North Carolina Workers’ Compensation Claims: Can I Choose My Own Doctor?

This seems like such a simple question. In fact, it is in the form of a “yes” or “no” question. However, the answer isn’t a simple “yes” or “no.” The answer is, yes, under certain extremely limited circumstances, so in reality, rarely.

Let’s break this down and dig into the specifics behind the answer. Through case law, it has been established that if the employer/insurance company accepts liability for the claim by filing either a Form 60 or Form 63, the employer/carrier gets to “direct care.” See Kanipe v. Lane Upholstery, 141 N.C. App. 620, 623-24, 540 S.E.2d 785, 788 (2000). The statute itself does not state that defendants get to choose the doctor even in an accepted case so how did we get from the statute to the case law regarding direction of care? We’ll start with the statute. NCGS §97-25 (a) states that the employer shall provide medical compensation. In subsection (c) it states that an employee may request a change of physician and sets out the requirements, including that to prevail in the motion to change physicians, the employee must show by a preponderance of the evidence that the change is reasonably necessary to effect a cure, provide relief, or lessen the period of disability. The logic that developed appears to have been that since the employer shall provide medical compensation and in order to change doctors, employees must request permission and meet a substantial burden to support the request to change physicians, the choice of physician must originate with the employer. In its most simple form, the Commission and our courts are taking a general “if they have to pay for the treatment, then they should get to choose the doctor providing the treatment” approach.

As an aside, the right to direct care is not recognized until the case is accepted as noted above. However, if you’ve been hurt at work and your employer directs you to a particular doctor / facility, it would be in your best interest to go to that doctor / facility to ensure that the employer / insurance company are responsible for paying for the treatment. Most injured workers do not know exactly when an employer “accepts” or “denies” a case to know when or if the right to direct care was triggered. If the employer instructs an injured worker to seek treatment from a specific doctor, they will be required to pay for that treatment even if the claim is later denied. Conversely, if an employer instructs an injured worker to see a particular doctor but the employee refuses and goes to a different doctor, if the claim is later accepted, the employer will not likely be required to pay for that treatment.

When does the employee get to choose? If the claim is denied, the employee can choose the doctor(s) they see. That is consistent with the he who pays, decides stance. In a denied claim though, defendants can require the injured worker to present for an independent medical evaluation with a doctor of their choosing.

Employees may also request and ultimately petition for a change of physician under NCGS §97-25 (c) as outlined above. Proving by a preponderance of the evidence that the change is reasonably necessary to effect a cure, provide relief, or lessen the period of disability is a hefty burden. It is not enough to say that the injured worker just doesn’t feel that the authorized doctor is fair or attentive or even that another doctor may order different treatment or progress through treatment options more quickly. Another instance in which the employee has a say in the medical provider is under NCGS §97-25 (b), an employee may request a comprehensive, second opinion with the doctor of his/her choosing. Defendants have 14 days to accept or deny the request. If it is denied, the employee’s burden to justify the request is much less than the burden for requesting a change of physician. The specific burden of proof isn’t listed in the statute but these types of requests are rarely denied if any good cause is shown. An employee also gets to choose the doctor to provide a second opinion as to any disability rating assigned.

The workers’ compensation system in North Carolina, as demonstrated above, can be complex. An experienced attorney can help answer questions you may have and help you successfully navigate this system. If you’ve been hurt at work, your health and financial well-being should be top priorities. Consult a qualified attorney to ensure you maximize the benefits that are available to you and to protect your interests.