Appealing a Denied Workers’ Compensation Claim
Wilmington Workers’ Compensation Lawyers
In North Carolina, nearly every employee is covered by workers’ compensation. However, even if you are eligible, you may have trouble recovering benefits. Unfortunately, many workers’ compensation claims are denied. If this has happened to you, there is hope!
David & Associates, Attorneys at Law, PLLC can help you appeal a denied workers’ compensation claim and seek the benefits you are owed. With over a century of combined experience, our Wilmington workers’ compensation attorneys are prepared to fight tirelessly for your rights. We understand the appeals process and have what it takes to advocate aggressively for you.
Why Are Workers’ Compensation Claims Denied?
Workers’ compensation claims are frequently denied due to a wide variety of reasons. Simple mistakes on your form, failure to meet reporting deadlines, employee misclassification, and other factors can all play a role in your claim being denied.
Some of the most common reasons workers’ compensation claims are denied include:
- Disputes Regarding a Worker’s Employment Status: In North Carolina, workers are only covered by workers’ compensation if they are classified as “employees.” Independent contractors and certain other workers are not covered.
- Eligibility Issues: In addition to employment status, workers must work for an employer with three or more employees or one who has decided to purchase workers’ compensation insurance regardless of the number of employees.
- Failure to Notify an Employer/Report an Injury: You only have 30 days from the date of the injury/illness to notify your employer, and you only have two years from that date to file a workers’ compensation claim.
- Missing Information: Missing information on your workers’ compensation claim can lead to your claim being dismissed. This includes both incomplete and missing medical information, as well as other critical details.
- Scope of Employment Disputes: Workers’ compensation only covers injuries and illnesses incurred in the “scope of employment.” Your employer may argue that you were not working or were not carrying out duties to their benefit at the time of the injury/illness.
- Employee Negligence: Your employer or their insurance provider may argue that you are not covered by workers’ compensation because your own negligence contributed to your injuries or illness. This could be the case if you were intoxicated or engaging in other misconduct.
- Causation Disputes: Your employer’s insurance provider may state that there is no connection between your reported injuries and the workplace accident that took place. You may need a second medical opinion to fight back against these types of claims.
Regardless of the reason for your claim being denied, you may be able to recover benefits by negotiating a settlement or filing an appeal. Our Wilmington workers’ compensation lawyers are here to represent you throughout the process.
How the Appeals Process Works
If you (or your attorney) are not able to negotiate a settlement, the next step is filing an official appeal. The workers’ compensation appeals process is a complicated, multi-step process; it is absolutely essential that you work with a knowledgeable lawyer who can help protect your rights and represent you throughout the appeal.
Below, we have provided a brief overview of how the North Carolina denied workers’ compensation claim appeals process works:
- Intent to Appeal: After receiving notice that your workers’ compensation claim has been denied, the first step is notifying the North Carolina Industrial Commission of your intent to appeal this denial. You must notify the N.C. Industrial Commission of your intent to appeal within 14 days of receiving the denial notice. If more than 14 days have passed, you may lose your right to appeal. However, we encourage you to contact our firm to learn how we may be able to help. We offer free, no-obligation consultations and case evaluations.
- Mediation: The N.C. Industrial Commission will schedule a conference with you/your attorney, a representative from your employer’s insurance company, and a mediator once it has received your notice of intent to appeal. During mediation, you may present evidence to support your claim. The mediator will then make a recommendation based on this evidence and send it to the N.C. Industrial Commission.
- Hearing: If the mediator does not decide in your favor, you may request a hearing. This hearing will be held before an administrative law judge (ALJ). At the hearing, which operates much like a trial, you/your attorney will present evidence to the ALJ in support of your claim. The insurance representative will also be able to present evidence in support of their side. After hearing all the evidence, the ALJ will decide on your claim.
- Panel Hearing: If the ALJ does not decide in your favor, you may request a panel hearing before three ALJs. At the panel hearing, the ALJs will review the initial hearing and either uphold the original ALJ’s decision or reverse it.
- Next Steps: If the panel of ALJs upholds the original ALJ’s decision to deny your claim, you may take several additional steps in an effort to recover benefits. We strongly advise you to reach out to our attorneys for help at this point if you have not already hired a lawyer.
Important Steps You Should Take If Your Claim Is Denied
If you receive notice that your workers’ compensation claim has been denied, there are a few important steps you should take right away to protect your rights.
At David & Associates, Attorneys at Law, PLLC, we recommend that you:
- Make sure your employer submitted the appropriate forms with all required information
- Provide any additional information to the insurance company that may be needed
- Contact the North Carolina Industrial Commission to ensure they have all necessary forms
- Keep copies of your official claims and forms, medical records, and other evidence
- Save all medical bills (or make copies), witness statements, previous tax returns, etc.
- Follow your doctor’s orders, including attending follow-up appointments
- Inform your doctor of any new or worsened symptoms you are experiencing
- Contact an attorney right away
Because you must notify the N.C. Industrial Commission of your intent to appeal within 14 days of receiving the denial notice, it is critical that you act quickly. Do not wait to reach out to our legal team until it is too late; get in touch with us today to learn how we can help you with your appeal.
Put the Power of Experience on Your Side
Navigating the workers’ compensation system is difficult enough; don’t try to appeal a denied workers’ compensation claim on your own! You need an experienced legal team that knows how to advocate for your rights and fight for the fair compensation you are owed.
With over 120 years of combined experience, the team at David & Associates, Attorneys at Law, PLLC is ready to fight for you. We can help prepare you for the appeals process and represent you every step of the way. We are available 24/7 to answer your calls, answer your questions, and address any concerns you may have.