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Charles’ Story Pt. 3: Benefits, Return to Work, and Life After the Injury

When a worker is injured on the job, Workers’ Compensation is supposed to kick in and replace the earnings he or she is missing due to the injury. But how much does Workers’ Comp cover? How long do the benefits last? An experienced Workers’ Comp attorney can help answer these questions.

For now, we return to the story of Charles, our fictional example worker who was hurt on the job in North Carolina. If you have not, you may wish to read part one and part two of this series to get up to speed.

Wage Replacement Benefits of Workers’ Compensation in North Carolina

Whether they’re living alone or providing for their families, workers depend on their earnings to stay afloat. The bills keep coming in even if the paychecks do not. So how much can an injured worker get, and for how long?

The answer is, it depends. How much an employee gets to replace wages depends on a few factors, and is governed by North Carolina General Statute 97-2(5).

How Much Did the Worker Make Before the Injury and How Much of His or Her Wages Are Replaced by Workers’ Comp?

This seems simple, but it’s deceptive. How much Charles gets when he is unable to work depends on how much he earned in an average week before he got hurt. This is called the Average Weekly Wage (AWW). To start with, there are four ways to calculate AWW:

  • If Charles worked for his employer for more than a year before getting hurt, his earnings over the last year are divided by 52 weeks. This excludes any period of seven or more days that the workers was not earning. Ex: $52,000 / 52 weeks = $1,000 per week. In this example, Charles’ AWW is $1,000.
  • If Charles worked for his employer for less than a year, his earnings during that time are divided by the number of weeks worked. So if a worker has been employed for six months, the earnings are divided by 26.
  • If Charles had worked for his employer for less than three months, and the period of work is too short to provide a fair amount, then the earnings of a similar worker can be substituted. So, the wages of a worker performing similar duties at a similar skill level in the same location could be used to determine his average weekly wage.
  • In case where none of these methods would produce a fair result, other methods can be used to try to approximate how much Charles would be earning if he had not gotten injured.

The numbers are based off the gross, or pre-tax, wages of the worker. It counts as income things like bonuses, overtime, stipends, per diem, and allowances in addition to wage, such as those for housing or fuel. Whatever all of those sums add up to is the gross income. That number is then divided as necessary to provide the Average Weekly Wage.

Average Weekly Wage is important because in North Carolina, the Workers’ Compensation wage replacement benefit is set at two-thirds of that AWW, up to a maximum amount set by the North Carolina Industrial Commission each year. This two-thirds is called the Compensation Rate.  For 2020, the maximum compensation rate was set at $1,066.

So, if Charles was earning $52,000 a year, divided by 52 weeks, his AWW would be $1,000, and his Compensation Rate would be two-thirds of that, or $666.66.  Therefore, he would be entitled to receive a check for $666.66 from the insurance company every week that his authorized doctor said he was unable to work because of his injury.  No taxes are taken out of these checks.

How Long can a Worker Receive Wage Replacement Benefits?

Injured workers, like Charles, can get weekly checks at their Compensation Rate, as long as their authorized doctors says they are completely unable to work, up to a maximum of 500 weeks. This is called Temporary Total Disability or TTD.

If an injured worker, like Charles, is capable of doing some work, but cannot earn as much as he earned before he got hurt, he can receive partial payments from the insurance company.  These checks will be two-thirds of the difference between what Charles earned before his injury and what he earns after his injury.  This is called Temporary Partial Disability or TPD.

  • For example, Charles’ doctor says he can only work 20 hours a week. Charles goes back to work, but instead of earning $1,000 a week, he is only earning $500.00 a week.  He would be entitled to get two-thirds of the difference from the insurance company.  $1,000.00 – $500.00 = $500.00 ÷ 2/3 = $333.33.

Some insurance companies may "turn off" payments. Know how the system works and how to protect yourself.

A Word on Permanent Partial Disability (PPD)

This part of Workers’ Compensation law can be very confusing, so it is important to understand that each worker’s situation is unique, and the most beneficial course of action may be different from case to case. Here is a barebones explanation.

Payment for a Permanent Partial Disability is calculated by looking at North Carolina General Statute 97-31 and figuring out how many weeks of benefits the injury is worth. For example, a 100% injury to the knee is worth 200 weeks of benefits at the employee’s compensation rate. If an employee was given a disability rating of 10%, it would be worth 20 weeks of benefits.  In this case, he would be entitled to receive a payment of 20 weeks at his compensation rate.

a partial permanent disability may worsen over time

The Benefits and Battling to Keep Them

It happens all the time. A worker is receiving treatment and wage replacement benefits and, after a period of time, the insurance company stops paying them, or pushes the worker to return to the job. Again, this is all part of doing business and insurance companies are businesses. Paying less in benefits equals more profit.

However, injured workers should never be rushed back to work. This only increases their risk of getting reinjured and poses a risk to those around them.

