How to Appeal a Workers’ Comp Denial in North Carolina

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Your workers’ compensation claim may not go as smoothly as you hoped. There is an insurance company involved in the process, which has their own financial motives. They are not interested in your health or how much you need the benefits. These insurance companies could be aggressive about denying your claim. When your initial claim for workers’ compensation benefits is unsuccessful, you have the ability to fight back under North Carolina law. Our Wilmington workers’ compensation attorneys will represent you when you file an appeal. Contact Horton & Mendez Injury Attorneys to get started.

How Long Your Employer Has to Respond to Your Claim

Once you file your claim for workers’ compensation benefits, you will wait for a decision. Your employer has 14 days to notify you whether your claim has been accepted or denied. You may not receive the result that you wanted at first.

Reasons Why Your Claim May Be Denied

Your workers’ compensation claim could have been denied for the following reasons:

  • Your injury was not work-related.
  • The injury was a pre-existing condition, as opposed to work-related — although aggravating a pre-existing condition could still entitle you to benefits.
  • You are not an employee who is entitled to workers’ compensation benefits.
  • You did not properly follow the claim instructions or submit enough evidence in support of your claim.
  • You were under the influence of drugs or alcohol at the time of the accident.

Receiving a claim denial when you expected benefits is beyond disheartening. You need the money that the benefits provide, so you can keep paying your bills.

How You Can Appeal Your Workers’ Compensation Claim Denial

All hope is not lost when your workers’ comp claim is denied. You have the right to file an appeal and fight for your benefits.

The insurance company does not get the final word. You would get a hearing in front of an objective third party neutral who will decide your case.

In North Carolina, some grounds of appeal to challenge the denial include:

  • The insurance company failed to consider certain evidence in your favor.
  • The opinion of your treating doctor was not given enough weight in the denial.
  • Your injury did occur at a time that would be considered part of your work — such as on break and on the premises.
  • Your paperwork was complete, and you followed all the requirements. Usually, denials surrounding incomplete claims are resolved well before a hearing.

You May Be Able to Convert the Denial Into Benefits

Before you even file an appeal, your attorney may try to engage the insurance company or employer. While many claims may be denied at first, some claim denials result from a misunderstanding or missing information. The best outcome is one in which you can receive your benefits without having to go through the legal process of an appeal.

If you have to appeal your workers’ compensation claim denial, statistics show that you have a good chance of some type of successful outcome. Some estimates have as many as two-thirds of denied claims being converted to benefits or reaching a settlement. However, you stand far less of a chance of overcoming a denial when you do not have an experienced workers’ compensation attorney fighting for you.

If your claim has been denied, it is the time to hire a workers’ comp lawyer for an appeal if you do not already have one. They will handle the entire appeals process from start to finish. A lawyer knows how to deal with the insurance company and present the evidence that you need to make a compelling case.

How the North Carolina Workers’ Compensation Appeals Process Works

Your attorney would first review the reason given for your claim denial and work to line up additional evidence that supports your case. If your claim was denied because the insurance company does not believe that the injury was work-related, you may need additional witnesses who may be able to help tie the injury to your job. If the claim denial was for medical reasons, your attorney would line up testimony from treating doctors.

You have two years from the date of the denial to file an appeal, although you should never wait that long because you need the benefits. You would file Form 18 with the North Carolina Industrial Commission, which would notify them of your intent to appeal the denial.

Once your case progresses through the appeals process, the insurance company may offer to settle your claim. Your attorney may negotiate with them before your case goes to a hearing in the hopes of reaching a settlement and getting money for your claim.

You would attend a hearing in front of a Deputy Commissioner, who acts as an administrative law judge. Both your attorney and the insurance company’s counsel would present evidence and testimony that support their positions. You may be asked to testify at this hearing. After the conclusion of the hearing, the Deputy Commissioner would issue a decision on your appeal.

If your appeal is not successful, you can request a hearing in front of a panel of Commissioners.

They would review your case to determine whether the Deputy Commissioner made an error in denying your appeal.

If you are still not successful, you can take your case to the state court system, requesting an appeal with the North Carolina Court of Appeals. You can appear all the way up to the North Carolina Supreme Court.

Contact Our Firm for Help Appealing a Workers’ Comp Claim

If your workers’ compensation claim has been denied, you need to contact an experienced attorney immediately. You must have help for your voice to be heard.

The team at Horton & Mendez Injury Attorneys will get involved in your case, helping you build the evidence and record necessary to overturn the denial. You do not need to pay for our services unless you win your case. We can discuss your claim in a free initial consultation. Reach out to us online or call us today at 910-405-7751 to begin the legal process.

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