Valid workers’ compensation claims can be denied for a number of reasons ranging from a failure to file a claim on time and a lack of evidence to an employer’s claim that an employee’s injury is not work-related. Having a workers’ compensation claim denied can leave many injured employees with a mounting pile of medical debt and no other hope of relief. Fortunately, in North Carolina, employees are guaranteed the right to appeal a denied workers’ compensation claim, so if you sustained a job-related injury or illness and received a denial of your claim, it is important to obtain the advice of an experienced workers’ compensation attorney who can evaluate your claim and help you navigate the appeals process.
Filing an Initial Appeal
In North Carolina, an employer’s workers’ compensation insurer is required to either approve or deny an injured worker’s claim for benefits within two weeks of the accident. If the insurer refuses to provide benefits, it must send a notice to the employee that explains the reason for the denial. At this point, an injured employee has the option of appealing the denial by submitting Form 33, or a Request That Claim Be Assigned for Hearing, to the North Carolina Industrial Commission (NCIC), which resolves workers’ compensation complaints across the state. Claimants must also send a copy of Form 33 to their employer and the insurer.
This form requires the claimant to provide specific information, including:
- A description of his or her injury;
- What benefits he or she is requesting, which could include payment for medical expenses, compensation for days missed, and payment for permanent disability;
- A list of all witnesses (as well as their contact information) who saw the accident occur and can testify as to the employee’s injuries; and
- The specific reason that the parties have been unable to reach an agreement.
To qualify for a hearing, the claimant must file the appeal within two years of the injury.
Although Form 33 is technically a request for a hearing before a deputy commissioner, the NCIC automatically refers all cases to mediation before scheduling a hearing date. Mediation is basically an informal meeting between opposing parties, where a neutral third party attempts to help the parties reach a settlement. In these cases, the parties are given the option of choosing a mediator from an approved list. However, if an agreement cannot be reached, the NCIC will appoint a mediator. In either case, the parties are required to split the cost of the mediator’s fee.
At mediation, each party submits evidence to the mediator, who after hearing both sides of the story, recommends a solution and then attempts to facilitate a negotiation. If the parties are able to come to an agreement, each will sign a document outlining the terms of the settlement. However, if negotiations stall, the case will move on to a formal hearing, usually within one to two months. Regardless of the outcome, the mediator is required to send a written report to the NCIC describing the results of the mediation.
At the formal hearing, each party will present evidence proving that the initial denial was incorrect. This evidence could include:
- Witness testimony, which is given under oath;
- Medical records; and
- Medical or vocational expert testimony.
After hearing the evidence, the judge will issue a written order. If a claim is denied for a second time, the claimant has the option of appealing the case to the Full Commission by submitting an Application for Review to the NCIC within 15 days of the deputy commissioner’s decision.
Full Commission Appeal
When submitting the second appeal, it is very important for claimants to carefully list the reasons that the previous denial was incorrect because any arguments that are not explicitly stated on the form are considered waived and cannot be raised at a later date. It may even be necessary to cite the pages in the transcript on which the errors are recorded. Within a month of receiving the request for review the NCIC compiles the transcript and exhibits from the previous appeal and sends them to the parties free of charge. At this point, the claimant has 25 days to file a written brief in support of review with the NCIC, although in some circumstances, the parties can request a 15 day extension from the Docket Director. The other party then has the same amount of time in which to file a response. It is important to submit the brief on time as a party’s failure to do so bars him or her from participating in oral arguments at a later date.
The Full Commission, which is made up of three judges, then has the option of making a decision based purely on the written briefs. Alternatively, the judges can schedule a hearing for oral arguments. In cases involving an appeal of an award for disfigurement, presence at the hearing is not optional for the claimant, who is required to appear before the Full Commission, so that the panel can view the extent of his or her disfigurement before making a decision. After hearing all of the evidence, the panel will issue a written decision. If the claim is again denied, the injured party can file an appeal with the North Carolina Court of Appeals, after which he or she can only seek relief from the North Carolina Supreme Court.
Contact an Experienced Workers’ Compensation Attorney Today
In some cases, workers’ compensation is the only form of relief available to injured employees. For this reason, it is especially devastating when an injured party’s valid claim is denied. Although many North Carolina residents are unaware of it, employees in the state have the right to appeal a denial before they can be billed for medical treatment, so if you live in Charlotte and were injured while on the job and were initially denied compensation, please contact the law firm of Ted A. Greve & Associates, P.A. by completing one of our contact forms and we will help you set up a free consultation with a dedicated work injury lawyer in Charlotte, NC at your earliest convenience.