There are only two reasons an insurance company is technically allowed to cancel Charles’ benefits – if he returns to work or if they get permission from the NCIC. Lots of battles arise when the authorized doctor says the injured worker is ready to go back to work full duty, but the injured worker disagrees.

In this situation, the insurance company will file an application with the Industrial Commission for permission to terminate the worker’s benefits.  The worker, or more likely the worker’s attorney, will fight back by seeking a second opinion with another doctor.  If that doctor believes that the injured worker is NOT able to return to full duty work, the worker’s attorney can submit that doctor’s opinion to the Industrial Commission to try to protect the worker’s benefits.

Returning to Work

We’ve followed Charles from the beginning. Now his saga is coming to an end. After six months of treatment, he’s feeling better. Not quite 100%, as he still has very little strength in his hurt shoulder due to not being able to use it. His back, however, is feeling a lot better and improving every day, for which he feels fortunate.

workers' comp law has intricacies on when a worker can return to work after an injury

Charles’ doctor finally clears him to return to work, but not at his full pre-injury level. His shoulder is not yet ready for that. So the doctor recommends a trial return to work. This is basically a time when Charles goes back to work to see what he’s capable of doing. Medical benefits are still in force, but the wage replacement may be suspended depending on how much he is earning. (See TPD explanation, above).

There are a number of things that can happen at this point, and handling them can be complicated:

  • Charles can accomplish the modified or reduced tasks that his employer assigns him until he’s fully capable again of returning to his pre-injury job.
  • Charles has difficulty performing the modified or reduced tasks provided by his employer. He needs to return to the authorized doctor and see about getting more appropriate restrictions.
  • Charles reinjures his back while performing the modified or reduced tasks. Again, he should return to his physician, be restricted from all work until his condition improves, and have his wage loss benefits reinstated.
  • Charles continues working at the modified job until his doctor says he has completed his treatment. Unfortunately, his doctor says he is not able to physically handle his original pre-injury job. It may be time for Charles to . Alternatively, instead of settling, the insurance company may decide to try to locate a new job for Charles at a different company.

Vocational Rehabilitation for Injured Workers

If a worker is injured and cannot return to his or her former job, the insurance company may choose to provide vocational rehabilitation. This training can include:

  • transferable skills analysis and testing
  • resume, interviewing and job application services
  • job search assistance
  • retraining/education
  • other services deemed appropriate

The End of Charles’ Story of Workers’ Compensation in North Carolina

Our friend Charles has been through a lot. From a hurt back and shoulder through the workers’ comp process, he’s been faced with many challenges. Everyone likes a happy ending, so Charles is able to return to work and makes a full recovery. Many, many workers in North Carolina are not so lucky.

In fact, many find themselves at the mercy of a system that they do not fully understand. In many of the examples of the process with and without an attorney in parts one and two of this series, the main takeaway may appear to be convenience. The truth is far deeper. A worker can, if he or she is so inclined, read everything possible on workers’ comp law in North Carolina and still miss something small that leads to big problems.

Charles was an example, and it is easy to minimize the differences when you’re not actually injured and in the system. Having an advocate with experience working in the system, battling insurance companies, and looking out for your best interests is a huge advantage in terms of both time and stress. While no result is guaranteed, who has a better chance of successfully navigating the workers’ comp system: an attorney who is dedicated solely to the practice of workers’ compensation law, or a worker who is in pain and finding his or her way through the system for the first time?

If You Were Hurt at Work, Contact an Experienced, Dedicated Workers’ Compensation Attorney

It’s not just a case, it’s your livelihood. From medical coverage to the money to pay bills, you need help as soon as possible. There are many great workers’ advocates in North Carolina. To speak with one of ours, just call 1-866-900-7078. You’ll hear a friendly voice, and get a free case evaluation, with no obligation. You can also chat with us, or contact us online. Whatever is easiest. Don’t sit and suffer. Tell them you mean business.

Charles’ Story Pt. 2: Filing for a Hearing, Medical Treatment and What to Watch For

Workers’ Compensation claims in North Carolina are a matter of process. The process for Charles, our fictional injured worker, has just begun. As we proceed, we’ll show how the process differs with and without an experienced Workers’ Compensation attorney, and in this installment, how medical treatment works under NC Workers’ Compensation law.

In part one, Charles filed for Workers’ Compensation and received a Form 61 – the insurance company has denied his claim. Now what?

Requesting a Hearing After a Workers’ Compensation Claim is Denied

Charles’ claim being denied should not come as a surprise. Insurance companies make money by limiting their payouts – that’s simply the nature of the business. Denying claims may make workers who are mildly injured simply give up. Charles, however, has serious upper and lower back pain and left shoulder pain as well. He’s not going to give up.

