Workers Comp Claim Denied in North Carolina: Reasons, Now What?

Workers’ compensation benefits are essential for injured workers in North Carolina, but unfortunately, claims are often denied. If your claim has been denied, it is crucial to understand the reasons behind it and what steps you can take next. Below, we outline the common reasons for Workers Comp Claim Denials in North Carolina and the options available to appeal the decision.

Common Reasons for Workers’ Compensation Claim Denials in North Carolina

1. Failure to Report the Injury on Time

North Carolina law requires injured workers to report their injuries to their employer within 30 days. If you fail to do so, your claim may be denied. Employers and insurers may argue that a delay in reporting suggests that the injury did not occur at work or is not as serious as claimed.

2. Employer Disputes the Injury

Sometimes, an employer may challenge your claim by arguing that the injury did not happen at work or that it was due to a pre-existing condition. If your employer denies that your injury is work-related, you may need additional evidence to support your case. 

3. Insufficient Medical Evidence

Your workers’ compensation claim requires medical documentation proving that your injury or illness is work-related. If your medical records do not clearly show the connection between your job and your condition, your claim may be denied. Insurers often look for gaps in treatment or lack of objective findings as reasons to reject claims. 

4. Missed Deadlines in Filing the Claim

Workers’ compensation claims must be filed within two years of the injury date. If you miss this deadline, your claim will likely be denied. It is crucial to file your claim as soon as possible to avoid any issues related to timing.

5. Pre-Existing Conditions

If an insurance company believes that your injury is related to a pre-existing condition rather than a workplace accident, they may deny your claim. However, if your work aggravated a pre-existing condition, you may still be eligible for benefits.

6. Lack of Witnesses or Contradictory Statements

If no one witnessed your injury or if there are inconsistencies in your statements, the insurance company may deny your claim. Insurers may use any discrepancies in your reports or medical records as a reason to reject your case.

7. The Injury Occurred Outside of Work

Workers’ compensation only covers injuries that happen while performing job-related duties. If an injury occurs outside of work hours or away from the workplace (without a clear connection to work responsibilities), the claim may be denied.

What to Do If Your Workers’ Compensation Claim is Denied in North Carolina

1. Review the Denial Letter

When your claim is denied, the insurance company must provide a written explanation. Review this letter carefully to understand the specific reasons for denial. 

2. Gather Additional Evidence

If your claim was denied due to insufficient medical evidence or employer disputes, you may need to collect more documentation. This could include medical records, expert testimony, and witness statements.

3. File a Formal Appeal

In North Carolina, you can appeal a workers’ compensation denial by filing a request for a hearing with the North Carolina Industrial Commission (NCIC). This process includes:

1. Filing a Form 33 – This form requests a hearing before the NCIC.
2. Mediation – Before a formal hearing, you may need to attend mediation to resolve the dispute.
3. Hearing Before a Deputy Commissioner – If mediation fails, a formal hearing will be held where evidence is presented.
4. Further Appeals – If the deputy commissioner denies your appeal, you can request a review before the full NCIC, and if necessary, escalate the case to the Court of Appeals.

4. Attend Mediation

Before a hearing takes place, you may be required to go through mediation, where you and the insurance company attempt to resolve the dispute with the help of a neutral third party. Mediation can often lead to a favorable settlement without the need for a court hearing.

5. Prepare for a Formal Hearing

If mediation does not result in a resolution, your case will proceed to a formal hearing before a judge. You will need to present evidence, call witnesses, and argue your case before the NCIC. It is highly recommended that you have legal representation during this stage.

FAQs

Q. Why was my NC workers’ comp claim denied?

Your claim may have been denied due to missing medical records, filing too late, a dispute over whether your injury was work-related, or a pre-existing condition. Insurance companies in North Carolina often look for reasons to reject claims, so having solid proof is key.

Q. Can I appeal a workers’ comp denial in North Carolina?

Yes. First, check the denial letter, gather more evidence, and file Form 33 with the North Carolina Industrial Commission (NCIC). If needed, you can request a hearing to challenge the decision.

Q. What if my NC employer says my injury wasn’t work-related?

You need to show medical records, witness statements, and any other proof that your injury happened at work. A North Carolina workers’ comp attorney can help you build a strong case.

Q. How long do I have to file a workers’ comp claim in North Carolina?

You must report your injury within 30 days and file a formal claim with the NC Industrial Commission within two years. Missing these deadlines can lead to a denial.

Contact an Experienced North Carolina Workers Compensation Lawyer Today

A workers’ compensation denial can be frustrating, but you have options. Understanding the common reasons for denials and the steps to take afterward can help you navigate the process effectively. If your claim has been denied, seeking legal assistance from experienced workers’ compensation attorneys can increase your chances of securing the workers comp benefits you deserve.

If you need help appealing a denied workers’ compensation claim, Ayers, Whitlow & Dressler is here to assist injured workers throughout North Carolina. Contact us for a consultation today.