My Claim Was Denied... Now What?

Workers’ compensation claims adjusters routinely send out claim denials when they receive a report of injury in North Carolina. Here’s what to do if you get one:

I received a Form 61 Denial of Claim… is this the end?

No, but it is easy to fall into the trap of believing there is no hope. Although the denial form is supposed to include an explanation of the reason for the denial, usually it is unhelpful and vague. Our favorites:

  • “Claimant’s description of incident lacks credibility.”
  • “The description of accident does not amount to compensable event.”
  • “Untimely notice.”
  • “Not compensable under workers’ compensation act.”
  • “No injury by accident or specific traumatic incident”

How can anyone argue against those generalities? Worse, when an injured worker is not represented by counsel, the insurance adjuster often supplements the form with a decisive letter or phone call designed to convince the injured worker their decision was based on a thorough investigation, is legally sound, and is final. Unfortunately, many injured workers swallow it hook, line, and sinker. No surprise there, because insurance adjusters are expert negotiators. Don’t be fooled… a denial is just a jumping-off point.

What is the real reason for the denial?

It depends; and, without a lawyer, you may never find out. Before denying a claim, most workers’ compensation insurance adjusters perform an initial investigation, but not always a thorough one. For example, an adjuster may mistakenly deny a claim for “lack of timely notice” simply because the employer’s HR department did not receive notice of the accident from the supervisors or managers.

Other errors occur when details are unclear about how and when the accident took place. Sometimes, a well-meaning adjuster simply received false information from the employer or a co-worker during the investigation. Other times, the adjuster just misunderstood the law about what constitutes a compensable accident. After all, North Carolina’s Workers’ Compensation Act fills a whole book and contains more than 50,000 words, which our appellate courts have been interpreting for decades.

Yes, it is possible – even likely – that the denial was a mistake, which the North Carolina Industrial Commission will correct if given the chance to review. Whatever the reason, following a denial, a full investigation is warranted to determine if the denial was legitimate or groundless.

How can I challenge it?

Ahh, the tricky part. Assuming you found some legal grounds to challenge the denial, your best bet is to file a Form 33 Request for Hearing. Go ahead, click on it… looks simple enough, right? Yes, injured workers in North Carolina have the right to represent themselves and may even complete and file this form without the help of an attorney. But we don’t recommend it.

Because of the complexity of North Carolina’s workers’ compensation laws, we strongly encourage attorney involvement for any motion or proceeding at the Industrial Commission, especially when a hearing is requested. Those 50,000 workers’ compensation words we mentioned earlier? Every. Single. One. Matters. If you decide to challenge the denial of your workers’ comp case, let an experienced workers’ compensation attorney help you select the right ones.

Contact Ricci Law Firm, P.A. for help: (252) 285-4081. You can also complete an online evaluation form here. Your first consultation with a Greenville workers’ compensation lawyer at our office is free, so don’t wait!

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