Health Care

Injuries Accepted in a Workers Compensation Claim

megan July 5, 2021

Injuries Accepted in a North Carolina Workers Compensation Claim

When we get a call from someone asking for assistance with their case we commonly ask if their case is accepted. The general response is “yes they are paying for my treatment.” Unfortunately, this does not mean your case is accepted or that a certain body part is accepted.

Just because an Insurance Company is paying for your medical treatment and paying your weekly benefits doesn’t mean you have an accepted claim. Insurance companies want injured workers to believe this but it is not always accurate. Do not be tricked by the insurance company because they Tell you your case is accepted or they are paying for treatment. Two main statutes control this!!

N.C.G.S 97-24 states: “The right to compensation under this Article shall be forever barred unless (i) a claim or memorandum of agreement as provided in G.S. 97-82 is filed with the Commission or the employee is paid compensation as provided under this Article within two years after the accident or (ii) a claim or memorandum of agreement as provided in G.S. 97-82 is filed with the Commission within two years after the last payment of medical compensation when no other compensation has been paid and when the employer’s liability has not otherwise been established under this Article.” This requires us to look at 97-82 to see what is accepted.

NCGS 97-82(b) states: (b)….Payment pursuant to G.S.97-18(b), or payment pursuant to G.S.97-18(d) when compensability and liability are not contested prior to expiration of the period for payment without prejudice, shall constitute an award of the Commission on the question of compensability of and the insurer’s liability for the injury as reflected on a form prescribed by the Commission pursuant to G.S.97-18(b) or G.S.97-18(d) for which payment was made. An award of the Commission arising out of G.S.97-18(b) or G.S.97-18(d) shall not create a presumption that medical treatment for an injury or condition not identified in the form prescribed by the Commission pursuant to G.S.97-18(b) or G.S.97-18(d) is causally related to the compensable injury.

In Order to have an accepted claim an injured worker must have a Form 60 (G.S.97-18(b)) or a Form 63 section 1 (G.S.97-18(d)) once the 90 days has expired. Second, the body part or injury must be listed on the form. Not just one body part but all the body parts you need treatment on.

Insurance companies are attempting to get around injured worker accepted claims by not listing all the body parts or listing a very small body part/injury and later denying medical care if it becomes too expensive. This is dirty but is what we are seeing from Insurance companies in attempts to save them money.

Example: An injured work falls and hurts their back, head and both legs when a machine falls on them. The Injured worker files a Form 18 listing “back, head, both lower extremities.” The Insurance company files a Form 60 accepting the back. Despite this they pay for medical treatment for years on the both legs and knees. When a knee surgery is ordered they deny it and state it was not listed on the Form 60. Unfortunately, the insurance carrier will be allowed to force the injured worker to go to court to get the treatment they need.

If the Insurance company has told you your case is accepted and are denying you medical care, please contact us and speak with one of our board-certified workers compensation lawyers to discuss your claim. We can examine what forms are filed and help you determine if your claim is accepted.

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