You were counting on workers’ compensation benefits to get medical treatment and cover your expenses while your injury keeps you out of work. Now you find out your employer’s insurance company has denied your claim or issued benefits that do not even come close to covering what you need. Fortunately, you still have options for recourse.
You should receive a decision on your claim within 14 days of filing it. The insurer must either begin paying your benefits or send you a notice of denial that also lists the reasons why. If you are not satisfied with the decision, speak with your attorney as soon as possible about taking further action.
Common reasons for denials
Insurance companies deny workers’ compensation claims for various reasons. They may decide your injury did not happen at work. People who work off-site, such as drivers, may encounter this type of denial more frequently. The insurer may also deem your injury or condition occurred as a result of a prior illness or accident that did not relate to your work. In cases where benefits do not suffice, the insurer may disagree about the extent of your injury or about which treatments are medically necessary.
Asking for a hearing
You can appeal the insurer’s decision by sending a Form 33 request to the North Carolina Industrial Commission, which is the state agency in charge of workers’ compensation. This form requests a hearning before a judge to evaluate your claim. You will need to provide information about your case, including the reasons you are disputing the insurer’s decision.
Mandatory mediation and further steps
In North Carolina, you will need to go through mediation before the judge actually hears your case. This consists of an informal meeting with a neutral mediator, where both parties present their sides and supply evidence such as medical records. Most cases end up settling at this stage. If yours does not, the mediator will report to the NCIC and you will proceed to the hearing stage, which is similar to a trial. If you want to appeal the outcome of the hearing, you have 15 days from the decision to request a Full Commission appeal, where three judges will review your case.
Workers’ compensation appeals often involve complicated questions of law and detailed evidence. A qualified lawyer can develop effective strategies to help you get the benefits you need.