Why are North Carolina Workers Compensation Claims Denied?

When a worker is injured on the job in North Carolina, many feel they'll receive their medical bills and weekly disability benefits. Unfortunately, claims adjusters for insurance companies regularly deny what should be approved. They do this I believe to save money. Often Raleigh workers denied benefits fail to contact a lawyer. This is a mistake. Many denied claims are in fact valid claims. Contact us for a lawyer experienced in workers comp. Your claim may become successful. @raleighcomplaw

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Workers' Compensation in North Carolina is often an injured workers' only legal remedy for an on the job injury. The Workers' Compensation Act is the law, and it is administered by the Industrial Commission, which issues orders and presides over hearings to determine issues such as the nature and extent of benefits. Under the North Carolina Workers' Compensation Act, there are two kinds of claims: occupational injuries or occupational diseases. 

Occupational Injury vs. Occupational Disease

An occupational injury arises out of work. For all parts of the body except spinal (back or neck) injuries or hernias, the injury must be the result of an accident. If the injury comes as a result of just doing your normal routine work activity, it is not covered, but just about anything out of the ordinary or unusual can meet the requirement for an "accident." This includes not only twisting, landing, or lifting in a awkward position, but also doing something you might never or rarely do in your job. However, if you "don't know why" your knee (or other body part) gave out, it is not going to be considered an "injury by accident" and will instead be considered as arising from an idiopathic (pre-existing) condition. 

Spine injuries and hernias do not require an accident, but there must be a "specific traumatic incident." This means you should be able to point to a specific activity or occasion when you did something and "felt something in your back (or neck)" after which it began hurting. Hard work over the course of several hours or even days resulting slowly progressing pain does not qualify for workers' compensation because there is no specific traumatic incident. 

An occupational disease is a long-term adverse consequence of your work. 

If you have a disability or medical condition that develops over time, such as carpal tunnel syndrome or lung breathing problems, it may be covered under the North Carolina Workers' Compensation Act. There are two things that you must prove to establish most occupational diseases:

1. The disease or condition must have arisen from the job, or your position must have at least been a significant contributing factor in the development of the disease. Even if your work is just a contributing factor, you must establish that the conditions of work can lead to the condition or medical problem.

2. Your work must have exposed you to a greater risk of developing the disease or medical condition, than the risk experienced by the general public. To establish that you meet the requirements for an occupational disease under the workers' comp act, a doctor must detail this.

Starting a Workers' Comp Claim

Initiating a workers compensation claim in North Carolina is relatively simple. The Workers Compensation Act says an injured employee should notify the employer in writing within 30 days of the injury, but as a practical matter most employers are aware of employee injuries, and if the worker tells an official of the employer about the accident, that probably suffices as long as a hearing request is filed in time. Still, it is a good idea to file an accident report every time there is an on the job injury, even if it is minor.  If the worker has never been paid workers comp disability benefits (and salary continuation or short term disability benefits do not count) then the employer and insurance carrier may not have admitted liability. The payment of medical expenses without ever paying weekly disability benefits does not admit liability.

Request a Hearing

If the employer has not admitted liability for the injury, the injured worker must file a request for a hearing with the Industrial Commission within two years of the injury. If the worker fails to file within two years, it is likely that the case will be deemed untimely and the benefits will be denied. The form for a worker to report an injury is Form 18. The form to request a hearing is form 33. Both forms can be found on the Industrial Commission website. It is important to also send a copy of any form filed with the Industrial commission to the employer (and retain a copy for personal records!). Anything sent to the Industrial Commission should be sent certified mail, return receipt requested, so there is proof that the Commission received it. Documents filed at the Commission get lost more than they should. Often times more than an entire year passes from the time a hearing is requested from the Commission until a decision issues. If an appeal is required, it could take a year or even several years more. 

Other actions to protect an injured worker's right to Compensation.

If you are hurt or experience pain on the job, report it, and the best way is to report it in writing. Keep a copy of any written report you submit.  If you go to your regular doctor, or a doctor that you have seen before, after you hurt yourself on the job, make sure you tell the doctor the pain or problems started after something happened to you on the job.  Having this type of information in the medical record can make the claim easier to later prove. 

Subsequent related injuries: If you hurt one body part, maybe a wrist or a knee from a fall at work, and a few days to a few weeks later, you start having pain in other areas of your body, like in your neck or back, make sure you inform your doctor about the pain that is developing in other areas. If you have never before had pain in those areas, you need to make sure that you inform your physician. 

Claims adjustor interview: If you are hurt on the job and report the injury, it is likely that you will be called and interviewed by a claims adjuster for the insurance company, with the interview being recorded. You do not have to talk to the claims adjuster. (Although if you refuse they will probably use that as an excuse to deny you disability benefits.) If you do submit to a recorded interview, be very clear that what caused your injury was an accident or something out of the ordinary at work; or, in the case of a spine (back/neck) or hernia injury, that the pain started from a specific incident. The claims adjusters will ask you questions in a way to get you to say things that give them an excuse to deny your claim, so do not let them manipulate your words. 

If you are receiving on-going medical treatment that workers' comp is paying for, you will probably have a “nurse case manager” assigned by the insurance company to your case. Understand they are employed by the insurance company and their job is to save the company money. Even though comp is paying for your treatment, you still have a right to have private meetings and examinations with your doctor. Never allow a nurse case manager to come into the exam room while the doctor is examining you and discussing how you are doing. The nurse case manager will often try to answer the doctor's questions for the injured worker, and also try to get the doctor to not recommend further treatment or tests.

After a doctor has completed their examination of you, the case manager can talk to the doctor, if the doctor is willing to do so. However, the nurse case manager is only supposed to talk to the doctor in your presence. Never allow the nurse case manager to talk to the doctor outside your presence. 

Medical Records Release: Many insurance companies, or the nurse case mangers for the insurance companies, will ask workers to sign medical authorizations that allow the company to get medical records from any doctor you have ever seen at any time in your life, and also permits the insurance company to communicate to doctors outside your presence. Never sign a medical release that allows the adjuster to obtain medical records from your entire medical history, or allows them to speak with your doctor when you are not present. The only type of release that you are required to sign gives the insurance company and the nurse case manager the permission to get the records only from the doctors that have treated you for your work-related injury. It also does not allow them to talk to the doctor. That medical release is a Form 25C, and it can be found in the Industrial Commission's form bank on their website. Form 25C is the only type of medical release you should ever sign in a workers' compensation case. 

Do not trust a plant nurse or doctor. Make a record of every time you go to see them about your work-related injury, and the types of things that you tell them.  Workers' compensation cases can usually benefit from the assistance of experienced legal counsel, because the insurance company that covers the injury is in the business of making money, and the company increases profits by denying or minimizing benefits due under the law. The Workers' Comp attorneys at Edelstein & Payne are available for consultation and  representation on job injury cases for any town or city in North Carolina. 

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Does NC Comp law require injuries be caused by an Accident?

Raleigh Durham North Carolina comp victims often fill out an accident report prior to speaking with an attorney.  NC law requires an injury be caused by an accident.

There are things that amount to accidents that could be used to make an injury compensable under the law. You need to think about these things before you file your report, and before you actually talk to a claims adjuster.  For further legal advice, please contact us via our website form. We provide free Lawyer case evaluations.

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