If your Wilmington, NC, workers’ compensation claim is denied, you may challenge the denial, or do nothing. To challenge the denial, you must file paperwork to request a hearing. As part of the process, you’ll probably have mediation. If you do nothing, you will not receive benefits.
Our experienced Wilmington workers’ compensation lawyers at Horton & Mendez, Injury & Car Accident Attorneys represent employees whose workers’ compensation claims have been denied. Contact us now.
My Workers’ Compensation Claim Was Denied! Now What?
To continue to pursue your benefits after a workers’ compensation claim denial, you must take the following steps. The next steps are to file paperwork continuing your case, preserve the evidence, and pursue the claim through the North Carolina workers’ compensation process. There are deadlines to meet. You may have a workers’ compensation denial lawyer represent you.
Common Reasons Workers’ Compensation Claims Are Denied in Wilmington
Reasons that workers’ compensation claims are denied in Wilmington, NC, may include:
- Information is missing from the claim, so the employer can’t decide liability.
- There was no workplace accident or incident.
- The employee didn’t report the claim in time.
- Injuries are the result of a pre-existing condition or a different accident and not a workplace incident.
- You were a contractor and not an employee.
- The injury was caused by the employee’s own intoxication or intentional harm.
The employer’s reason for denial can be frustrating and stressful. Remember, you can take steps to continue to pursue your case. An attorney can assist you in this process.
What To Do Immediately After a Workers’ Compensation Denial
If your workers’ compensation claim is denied, you should receive Form 61 – Denial of Workers’ Compensation Claim. Your employer or their insurer completes this form, which must state, in detail, the reasons the employer denied your claim. These are the contested issues going forward in your case.
The first steps for you are to file Form 18 to preserve your right to benefits and Form 33 to request a hearing. The employer and their insurance company don’t necessarily have the final say. You can ask a neutral hearing officer from the North Carolina Industrial Commission to decide your right to benefits.
How To Appeal a Denied Workers’ Compensation Claim in NC
To appeal a denied workers’ compensation claim in NC, follow these steps.
File Form 33 – Request for Hearing
Form 33 notifies the Commission that there is a dispute and asks the Commission to set the case for a hearing. The Form identifies the case and summarizes the issues in dispute. The employee details what they believe they deserve in benefits. Form submission instructions are located at the bottom of the form.
Send copies to the employer and insurer
The employee must serve a copy of Form 33 on the employer and their insurer. Instructions are on page 2 of Form 33. Complete the Certificate of Service located on the form.
Wait for the employer’s response
The employer, or their insurance company, must respond to Form 33 with Form 33R. The response must state why the parties have been unable to agree on the case. The employer must identify witnesses, including doctors, who may be examined in the case.
Participate in mediation
Typically, you will participate in case mediation, which is a formal settlement negotiation. A mediator facilitates the proceedings. The parties may agree on whether to conduct the mediation in person or virtually. After the mediation, the mediator submits Form MSC5, reporting whether the mediation was successful in resolving the case.
Take the next steps
If you resolve the case at mediation or before, you’ll finalize the agreement in writing. Compromise settlement agreements must be approved by the Commission. Agreements deemed fair and just and in the interests of all parties will be approved. Once finalized, you should receive your payment.
Proceed to the hearing
If the parties are unable to resolve the case by agreement, you proceed to a hearing before an NCIC Commissioner. The first hearing is before one Deputy Commissioner. Evidence, including medical records, must be submitted in advance of the hearing. Parties will discuss the submission of medical evidence in advance. There is a possibility of post-hearing depositions. The hearing officer conducts the hearing, reviews the evidence, and issues a decision.
Deadlines for Appealing a Workers’ Compensation Denial
The deadlines for appealing a workers’ compensation claim denial vary based on the stage of the case.
Initial denial
If you’re appealing the employer’s initial denial of your North Carolina workers’ compensation claim, you have two years to file Form 18 and Form 33 to appeal the denial and protect your right to benefits. However, you shouldn’t wait and should promptly file forms to preserve key evidence and pursue your benefits quickly.
Appeal of the Deputy Commissioner’s decision (first hearing)
If you’re appealing the Deputy Commissioner’s decision from your first hearing to the full Commission, you have 15 days to submit the Notice of Appeal to the Full Commission. The time limit is measured from when the party appealing receives the Deputy Commissioner’s decision.
Motion to Reconsider
The time limit for a Motion to Reconsider the Deputy Commissioner’s decision is also 15 days.
Appeal from Full Commission to the Court of Appeals
If you’re appealing from the full Commission to the North Carolina Court of Appeals, the deadline is 30 days from receipt of the previous decision.
Evidence That Can Strengthen an Appeal
Just submitting the paperwork for an appeal is unlikely to change the outcome of your case. You must address the reasons given for the denial. Usually, this means gathering evidence, which is often medical, including treatment records and expert opinion. You may also rely on photographs of the accident scene, lay witnesses, occupational experts, pay stubs, employer communications, and impact journaling. An attorney can help you prepare the evidence to strengthen your appeal.
What Benefits You May Still Be Entitled To
There are several categories of benefits. Even if one type doesn’t apply, you may be entitled to other awards. In addition, you may qualify for a third-party claim if someone other than the employer is responsible for negligence. You may qualify for Social Security disability or payments through your private disability insurance policy.
How a Wilmington Workers’ Compensation Lawyer Can Help
Horton & Mendez, Injury & Car Accident Attorneys, represent people in Wilmington, NC, whose workers’ compensation claims are denied. Our lawyers can advocate for you. If your case has been denied, don’t wait. Contact us for immediate attorney assistance.
