What is workers’ compensation?
Workers’ compensation is a state-mandated insurance that pays wages and medical expenses to employees who are injured in the course of employment in exchange for the employee’s agreement to not sue the employer for damages.
What does workers’ compensation cover?
Workers’ compensation covers the cost of diagnosing your injuries and the necessary treatment. In addition, it pays wages if you are unable to immediately work due to to injuries. If rehabilitation or training is needed for your return to work, workers’ compensation pays this cost as well.
Am I covered by workers’ compensation insurance?
Your coverage under workers’ compensation depends on your employer, as well as your job type. Not all employers are required to carry workers’ compensation insurance under North Carolina law. Only those business that employ three or more employees are subject to the state’s workers’ compensation regulations. In addition, certain types of employees are exempt from coverage under workers’ compensation policies including:
- employees of certain railroads;
- casual employees whose job duties do not fit the definition of “work pertaining to the regular course of defendant’s business”;
- domestic servants directly employed by the household;
- farm laborers when fewer than 10 full-time, non-seasonal farm laborers are regularly employed by the same employer;
- federal government employees in North Carolina (coverage is governed by federal law; and
- “sellers of agricultural products for the producers thereof on commission or for other compensation, paid by the producers, provided the product is prepared for sale by the producer.”
There are special considerations for independent contractors. Employers cannot avoid their workers’ compensation responsibility by simply labeling their workers as independent contractors. When determining whether or not a worker is an employee under the state’s employment laws, the worker’s label is irrelevant. Instead, the law looks at the level of control that the employer exercises over the worke. If this level of control is substantial, an independent contractor may be eligible for workers’ compensation coverage.
What does it mean that workers’ compensation is a “no-fault” system?
In general, workers’ compensation coverage applies regardless whether fault lies with the employer, the employee, a coworker, client or other third party. However, there are exception to this rule under certain circumstances.
- Injuries occurring while the employee is under the influence of alcohol or drugs;
- Injuries that are self-inflicted;
- Injuries suffered while a worker was in the commission of a serious crime;
- Injuries suffered while an employee was not on the job or engaged in job related duties; and
- Injuries suffered when an employee was in the process of violating company policy.
Can I receive benefits if I was injured while not at my physical workplace?
You physical location will not prevent your receipt of benefits if you were engaged in job related duties when the injury occurred. For example, a delivery truck driver may be injured while delivering the company’s product. Even though he is away from the job’s physical location, he may still be eligible for benefits.
What do I do if I am injured on the job?
Report your injury to your employer verbally and in writing as soon as possible. If you are directed to a particular healthcare provider, report for treatment immediately. If there is no dedicated provider, see a doctor of your choice. Be sure to inform the physician that this is a work related injury and the name of your employer.
If not already done, report your injury to your employer. If you are not able to do so personally, as a friend or family member to do it for you. Provide written notification to your employer within 30 days of the injury to preserve your coverage eligibility.
Do I have to see the doctor referred by my employer?
Under North Carolina law, you are required to see the doctor referred by the employer or insurance company. You can request a change in medical providers for reasonable grounds. However, insurance payment is only guaranteed if you received permission to see another doctor before the receipt of any treatment.
Can I be fired for filing a workers’ compensation claim?
The state prohibits employers from retaliating against employees who file workers’ compensation claims. This includes punishment, discrimination and discharge. In cases where the employer does retaliate, the employee can file a complaint with the state regulatory body or institute a lawsuit against the employer for retaliatory discharge.
What options do I have if I do not agree with a decision or action of the insurance company?
The North Carolina Industrial Commission regulates workers’ compensation insurance within the state and provides services to assist the employer and employee when injuries occur. Questions and concerns can be directed to the Commission. An experienced workers’ compensation attorney can also prove helpful in resolving issues between you and your employer.
How often are insurance payments made and at what rate of pay?
Though payments are generally made on a weekly basis, the Commission can authorize monthly payments as well. It is paid at a rate of 66 ⅔ percent of your average weekly wage, not to exceed the yearly maximum amount set by the state.
Can I refuse workers’ compensation insurance and sue my employer for a work related injury?
Generally, you are obligated to accept workers’ compensation insurance for your injuries. However, under certain situations, you have the right to refuse the insurance and file a lawsuit against your employer under a personal injury claim. For example, you may have this option if your injuries stemmed from the employer’s intentional and egregious actions.
When do I become eligible for wage loss payments?
Under North Carolina law, there is no payment for the first seven days of injury, unless the injury duration is longer than 21 days.
Is there a statute of limitations for workers’ compensation cases?
Under North Carolina law, the statute of limitations for filing a workers’ compensation claim is two years from the date of injury. Additionally, in cases where the employer is accused of retaliation, there is a three year statute of limitations to file a lawsuit for unlawful retaliation.
Can I receive reimbursement for travel to and from my doctor’s appointments?
