Employers who have four or more regular employees are required to have workers’ compensation insurance.
You should report your injury to your employer as soon as possible. If an injured worker does not report the injury within 90 days, they face the possibility of not receiving benefits. The statute of limitations to file a workers’ compensation claim is 2 years.
Generally, injured workers receive payment for lost wages, medical treatment and permanent impairment.
Medical treatment includes conservative care such as medication and physical therapy, surgery, medical supplies, and medical equipment. The insurance company selects the physician who provides medical treatment.
Lost wages during time that you are unable to work as a result of the injury are paid at 2/3 of the injured worker’s average weekly wage. If you had two jobs at the time of injury, lost wages can account for both jobs.
Permanent impairment for loss of use of a body part(s) is assigned by the treating doctor at the conclusion of the medical treatment.
Injured workers can request another opinion with their insurance adjuster or if the adjuster refuses, they can request a hearing to request that the Commission to order a second opinion. In many situations, second opinions are provided by the insurance carrier.
Yes. Injured workers receive mileage for round trips over ten miles.
Workplace injuries that made pre-existing conditions worse are still compensable.
A Form 50 can be filed to request a hearing at the South Carolina Workers’ Compensation Commission. Hearings are often requested when there is a dispute in benefits or the claim is denied.
Yes. Claimant approved for Social Security disability receive Medicare after receiving disability benefits for two years (24 months). All claimant approved for benefits receive nothing for the 5 months after their onset date. After five months benefits begin and after two years of receiving benefits they will become eligible for Medicare. For many disabled individuals, Medicare is the more important benefit because without it there is no chance to obtain medical coverage.
The hearing is an opportunity for the claimant to provide their testimony about their impairments and how those impairments affect their activities of daily living and work activity. It is also a chance for the Administrative Law Judge to make a decision on the claimant’s credibility and attempt to get more information about any of the information in the record. The Administrative Law Judge will usually consult a vocational expert in determining whether the claimant’s specific limitations will make full time work impossible.
Yes. Claimants can file a “Request for Reconsideration.” If that is denied, then the claimant can “Request a Hearing” before an Administrative Law Judge (ALJ). Quite often, a claimant’s best chance for approval is before an ALJ.
The Social Security Administration employs a five stop process to decide whether a claimant is disabled. Step 1 looks into whether the claimant is actually performing substantial gainful activity. If the claimant has been earning more than about $1,200 a month, they will not be eligible for disability benefits. Step 2 looks into whether the claimant has severe medically determinable impairments. These impairments can be physical or mental impairments but must be more than a minimal effect on work activity. Step 3 looks to see whether the severe impairment or impairments meet a listing. Listings lay out the standards that medical impairments must meet in order to result in a finding of disability. Step 4 looks into the claimant’s past relevant work. If the claimant is able to perform any of their jobs within their past relevant work (work they performed during the last 15 years), then they are not disabled. Finally, in Step 5, a determination is made whether the claimant can perform any other work in the national economy.
Not necessarily. The Social Security Administration does not have to accept your doctor’s opinion on your inability to work as determinative. The Administration is usually more interested in how an individual’s impairments affect their ability to perform work tasks. A physician’s opinion about a patient’s specific work restrictions will often be stronger evidence – especially if those opinions are supported by objective medical testing.
Yes. The Social Security Administration does not view the receipt of workers’ compensation benefits as substantial gainful activity. Individuals receiving workers’ compensation benefits may still apply for Social Security disability benefits. However, if approved, their Social Security disability benefits will be offset by the periodic payments of workers’ compensation.
Yes. SSDI has a trial return to work program for those people who are able to work. In order to be eligible for disability benefits initially, the disability must last for at least one year.
Not necessarily. SSDI is an insurance program that requires workers to pay taxes in order to be insured for disability benefits. However, the general rule is that a worker must typically have worked 5 out of the last 10 years to be eligible for disability benefits. Having some gaps in your work history does not prevent being eligible for benefits.
Both programs are disability programs. SSDI is an insurance program that requires a work history. For those individuals that are no longer insured, SSI is available if they are disabled and qualify financially.
Insurance companies have no interest in paying you all that you deserve. They often deny claims, delay giving you answers, and hope you become so frustrated that you give up. An attorney can make sure you obtain what you are entitled to, not only from the other driver’s insurance company but also from your own insurance policy that you purchased to protect and cover you.
Yes, unlike workers’ compensation cases where pain and suffering is not a benefit, people injured as a result of another person’s negligence can receive compensation for pain and suffering. Pain and suffering can include many, many things and cover a wide variety of situations. Just a few examples of this could include pain recovering from surgery or burns, suffering from losing a job, or not being able to hold your child due to your injuries. Injured individuals should consider creating a daily journal or some kind of record of pain following an injury.
Unfortunately, probably not. North Carolina is a contributory negligence state. What that means is that if you are found to have contributed in any way to the fault of the accident then you cannot recover at all from the other person. (not even if you are 1% and the other person is 99%) For example, if you are texting and driving and get hit by a car you might not be able to recover if it is found that you could have avoided the accident by staying off your phone.
You can go to your doctor(s) for medical treatment. The sooner the better! Since the insurance company in a car accident does not pay for your medical bills upfront, you may go where ever you want for treatment. Document the medical facilities where you’ve received treatment and keep records of all your bills so at the end of your medical treatment you can ask the insurance company to reimburse you for bills that have been paid or are outstanding.
Seek medical attention if you are injured! Take pictures, get the names and numbers of any available witnesses, remain at the scene to collect all the insurance information and contact information of everyone involved. Talk to an attorney prior to talking to the insurance companies.
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).
Yes. An injured worker receiving weekly benefits from an insurance company can still apply for Social Security Disability benefits. If the injured worker is approved for Social Security Disability, they may not be eligible for their entire Social Security Disability monthly benefit because the workers’ compensation benefits might offset the Social Security benefit, but they can certainly apply and even be approved.
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.