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June 15, 2024
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Denied Workers' Compensation Claim in Wilmington, NC: What Are the Reasons and How to Appeal

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You've been injured on the job in Wilmington, North Carolina. The pain is constant, and the medical bills are piling up. You followed all the necessary steps to file a workers' compensation claim, believing that you'd receive the benefits you need to cover your expenses and lost wages while you recover. You waited patiently for a response, hoping for good news.

But then, the unthinkable happens. You receive a letter in the mail, and your heart sinks as you read the words "Claim Denied." Shock, confusion, and frustration overwhelm you. You know your injury is legitimate and that it happened at work, so why was your claim denied? How will you pay for your medical treatment and support yourself and your family?

If you find yourself in this devastating situation, it's essential to remember that you have options. A denied workers’ compensation claim is not the end of the road. By understanding the common reasons claims are denied and familiarizing yourself with the appeals process, you can fight for the benefits you need to move forward.

In this blog, we'll explore the typical grounds for denied workers' compensation claims in Wilmington, NC, and provide you with a step-by-step guide to appealing the decision. We'll help you understand your rights and empower you to take action, so you can focus on your recovery and get your life back on track.

Understanding the North Carolina Workers' Compensation Act

Before diving into the specifics of denied claims and the appeals process, it's essential to understand the North Carolina Workers' Compensation Act. This law provides important protections for employees who are injured on the job. Under the Act, most employers are required to carry workers' compensation insurance to cover the cost of medical treatment and lost wages for employees who suffer work-related injuries or illnesses.

Some key provisions of the Act include:

  • Coverage for medical expenses related to the work injury, including doctor visits, hospital stays, medications, and physical therapy
  • Temporary total disability benefits equal to two-thirds of your average weekly wage if you're unable to work for more than seven days
  • Permanent partial disability benefits if you suffer a permanent impairment as a result of your work injury
  • Death benefits for the dependents of workers who are killed on the job

By familiarizing yourself with the Workers' Compensation Act and understanding your rights, you'll be better equipped to recognize when a claim has been wrongfully denied and can proceed with the appeals process with confidence.

Common Reasons for Denied Workers' Compensation Claims

Common Reasons

Now that you have a better understanding of the North Carolina Workers' Compensation Act, let's explore some of the most common reasons why workers' compensation claims are denied in Wilmington, NC:

  • Missing deadlines or failing to follow proper procedures: North Carolina law requires you to notify your employer within 30 days of your injury and file a claim with the North Carolina Industrial Commission within two years. Failing to meet these deadlines or follow proper procedures can result in a denied claim.
  • Lack of sufficient evidence: If you don't provide enough medical evidence or documentation to support your claim, the insurance company may deny your benefits. This can include incomplete medical records, a lack of witness statements, or insufficient proof of the extent of your injuries.
  • Pre-existing conditions: If the insurance company believes that your injury is related to a pre-existing condition rather than a work-related incident, they may deny your claim. It's crucial to provide evidence that shows how your work duties aggravated or exacerbated your condition.
  • Employer disputes liability: If your employer argues that your injury did not occur on the job or that they are not liable for your injuries, your claim may be denied. This can happen if there are conflicting accounts of how the injury occurred or if your employer believes you were engaging in horseplay or other non-work-related activities at the time of the incident.
  • Intoxication or drug use: If your injury occurred while you were under the influence of drugs or alcohol, your claim may be denied. North Carolina law allows employers to deny benefits if they can prove that your intoxication was a proximate cause of the accident.
  • Not seeking timely medical treatment: If you delay seeking medical treatment for your injuries, the insurance company may question the severity of your condition and deny your claim. It's essential to get a medical evaluation as soon as possible after your injury and follow your doctor's treatment plan.

nc workers' comp attorney

The Workers' Compensation Appeals Process in North Carolina

If your workers' compensation claim has been denied in Wilmington, NC, don't give up. You have the right to appeal the decision and fight for the benefits you need. Here's a step-by-step guide to the appeals process:

Step 1: Carefully Review the Denial Letter

When you receive a denial letter, read it carefully to understand the specific reasons why your claim was denied. The letter will also provide information on how to appeal the decision and the deadlines you must meet. Make sure you follow these instructions closely to avoid missing any important steps.

Step 2: Request a Hearing

To begin the appeals process, you must request a hearing by submitting Form 33 – Request that Claim be Assigned for Hearing to the North Carolina Industrial Commission (NCIC). This form officially requests that the NCIC schedule a hearing to review your denied claim.

Step 3: Participate in Mediation

Before proceeding to a hearing, the NCIC typically requires parties to participate in mediation. During mediation, you and your employer will attempt to reach an agreement regarding your claim. The mediator will facilitate the discussion and help both parties explore potential solutions.

Step 4: Review the Mediator's Recommendation

If you and your employer reach an agreement during mediation, the mediator will draft a written agreement for both parties to sign. If no agreement is reached, the mediator will forward their recommendation to the NCIC for review.

Step 5: Prepare for the Hearing

If you cannot reach an agreement during mediation or if you disagree with the mediator's recommendation, your case will proceed to a hearing. To prepare for the hearing, gather all relevant evidence, including medical records, witness statements, and expert opinions. You may also wish to consult with a workers' compensation attorney to help you build a strong case.

Step 6: Attend the Hearing

At the hearing, you will present your evidence and argument before an NCIC Deputy Commissioner. The Commissioner will also hear testimony from witnesses and may ask questions to clarify issues. Your employer or their insurance company will have the opportunity to present their case as well.