North Carolina does allow for this type of reimbursement. If you travel at least 20 miles to a doctor’s appoint or medical treatment, workers’ compensation can reimburse you at the current government travel rate.
When am I eligible for lost wages?
Under North Carolina law, you are not eligible for lost wages until your eighth day of absence from work, unless your absence continues past 21 days. For example, if you are absent from work for 15 days, you will not receive lost wage pay for days one through seven. If you injury absence extends for two days, you will receive payment for the first seven days following your 21st day of absence.
What if a third party is responsible for my injuries?
You can seek third party liability by making a claim against the third party for compensation for work related injuries.
While workers’ compensation provides employees with financial compensation, it only covers current medical expenses. A third party lawsuit can prove useful in making up for these limitations. This type of lawsuit differs from the workers’ compensation claim and requires proof of negligence on the part of the defendant.
In these situations, North Carolina allows the employer’s insurance company to pursue a subrogation claim. This action is meant to recoup insurance payments for medical treatment and lost wages. The employee and the employer must agree to any proposed settlement amount, and the employer receives compensation first, before the employee claims any portion of the payment.
What options are available if I am not in agreement with the insurance company?
The North Carolina Industrial Commission offers mediation services for situations where injured employees and workers’ compensation insurance companies cannot reach an amicable agreement. However, not all cases are sent for mediation. When a party files a hearing request, the system automatically sends both parties an acknowledgement letter, along with an Order for Mediated Settlement Conference. If all parties are in agreement, mediation is scheduled. If efforts at mediation fail, a lawsuit may prove necessary.
How are medical bills handled?
Medical bills are paid according to a statutory fee schedule, which fixes the maximum payment amounts for specific services and treatments. when providers do not agree with these fees, they can apply for a review before the Industrial Commission.
Service providers are required to submit their payment requests within 74 days of service or within 30 days of month’s end for multiple treatments. The employer or insurance company has 30 days from the receipt of statement to pay the requested amount or submit objections to the bill amount in writing. Disputes are handled through contractual agreement or through the Industrial Commission. If the Commission approves the bill amounts, the services must be paid within 60 days or penalties are added.
Responsible parties have the option to request an audit of all hospital charges. The service provider is prevented from seeking payment from the employee unless the treatment cost is determined non-compensable by the Commission, or the employee fails to request an appeal hearing for a denial of employer liability
Does workers’ compensation only cover accident causing injuries?
Workers’ compensation does not solely cover injuries stemming from accidents. Stress injuries from the overuse of certain muscles are also covered, as are illnesses and diseases that result from employment conditions.
What is an occupational disease?
These are illnesses that were significantly caused by the duties of your employment, or your employment significantly contributed to the disease’s development.
What is a clincher under North Carolina workers’ compensation law?
A clincher is a settlement agreement between the injured employee and the employer or insurance company. When these parties are at odds with each other over some aspect of the workers’ compensation process, they may work to reach a settlement agreement to avoid any court appearances. Generally, these negotiations involve attorneys, so it is advisable that you secure the services of an experienced workers’ compensation attorney to advocate on your behalf.
Once the negotiations reach a level of compromise, both sides will sign on a clincher, or agreement, that sets out the terms of the settlement and states that both sides are in agreement. The provisions of a clincher agreement generally include:
- A lump sum cash settlement amount that the employee will receive; and
- A statement that, in return, the employee releases the employer from all future liability.
A clincher does not go into effect until the North Carolina Industrial Commission approves it. In order to gain approval, the agreement must meet the Commission’s requirements under Rule 502, which is designed to protect the interests of the employee and ensure that the injured party is treated fairly. The rule states that the settlement agreement must include certain language. In addition, the following circumstances are required before the Commissioner will approve a clincher:
- All relevant medical and vocational assessments of the injured employee have been submitted;
- A list of all unpaid medical expenses is included, with designations as to who will pay them;
- All parties and attorneys have signed the agreement;
- A finding that the settlement agreement is reasonable regarding the payment of medical expenses; and
- A statement regarding whether the employer has not returned to employment in the original or similar position paying a substantially similar salary.
The purpose of a clincher is to end a workers’ compensation claim in a manner that is acceptable for all parties. It is especially useful for an injured employee who is forced to live off two-thirds of their usual income because it provides the employee with a lump sum of money that helps them return to financial stability. While it is an attractive option, there are also considerations for the injured employee.
For example, once you hold the employer harmless for all future expenses, you are solely responsible for all of your medical costs going forward. For serious injuries, these expenses can be substantial. In addition, you are also giving up your claim for the reimbursement of future lost wages, so these agreements can prove a gamble for you as the injured employee.
Employers like these agreement because it gives them some certainty about the amount of money your injury will cost the business, without the worry of future costs and expenses. For this reason, they may offer a low value clincher to minimize their financial responsibility. As an employee, you must be careful about quickly accepting this type of agreement without the guidance and experienced opinion of an attorney.