What Happens if My Employer Denies My Workers’ Compensation Claim?

What to Do if Your Workers Comp Claim is Denied By Your Employer

Common Reasons Employers Deny Workers Compensation Claims

Most employers in North Carolina are required to carry workers compensation insurance, but that doesn’t mean every claim gets approved. A denial can happen for several reasons, often leaving injured employees frustrated and unsure of their next steps. Understanding why your workers comp claim may have been rejected can help you prepare a stronger appeal. Here are some of the most common reasons:

Missed Deadlines

Under North Carolina law, an injured employee must properly report their injury within a set timeframe. If you fail to provide written notice or submit an electronic form within the required period, the workers compensation carrier may reject your claim.

• Reporting Deadline: In North Carolina workers compensation cases, employees are required to notify their employer of the work related injury within 30 days of the accident.
• Filing Deadline: The formal workers compensation claim must be filed with the North Carolina Industrial Commission (NCIC) within two years of the injury.
• Why This Matters: Even if you have a legitimate claim, missing these deadlines can result in an automatic denial, leaving you without medical benefits or wage replacement benefits.

Disputes Over Whether the Injury Happened at Work

An employer or insurance company may argue that your work related injury did not actually occur on the work site. This is a common tactic used to avoid paying out benefits.

• Off-Site Incidents: If the injury happened while you were commuting or on a break, your employer may claim it is not covered under North Carolina workers compensation.
• Gradual-Onset Injuries: Conditions like carpal tunnel syndrome or other occupational diseases that develop over time are often harder to prove as work related.
• Employer Surveillance: Some employers or insurance carriers use private investigators or workplace surveillance footage to dispute injury claims.

Pre-Existing Conditions and Occupational Illness

If your job related injury worsens a pre-existing condition, an employer may argue that your health issue was not caused by a work related accident. Similarly, proving that an occupational illness resulted from workplace exposure can be difficult without strong medical evidence.

• Example: If you have a history of back problems but suffer a severe back injury from lifting heavy equipment, your employer may claim that your condition existed before the workplace accident.
• Occupational Diseases: Conditions like lung disease from inhaling toxic chemicals, hearing loss from prolonged exposure to loud machinery, or repetitive stress injuries like carpal tunnel syndrome can be challenging to link directly to a job.
• Burden of Proof: In these cases, you will need medical records and expert opinions to prove that your job either caused or worsened your condition.

Lack of Medical Evidence

Failing to seek medical care immediately after an accident can weaken your claim. If you don’t receive medical treatment right away, the workers compensation carrier may argue that your injury isn’t severe or wasn’t work-related.

• Delayed Treatment: If you wait too long to see a doctor, your employer may argue that the injury occurred outside of work or wasn’t serious enough to require workers compensation benefits.
• Doctor’s Opinion: The workers compensation system may require you to see a physician approved by the workers compensation insurance provider, rather than your own doctor. If their evaluation downplays your injury, it could lead to a denial.
• Medical Documentation: Inconsistent records or gaps in treatment can also hurt your case, as insurance carriers may claim you were not actually injured at work.

Employer Allegations of Employee Misconduct

If an employer disputes your claim, they may argue that your work injury resulted from reckless behavior, failure to follow safety protocols, or substance use at the time of the workplace accident.

• Drug and Alcohol Testing: Many employers require a post-accident drug test. If any substances are found in your system, your claim could be denied—even if they did not contribute to the accident.
• Failure to Follow Safety Guidelines: If an employer believes you violated company safety procedures, they may argue that your own negligence caused the injury.
• Horseplay or Intentional Injuries: If an insurance company claims that your injury was the result of horseplay, fighting, or intentionally injuring yourself to receive workers compensation benefits, they will likely deny the claim.

What to Do If Your Workers Compensation Claim Is Denied

A denied claim doesn’t mean you’re out of options. If your workers comp benefits have been rejected, you can take steps to challenge the decision and fight for the medical benefits and wage replacement benefits you deserve. Here’s what you need to do:

Review the Denial Letter

After your claim is denied, your insurance carrier will send a letter explaining why. Carefully reviewing this letter is the first step in understanding whether your claim was rejected due to missed deadlines, lack of medical evidence, or an employer dispute over the accident.

Knowing the exact reason for the denial will help you determine the best course of action for your appeal.

Gather Evidence to Strengthen Your Case

If your claim was denied due to insufficient proof, you need to gather additional evidence to support your case. Medical records from your own doctor or a second opinion can provide critical documentation of your injuries. Statements from coworkers who witnessed the work-related accident may also help strengthen your claim.

Additionally, keeping a record of your medical care and medical expenses will demonstrate the financial burden caused by your injury. A detailed written statement explaining how the injury happened and how it has affected your ability to work can also support your case.

File a Workers Compensation Appeal with the NC Industrial Commission

If your employer or workers compensation insurance provider denies your claim, you have the right to file an appeal with the North Carolina Industrial Commission (NCIC), which oversees workers compensation cases in the state. To start the appeal process, you must submit Form 33, which requests a hearing before the NCIC.

Once the form is submitted, you will typically be required to participate in mediation to try to resolve the dispute. If mediation does not lead to a fair agreement, your case will move forward to a formal hearing before a judge.

