Workers’ compensation insurance is a benefit provided to nearly all North Carolina employees under the North Carolina Workers’ Compensation Act. Most employers are required to carry insurance to cover medical expenses and replace a portion of lost wages for work-related injuries and illnesses.
The law is intended to ensure that any worker injured on the job has access to medical care and financial support to help them pay bills while they are out of work recuperating. But there are situations in which insurance companies deny valid claims. If this has happened to you, you are probably worried about what happens to medical bills when workers’ comp is denied and what options you have.
Does Workers’ Comp Cover All Medical Bills?
Your employer’s workers comp policy covers all reasonable and necessary workers’ comp medical bills related to your work-related injury for medical treatment authorized by workers; comp. This can include paying for:
- An ambulance ride or ER visit
- Rehabilitative treatment, like physical or occupational therapy
- Specialist visits, like a pain management specialist
In an accepted claim to have your medical bills covered, workers’ comp has to authorize the medical treatment first. You should also follow all reasonable doctor’s recommendations. This includes attending all follow-up appointments, wearing a brace or using other medical devices as directed, and avoiding certain activities. Failing to adhere to the doctor’s orders can jeopardize your claim or give your employer grounds to discontinue benefits.
The Reason Why Your Claim Could Get Denied
The North Carolina Workers’ Compensation Act details certain situations in which an employer or its workers’ comp insurance administrator can deny a claim:
- You were under the influence of drugs or alcohol when the accident happened and it was a causal factor in the accident ( 97-12)
- You made a false representation about your physical condition during the hiring process ( 97-12.1)
- You were not performing job duties at the time of the accident (such as commuting to work or being clocked out on a meal break)
- You didn’t report the injury within the required period of time
- Your injury was unrelated to your work duties
If you believe that none of these situations applies to you, but your claim was still denied, then you may have legal options to contest the denial. An experienced NC workers comp lawyer can explain what recourse you have under North Carolina workers’ comp law.
What To Do If Your Claim Is Denied
If your employer doesn’t approve your workers’ comp claim, what happens to medical bills when workers’ comp is denied?
The medical bills are your responsibility. Your health insurance may cover the cost of treatment until you and your attorney can pursue a better resolution with your employer’s workers’ comp carrier. Depending on your health insurance plan, you could still owe co-pays and co-insurance for your treatment.
If you are having trouble getting your work-related accident medical bills paid by the insurer, seek the help of a workers’ compensation lawyer. You should discuss the situation with an attorney before accepting “denied” as the last word on your claim. North Carolina does have an appeals process for denied workers’ compensation claims. The easiest way to handle the situation is to let your attorney communicate with the healthcare provider.
You and your attorney will likely want to file a request for a hearing with the North Carolina Industrial Commission.
What Options Do You Have if Workers’ Comp Denies Your Claim?
If your workers’ comp claim is denied, your first option is to file a hearing request with the North Carolina Industrial Commission by submitting a Request That Claim Be Assigned for Hearing. An attorney can file this form on your behalf.
The request for a hearing requires the following information:
- How you were injured, specifically, and how the accident happened
- The reason your claim was denied
- The benefits you are eligible to receive
You have space to list witnesses who can testify about the accident. You will have an opportunity to present your case.
Before your hearing, though, you are required to attend mediation to try to resolve the issue in dispute. Mediation is a structured negotiation between the injured worker and the employer’s insurance administrator. During the process, a trained mediator tries to help the two sides reach a compromise. You may be able to settle your appeal through mediation. If not, you will have an opportunity to present your case at the hearing.
You are not required by law to have a North Carolina workers’ compensation lawyer represent you in the hearing or in mediation. However, there are many benefits to working with an attorney who understands N.C. workers comp law and has experience handling appeals.
Depending on your case, your lawyer may be able to:
- Submit a request that your claim be assigned for hearing. These forms can be confusing for many people. A lawyer who is familiar with the forms and how the answers should be phrased can complete the form, include all relevant information, ensure its accuracy, and submit it.
- Represent you in mediation. This can be an intimidating experience for many people. An attorney’s professional representation and guidance can help you remain calm and focused on your best interests during mediation.
- Communicate with the other parties on your behalf. You can refer any phone calls, emails, or letters from your employer or insurance company to your lawyer.
- Argue your claim before the Industrial Commission. Your attorney can craft a solid argument using evidence and witness testimony and present it before the Commission.
Get in Touch with Our Workers’ Compensation Lawyers in Raleigh
Do you need help getting your workers’ compensation benefits approved? Are you struggling with medical bills after a denied workers’ compensation claim? Let us review your situation and discuss how we can help. Contact Younce, Vtipil, Baznik, & Banks, P.A., today at 919-661-9000 for a free consultation with an experienced Raleigh workers’ compensation lawyer.