Charles is a construction worker in NC, hourly workers, same company for 5 years, received a raise 6 months ago

Knowing that the bills for his treatments are going to pile up, Charles decides to press forward on his claim. To do that, Charles must file a Form 33 Request for Hearing with the North Carolina Industrial Commission. This is Step 5 of the claim process. For information on Steps 1-4, please refer to part one of this series.

Preparing for a Hearing

To read the NCIC’s own information on preparing for a hearing, you can read this document. It can seem overwhelming to anyone who isn’t an attorney, and even to attorneys who do not focus their practice in Workers’ Compensation. A general practice or family law attorney may miss some of the nuances of the Workers’ Comp processes, which is why it is preferable to enlist the services of an attorney with experience, There are a lot of great Workers’ Comp attorneys. Hopefully, you’ll consider ours. You can call 866-900-7078 for a free case evaluation or contact us online.

File form 33 with the NCIC, go to settlement conference, NCIC hears claim, get treatment

STEP 5: File Form 33 with the North Carolina Industrial Commission (NCIC).
IF FILING WITHOUT AN ATTORNEY, Charles must file Form 33 with the NCIC. At a glance, it seems like a restatement of a lot of the information from Form 18. Some is, but there are other important aspects that Charles may not know how to handle, including the length of the hearing and the written reason he and the insurance company disagree.

IF FILING WITH AN ATTORNEY, Charles would simply review this document, as the attorney would be the one completing it and submitting it. An experienced attorney will know how to complete this form effectively, and word it properly for the desired result. The attorney will also know what compensation and benefits to ask for and how to push for the maximum compensation.

It’s important to know that filing for a hearing isn’t “suing the employer.” This not a civil lawsuit, but a request to the NCIC to hear the claim and decide whether or not the employer and insurance company should be responsible for providing Workers’ Compensation benefits.

Required Mediation, the NCIC Hearing, and Beyond

Before a worker like Charles ever gets to plead his claim before the North Carolina Industrial Commission, the Commission will probably order the insurance company and the worker to sit down and try to work out their differences through mediation.

STEP 6: Go to the NCIC-ordered mediated settlement conference.
WITHOUT AN ATTORNEY, when an injured worker is not represented by an attorney, the case usually bypasses mediation. This is unfortunate because mediations are the best opportunity that an injured worker may have to resolve their issues quickly without having to go through the lengthy and frustrating hearing process.  If Charles had an attorney, he would have a chance to negotiate a reasonable settlement and would have more control over the outcome of his case than he would have by just letting a hearing officer decide what he deserves.

WITH AN ATTORNEY, Charles has a seasoned, knowledgeable, and experienced advocate to help him prepare for mediation.  His attorney will correspond with the insurance company in advance, setting out the strengths of Charles’ case and making an appropriate settlement demand.  At the mediation, Charles will have his attorney with him the entire time. The longer the attorney has had his case, the more firepower he or she can probably bring to bear on his behalf. An experienced attorney will know the strengths of Charles’ case, be able to argue effectively for the best outcome possible, and explain the details and consequences of any settlement he’s offered. Charles will understand his options and his attorney will help him make the decision that is best for Charles.

Cases are often settled at mediation, but not always. It’s simply something the NCIC requires before they take their time to hear the claim.  For our example, we’ll say that Charles and the insurance company can’t agree, and the claim pushes forward to the hearing.

STEP 7: The NCIC hears the worker’s claim.
WITHOUT AN ATTORNEY, Charles will be answering the Commissions questions without any idea what to expect. He’s gotten this far on his own, and it hasn’t been easy. By now, he might wonder if he will ever get relief. If the NCIC rules against him, he will have very few options left.

WITH AN ATTORNEY coaching him and setting his expectations, Charles will likely be more comfortable in front of the Commission. The questions will likely be the same, but he will at least know what to expect and have time to consider his answers before the hearing. It’s still stressful, but not as much.

If the hearing officer, who is a Deputy Commissioner, denies Charles’ claim, he can appeal to a panel of three Commissioners.  If the worker is denied coverage at this level, the only avenue remaining is to appeal the decision to the North Carolina Court of Appeals, and then the North Carolina Supreme Court – at which juncture a lawyer is highly advised and perhaps too late! Fortunately for Charles, the NCIC rules in his favor, and the insurance company does not appeal.

Medical Treatment and Workers’ Compensation

Workers’ Compensation laws are focused on getting workers healthy enough to return to work. The law provides that the insurance company should pay for treatment that will enable a worker to get better and get back to work, including:

  • Medical Treatment: The services of a doctor or specialists to diagnose and treat the injuries
  • Hospital Care: Whether it’s day-of-injury or part of recovery for a surgery or medical treatment
    – Surgical Procedures: Getting the procedures necessary to treat the worker’s injuries
    – Nursing Care: If the worker requires the support of a nurse, or simply receives such care at a facility
  • Medicines: Anything the worker needs to take, including prescription medications, while recovering
  • Sick Travel: Reimbursement for any travel to authorized medical providers or pharmacies more than 10 miles away
  • Rehabilitative services, such as:

– Attendant care services for at-home care or physical therapy

– Vocational rehabilitation to find another job; the insurance company may pay for retraining or for a specialist to help a worker retrain

  • Other treatment: A catch-all category

KEEP IN MIND:  If the insurance company is paying for treatment, the insurance company gets to select the doctors.  It will be up to the doctor’s chosen by the insurance company, and not Charles, or his personal doctors, to decide what treatment Charles needs.

