Frequently Asked Questions About Workers' Compensation

Frequently Asked Questions About Workers' Compensation

How does workers’ compensation work?

Workers’ compensation is intended to pay wages and medical expenses for employees who are injured at work or in the course of their employment. It is a state-mandated insurance that protects employees and employers, as it covers expenses and prevents lawsuits.

What will workers’ compensation pay for?

Workers’ compensation will pay for the necessary expenses related to your injury or injuries in diagnosis and treatment. It will also pay for the lost wages that accrue when you miss work for injuries. Further, workers’ compensation will pay for rehabilitation and job training if this is necessary for you to recover from injuries and return to work.

How do I know if I’m covered?

Not all employers have to carry workers’ compensation insurance in North Carolina. If you work for an employer who has three or more employees, then the company must carry workers’ compensation insurance and you are likely covered.

Some exceptions to workers’ compensation coverage include employees of some railroads, causal employees, domestic servants, farm laborers if there are fewer than 10 full time employees, federal government employees, and sellers of agricultural products for producers on commission or for sale by the producer. Thus, you coverage will depend on the type of job you have and the size of your employer’s business and staff.

If you are an independent contractor, then you should be aware that this does not remove the responsibility of your employer to have workers’ compensation insurance under North Carolina law. Rather, if the level of control over the work is substantial, then independent contractors can still be eligible for workers’ compensation, again, dependent upon the employer and staff size.

What does ‘no-fault’ mean in workers’ compensation?

Workers’ compensation is a no-fault system, which means that it doesn’t matter who was at fault for the injury; the injured employee is still covered. If the injury occurred in the course of work, then the employee is covered, even if the injury was his or her own fault. There are exceptions to this, of course. For example, if the injury occurred while the employee was intoxicated, if the injuries were intentionally self-inflected, or if the injuries occurred in the course of committing a crime, then workers’ compensation will not cover these injuries. Other examples include injuries that occurred while violating company policy or while not engaged in relevant work.

I was injured away from my physical workplace; am I still covered?

As long as the injury occurred while you were engaged in job related activities, your physical location will not disrupt you workers’ compensation coverage. Delivery truck drivers, for example, can be injured in the course of their work, but away from their work locations, and they can still receive workers’ compensation benefits.

What is the first thing I should do after a workplace injury?

The first thing you need to do is report the injury to your supervisor in writing. Your employer may direct you to a particular healthcare provider, and you should report for treatment at this provider’s office as soon as you can. If you are not directed to a provider, you can use any healthcare provider of your choice. Make sure that you let the physician know that the injury occurred at work and give them the name of your employer. If you are unable to report your injury to your employer, ask a friend or family member to do this. You must notify your employer of injuries in writing within 30 days of the incident.

Can I see a doctor of my choice?

If your employer or insurance company refers you to a doctor, then you are required to see this doctor, under North Carolina law. However, you can ask to change medical providers if you have a good reason. Still, you must receive permission before receiving treatment.

What if my employer retaliates by firing me for filing a claim?

Legally, your employer is not allowed to retaliate against you in any way, including terminating your employment, for filing a workers’ compensation claim. Any punishment, discrimination, or discharge, as a retaliatory action, is illegal in North Carolina. The employer may still retaliate and give an excuse, like poor work performance, for termination. If you feel this has happened to you, then you should contact an attorney to file a complaint, and possibly a lawsuit.

I don’t agree with the insurance company; what can I do?

You do have options if the insurance company makes a decision that you don’t agree with. The North Carolina Industrial Commission will provide services to assist you and your employer after an injury, and you can direct any questions and concerns to them. You can also discuss your case with a qualified North Carolina workers’ compensation attorney.

How much will I receive in workers’ compensation and how often?

Workers’ compensation payments are based on your average weekly wage at 66 2/3%, without exceeding the state’s maximum amount (set yearly). Typically, you will receive your workers’ compensation payments on a weekly basis. In some situations, you may receive monthly payments.

Do I have to accept workers’ compensation or can I file a lawsuit against my employer?

It is very rare for it to be acceptable to refuse workers’ compensation insurance and file a lawsuit against the employer, and only certain situations will warrant this action. An example would be if the employer behaved in an egregious way to cause your injuries. In most cases, you will be obligated to accept workers’ compensation insurance.

