someone should immediately notify your employer.
Note that failure to report a work-related illness or injury right away can result in delay or even loss of benefits due to you.
When an Employer Rejects a Claim
Sometimes employers reject a Workers’ Compensation claim and advise the employee-member to file the claim with the
Fund. When this occurs, the Benefits Fund Office will thoroughly review the claim, including the injury report and the medical
record. If it is determined that the claim did not occur as a result of your employment, the Fund will process benefits.
If the claimant or his or her physician states that the injury was work-related, or if it is otherwise determined that the injury did
occur at work, the Fund will deny benefits. The injured party will have to seek benefits through the Workers’ Compensation
system.
Small Employers and Self-Employed Individuals
Sometimes an injured person, often the spouse of a UFCW employee-member, works for a small company or is
self-employed. In such situations, there is sometimes no Workers’ Compensation coverage. There is no good reason for this
to occur because Workers’ Compensation insurance can be purchased by any company or individual. The Health Plan does
not cover work-related injuries, regardless of who the employer is or whether or not other insurance was purchased.
Special Arrangement for Reimbursement
Two employers, Dominick’s and Kroger, have entered into agreements with the Fund that allow us to pay benefits for medical
costs while a claim is being adjudicated through the Illinois Industrial Commission
(or similar body in another state). If the company is eventually found liable for the injury, the company reimburses the Fund
for the medical benefits paid. These reimbursable benefits can only be paid for employees of Dominick’s and Kroger.
The Review and Appeal Process
Employee-members are entitled to a thorough review of their claim if benefits are denied for any reason. If a claim is denied
because we believe it is work-related and the employee-member disagrees, a review request
should be filed promptly. There have been cases where the onset of an illness occurred at work but was not related to
job duties. We are happy in those cases to reverse our determination. But a thorough review is often required, especially if
the claimant initially presented the claim as work-related.
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