The Insurance Company Chooses the Care Provider

In North Carolina, the workers’ compensation insurer chooses the care provider for the injured worker. They’re paying for the care, and they choose who provides it.

Remember that insurance companies are in business to make money. It stands to reason that, given the choice between care providers who claim to be able to accomplish the same treatments or results, they’re going to choose the least expensive option. They’ll also look at which option claims it can get the worker back to work the quickest, which saves them money in the long run.

Even if Charles’ doctor recommends a course of care, specific treatment, or recovery period for his injuries, the insurance company is not obligated to authorize it. The truth is, even when workers like Charles win benefits, the fight is only beginning. They often find themselves fighting for treatments and second opinions as well.

STEP 7: Getting optimal medical treatment.

WITHOUT AN ATTORNEY, Charles is not happy with the treatment he is getting from the doctor that the insurance company sends him to see.  The doctor says he just needs some physical therapy and some muscle relaxants and he should be able to return to work in a month or so.  Charles does the physical therapy and the doctor releases him to return to full duty work.  Charles is frustrated because he is still in the same amount of pain that he had in the beginning.  He knows something is wrong, but he doesn’t know what to do.

It’s important to note that even if the doctor recommended by the insurance company recommends more helpful treatment, the insurance company may still refuse to pay for it.

WITH AN ATTORNEY handling the claim for him, Charles will have more options.

If the insurance company refuses to pay for treatments recommended by the doctor they authorized, the attorney will know how to fight for the treatment.  And when the authorized doctor releases Charles from treatment before Charles feels he is ready, his attorney will know how to go about trying to get a second opinion for him with another doctor, who hopefully will be more helpful in recommending necessary and appropriate treatment.

It’s also important to note that the insurance company may deny suggested treatments even if those suggestions are from a doctor of their choosing!

In the Next Installment…

Charles finally gets the medical treatment he needs. We’ve covered the medical portion above, and even that’s not entirely complete. We just want to give you a feel for how the process can work – and how much work is involved.

In the next installment, we’ll take a look at the payments that Charles receives when he is unable to work because of his injury, how they’re calculated, what insurance companies may do to limit their payout, as well as Charles’ return to work and life after the injury.

If You Were Injured on the Job and Would Like to Know Your Options, Contact Us

Why go it alone? Being hurt on the job is a life-changing event and can be a source of immense stress. How will the bills get paid? What will you do if you can’t work? How can you get treatment? Call our experienced North Carolina Workers’ Compensation attorneys at 1-866-900-7078, or contact us online for a free case evaluation.


The Case of Charles Part 1: Hurt at Work and the Journey of a NC Workers’ Comp Claim

Hurt at work? Most North Carolina workers have no idea how the Workers’ Compensation system functions. Once they’ve suffered an injury, they’re at the mercy of a process they do not understand. So how does it work? What happens next?

To help you understand what goes into a Workers’ Comp claim, how they’re processed, and how an experienced Workers’ Compensation attorney can improve your claim and outcome, let’s explore the example of Charles.

Introducing Charles: a Fictional Worker Who Gets Injured on the Job

We’re going to show you how the system works with the help of a fictional character, we’ve named Charles.

Charles lives in and works construction in North Carolina. He’s worked for the same company for about five years, and the company employs more than forty workers like him. He’s an hourly employee, who received a raise about six months ago. He was doing well until he was injured. Now he has a Workers’ Comp claim. This is his story.

Charles is a construction worker in NC, hourly worker, same company for 5 years, raise 6 months ago

The Day of an On-the-Job Injury

We’re not going to describe the accident in which Charles was hurt, but it’s important to know that there are three primary ways a person can become eligible for Workers’ Comp in North Carolina.

  • Injury By Accident:The interruption of the regular work routine due to an unusual circumstance. Examples include an employee’s foot is run over by a forklift while she works in a warehouse, or an employee hurts his shoulder after falling off a ladder while doing construction work. In general, the injury cannot occur while the employee is performing a task the same way as always (e.g., he is bending down to lift a box when his knee pops).  Something out of the ordinary has to happen. NOTE: If an employee says he was doing his job in the normal way when the injury happened, the insurance company will deny it.
  • Specific Traumatic Injury (Back/neck injuries only):The law says you don’t have to have an injury by accident to have a compensable back or neck injury.  All you need for neck or back injuries is to be able to point to a specific time period when your back or neck began to hurt.
  • Occupational Disease: The NC Workers’ Compensation Act provides a list of all the diseases which are considered occupational at C. Gen. Stat. § 97-53. Conditions specifically listed in include asbestosis, lead poisoning, carbon monoxide poisoning, silicosis, and chemical exposure.
  • Other conditions, which are not listed, can be considered compensable as occupational diseases if the employment was a significant factor in the disease’s development and the employment exposed the worker to a greater risk of contracting the disease than the public generally. An example is a factory worker who develops carpel tunnel syndrome from repetitive motion.

