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.
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.
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.