Top Reasons Your WC Claims Are Denied

workers comp denial

Injured workers in North Carolina may file a claim for workers’ compensation benefits to cover on-the-job injuries and work-related illnesses. If your claim is approved, your employer’s worker’s compensation insurance will pay for your medical care and part of your lost wages while you are unable to work. Unfortunately, employers and insurers sometimes dispute valid claims or deny them on technicalities, leaving workers struggling to pay for medical treatment or make ends meet.

At Hardison & Cochran, we hear about denied workers’ compensation claims all too frequently. Our experienced Raleigh workers’ compensation lawyers have represented injured workers whose claims were denied for many reasons. Many denied claims can be successfully appealed.

Contact Hardison & Cochran if you have questions and would like to speak with an attorney about your workers’ compensation claim. You will not owe an attorney’s fee unless we obtain workers’ compensation benefits for you.

Top 3 Reasons Your Workers Comp Claim Is Denied in North Carolina

Keep reading to learn about the top three reasons that workers’ compensation claims are denied and how those denials can be appealed.

You Missed the Deadline To Report Your Injury

North Carolina law requires that you provide your employer with written notification of your job-related injury or illness within thirty days. If you miss the deadline, you might not receive the necessary benefits to cover your accident-related expenses.

The North Carolina Industrial Commission (NCIC), which oversees the state’s workers’ comp system, will only enforce the 30-day requirement if your employer can show it was prejudiced by your failure to submit the notification. Failing to report your injury within 30 days of the accident doesn’t necessarily mean you’re prohibited from receiving benefits. However, you shouldn’t take any chances. Notifying your employer of your injury promptly is always best.

Sometimes, your employer or the workers’ compensation insurer will claim your work-related injuries were never reported to your doctors. That means your initial medical records don’t mention the accident. Even if that’s the case, it shouldn’t disqualify you from seeking benefits.

Your Injury Isn’t Work-Related

Another common reason that insurers deny workers’ comp claims is if there is an issue about whether the injury is work-related. Only ailments that occur in the course of your employment are covered by workers’ comp. Injuries while off the clock or on a lunch break don’t qualify. However, sometimes unusual circumstances mean that an injury that would normally lead to a denied claim should be covered.

For example, suppose an employee takes out the trash at the end of their night shift. They’re not on the clock, technically, but doing so is part of their normal job duties. One night, they hurt their shoulder while bringing the garbage to the dumpster. Typically, the employee’s claim would be denied since it was not technically an injury at work.

However, the NCIC has previously ruled that unusual circumstances can trip the “injury by accident” standard. For example, if the dumpster was in a different location that night and the worker consequently had to change the way they disposed of the trash, their subsequent injury could be a covered event.

You Have a Pre-Existing Condition

A pre-existing condition is another common reason for denied workers’ comp claims. It refers to the worsening of an old injury or medical condition that predates an injury for which an employee is pursuing benefits.

Let’s say you hurt your back in a car accident five years ago. You fully recovered and were given no medical restrictions by your doctor. Then, a month ago, you injured your back trying to lift a heavy box at work. Now, the insurance company determines the car accident led to a pre-existing condition that was exacerbated by the back injury suffered last month. It might try to deny your claim on this basis.

However, if it is determined that your new injury was an aggravation of your previous one, the injury should still be compensable under North Carolina law.

What If My Workers’ Comp Claim Is Denied?

The insurance company must issue an approval or denial within two weeks of an employee filing a workers’ comp claim. If your claim is denied, the insurer must provide the reason in the denial letter. You have a right to file an appeal.

You must complete a Request That Claim Be Assigned for Hearing form and submit it to the North Carolina Industrial Commission, which hears workers’ compensation claims.

The form must include certain information, such as:

  • The type of benefits you are seeking, such as partial wage replacement, medical expenses, or disability
  • A description of your injury
  • The reason for the denied claim
  • Names and contact information of witnesses who saw the accident or can testify to your injury

The form is a request for a formal hearing. However, you must attend mediation first. A mediator will facilitate negotiations with you, your employer, or the insurance company representative. You might be able to settle the case through mediation. If you don’t, you can proceed to a formal hearing.

The formal hearing allows you and the opposing party to argue your cases and present evidence. You must show why you should receive workers’ compensation benefits with medical records, witness testimony, and information the mediator provided. To have the best chance of success at the hearing, you should have a workers’ compensation attorney represent you at the hearing.

A deputy commissioner on the Industrial Commission will review the appeal and issue a written decision. If they don’t rule in your favor, you can submit an Application for Review to the Industrial Commission to appeal your case to the Full Commission. You must submit the form within 15 days of the decision.

The form you submit must include relevant information about why the decision to deny your claim was incorrect. There are three judges in the Full Commission. They will review your application and briefs from the initial hearing. They can also decide whether they want to hear oral arguments.

If the Full Commission decides to deny your claim, you can file an appeal with the North Carolina Court of Appeals. If they issue another denial, your next option is to appeal your case to the state Supreme Court.

How Many Times Can I Appeal My Claim?

North Carolina has four levels of appeals after a workers’ comp claim is denied. That means you have four chances to appeal the decision. These levels include:

  • A formal hearing before the Deputy Commissioner
  • Review by the Full Commission
  • North Carolina Court of Appeals
  • North Carolina Supreme Court

How an Experienced Attorney Can Help with Denied Workers’ Comp Claims

Many injured workers mistakenly assume the insurance company is on their side. Workers’ compensation laws protect employees’ rights after job-related injuries and illnesses.

The experienced workers’ compensation lawyers at Hardison & Cochran know the tactics that insurers use to minimize claims and avoid paying full workers’ comp benefits. An attorney can represent you during each step of the workers’ compensation appeals process. You need a lawyer with the skills and resources to conduct a thorough investigation and gather evidence to demonstrate that your injury is related to your job duties or work conditions.

Contact an Experienced Raleigh Workers’ Comp Attorney

The workers’ compensation system exists to protect employees who get hurt on the job. A denied claim can cause financial hardship for an injured worker. You might think you’re out of options if your workers’ comp claim is denied. But you should talk with an experienced workers’ compensation attorney. The attorneys at Hardison & Cochrane can help you appeal the decision and fight for the compensation you deserve.

We have represented injured workers in Raleigh, North Carolina for more than 30 years. Call us for a free consultation at (252) 333-3333 if you have questions about appealing a denied workers’ compensation claim.