Charles’ injury was a workplace accident, not a specific trauma, or an occupational disease. Find more information on occupational diseases.

Inform supervisor verbally and in writing, seek treatment, file form 18, wait for response

The Claim Begins – the Process (With vs Without an Attorney)

Everything starts the moment Charles is injured. Clocks begin to tick. Generally, the injured worker should immediately notify his supervisor. The only exception is if the injury is so severe that emergency medical treatment must be sought first. Charles’ injury did not require immediate emergency care, but he was unable to continue working. Here are the steps Charles must follow:

STEP 1: Immediately inform the supervisor, employer, or owner of the company of the injury, first verbally and then in writing, as appropriate.
As soon as practical after the accident, and within thirty days, Charles should give written notice to his employer. A simple written statement giving the date of the accident and a brief description of the injury is all that is necessary.

Charles told his supervisor he was hurt right after it happened.  The next day he submitted written notice, though if he had been unable, a family member could have done it for him. It’s a good idea keep a copy of this document, and a record of when and where it was delivered to the supervisor. Simply snapping a photo with a smartphone is a good idea if this is done on-site immediately. Electronic notification is also acceptable, as emails can be sent with a “read receipt” to prove the other party has read the message.

Note that some employers may have an on-site care provider, and the employer may instruct workers to report to a designated health care office in case of work related injuries. If appropriate to the seriousness of the injury, workers should report to that facility. If there is no employer on-site or designated off-site health care provider, workers should seek medical care appropriate to their medical needs.

STEP 2: Seek treatment for the injury.
It is vital that injured workers seek care as soon as they’re able. This is obvious for serious trauma, but any injury that doesn’t require emergency care still requires care for two reasons.

  • One, treatment can help relieve pain and suffering, and is the first step to possible recovery.
  • Two, the employer and insurance company have no reason to compensate a worker who does not seek care or treatment for an injury.

Unless the injury requires emergency treatment, the employee should wait for the employer and insurance company to tell him/her where to go for treatment.  An employee who feels he/she needs treatment before it is authorized should be aware that they may end up being responsible for paying those bills out of pocket.  Insurance companies generally will not pay for medical treatment unless they chose the provider.

However, if the insurance company ends up denying responsibility for the claim, then the injured worker is free to get all the treatment they want from any provider they want.  Again, they will be responsible for paying the bills until or unless the insurance company changes its mind or is ordered to pay for the treatment later on by the NCIC.

For more on how medical care works, you’ll want to read part two .

Charles heads to his doctor the following morning after getting almost no sleep due to pain and discomfort. It is important that Charles tells his health care provider that his injury is related to his work and the name of his employer. This information allows the health care provider to bill treatment as a Workers’ Compensation claim.

STEP 3: File Form 18 within 30 days.
IF FILING WITHOUT AN ATTORNEY, Charles must file Form 18 with the North Carolina Industrial Commission (NCIC). Form 18 is also called Notice of Accident to Employer and Claim of Employee, Representative or Dependent for NC Workers’ Compensation Benefits. The form can be found on the North Carolina Industrial Commission website.

IF FILING WITH AN ATTORNEY, Charles would simply have his lawyer complete and file Form 18. If you look closely at the lower right part of the form, you’ll notice that the Commission has instructions on how lawyers are to file it. The information on this form is vital to the workers’ claim, obviously, but as you’ll learn, the information will likely be repeated.

About Form 18

Form 18 is just the beginning. Look at what it’s asking for. The contact information of the employee and employer are obvious. The next section talks about the injury itself. When and where did occur? What was hurt? How did it happen? There are very few lines offered to describe the injured body parts or how the injury occurred. In Charles’ case, let’s say that he hurt his back and his left shoulder.

Charles noted “upper and lower back, left shoulder” in the specific body parts field. In the following field, he must describe how the accident happened. What’s said here matters. “I was lifting a crate and my back went out,” is different from, “A crate slipped as I was carrying it and I was injured.” The idea here is to be truthful and complete. Don’t omit or incorrectly describe a detail that might get your claim denied.

