Filing for workers’ comp doesn’t automatically mean that you’ll receive benefits. Approximately seven percent of workers’ compensation claims are denied.
Don’t let your case be one of them!
You need to know the common reasons why workers’ comp claims are denied in NC.
Our experienced Gastonia workers’ compensation lawyers at Horton & Mendez, Injury & Car Accident Attorneys, explain common reasons for denied workers’ comp and what you need to know to make your case successful.
Seven Reasons Workers’ Comp Claims Get Denied
1. Missing Deadlines for Reporting Your Injury
A workers’ compensation claim starts with reporting the injury to your employer.
Most personal injury claims, other than workers’ compensation, start by filing a claim in court.
That’s not the case with workers’ compensation. Your first step is to tell your employer that you’re hurt. If you have a medical emergency, you can get medical attention first. But you should then tell your employer about the injury as soon as possible.
In North Carolina, you have 30 days to notify your employer of your injury. Give notice in writing, stating the date of the accident and a brief description of the injury. Tell your supervisor or human resources. Keep a copy of the letter or email that you send notifying of the injury.
Missing the deadline to report the injury can result in the denial of your workers’ compensation claim. NC.G.S. § 97-22 says that no compensation is payable unless notice is given within 30 days of the accident or death, unless a reasonable excuse is given, and the employer is not prejudiced by the delay. For example, there may be an exception if you were unconscious or otherwise physically unable to report.
Never wait to report your injury. In addition to missing the 30-day deadline, any delay in reporting your case can give the employer room to question whether your injuries are work-related.
2. Insufficient Medical Evidence to Support Your Claim
A workers’ compensation claim relies on medical evidence. You may need medical evidence to prove:
- You were hurt on the job
- The extent of injury
- How a pre-existing condition was made worse
- What lasting disability you have due to the injury
- Appropriate medical treatment and care
- When you can return to work
A claim may be denied for lack of medical evidence, so it’s important to build the evidence needed to support your claim.
3. Disputes Over Whether the Injury Is Work-Related
In North Carolina, a compensable work-related injury arises out of and in the course of employment. A common reason for workers’ comp claim denial is that the injury is not work-related.
The employer may claim that you were injured in another way. They may claim that you have a pre-existing condition. Sometimes, the point of dispute is the extent of the pre-existing condition.
There are some rules for specific situations. For example, a back injury arising from an accident includes any disabling physical injury to the back causally related to and arising out of a workplace incident. Injury includes broken glasses, hearing aids, dentures, and other prosthetics, but eyeglasses and hearing aids are only compensated for a compensable injury.
Disease doesn’t count unless it results naturally and unavoidably from an accident.
4. Failure To Follow the Approved Medical Treatment Plan
Workers’ compensation pays benefits, but there are conditions. The worker must go to the medical care provider chosen by their employer, except for emergency care. They must adhere to their treatment plan, including attending medical appointments and physical therapy. An injured worker must follow restrictions on their activity.
If the injured worker doesn’t meet the requirements, benefits may be denied or stopped. An attorney for workers’ compensation can help you understand what’s required of you to make sure that you stay in compliance.
5. Pre-Existing Conditions Used To Deny Benefits
Workers’ compensation benefits are payable because of a new injury or because a pre-existing injury is made worse. When a pre-existing injury is made worse, benefits are payable to return the person to their condition before the workplace injury.
Having a pre-existing condition isn’t automatically disqualifying. Benefits are available for a new injury or for an injury that worsens a pre-existing condition.
6. Employer or Insurer Claims of Misconduct
A workers’ compensation claim may be denied for employee misconduct. For example, intoxication on the job is usually disqualifying.
Being under the influence of a controlled substance not prescribed by a medical health professional is also disqualifying.
A worker intending to harm themselves or another cannot claim benefits.
In addition to these grounds for claim denial, if the injury is caused by a willful failure to use a safety appliance or by breach of a regulation, compensation may be reduced by 10%.
7. Refusing Suitable Employment
People claiming workers’ compensation benefits must accept suitable work when it is available.
Work must be within your injury restrictions, considering physical and mental limitations.
N.C.G.S. § 97-32 allows the employer to deny compensation during any period where the worker refuses suitable employment.
How To Appeal a Denied Workers’ Comp Claim in NC
If your workers’ comp claim is denied in NC, you can appeal the decision. The worker must complete Form 33, “Request that Claim be Assigned for Hearing.” The worker files the appeal with the NC Industrial Commission.
There will be mediation, followed by a hearing before an NCIC Deputy Commissioner. You will have the opportunity to submit evidence and make arguments. You must file Form 33 within two years of the date of injury or the last payment of benefits.
If you are unsatisfied with the decision of the NCIC, you may pursue further appeals.
Contact an Experienced Gastonia Workers’ Compensation Lawyer
Don’t let your workers’ compensation benefits get denied. We invite you to contact an experienced Gastonia workers’ compensation lawyer. Whether you need to fight a denial or you want to make sure you build the strongest case from the beginning, please contact Horton & Mendez, Injury & Car Accident Attorneys. Talk to a lawyer about your case and get legal help today.
