Disability benefits are paid to injured workers in accepted claims (or claims where the workers’ compensation insurance company admits that the worker is entitled to compensation). Weekly benefits are paid when there is total disability (the injured worker is not capable of any work) or when they can return to work at lesser wages (partial disability). Permanent partial impairment ratings are also paid out over a set period of weeks on some case.
In addition to disability benefits, the North Carolina workers’ compensation system allows for medical compensation.
The North Carolina Workers’ Compensation Act requires that an injured worker notify their employer in writing within 30 days of suffering a workplace injury. It is the injured worker’s responsibility to file a “Form 18” with the North Carolina Industrial Commission.
Workers’ compensation insurance companies are supposed to accept or deny a claim within 30 days of notice of the claim. However, the insurance company can ask for an extension of time up to 90 days to make a decision. More recently, the trend is for insurance companies to place conditions on their acceptances – they accept claims as “medical only” on a Form 63 or only accept some of the body parts that require treatment.
They certainly could be. If the injury is compensable, the worker might be entitled to medical compensation and possibly even compensation for a disability rating.
If the claim is accepted by the insurance company, then the injured worker will have to get treatment with physician that the insurance company selects. If the claim is denied, then the injured worker is free to see who they want with the hope that the insurance company will pay the bills later in a compromise or that the bills are ordered to be paid by the insurance company by the Industrial Commission.
Injured workers are entitled to receive all the medical treatment that was caused by the accident. In addition to being causally related, the treatment must also be reasonably required to effect a cure, provide relief, or lessen the period of disability. Besides hospital visits, surgery costs, and medications, injured workers may also receive mileage to travel to their appointments (as long as the round trip is over 20 miles) or attendant care.
Injured workers entitled to weekly disability benefits, or indemnity benefits, get 2/3 of their “average weekly wage.” Average weekly wage is generally defined as the average amount of income received by the injured worker during the 52 weeks immediately before their workers’ compensation injury. 2/3 of the average weekly wage is the “compensation rate.” Injured workers receive their compensation rate while out of work due to a workers’ compensation injury. Special determinations are made for injured workers that did not have a full 52 week work history with their employer before their injury. In North Carolina, there are also minimum and maximum compensation rates mandated by law.
Generally, an injured worker only receives compensation at the compensation rate for the employer that they were working for at the time of the injury. Workers’ compensation insurance companies are not responsible for the lost time of workers at other jobs. At the same time, the insurance company is not entitled to a credit for income that an injured worker returns to (if the worker had the second job at the time of the injury and the injured worker does not increase their compensation from the second job upon return after injury).
Claims are denied for several reasons, quite often for reasons that are unclear at first. We have seen over the past several years insurance companies be more aggressive in their denials of claims. Claims get denied frequently for credibility reasons – insurance companies believe the injured worker has not been entirely truthful about the circumstances of their injury. Claims get denied because there are prior claims or medical treatment that may be contributing to the current condition. Claims also get denied for legal reasons. Many types of claims require an “injury by accident” in order to be compensable.
Many, but not all, require that the injury be a result of an injury by accident. Simply put, injuries that are not born out of unusual circumstances and occur in the normal work routine are not compensable claims in North Carolina. Claims for most body parts require unusual circumstances in order for the insurance company to be liable. Back and neck claims are the exception in that no accident is required – only a specific traumatic incident.
There are several methods of investigation employed by workers’ compensation insurance companies. The most typical is the recorded statement. Adjusters will interview injured workers early in a case to ask questions about the circumstances of an injury. Adjusters will also review old medical records or communicate with other insurance companies to see if the worker has filed previous workers’ compensation or personal injury claims.
Yes. Several of our attorneys were once workers’ compensation defense attorneys and are fully aware the lengths that an insurance company will go to create evidence that puts the injured worker in an unfavorable light.
Yes. Another type of claim besides workplace accidents are occupational diseases. Occupational diseases can consist of everything from bursitis to asbestosis. Specific expert medical testimony is usually required to prove an occupational disease, but the North Carolina Workers’ Compensation Act specifically makes occupational disease claims compensable in certain circumstances.
As long as an injured worker can prove they are disabled, they are entitled to weekly benefits for up to 500 weeks. The North Carolina Workers’ Compensation Act allows for an extension of time on those 500 weeks in certain circumstances.
Family members (typically children and spouses) of injured workers that die as a result of a workplace accident are entitled to workers’ compensation death benefits. In addition to benefits, family members are entitled to burial expenses.
Injured workers can request a second opinion with a physician of their choice, at the insurance company’s expense, when determining whether the treating physician’s assigned disability rating is fair. However, it is more complicated when requesting a second opinion for diagnoses, treatment options, and work restrictions. The insurance companies still hold some control in those situations.
Every claim is different. The factors that matter most in this analysis include what the worker’s average weekly wage is, their vocational profile (age, education), the type of restrictions the treating physician assigns, and whether the injured worker can return to work at wages similar or greater than their pre-injury wages. There are literally dozens of other factors that affect the analysis. It takes attorneys years and practice to understand all the things necessary to think about when evaluating the worth of a claim.