Handling a workers’ compensation denial

On Behalf of | Mar 31, 2020 | Workers' Compensation |

When you suffer an injury on the job, you have the right to make a workers’ compensation claim. Most employers must carry this insurance under North Carolina law. When you file a claim, the insurance company will review it and decide whether to pay it. Your employer may also object to the claim. If this happens, you will get a denial form in the mail.

According to the North Carolina Industrial Commission, the insurer must provide you with a detailed explanation as to why it denied your claim. It cannot send you a form letter or general denial. You should receive Form 61 in the mail. The Commission will also receive this form, and your medical providers will receive it as well. If you have outstanding medical costs, the medical providers cannot bill you until you resolve your claim. After receiving a denial, you have the option to appeal it if you do not agree with the denial.

Appealing your claim

When you appeal the denial, you get the chance to plead your case and show that the denial has no basis. To file for an appeal, you will need Form 33 which you will send to the Industrial Commission for a hearing date.

In most cases, the Commission will likely send your case to mediation. You, your employer and other applicable parties have the opportunity during mediation to resolve any issues and move the claim along. If you cannot resolve the claim through mediation, then you will go to a hearing.

After the hearing

Once you reach a settlement through mediation or the Commission makes a decision in the hearing, the result will be one of two things. The insurer will pay your claim, or the denial will stand. If the denial stands, then you will not get any workers’ compensation payments. If the insurer pays the claim, then you will receive benefits according to the state workers’ compensation program rules.

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