Workers’ Compensation Appeals Process

Workers' compensation is designed to protect employees who are injured on the job, ensuring they receive appropriate benefits such as medical care and wage replacement. However, claims may sometimes be denied, leading to a complex and potentially overwhelming appeals process.

What is Workers’ Compensation?

In North Carolina, employers are required to provide workers' compensation insurance if they have three or more employees. This insurance covers medical expenses, lost wages, and disability benefits if an employee is injured or becomes ill due to work-related circumstances.

Why Do Some Workers' Compensation Claims Get Denied?

Workers' compensation claims can be denied for a variety of reasons. These denials can often be frustrating and confusing for workers who are just seeking assistance for their work-related injuries. Some of the common reasons for workers' compensation claim denials include:

Lack of Medical Evidence

One of the primary reasons for claim denials is insufficient medical evidence supporting the claim. If the medical records do not adequately link the injury to the workplace, the insurance company may deny the claim.

Failure to Report the Injury on Time

In North Carolina, an injured worker has 30 days to report a work-related injury to their employer. If the injury is not reported within this time frame, it can result in a claim denial.

Discrepancies in the Claim

If there are inconsistencies in your statement, discrepancies between your accident report and medical records, or conflicting testimonies from witnesses, the insurance company may deny the claim, suspecting fraud.

The Injury is Not Compensable

Not all injuries are covered under workers' compensation law. For instance, injuries resulting from horseplay or self-infliction, or those that occur while the worker is intoxicated, are typically not compensable.

Failure to Seek Medical Treatment

If an employee fails to seek medical treatment after the injury, the insurer might question the severity of the injury and deny the claim.

Employment Status

Workers' compensation only covers employees. Independent contractors, volunteers, and some other categories of workers are usually not covered. If there's a dispute about your employment status, your claim might be denied.

Claim Filed After Termination

If an employee files a claim after being laid off or fired, insurers may suspect that the claim is retaliatory and may deny it.

Denial of a claim doesn't mean the end of the road. You have the right to appeal, and an experienced workers' compensation attorney can help guide you through the appeals process to fight for your rights and your claim. At The Law Offices of John M. McCabe, we're ready to assist you every step of the way.

The Workers' Compensation Appeals Process: An Overview

If your workers' compensation claim is denied, you may appeal the decision. The process can be lengthy and detailed, requiring expert knowledge of workers' compensation law, which underscores the importance of having an experienced workers’ comp attorney.

Here is a broad overview of the steps involved in the North Carolina Workers' Comp Appeals process:

1. Reconsideration with the Insurance Company

When your claim is initially denied, your first step might be to ask for reconsideration directly with the insurance company. This can involve presenting new evidence or additional medical evaluations to support your claim.

2. Hearing Before the North Carolina Industrial Commission

If reconsideration is unsuccessful, you can appeal to the North Carolina Industrial Commission (NCIC). The appeal starts with filing a Form 33, "Request that Claim be Assigned for Hearing". The NCIC will then schedule a hearing with a Deputy Commissioner who acts much like a judge.

During the hearing, you can present your case, bring witnesses, cross-examine the insurer's witnesses, and introduce evidence to support your claim. It's crucial to be represented by a competent attorney at this stage because the proceedings are similar to a courtroom trial.

3. Full Commission Review

If you're dissatisfied with the Deputy Commissioner's decision, you can appeal to the Full Commission. You need to file a Form 44 "Application for Review" within 15 days from the date when the decision was filed. This review doesn't usually involve another hearing. Instead, the Full Commission, composed of three commissioners, reviews the evidence and testimonies from the previous hearing and makes a decision.

4. Court of Appeals and North Carolina Supreme Court

If you still disagree with the decision after the Full Commission review, you can appeal to the North Carolina Court of Appeals and, eventually, to the North Carolina Supreme Court. These steps are more complex and time-consuming and require a deep understanding of the law.

How Can a Workers' Compensation Lawyer Help?

A workers' compensation lawyer can be a critical ally in navigating the complex and often frustrating world of workers' comp claims and appeals. Here are some of the ways in which a workers' comp attorney can help:

Understanding and Explaining the Law

Workers' compensation law is intricate and detailed, varying from state to state. A skilled attorney can help you understand the specifics of North Carolina’s workers' comp laws, explain your rights and responsibilities, and guide you through the process.

Preparing and Filing Your Claim

Your lawyer will help gather all the necessary information to support your claim. This includes medical records, witness statements, and any other relevant evidence. They will also ensure that your claim is filed correctly and within the mandated deadlines.

Negotiating with the Insurance Company

Insurance companies often seek to minimize the compensation they pay out. A workers' compensation lawyer knows the tactics insurance companies use and can effectively negotiate on your behalf, ensuring you get a fair settlement.

Representing You at Hearings and Trials

If your claim is denied and you need to appeal, your attorney will represent you at all hearings and trials. They can develop a solid strategy, present compelling arguments, examine witnesses, and counter the arguments presented by the insurance company's lawyers.

Appealing a Denial

If your claim is denied by the North Carolina Industrial Commission (NCIC), your lawyer can guide you through the appeals process. This involves presenting your case to the Full Commission, the North Carolina Court of Appeals, and, if necessary, the North Carolina Supreme Court.

Providing Peace of Mind

Perhaps one of the most significant ways a workers' comp lawyer can help is by providing peace of mind. Dealing with a workplace injury is stressful enough without having to navigate a complex legal process. With a knowledgeable and experienced attorney at your side, you can focus on your recovery, confident in the knowledge that a professional is advocating for your rights.

Contact The The Law Offices of John M. McCabe

The workers' comp appeals process in North Carolina can be overwhelming, especially when you're dealing with the stress of an injury. If your workers' compensation claim is denied, it's essential to seek legal help from attorneys who specialize in this field.

At The Law Offices of John M. McCabe, we have the experience and expertise to navigate this complex process, advocate for your rights, and strive for the best possible outcome. Remember, the path to a successful appeal can be daunting, but you don't have to navigate it alone.

FAQs

What should I do if my workers' compensation claim is denied?

The first step is not to panic. A denial does not mean it's the end of the road. You have the right to appeal the decision. It's beneficial to hire an experienced workers' compensation attorney who can help you navigate the appeals process.

How long do I have to appeal a denial in North Carolina?

If you wish to appeal a denial, you need to file a Form 33 "Request that Claim be Assigned for Hearing" with the North Carolina Industrial Commission. This should ideally be done as soon as you receive the denial. If the hearing doesn't go in your favor, you have 15 days from the decision's filing date to apply for a Full Commission review by submitting a Form 44 "Application for Review".

Why was my claim denied due to a pre-existing condition?

While pre-existing conditions do not automatically disqualify you from receiving workers' compensation, you need to prove that your work-related incident aggravated or accelerated your condition. If the insurance company decides that your injury is solely related to your pre-existing condition and not your work, it can deny your claim.

Do I need a lawyer to appeal a workers' compensation denial?

It's not mandatory, but it's highly recommended. The appeals process can be complex and requires a deep understanding of workers' compensation law. A skilled attorney can effectively represent your interests, help build a strong case, and guide you through each stage of the appeal.

Can I be fired for filing a workers' compensation claim?

No, it's against the law for an employer to retaliate against an employee for filing a workers' compensation claim. If you feel you've been unfairly treated or terminated due to your claim, consult with an attorney.

What if I can't afford a lawyer?

Many workers' compensation lawyers work on a contingency basis, meaning they only get paid if they win your case. They'll receive a percentage of the benefits you're awarded. At The Law Offices of John M. McCabe, we offer free consultations to discuss your claim and our fees.