Also note that the actual deadline to file a Form 18 is two years from the date of the injury. In practice, this is more a time period for those who develop occupational diseases, but it also helps those who suffer an injury that becomes worse over time. However, the sooner you file the Form 18, the more likely it is that the claim will be accepted. Late reporting is often why the insurance company will deny a claim that would otherwise be accepted.  Anyone who is hurt on the job should immediately seek benefits to continue to support his or her family and pay the bills.

In Charles’ case, his Form 18 is filed within a week of his injury. In practice, the Form should be filed as soon as possible, and a signed copied should be sent to the NCIC and Charles’ employer, with Charles keeping a signed copy for himself.

The Workers’ Comp Claims Process – Employer Response, and Charles Is Denied

STEP 4: Wait for a response to the claim.
Within 14 days of filing a claim, an injured worker should receive one of three forms in response to his or her claim, although in practice, these forms are VERY rarely sent within 14 days. All three are filed by the employer/insurance company.

  • Form 60, Employer’s Admission of Employee’s Right to Compensation
    This Form essentially accepts that the worker’s injury is real and compensable.
  • Form 61, Denial of NC Workers’ Compensation Claims
    This Form is the employer’s denial of the worker’s claim, and should explain why the claim was denied.
  • Form 63, Notice to Employee of Payment without Prejudice
    This Form is only a provisional acceptance of the worker’s claim that the insurance company can revoke at any time. The term “without prejudice” basically means that the filer of the Form reserves the right to deny the claim later on.

No matter which Form is filed, Charles’ journey isn’t over. Even if a Form 60 is filed, the employer can still cut off benefits in the future for various reasons. In Charles’ case, he receives a Form 61 stating that his employer has denied his claim. Now what?

There are no statistics for the percentage of claims that are initially denied in North Carolina. Many claims are denied, some for legitimate reasons and many without. Any claim, no matter how worthy, can be denied.

To Hire an Attorney or Not to Hire an Attorney

For many workers, the denial of a claim is the trigger to hire an attorney. An attorney can be a great help in explaining the process, setting expectations, and handling the communication, forms, and details. Many people tell us they wish they’d hired an attorney sooner. Having an attorney takes the burden of managing a claim off the worker and allows them to focus on healing.

Of course, handling your own claim seems simple at first. The forms are all available, after all. Any worker can read the steps he or she has to take, and for the most part, can do it themselves. Functionally, however, there are a few things worth noting before making this decision.

  • There are a number of deadlines for filing different forms and requests with the NCIC. Missing any of them can harm or totally destroy a claim.
  • Knowing what to send and what to say. It’s not uncommon for workers to describe their injuries poorly, or to falter in communicating with their employer. Talking to the insurance company is usually a bad move unless you know exactly what to say – and not to say. There are a lot of traps that the insurance company has set for you. If you say the wrong thing, your case can be denied.
  • Losing patience. The process of a Workers’ Comp claim can take many months, depending on the insurance company, employer, worker, and the NCIC. An experienced attorney knows how to navigate the process and where it can be accelerated.
  • Maximizing benefits. Injured workers often think, “It could have been worse.” And, of course, it could have. Minimizing the injury is also something that some workers do because they do not want to seem weak. An attorney takes the ego out of the equation, and knows how to pursue the maximum compensation a worker is owed, often negotiating better settlements than a worker could have on his or her own.
  • Having a support system. A legal team can help the injured worker understand and prepare for what to expect at each step of the way and thereby reduce a lot of stress and anxiety.

In the Next Installment…

This series is meant to walk people through the claims process of Workers’ Comp in North Carolina, so we’ll continue to cover the process step by step – one path with an attorney, and one path without. Every time it seems like the battle for benefits is over, it’s just another step.

The process of making a claim is really just the beginning. Getting medical coverage isn’t the end of the story either. We’ll cover that in part two!

If You Were Injured on the Job and Would Like to Know Your Options, Contact Us

Why go it alone? Being hurt on the job is a life-changing event and can be a source of immense stress. How will the bills get paid? What will you do if you can’t work? How can you get treatment? Call our experienced North Carolina Workers’ Compensation attorneys at 1-866-900-7078, or contact us online for a free case evaluation.

How Do Settlements Work in Workers’ Compensation Cases?

Settlements in workers’ compensation cases are very different than settlements in other kinds of personal injury matters. It is important to understand why.

Many people assume that when they get hurt at work, workers’ compensation insurance will reimburse them fairly for everything they have suffered and lost. Many people also assume that workers’ compensation will pay for all their medical treatment and pay their wages while they are unable to work.

This is partially, but not entirely, true.

The three kinds of workers' compensation benefits - medical treatment, wage loss & permanent impairment rating payment.

