Filing Form 33 starts the formal process for resolving the dispute. Depending on the case and whether you are represented, the process may include mediation and a hearing before a Deputy Commissioner.

First, Identify What the Insurer Denied

Before taking action, determine whether the insurer denied the entire workers’ compensation claim or only a particular benefit.

A Form 61 generally means the employer or carrier is denying responsibility for the claim or denying liability after making payments without prejudice. Other disputes may concern a specific medical treatment, wage benefits, a request to change physicians, or an attempt to terminate benefits that were already being paid.

The notice or form you received should help identify the disputed issue. That distinction matters because the appropriate filing and procedure may be different.

Common Reasons Your Workers’ Comp Claim Might Be Denied

When an insurance company denies a claim, they must provide a reason. While every case is different, many denials stem from a few common issues.

Here are some typical reasons an insurance carrier may give for not paying:

• Missed Deadlines: In both North Carolina and South Carolina, there are strict deadlines for reporting an injury to your employer and for filing a claim with the state. Missing one of these deadlines is a very common reason for an initial denial.
• Dispute Over Work-Relatedness: The insurance company might argue that your injury did not happen at work or was not related to your job duties. This can happen with injuries that develop over time, like carpal tunnel syndrome, or if the accident was not witnessed.
• Pre-Existing Condition: The insurer could claim that a pre-existing injury or medical condition is the true cause of your current pain, not the workplace incident. For example, they might point to a previous back injury to deny a new claim for back pain after a fall at work.
• Inconsistent Information: If the details you gave your doctor differ from what you told your employer or what was in the official accident report, the insurance company could use that inconsistency to question the validity of your claim.
• Failure to Use an Authorized Doctor: In most cases, your employer or their insurance carrier directs your medical care. If you seek treatment from your own doctor without approval, they might refuse to pay for it.

These are just a few examples, and sometimes the reason given can feel unfair or simply incorrect. This is often the point where an injured worker decides to seek legal guidance to help protect their rights.

Your First Steps After a Denial

Receiving a denial can be upsetting, but how you respond can make a significant difference. Act promptly and keep track of any deadlines that apply to your original claim, hearing request, or further appeal. The applicable deadline depends on the stage of the case and the action being taken.

First, remember that a denial is a roadblock, not necessarily a final judgment. Second, start getting organized. Here are the immediate steps I recommend people to consider when their workers’ comp claim is denied.

1. Carefully read the denial notice: Identify every reason the insurer gives for denying the claim. In North Carolina, the employer or carrier generally uses Form 61 or an attached denial letter and must provide a detailed explanation of the grounds for denial. Determine whether the dispute concerns notice, filing deadlines, employment status, whether the injury was work-related, medical causation, or another issue.
2. Gather the records related to the denial: Save the Form 61 or denial letter, Form 18, accident report, written notice to your employer, medical records, work restrictions, wage records, correspondence with the adjuster, and notes about relevant conversations. Prioritize records that directly address the reason stated in the denial.
3. Preserve any evidence: If there were witnesses, write down their names and contact information. If you have photos of the accident scene or your injury, make sure they are saved in a safe place.
4. Take the formal step required to dispute the denial: Speaking with the adjuster may help clarify the insurer’s position, but it does not replace filing the appropriate form with the appropriate agency.In North Carolina, first confirm that the underlying claim was filed through Form 18. If the insurer denied the claim, Form 33 is generally used to ask the North Carolina Industrial Commission (NCIC) to assign the dispute for a hearing.
5. Consult a workers’ compensation attorney to help understand all of your options and make the right decision for you.

Building Evidence to Contest the Denial

Once you have filed your formal dispute, the next phase involves building a compelling case to counter the insurance company’s denial. They have their reasons for saying no, and your job is to present evidence to prove them wrong. This is where attention to detail becomes essential.

Contesting a denial requires evidence that addresses the insurer’s stated reasons. Depending on the dispute, that may include medical opinions connecting the condition to the job, proof that notice and filing requirements were met, witness statements, employment records, or evidence addressing an alleged pre-existing condition.

Collecting and Examining Evidence

The foundation of any strong appeal is the evidence you can present. The insurance company likely has adjusters and attorneys whose job is to scrutinize every detail to protect their bottom line. An experienced workers’ compensation attorney can identify the legal and factual issues behind the denial, obtain relevant evidence, manage required filings, and represent the injured worker during mediation or a hearing.

Our help for clients includes collecting the following, as needed:

• Your Complete Medical History: We gather not just the records from your work injury, but sometimes records of past treatments to try to show that a pre-existing condition was stable or asymptomatic before the workplace accident.
• Witness Statements: Statements from coworkers who saw the accident or know about the hazardous conditions that led to it can be very persuasive.
• Expert Opinions: As needed, we work with vocational experts who can testify about your inability to return to your previous job or other experts who can reconstruct an accident scene.