Step 7: Await the Commissioner's Decision

After the hearing, the Deputy Commissioner will review the evidence and issue a written decision. If you disagree with the decision, you have 15 days to request an appeal with the Full Commission, which consists of three judges.

Step 8: Appeal to Higher Courts (If Necessary)

If you disagree with the Full Commission's decision, you may appeal to the North Carolina Court of Appeals. If you are still unsatisfied with the result, you have the option to appeal to the North Carolina Supreme Court.

Throughout the appeals process, it's highly recommended that you consult with an experienced workers' compensation attorney. An attorney can help ensure you follow the proper procedures, meet all deadlines, and present the strongest possible case to support your claim for benefits.

How a North Carolina Workers' Compensation Attorney Can Help

denied workers' compensation claim

Dealing with a denied workers' compensation claim can be a complex and emotional process, especially when you're also trying to recover from a work-related injury. An experienced North Carolina workers’ compensation attorney can provide invaluable guidance and support throughout the appeals process and fight for the benefits you need.

Here are some of the key ways a skilled attorney can help:

  1. Explaining your rights and options: A workers' compensation attorney can help you understand your rights under the North Carolina Workers' Compensation Act and explain the various options available to you, such as filing an appeal or negotiating a settlement.
  2. Gathering and organizing evidence: Your attorney can help you gather and organize the necessary medical evidence, witness statements, and other documentation to support your claim. They can also work with medical experts to ensure that your injuries and limitations are properly documented and presented.
  3. Negotiating with the insurance company: Insurance companies often have their own legal teams working to protect their interests. Your attorney can level the playing field by negotiating with the insurance company on your behalf to secure a fair settlement or benefits package.
  4. Representing you at hearings and appeals: If your case goes to a hearing or an appeal, your attorney can represent you before the deputy commissioner, the Full Commission, or the North Carolina Court of Appeals. They can present evidence, cross-examine witnesses, and make legal arguments on your behalf.
  5. Maximizing your compensation: An experienced workers' compensation attorney can fight for the maximum compensation available to you under the law, including medical benefits, lost wage replacement, and disability benefits. They can also help you explore other potential sources of compensation, such as third-party claims or Social Security disability benefits.

When choosing a workers' compensation attorney, look for someone with significant experience handling claims in North Carolina and a proven track record of success. Don't hesitate to ask for referrals, read online reviews, and schedule consultations with multiple attorneys to find the right fit for your case.

denied workers' compensation claim

Tips for a Successful Workers' Compensation Claim

To increase your chances of a successful workers' compensation claim, keep these tips in mind:

  • Meet all deadlines: Be sure to notify your employer within 30 days of your injury and file your claim with the North Carolina Industrial Commission within two years.
  • Follow proper procedures: Provide complete and accurate information when filing your claim and throughout the appeals process.
  • Gather strong medical evidence: Seek medical attention immediately after your injury, follow your doctor's treatment plan, and keep detailed records of your symptoms, limitations, and progress.
  • Stay organized: Keep all relevant documents, such as medical records, witness statements, and accident reports, in a single, easily accessible location.
  • Hire an attorney: An experienced NC workers' comp attorney can help you navigate the complex claims and appeals process and fight for the compensation available to you under the law.

denied workers' compensation claim
Receiving a denied workers' compensation claim can be a frustrating and stressful experience, but it's important to remember that you have options. By understanding the reasons for the denial, gathering strong evidence to support your claim, and following the steps for an appeal, you can fight for the benefits you need to move forward after a work-related injury.

Don't Face a Denied Workers' Comp Claim Alone: Speak with Us

If your workers' compensation claim has been denied, it's crucial to have an experienced attorney guide you through the appeals process. The team at Speaks Law Firm has been fighting for the rights of injured workers in Wilmington, North Carolina, for decades, and we're here to help you navigate the complexities of appealing a denied claim.

Our North Carolina workers’ compensation lawyers will work diligently to gather evidence, build a strong case, and present compelling arguments to support your right to benefits. We'll represent you at hearings, negotiate with insurance companies, and fight to ensure you receive the maximum possible compensation for your injuries and losses.

If you're considering filing a workers' compensation claim, it's equally important to have an attorney on your side from the start. Our knowledgeable NC workers' comp attorneys can help you avoid common mistakes and pitfalls that can lead to a denied claim. By working with Speaks Law Firm from the beginning, you can feel confident that your claim is being handled properly and that you have the best chance of securing the benefits you need.

We understand the profound impact a workplace injury can have on your life, and we're committed to providing you with the guidance and support you need during this challenging time. Don't let a denied claim or an uncooperative employer hinder your recovery.

Contact Speaks Law Firm today to schedule a free consultation with one of our experienced workers' compensation attorneys. We'll review your case, explain your options, and help you take the first steps toward securing the benefits you need to move forward. Reach out by calling us at (910) 341-7570 or through our online form to begin the process of reclaiming your life.

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Copyright © 2024. Speaks Law Firm. All Rights Reserved.
The information in this blog post (“post”) is provided for general informational purposes only and may not reflect the current law in your jurisdiction. No information in this post should be construed as legal advice from the individual author or the law firm, nor is it intended to be a substitute for legal counsel on any subject matter. No reader of this post should act or refrain from acting based on any information included in or accessible through this post without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer licensed in the recipient’s state, country, or other appropriate licensing jurisdiction.
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