The 3 Kinds of Workers’ Compensation Benefits You Can Receive If You Are Injured at Work in North Carolina

The actual benefits that an injured worker gets through workers’ compensation are determined by state law. North Carolina workers’ compensation law says that there are three benefits you can receive if you are injured at work:

  1. Wage loss,
  2. Medical treatment, and
  3. Payment of a permanent impairment rating if your doctor gives you one at the end of your treatment

However, there are limitations on all these benefits. The law also says:

  • You are only entitled to get two-thirds of your normal wages while you are recovering from your injury and unable to work.
  • The workers’ compensation insurance company gets to select your doctors, not you.
  • The amount of your permanent impairment rating depends on how much money you make – if you earn less, your permanent impairment rating will be worth less than someone who earns more.

There is a lot that is unfair in the way North Carolina workers’ compensation law was written, which is why it’s important that you speak with an experienced workers’ comp attorney.

People are most shocked when they find out that workers’ compensation law does not include any settlement money for the pain and suffering they and their family go through. This is perhaps the most upsetting thing of all.

Maximum Medical Improvement or MMI

In most cases, settlement does not take place until the medical treatment is completed and the doctor releases you from treatment. This is called reaching maximum medical improvement, or MMI, for short.

At MMI, the doctor will decide:

  1. Whether you have any permanent impairments
  2. Whether you have any permanent physical restrictions
  3. The doctor may also address your risk of any additional necessary medical treatment in the future.

These are the things that determine how much your case is worth in settlement.

Settling a Workers’ Compensation Case

Your workers’ compensation attorney will analyze the factors the doctor provided to determine how much money they believe workers’ compensation should pay you to settle your case fairly.

If you have no physical restrictions and can return to your regular job, your settlement will be based on the value of your rating, but there will be no money offered for wage loss. You will be expected to return to your pre-injury job. In this situation, you will still be able to get additional medical treatment if you need it within a two year period from when the payment for your rating was issued.

On the other hand, if your physical restrictions prevent you from returning to your pre-injury job, your settlement will include money for future wage loss benefits and future medical treatment. You will generally be expected to resign from your job. In this situation, we will have to negotiate with the workers’ compensation insurance company because your settlement will be based on how long it takes you to find another job, what your earnings will be at the new job, and the cost of future medical treatment you might need for your work injury. Since neither side has a crystal ball, there is usually a lot of room to negotiate.

What Happens at a Workers’ Compensation Settlement Negotiation?

Settlement negotiations are usually done at a mediation, which is also known as a settlement conference. You will be expected to attend the mediation with your attorney. There will also be an attorney there representing your employer and their workers’ compensation insurance company. Both attorneys have to agree in advance on selecting a professional mediator to run the mediation. These professional mediators are attorneys who are very knowledgeable about NC workers’ compensation law, but they do not know anything about your case until the opening session. Mediations usually last about three to four hours and are held in one of our offices that is closest to where you live.

  • The first thing that happens at the mediation is called an opening conference. This is when all the parties meet together in one room. The mediator starts out by explaining the process and then asks your attorney to explain the facts of your case. It is not necessary for you to say anything during the opening conference.
  • After your attorney has told the mediator what is important about your case, the employer and insurance company attorney will have a chance to tell the mediator what their clients want the mediator to know about the case.
  • After the mediator understands the issues and the differences between how the attorneys see the case, the sides will separate into different rooms.
  • From then on, the mediator will move between the two rooms exchanging information, monetary offers, and counter offers.
  • The mediation will continue until the sides have reached an agreement to settle the case or the mediator decides that the sides are too far apart in their evaluations of how much the case is worth. In that situation, the mediator will close the mediation and call an impasse.

If the parties agree on a settlement amount and other terms, a document will be signed, which is a binding legal contract that a court would enforce if either side tried to back out later.

If the parties don’t agree on a settlement amount, there could be a hearing at the North Carolina Industrial Commission (NCIC) if either side has filed a hearing request. If no hearing request has been filed, the case will continue until such time as a settlement can be reached in the future.

Why Settle a Workers’ Compensation Case?

A large majority of workers’ compensation cases settle at mediation. Both sides generally prefer to have some measure of control over the outcome, which they don’t have if a NCIC hearing officer is the decision maker.

In addition, mediation is much faster than going to court. It can take almost a year to get a decision from the NCIC hearing officer, and the decision can be appealed by either side, which can add more years to the process.

Finally, the hearing officer at the Industrial Commission is not allowed to decide what a case is worth. The hearing officer can only make limited decisions, such as whether an injured worker is entitled to more treatment or to see a different doctor.

If you settle at mediation, you will generally receive your settlement within several months and you can move forward with your life on your own terms without the interference of the workers’ compensation system.

Contact a North Carolina Workers’ Compensation Lawyer

The workers’ compensation team at the Law Offices of James Scott Farrin includes nine North Carolina State Bar Board Certified Specialists in Workers’ Compensation Law. Our team of legal professionals is ready to serve you in your workers’ compensation matter. Please call 1-866-900-7078 today, or contact us here for a free, no-obligation case evaluation.