This evidence can help create a full picture of what happened and demonstrate the true extent of your injuries and their impact on your ability to work.

The Importance of Medical Opinions

Often, a workers’ compensation case comes down to a battle of medical opinions. The insurance company’s doctor might say you are ready to return to work, while your own body may be telling you that you are still in pain. Your treating physician’s opinion is incredibly important.

To build the medical side of your case, we may:

• Request a Second Medical Opinion: If you disagree with the diagnosis or treatment plan of the company-approved doctor, you have the right to request a second opinion. In North Carolina, you can petition the Industrial Commission for a change of physician.
• Depose Your Doctor: A deposition is sworn testimony given outside of court. We can depose your doctor to get their formal, detailed medical opinion on the record regarding the cause of your injury, your physical limitations, and your prognosis for recovery.
• Obtain a Functional Capacity Evaluation (FCE): This is a comprehensive set of tests that can provide objective data about your physical abilities and limitations, which can be compelling evidence that supports your claim for ongoing disability benefits.

Strong medical evidence is often vital to trying to overturn a denial and getting the insurance company to approve necessary treatments and pay for your lost time from work.

How a Denied Workers’ Comp Dispute May Proceed

The appeals process follows a structured path designed to resolve disputes. While the specifics vary, both North Carolina and South Carolina have multi-stage processes. After you file your initial appeal form, the case does not usually go straight to a courtroom.

After a hearing request is filed, the case may proceed to mediation before a formal hearing. In North Carolina, represented cases are commonly ordered to a mediated settlement conference. When the injured worker is not represented, the Industrial Commission generally dispenses with mediation unless the worker requests it. A mediator does not decide the case but helps the parties explore whether they can resolve the dispute.

If mediation is unsuccessful, your case can be scheduled for a formal hearing.

In North Carolina, a Deputy Commissioner of the Industrial Commission hears the disputed claim. The parties may present testimony, documents, medical evidence, and other relevant evidence. The Deputy Commissioner then issues a written Opinion and Award.

After the initial hearing, either party may have the right to seek further review. In North Carolina, a party that disagrees with the Deputy Commissioner’s Opinion and Award may appeal to the Full Commission. Further review may be available through the North Carolina appellate courts. Each stage has separate filing requirements and deadlines.

What Our Attorneys May Review After a Workers’ Comp Denial

When reviewing a denied claim, we may examine:

• The Form 61 or denial letter
• Whether the Form 18 was properly filed
• When and how the injury was reported
• Medical records and work restrictions
• The reason the insurer says the injury is not compensable
• Prior medical records relevant to an alleged pre-existing condition
• Wage and employment records
• Communications with the employer or insurance adjuster
• Applicable filing and hearing deadlines
• Whether a specific treatment or benefit was denied rather than the entire claim

The documents and legal issues involved will depend on the reason for denial and the stage of the claim.

How an Attorney Helps You When Workers’ Comp Won’t Pay

When you are injured and out of work, the last thing you likely want is to face a large insurance company by yourself. Their adjusters and attorneys handle these disputes every day. An experienced workers’ compensation attorney can level the playing field and handle the legal process on your behalf, allowing you to focus on your recovery.

A lawyer’s role goes far beyond just filing paperwork. We become your advocate and your guide.

Here is what an attorney can do to help:

• Manage All Communications: We communicate with the insurance company so you don’t have to deal with adjusters – some may be pressuring you to accept a low offer or return to work before you feel ready.
• Build and Manage Your Case: We handle the evidence gathering, from requesting medical records to deposing doctors and witnesses if needed. We know what it takes to build a compelling case and how to counter the insurance company’s arguments.
• Meet All Deadlines: The workers’ compensation system is full of deadlines that can make or break a case. We manage the calendar to make sure forms are filed correctly and on time.
• Negotiate on Your Behalf: We seek the maximum compensation possible in your case. This includes seeking full payment of medical bills, replacement of any lost wages, and the highest possible lump sum settlement when appropriate.
• Represent You at Hearings: If your case cannot be settled, we can present your case before a Commissioner, arguing the facts and applying the law to seek a favorable decision.

The Law Offices of James Scott Farrin has more than 60 attorneys and over 200 staff. Many of Farrin’s workers’ compensation attorneys are North Carolina State Bar Board Certified Specialists in Workers’ Compensation Law. The team also includes attorneys with prior North Carolina Industrial Commission and insurance-defense experience.

FAQs for What to Do if My NC Workers’ Comp Claim is Denied

Here are answers to some common questions we hear from people dealing with a denied workers’ compensation claim.