Few things are more stressful than getting hurt at work only to find out that your workers comp claim has been denied. You count on these benefits to cover medical care, replace lost wages, and support your recovery. When the North Carolina workers compensation system pushes back, it can leave you feeling frustrated and unsure of what to do next.
At Roane Law, we help injured workers across North Carolina understand their rights, identify why their claims were denied, and take the right steps to fix it. Many denials are the result of preventable issues or misunderstandings. Even if your claim has already been rejected, you still have options.
Common Reasons Workers Comp Claims Are Denied in North Carolina
Workers compensation claims can be denied for many reasons, but some patterns occur again and again. Understanding these issues helps you build a stronger case moving forward.
1. Your Employer Disputed Whether the Injury Was Work Related
The most common reason for claim denial is that the employer or their insurance carrier argues that your injury did not happen at work or was not caused by your work duties. For example, they may claim your injury was a pre existing condition or that it happened off the clock.
North Carolina law requires that your injury arise out of and in the course of employment. Despite this clear standard, insurance companies often dispute the facts without solid evidence. If this is the reason for your denial, strong medical documentation and witness statements can make all the difference.
2. You Missed the Reporting Deadline
North Carolina requires injured employees to report the injury to their employer in writing as soon as possible. Ideally this should happen within 30 days. If too much time passes, the insurer may use the delay as grounds for denial.
Late reporting does not automatically end your claim, but it does create an argument the insurance company will use against you. If the denial cites late notice, you will need to explain the delay and support your case with evidence.
3. There Is Not Enough Medical Evidence
Workers comp insurers frequently deny claims by arguing there is insufficient medical proof connecting your injury to your job. In some cases, the doctor chosen by the employer may not fully document the extent of your injuries. Other times, the insurance company may ignore or discount your doctor’s opinion.
If lack of medical evidence is listed in your denial, do not assume the insurer is correct. A second medical opinion or additional documentation often resolves these issues.
4. You Had a Pre Existing Condition
Having a pre existing condition does not bar you from receiving workers comp benefits. In fact, North Carolina law clearly states that work injuries that aggravate or worsen a pre existing condition are covered.
However, insurance companies often deny claims anyway, arguing that your symptoms are due to your prior condition rather than your workplace injury. This tactic is especially common with back injuries, repetitive stress injuries, and joint problems.
5. The Insurance Company Claims There Were Inconsistencies in Your Statements
Insurers often look for any inconsistencies in how you described your injury to your employer, your medical providers, and the insurance adjuster. Even small differences can become an excuse for denial.
If your claim was denied for inconsistent statements, you may need assistance organizing your timeline and correcting misunderstandings in the record.
6. You Did Not Follow Medical Instructions
If the insurer claims you missed appointments, failed to follow doctor instructions, or returned to work too early, they may deny your claim. Sometimes the accusation is inaccurate or based on incomplete records.
This is fixable, but it often requires gathering medical records and clarifying the facts.
How to Fix a Denied Workers Comp Claim in North Carolina
A denial is not the end of the road. You can challenge the decision through the North Carolina Industrial Commission, provide additional evidence, and work with an experienced workers comp attorney to correct the problem.
1. Read the Denial Letter Carefully
Your denial letter will explain the specific reasons your claim was rejected. This document is important because it tells you exactly what issues you need to address. Some denials are straightforward while others contain vague or confusing explanations.
If your letter is unclear, a lawyer can help interpret it and determine the best way to respond.
2. Gather Additional Evidence
Most denials can be overturned by strengthening the evidence. Depending on your situation, this may include:
- Updated medical records
- Statements from coworkers or witnesses
- Accident reports
- Documentation of job duties
- Expert medical opinions
For example, if your denial involved wage calculations or lost income, you may need to verify your earnings. You can learn more about how wages are calculated for benefits by reviewing how your average weekly wage is determined.
3. File a Hearing Request With the North Carolina Industrial Commission
If the insurance company refuses to reverse the denial voluntarily, you can file a Form 33 to request a hearing before the Industrial Commission. This is essentially your opportunity to present evidence and argue your case before a Deputy Commissioner.
Hearings can be complex and involve legal rules of evidence. Most injured workers benefit from having an attorney handle this process.
4. Understand the Types of Benefits You May Be Entitled To
Many people do not realize how much they may be missing out on when a claim is denied. Workers compensation can include medical treatment, wage loss benefits, and disability benefits. You can learn more about what benefits may be available to you by reviewing the different types of workers comp benefits.
If your claim was denied, you may still qualify for temporary total disability, permanent partial disability, medical treatment, and more.
5. Correct Any Reporting or Documentation Issues
If the denial was caused by an issue like late reporting or incomplete documentation, you will need to address those gaps directly. You may need to provide a written explanation, missing forms, or supporting evidence. Sometimes simply fixing a paperwork error can turn a denial into an approval.
6. Get Medical Support to Document Your Injury
Medical opinions carry significant weight in workers comp cases. If the insurance company is relying on a doctor chosen by your employer, you may need an independent medical evaluation. A stronger medical link between your injury and your work duties can often reverse the denial.
7. Consult a North Carolina Workers Comp Attorney
Insurance companies deny claims frequently because they know many workers will give up. Having an experienced attorney changes the balance of power. Your lawyer can manage deadlines, gather evidence, challenge the insurer’s claims, and present your case effectively at a hearing.
If you suffered an injury and do not know what to do next, you can start by reading this guide on what to do after a workplace injury.
How Much Compensation Could You Recover After Fixing a Denied Claim?
Once your claim is accepted or overturned, the value of your workers comp case will depend on the severity of your injury, your average weekly wage, your medical needs, and any lasting disability. Many injured workers are surprised to learn how much compensation they may be entitled to once their claim is properly documented.
You can explore what may affect your case value by reviewing how much your workers comp claim may be worth.
Helpful Resources for Injured Workers
For additional information on your rights, the North Carolina Industrial Commission provides helpful guidance on filing claims and understanding the appeals process. You can review the Commission’s official information at the North Carolina Industrial Commission.
If you want to better understand workplace safety standards that may apply to your job, the Occupational Safety and Health Administration offers detailed guidance on preventing workplace injuries. You can explore their resources at OSHA’s worker information page.
For general information on how workers comp systems function nationwide, the National Institute for Occupational Safety and Health provides research and statistics that help explain common injury patterns and risk factors. Their reports are available at NIOSH’s workers compensation topic page.
Roane Law Can Help You Turn a Denial Into an Approval
A denied claim should not stop you from getting the support you need. If your North Carolina workers compensation claim has been denied, Roane Law can help you fight back. Our team understands how insurers operate and what evidence is needed to secure the benefits you deserve.
Do not navigate this process alone. We are here to guide you through every step, protect your rights, and fight for your recovery.
Contact Roane Law today for a free consultation.