Social Security Disability Hearings – What You Can Expect

Social Security Disability hearings are an important part of the disability claim process. Although many claims make it to the hearing stage, it is important to know what happens before the hearing and why so many cases are scheduled for a hearing.

Disability examiner, administrative law judge, vocational expert are involved in SSD hearings

What Happens in Order to Get to a Hearing?

When you apply for disability, the Social Security Administration (SSA) will review your medical records, your work history and information about your background. After reviewing this evidence, the SSA will make an initial decision either approving or denying you for disability. Typically, the only cases that are approved immediately are for people who have extremely severe medical conditions like terminal illnesses.

Because the vast majority of people filing for disability have their claims denied initially, an appeal is necessary to have a chance of being approved for disability benefits. Once a claim has been denied at the Initial stage, you will need to appeal and request Reconsideration of your evidence. At the Reconsideration stage, the SSA will conduct the same review as was done in the Initial stage but the file will be reviewed by a different Disability Examiner.

The Disability Examiners have the same procedures for reviewing disability claims and therefore, people who are denied at the Initial stage are likely to be denied at the Reconsideration stage. Appeals after Reconsideration go to the Hearing stage.

What’s Different About a Hearing?

At this stage, the claim is no longer reviewed by Disability Examiners; your claim is presented to an Administrative Law Judge (ALJ).

Appealing to the ALJ Hearing stage is generally the best place to fully present your disability claim. Statistically, you are more likely to be successful at the hearing than at the Initial and Reconsideration stages. You are also more likely to be successful at the hearing than at the Appeals Council and Federal District court, the two appeals stages after the hearing. To try to have a successful hearing, you’ll need to know what to expect and how to best prepare for the hearing.

Preparing for a Hearing

Once your hearing is scheduled, you’ll want to make sure that all of your medical records have been submitted to the SSA. For the judge to have a clear picture of your medical conditions and how they limit you, the judge will need to have all of your evidence. If you would like to ensure that all records have been submitted and if you have any additional evidence, like witness statements or witnesses that would like to attend the hearing on your behalf, you should speak with your attorney to prepare for the hearing date. It is important to ensure that all evidence and statements are prepared because the hearing itself is informal and quick.

Not a Day in Court, an Hour in a Hearing Office

ALJ hearings are informal hearings and therefore, the hearing will not be a trial that occurs in a courtroom. Once you receive your Notice of Hearing from the SSA, you will notice that the ALJ hearing occurs in the SSA’s Office of Hearing Operations (OHO). The SSA has numerous OHO locations and your hearing will be scheduled at the OHO nearest to your home.

The hearing occurs in a hearing room with you, your attorney, any witnesses you have, the judge, a Vocational Expert (VE), and a court reporter. The judge and VE may attend the hearing in person, by webcam or telephone. ALJ hearings typically take less than an hour.

What Happens During the Hearing?

The hearing starts with a swearing in and documentation of everyone participating in the hearing. The judge generally begins the hearing by reading a brief statement about your claim and then begins asking you about your background, your work history and your medical conditions and how they limit you.

Some judges ask the bulk of the questions and then ask your attorney to follow-up and some judges prefer that your attorney do most of the questioning and then the judge follows up. After testimony is complete, the judge will want to question the VE.

The Role of the Vocational Expert

The VE attends the hearing to give the judge their expert opinion on jobs available in the national economy and what jobs a person is capable of doing, despite limitations. The VE’s opinion is important because the judge’s decision will reflect the VE’s opinion of the work available and what type of a work a person with limitations similar to yours can do.

If your attorney deems it necessary, he or she may question the VE about their opinion. Remember, the goal of the hearing is to show the judge that the limitations you have prevent you from performing your past work and any other work. The VE is supposed to be an impartial witness who responds to hypothetical questions from the judge about what work can be performed by individuals with specific limitations.

The Decision, and More Waiting

Once the VE gives his or her opinion, the judge may ask you and your witnesses if you have anything else to say. At that point, you can tell the judge about any other ways in which your background, your medical conditions or your limitations stop you from working. However, do not be concerned if the judge doesn’t ask if you have something to add. The judge may have enough evidence through medical records, doctors’ statements, your testimony, and the VE’s testimony to render a decision.

After your hearing is complete, the judge will start working on making a decision in your claim. You will not get a decision on your case that day. Usually, you can expect to get a written decision from the ALJ within one to two months.

For more information on SSA Hearings, visit their website: https://www.ssa.gov/appeals/hearing_process.html.

Your Social Security Disability Claim May Be Denied – Don’t Go Through Hearing Stage Alone!

An experienced Social Security Disability attorney can help you prepare you and your case for your moment before the Administrative Law Judge. This is the stage where you’re most likely to be approved, so having an advisor and advocate on your side for the hearing makes sense. If you or someone you know is filing for SSD, or has filed and been denied, call the Law Offices of James Scott Farrin at 1-866-900-7078 for a free case evaluation, or simple contact us online.