What Can I Do If My Workers' Comp Claim Was Denied?

North Carolina law allows qualifying employees to receive workers’ compensation benefits if they are injured or become ill on the job. These benefits are supposed to be paid regardless of fault, but many hardworking citizens are discouraged to find that their claims are denied.

Fortunately, an initial denial is not the end of the road. Appeals are possible, but it’s critical to learn how to win a workers’ comp case. If you’re struggling, look to the workers’ compensation lawyers at Stewart Law Offices for help. Our experienced legal team can prepare your appeal and fight for the benefits you need and deserve.

Why Was My Workers’ Comp Claim Denied?

Workers’ compensation claims are denied for a number of reasons. Some of the most common explanations include:

• Your injuries are not eligible: Not all job injuries are compensable under North Carolina workers’ compensation laws. To qualify, your injury must be work-related. If your employer or its insurance adjuster argues that your injuries were not caused by an accident that occurred while you were performing duties within the scope of your job, they may deny your claim.
• You did not report the injury promptly: In North Carolina, you have only 30 days to report any injury resulting from a workplace accident. You must report the injury to your employer, supervisor, or any other appropriate party, such as the Human Resources (HR) Department. If you did not notify your employer within that timeframe, it could be used as a reason to deny your claim.
• Your employer disputes the injury: Sometimes, an employer will argue that an individual’s workers’ comp claim is invalid. It may say that you are not hurt or that the injury is not job-related. Another argument that can result in denial could be that you performed especially reckless conduct that caused your injury, such as driving drunk while making a delivery.
• Your employer challenges your employment status: Most N.C. employers with more than three employees are required to carry workers’ compensation insurance. To avoid increasing their insurance premiums, employers have been known to misclassify employees as independent contractors, which renders them ineligible for workers’ compensation benefits. You did not provide proof of medical treatment: You can’t get your medical costs paid by workers’ comp if you never saw a doctor. In general, you will need to pick a doctor from the insurance company’s approved list of providers. There are limited circumstances where you can see your own doctor, but you will need to show “by a preponderance of the evidence” why the change is necessary and it must be approved by the employer, insurance company, or the North Carolina Industrial Commission (NCIC).
• Lack of causation: Insurance adjusters want to know the link between the accident and your condition to prove that your injuries occurred at work. If you cannot establish that link, it may provide a reason to deny your claim.

Getting a second chance at receiving benefits will depend on supplying strong evidence that counters the reason for your workers’ comp denial. The workers’ compensation lawyers in North Carolina at Stewart Law Offices are fierce advocates for their clients and know what it takes to present a strong appeal.

How Many Times Can I Appeal My Claim?

You have four chances to appeal to your workers’ compensation case. The levels of appeal include:

1. A formal hearing, held in front of a Deputy Commissioner of the NCIC
2. An appeal in front of the Full Commission
3. The N.C. Court of Appeals
4. The N.C. Supreme Court

A skilled workers’ compensation lawyer can guide you through the appeals process from start to finish. Although it’s not required, having legal representation during an appeal can improve your chances of a favorable result.

How to Appeal A Workers’ Compensation Claim Denial

Your employer’s insurance company has two weeks to approve or deny your workers’ comp claim. If you are denied, you must be notified of the reason for the denial. You can then appeal the decision by submitting Form 33, or Request for Claim to be Assigned for Hearing, to the NCIC, your employer, and its insurance company. You must include certain information on this form, including:

• A description of the injury
• The specific benefits you are requesting, which can include medical expenses, partial wage replacement, and disability benefits
• Names and contact information for witnesses who can testify about your injuries
• The reason for the denial

In Form 33, you are asking for a formal hearing in front of a Deputy Commissioner. But first, you will have to go through mediation to try and resolve the dispute.

During mediation, a neutral third party (called a mediator) will work with you, your employer, and/or its insurance representative in an attempt to reach an agreement. You and the other party can agree on a mediator. But if you cannot, the NCIC will appoint one for you.

If you cannot resolve the dispute during mediation, you will attend a formal hearing. During the formal hearing, you and the other side will present evidence to argue each side of the case. Through witness testimony, medical records, and information supplied by the mediator, you must show why your claim was wrongfully denied.

A Deputy Commissioner will issue a written order after reviewing the appeal. If the Commissioner does not decide in your favor, you can then appeal the case to the Full Commission. To do this, you must submit an Application for Review to the NCIC within 15 days of the decision.

The Full Commission is composed of three judges. They will review the briefs from the hearing and your submission. The Commission may also choose to hear oral arguments. After hearing the evidence, the Commission will issue its written decision.

In your appeal to the Full Commission, you must list all of your reasons for believing the denial during the formal hearing was incorrect. It’s important to raise all relevant issues at this point because you cannot go back later and add them.

If your claim is still denied after appealing to the Full Commission, you have the option to file an appeal with the N.C. Court of Appeals. If you are still denied, you may then appeal to the state Supreme Court.

Workers’ compensation appeals are complicated proceedings, with many rules and procedures that must be followed. Hiring a proven lawyer to represent you during this critical phase of the workers’ comp process can protect your rights and give you peace of mind that your appeal is being defended properly.

Proving Liability After Your Work Injury

North Carolina provides workers’ compensation benefits to eligible employees regardless of who is to blame. Proving liability is not necessary in this no-fault system.

However, there are certain circumstances where liability comes into play. You cannot sue your employer for negligence if it provides workers’ compensation insurance. But if a third party (someone unrelated to your employer) is responsible for your work injury, you may have grounds to file a personal injury claim against that party.

To be successful in a personal injury claim, you must identify the liable party, prove they acted recklessly, and show the link between their actions (or inactions) and your injuries.

Identifying the liable party and proving that they acted negligently is one of the most difficult parts of any personal injury claim. A competent lawyer can collect compelling evidence and craft an argument for why you deserve full and fair compensation.

When possible, a personal injury claim has a distinct advantage over a workers’ compensation claim. You can recover money for pain and suffering in a personal injury lawsuit, but workers’ compensation benefits do not provide for such losses. For this reason, a personal injury claim has the potential to put more money in your pocket.

  Let us get to work for you now. Call or contact us today for a free case review.

How A North Carolina Workers’ Compensation Attorney Can Help With Your Appeal

North Carolina employees count on workers’ compensation benefits to keep them financially afloat after on-the-job accidents. Receiving a denial can be a crushing blow. However, a successful appeal can provide immense relief to those who are sidelined due to a work injury.

If you’re struggling to obtain workers’ compensation benefits in North Carolina, contact Stewart Law Offices today. A North Carolina workers’ compensation lawyer can sit down with you to discuss your case and options for appeal right away.