At what point can I start receiving wage loss payments?

You will become eligible for workers’ compensation wage loss payments once you’ve been out of work for more than seven days. You will not receive payment for the first seven days unless you are out of work for more than 21 days.

What statute of limitations applies to workers’ compensation claims?

In North Carolina, the workers’ compensation statute of limitations is two years. This means that you must file a workers’ compensation claim within two years of the date that the injury occurred. If your employer retaliates against you, then you have a three year statute of limitations to file a lawsuit against your employer for unlawful retaliation.

Will I be reimbursed for travel expenses related to medical care?

You can receive compensation for your travel expenses if you must travel 20+ miles to your appointments. Your reimbursement will be the same as government travel rates.

What if someone else caused my workplace injuries?

If someone else is responsible for your injuries that occurred at work, then you can also seek a third party liability claim against that person/entity. This could be in your best interests because workers’ compensation will only provide financial compensation for wages and medical expenses. If you are able to file a third party lawsuit, then you can seek compensation for other losses. However, you must be able to prove negligence.

North Carolina also allows the insurance company of the employer to pursue subrogation claims against any liable third parties. In these cases, the employer will be able to recover some of the payments that have been made through workers’ compensation to cover the expenses of your lost wages and medical care.

How will I pay my medical bills?

A statutory fee schedule fixes the maximum payment amounts for services and treatments that you may receive, and medical bills are paid according to this schedule. If your provider disagrees with the fees, then he or she can request that the Industrial Commission review their concerns.

Any provider of care has 74 days to submit payment requests after the date of service or must do so within 30 days of the end of multiple treatments. Then, the insurance company or the employer can pay the amount or object to it in writing within 30 days of receipt. Any disputes will be addressed through the Industrial Commission and the contractual agreements. The services must be paid within 60 days of the Commission’s approval of bills, or there will be penalties.

Anyone responsible can request a hospital charge audit. The medical care provider cannot come after the employee for payments until it is determined that the Commission will not compensate the treatment or until the employee has not and can no longer request an appeal.

Will workers’ compensation only cover accidental injuries?

Workers’ compensation covers accidental injuries, but also covers occupational illnesses and injuries that result from stress and overuse of certain muscles.

What are occupational illnesses?

Occupational illnesses or diseases are ailments that result from the activities and exposures involved in your employment. For example, being exposed to asbestos can cause an occupational disease, and medical professionals can contract occupational illnesses from a variety of sources, including ill patients, accidental contact with needles, and more.

What is a clincher agreement?

When an injured employee comes to a settlement agreement with his or her employer or with the workers’ compensation insurance company, this is known as a clincher. Typically, attorneys are involved in such settlement negotiations, and you’d be wise to secure legal representation before attempting to negotiate with your employer or insurance company. Both sides may be at odds with each other, but can typically come to a settlement agreement to avoid trial.

Whenever both sides compromise and sign a clincher agreement that defines the settlement terms, they will determine a lump sum cash settlement in exchange for the employee’s agreement to release the employer from any future liability. The clincher will not be effective, however, until it is approved by the North Carolina Industrial Commission. To be approved, the agreement must satisfy Rule 502, protecting the interests of the employee and fair treatment. Thus, certain language must be included within such a settlement agreement and certain circumstances must be met.

To be approved a clincher must include the submission of all relevant medical and vocational assessments of the injured employee, a list of unpaid medical expenses and who will pay them, the signature of all parties and attorneys, a finding that the settlement agreement is reasonable, and a statement regarding whether or not the employee has returned to similar employment.

Clinchers are particularly useful for employees who are struggling to live off of 2/3 of their former income. It provides a lump sum of money which can help the employee regain his or her financial stability and get back on their feet. Having said taht, there are some important things to keep in mind. Once you have signed an agreement that releases your employer from paying future expenses, you will be responsible for any expenses that may come up in the future. Further, you can no longer make any claims for future lost wages.

Employers will often agree to these settlements because they can then establish a particular amount of money that they’ll pay without the uncertainty of unknown future expenses. As the employee, you should not agree to anything without the advice of an attorney.