What to Do If Your Workers’ Compensation Claim is Denied

In North Carolina, you are legally entitled to receive workers’ compensation benefits if you suffer a work-related injury. The requirements that must be met before you can receive workers’ compensation benefits are as follows:

• You have an injury that requires medical treatment and keeps you from working.
• The injury was suffered on the job or as a result of your job.
• You followed the requirements for notifying your employer in a timely manner.

For every workers’ compensation claim, there is an insurance company involved. Your employer has a legal obligation to purchase a policy that covers you. To receive benefits, you must file a claim with the insurance company. They are the ones who decide whether to grant benefits. If your claim is approved, they are the ones who will pay your medical costs and part of your salary.

The insurance company is a for-profit business, and paying claims costs them money from their bottom line. Their motivation is to keep as much of the premiums that your employer pays them as possible. In some cases, they may deny your claim, leaving you in a very difficult situation. You may not have money coming in, and your insurance company can object to covering medical care for injuries suffered on the job.

You Have the Right to Appeal a Workers’ Compensation Denial

In North Carolina, the insurance company does not get the final word about whether you can receive workers’ compensation benefits. While the insurance company makes a coverage decision and pays the claim, they are still an intermediary. Your real legal right to benefits comes under state law. Therefore, you can challenge the insurance company’s denial of your claim.

The first thing that you should do when your claim is denied is to contact an experienced workers’ compensation attorney if you do not have one already. There is a chance that the insurance company may have denied your claim because of a misunderstanding.

Your attorney can clear up this misunderstanding if they contact the insurance company and have a conversation with them. In some cases, you can reach a settlement through negotiation. However, you may not want to sacrifice some of your benefits if you are legally entitled to full payment.

The North Carolina Workers’ Compensation Appeals Process

If the issue is deeper than a misunderstanding, you have the right to an appeal under North Carolina law. In North Carolina, the government agency that is tasked with deciding workers’ compensation appeals is the North Carolina Industrial Commission. They are the ones responsible for administering and enforcing the state’s workers’ compensation laws.

You do not have a long time to decide whether to appeal the denial of a claim. The first step is to notify the Commission of your intent to appeal, and that must be done within four days of when you receive a denial. You can request a hearing for your appeal.

Your hearing is held in front of a deputy commissioner of the Industrial Commission. They have the power of an administrative law judge. When you show up to the hearing, you should have an experienced attorney present your arguments about why you deserve workers’ compensation benefits.

Presumably, the main crux of this hearing is to show that you have been injured in a manner that entitled you to workers’ compensation benefits. Your case will consist of medical evidence that details your injury. Then, your attorney will connect it to your job and prove that it was work-related.

Your task might be slightly more difficult if your injury came from repetitive stress or exposure to a toxic substance. Nonetheless, your attorney will work to show that your injury was related to your job duties, whether you are filing a claim against your employer or a previous one.

The Deputy Commissioner will make their decision about your legal entitlement to benefits based on the record in your case. Many denials are ultimately converted to benefits when you take your appeal to an objective third party. The Deputy Commissioner does not have the same financial self-interest as an insurance company.

If you lose your case at the first stage of your appeal, you have further rights to contest the denial of your claim. First, you will continue to appeal the denial to a panel of the Industrial Commission. They will not find facts in your case from scratch. Instead, they will review the ruling from the Deputy Commissioner to see if a mistake was made.

If you still do not win at that point, you can take your case to the North Carolina Court of Appeals. Similarly, they will review the prior ruling for an error.

Claimants Often Win Workers’ Compensation Appeals

Many claimants have success when they appeal their denial. The insurance company often backs down or is made to back down by a court. Before you appeal your claim denial, you should contact an experienced workers’ compensation attorney who knows the system. Many of these cases come down to medical evidence and how it is presented to the court. Insurance companies have their own lawyers who will explain why you do not deserve benefits. You need to counter them with a lawyer who has a mastery of both the law and the facts of your case.

Call a Wilmington Workers’ Compensation Attorney

When you need to fight a workers’ compensation denial, the attorneys at Horton Mendez are in your corner. Call us immediately after your claim has been denied or even before you file a complex claim. Reach out to us online or call us at (910) 668-8067 to schedule your free initial consultation.