Has your workers’ compensation claim been denied in North Carolina? A denial can be frustrating, but it does not necessarily mean your case is over. You have the right to challenge the decision and fight for the benefits you need. The appeals process can be difficult, but working with a knowledgeable attorney can significantly improve your chances of success.
At Kreger Brodish, we have extensive experience handling workers’ compensation appeals and are ready to take on your case. We can review your denial letter, gather medical records, and present strong arguments on your behalf. Whether you need help with mediation, hearings, or high-level appeals, we are here to stand by your side. Contact us today for your free consultation so we can discuss your case and help you take the next steps toward getting the benefits you deserve.
Common Reasons for Workers’ Compensation Denials
Workers in North Carolina sometimes receive denials after filing workers’ compensation claims. Below are some common reasons for these claim denials:
- Missed Deadlines: North Carolina law requires you to report injuries to your employer within 30 days. You must also file your claim with the North Carolina Industrial Commission (NCIC) within two years. If you do not meet these deadlines, the insurer could deny your claim.
- Lack of Medical Evidence: You must show that your injury or illness is work-related. If medical records do not support your claim, or if you delay seeking treatment, the insurer could argue that your injury is not serious or did not happen at work.
- Employer Claim Disputes: North Carolina law covers injuries and illnesses that happen while workers are performing job duties. Employers sometimes challenge claims by saying the injury did not happen on the job. If your employer disputes the claim, the insurer could deny benefits.
- Pre-Existing Condition: If you had a previous injury or condition, the insurer could argue that the workplace injury is not new. In these cases, you must show that your job made the condition worse or caused a separate injury.
- Failure to Follow Medical Advice: You must follow your doctor’s treatment plan after an occupational injury. If you skip appointments, refuse treatment, or ignore work restrictions, the insurer could claim you are not taking your recovery seriously and deny or stop benefits.
- Filing Errors: You must complete all forms correctly and submit them to the right agencies to file a successful workers’ compensation claim. If you make mistakes on paperwork, leave out key information, or file the wrong form, the NCIC or insurer might deny your claim.
Step 1: Understanding the Denial Letter
You should carefully review the denial letter as soon as you receive it. This letter will explain why the insurance company rejected your claim and provide important details about your next steps. Just because the insurance company provides a denial reason does not necessarily mean your claim is over.
In the letter, look for specific deadlines in addition to the reason for the denial. You typically have a limited amount of time to appeal, and missing a deadline could mean losing your right to demand benefits. Check if the insurer claims that paperwork is missing or incomplete. If the issue involves medical records, you might need to contact your doctor for additional documentation. If anything in the letter is unclear, talk to a workers’ compensation attorney to clarify your situation.
Step 2: Talk to an Attorney
You should consider speaking with an attorney if you receive a claim denial. North Carolina’s workers’ compensation laws can be difficult to interpret, and a lawyer can explain your rights and legal options. They can determine whether the denial was due to a legal error, missing evidence, or another issue that can be corrected. Your attorney can also identify the ideal strategy for challenging the denial.
If necessary, your lawyer can handle negotiations with the insurance company. Sometimes, a denial happens because of an error or missing paperwork, and an attorney might be able to resolve the issue without a formal appeal. If your case requires a hearing, your lawyer can help you prepare, present evidence on your behalf, and argue your case before the NCIC.
Step 3: File an Appeal
If the insurer denies your claim, you have the right to appeal the decision. In North Carolina, you may request an appeal through the NCIC by filing a Form 33, which asks the NCIC to review your case. Once you file the Form 33, the NCIC will schedule a mediation conference to give both sides the opportunity to negotiate and possibly resolve the dispute without a hearing. If mediation does not work, your case will move to a formal hearing before a judge.
You should prepare carefully for your appeal because the process can be complex. A hearing requires strong evidence and clear arguments, which is why many workers choose to have an attorney represent them. If the judge rules against you, further appeals might be possible.
Step 4: Mediation
Mediation can save you time and effort if both sides reach an agreement. During mediation, a neutral mediator guides the discussion. The mediator does not make decisions but helps both sides negotiate as effectively as possible. You will have the chance to present your case, including medical records and other evidence. The insurance company could offer a settlement, or they might argue that your claim does not meet the legal requirements for benefits.
You should prepare for mediation by gathering all relevant documents and highlighting the strengths of your case. If you have an attorney, they can help you evaluate settlement offers and decide whether to accept or proceed to a hearing. If mediation does not resolve your case, you move forward with the next step in the appeal process.
Step 5: Prepare for the Hearing
If mediation does not lead to a settlement, you must prepare for a formal hearing before the NCIC. This hearing works like a trial, where you present evidence and explain why you qualify for workers’ compensation benefits.
If you have an attorney, they will help you develop a strategy. They can also question witnesses or cross-examine the insurance company’s representatives on your behalf. Your lawyer will also make sure you understand what to expect during the hearing and review any possible arguments the other side might present to challenge your case.
Careful preparation increases your chances of success. You must present clear and convincing evidence that proves your injury happened at work and qualifies for benefits under North Carolina law.
Step 6: The Hearing Process
The formal hearing takes place before a Deputy Commissioner of the NCIC. During the hearing, the insurance company will challenge your claim. Their attorneys might argue that your injury is not work-related, that you did not follow medical advice, or that your condition does not prevent you from working. You must be ready to respond with clear evidence and testimony.
Both sides may call witnesses, including doctors, coworkers, and medical experts. The Deputy Commissioner will listen to all testimony and review the evidence before issuing a written decision. The decision will not come immediately. Instead, you will receive a written ruling after the Commissioner reviews all the case details.
Step 7: Post-Hearing Appeals
If you receive an unfavorable decision after the hearing, you still have the right to appeal. However, you must act quickly to do so because North Carolina law limits the time you have to challenge a ruling.
The next step in the appeals process is filing an Appeal to the Full Commission. At this level of the appeals process, a panel of commissioners will review your case and the Deputy Commissioner’s decision. You might need to submit additional arguments or legal briefs explaining why you believe the ruling was incorrect.
If the Full Commission also rules against you, you can appeal to the North Carolina Court of Appeals. This step involves complex legal arguments and procedures, so you will need an attorney to represent you. The appeals process can take months, but it gives you another opportunity to fight for benefits.
Tips for Strengthening Your Case
You can improve your chances of recovering the full workers’ compensation benefits you are due by taking the right steps to strengthen your case. Here’s what you can do:
- Report the injury to your employer immediately. Notify your employer in writing about any changes in your medical condition.
- Seek medical treatment as soon as possible. Follow your doctor’s instructions and attend every follow-up appointment. Keep copies of all your medical records and treatment notes.
- Document the accident details, including the time, place, and cause. Get written statements from any coworkers who witnessed the accident.
- Keep a personal journal to track your symptoms, pain levels, and treatment progress. Keep copies of all communication with your employer and their insurance company.
- Contact a workers’ compensation attorney for help as soon as possible.
- Avoid discussing your claim with your employer’s insurance company without legal advice. Avoid social media posts about your injury or recovery.
How Kreger Brodish Can Help
A workers’ compensation denial can leave you feeling frustrated and uncertain about what to do next. Kreger Brodish can help you appeal your denial and fight for the benefits you deserve. Contact us today for a free consultation to take the next steps toward securing your benefits.