Consider Mediation and Settlement Options

Mediation is an essential part of the workers compensation process and is required before your case can proceed to trial. A neutral mediator will work with you, your employer, and the insurance company to negotiate a fair settlement.

If both sides can reach an agreement, you may receive compensation without the need for a hearing. However, if mediation does not result in a resolution, your case will move forward through the North Carolina court system.

Prepare for a Formal Hearing

If mediation fails, your case will be presented before a judge. At this stage, it’s crucial to have strong evidence supporting your claim. This may include medical documentation, expert testimony, and witness statements.

Since your employer and their insurance carrier will likely have legal representation, having an experienced workers compensation attorney on your side can significantly improve your chances of success.

Your attorney will present your case before the North Carolina Industrial Commission, challenge any arguments made by your employer, and work to ensure that you receive the workers compensation benefits you are entitled to under North Carolina law.

A formal hearing is often the final step in securing benefits, making it critical to prepare thoroughly and present a compelling case. If your claim has been denied, don’t navigate the workers compensation system alone—seeking legal guidance can help protect your rights and increase your chances of a successful appeal.

How a Workers Compensation Attorney Can Help

Navigating the workers compensation process alone can be overwhelming, especially when dealing with a denied claim or an insurance company that refuses to pay the full benefits you deserve. A skilled law firm specializing in workers compensation law can provide the legal guidance and representation needed to help you fight for your rights.

Ensure All Forms Are Filed Correctly

The workers compensation system requires strict adherence to filing deadlines and procedural rules. A simple mistake, such as missing a deadline or submitting incomplete paperwork, can result in delays or a denied claim. An attorney ensures all required forms, including medical reports and wage loss documentation, are properly completed and submitted on time to avoid unnecessary complications.

Collect Medical Records and Expert Testimony

Strong medical evidence is essential in proving the extent of your work-related injury. A workers compensation attorney will work with your own doctor or independent medical experts to gather comprehensive medical treatment records, obtain necessary second opinions, and provide expert testimony that supports your claim.

They will also ensure that your medical documentation aligns with the requirements set by the North Carolina Industrial Commission (NCIC).

Represent You in Mediation, Hearings, and Appeals

If your claim has been denied or disputed by your employer or insurance carrier, an attorney will advocate for you throughout the appeal process. This includes representing you in mediation to reach a fair settlement, preparing you for hearings before the NC Industrial Commission, and taking your case to the North Carolina Supreme Court if necessary. Their legal expertise ensures that your case is presented effectively with solid evidence and witness testimony.

Negotiate a Fair Settlement with the Insurance Company

Insurance companies often attempt to settle workers compensation claims for less than injured workers deserve. A skilled attorney will calculate the true value of your claim, factoring in medical expenses, lost wages, ongoing treatment costs, and potential permanent disability. They will negotiate aggressively to ensure you receive maximum compensation and won’t be pressured into accepting a lowball offer.

Fight for Permanent Disability or Permanent Partial Disability Benefits

If your injury results in long-term or lifelong impairments, an attorney can help secure permanent disability or permanent partial disability benefits. They will ensure you receive appropriate wage replacement benefits, continued medical care, and financial support for any necessary accommodations.

If your injury prevents you from returning to work, they can also assist with filing for Social Security Disability benefits.

If your workers comp claim was denied, don’t wait to take action. The longer you delay, the harder it may be to gather the necessary evidence and file an appeal. Schedule an initial consultation today with an experienced workers compensation attorney to protect your rights, navigate the workers compensation system, and secure the benefits you deserve.

What Happens If You Lose Your Appeal?

If your appeal is unsuccessful at the North Carolina Industrial Commission (NCIC), you still have options to pursue the workers compensation benefits you deserve.

You may be able to take your case to the North Carolina Court of Appeals or even the North Carolina Supreme Court if there are legal grounds to challenge the decision. These higher courts review whether the NCIC made an error in interpreting workers compensation law, but they do not accept new evidence, so a strong legal argument is essential.

If your injury prevents you from working, you might also qualify for Social Security Disability Insurance (SSDI). Even if your workers comp claim is denied, you could still receive disability benefits through the Social Security Administration (SSA), which requires medical proof of long-term impairment.

In some cases, if your employer disputes your claim unfairly or fails to carry workers compensation insurance, you may have grounds for a personal injury lawsuit or other legal action.

A knowledgeable workers compensation attorney can assess your options and help you determine the best course of action based on your situation. If your workers compensation appeal has been denied, don’t wait—seek legal guidance to protect your rights and financial future.

Take Action Today – Get the Benefits You Deserve

A denied claim can feel overwhelming, but you don’t have to navigate the workers compensation process alone. If you’ve suffered a work-related injury, don’t let an insurance company or employer decide your future. At 1 Charlotte Injury Lawyers, we are committed to fighting for your workers compensation benefits, ensuring you receive the medical treatment, medical benefits, and wage replacement benefits you deserve.

Don’t wait—your rights and financial stability are too important. Contact us today for a free consultation and let us help you get back on the path to recovery.

Call (704) 706-2689 now to speak with an experienced workers compensation attorney who will advocate for you every step of the way.