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  • N.C. Workmans comp claim denied North Carolina

    I was denied on a claim due to the fact that The injury was from a previous time a few weeks before this injury, and the first time it was not reported by my employer I was told by my employer the reason I was denied was I talked to much and should of never told them about how it happend the first time.

    The first time I slipped down a ramp and went to the doctor a few day after He gave me a cortisone shot and it was like it never happend all good.Then 2 weeks later I was getting in back of my work truck when my knee pop and I had this very very strong pain that was the big one so went back to the doctor .
    He said its a possible torn meniscus.I was then sent to another doctor.He ordered a MRI and released me on very limited work duty.At this time My work does not have anything for me to do with these limits.I am still with no work or any money I am getting in very bad shape

    Workman comp has denied this claim due to the fact that the first was not reported to them and they are saying

    THIS "YOU DID NOT SUSTAIN A COMPENSABLE INJURY BY ACCIDENT NOR HAVE YOU BEEN DIAGNOSED WITH A COMPENSABLE OCCUPATIONAL DISEASE AS DESCRIBED IN THE SECTION 97-2 OR 97-53 OF NORTH CAROLINA WORKERS COMPENSATION ACT.

    Is there anything I can do I am stuck with no money and What it looks like the doctor wont call me back DUE to workmans comp has stop payment so now I can't be released back to work and everything is at a stand still.

  • #2
    Actually, I think the denial has more to do with the ay the second injury occured rather than the fact that you had the prior injury. Was the prior injury work related? When did you report it? Was the injury to your knee?

    On the 2nd claim. Only injuries that are arising out of and in the course of the employment are covered. Just because it happened at work, doesn't mean it is covered by WC. Unless you slipped getting into the vehicle or there was some other sort of unusual occurrance that led to the injury, it wouldn't meet the standard. Even if you were you entering the vehicle while in the course of your duties, it may not meet the "arising out of" prong.

    If you also had an injury to the same body part just two weeks before this that required a cortisone shot, that further refutes the possibility that work caused this injury and the prior injury didn't play a role. Whether you told them about the prior injury or not, once the medical records were requested, WC would have found out. The doctor would also have gotten this info from the medical history that you shared before treatment. Lying about prior injuries is not only a bad idea as it hampers the doctor's ability to properly treat you, but it is fraud and carries some stiff penalties.

    At this point, you can go one of two ways. 1. you can treat this as any other injury and use your regular medical insurance to cover treatment and take whatever leave available to you at work. 2. You can appeal the decision with WC. If you do, I'd suggest hiring a lawyer. The procedure for appealing should be on the form you received in the mail denying the claim.
    I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

    Comment


    • #3
      Originally posted by ElleMD
      Actually, I think the denial has more to do with the ay the second injury occured rather than the fact that you had the prior injury. Was the prior injury work related? When did you report it? Was the injury to your knee?

      On the 2nd claim. Only injuries that are arising out of and in the course of the employment are covered. Just because it happened at work, doesn't mean it is covered by WC. Unless you slipped getting into the vehicle or there was some other sort of unusual occurrance that led to the injury, it wouldn't meet the standard. Even if you were you entering the vehicle while in the course of your duties, it may not meet the "arising out of" prong.

      If you also had an injury to the same body part just two weeks before this that required a cortisone shot, that further refutes the possibility that work caused this injury and the prior injury didn't play a role. Whether you told them about the prior injury or not, once the medical records were requested, WC would have found out. The doctor would also have gotten this info from the medical history that you shared before treatment. Lying about prior injuries is not only a bad idea as it hampers the doctor's ability to properly treat you, but it is fraud and carries some stiff penalties.

      At this point, you can go one of two ways. 1. you can treat this as any other injury and use your regular medical insurance to cover treatment and take whatever leave available to you at work. 2. You can appeal the decision with WC. If you do, I'd suggest hiring a lawyer. The procedure for appealing should be on the form you received in the mail denying the claim.
      First off there has not been a lie told on my part The problem here is that my employer did not report the first time I was injured because He thought it was not bad enough to report

      The second time I was injured was really from the first time it just happend when I was getting in the back of this work truck to get something out for the job I was doing.The only BAD thing here is my employer not making the first injury report the first time and causing this problem.

      I have been very honest and ready to get this over with and return back to work if ok with my doctor

      But everything is on freeze right now till WC can fix this I am stuck between wc and my employer it has been told to me they are starting all over again and going to get this streight But so far WC has not returned my calls other than a automated person saying they were sending me a med card for my medication.The problem with that I am not on any medication.
      Also before I got this letter that they denied this case They relesed the doctor to do a MRI and now they said in the letter that they were not paying for any of this.I am really stuck with a big problem and it is all comes down to my employer not making the report when I told him the first time I got hurt when I Fell down on the ramp .

      ps I told wc about complete story the truth my employer thinks I sould of never told them But you are 100% right wc would of found out Thats why I told the truth in the first place its not about me its my employer I did everything I should BUT IN RETURN I AM THE ONE THAT IS GETTING KICKED IN THE FACE.
      I have been working with this co for 11 years and have only been hurt one other time and that was with my back and that was a problem also and again it was because my employer did not make the report when in should but that was resolved It took a pretty long time but we got it worked out and that was 2 years ago and since then my employer has changed insurance co and these people do not seem to even care if or when I go back to work or if I go broke Before the other insurance co had worked out with my employer for me to return back very quickly under limited dutys This time no one has said one thing about me returning under these sedentary dutys.I am have done everything I can to keep this at peice But it's getting where I am going to lose everything I have if something is not soon done over one mistake that was not in my falt.

      To answer your question Yes I was injured on the job the first time and yes it was my knee I was going down a ramp when I started to slip and feel back it gave me some problems but did not seem to be very bad over time it got worse but would go and come I called my employer when I got home that night at his house and he just said ok it will be ok

      Never any report was done I have no control if he did not file.
      I guess he thought it would never mount to anything, as I didnt think it would also But I guess even though I got hurt bad enough the second time that stopped me from working and going to the doctor.When my employer made the report he should of made it out for the first time THAT I reported to him then everything would of been in place. IF there are anymore questions to ask I will be glad to answer.
      Last edited by robbg316; 09-20-2006, 07:58 AM.

      Comment


      • #4
        OK, I can understand your employer not reporting it if you fell, but didn't seek treatment for the fall, even if you said your knee hurt. Only those claims which result in outside medical care or lost time from work need to be reported to the WC carrier. When you later sought treatment for your knee, did you inform your employer that you had?

        You also can file a claim whether your employer "wants" you to or not. From the state website
        Q: What must an employee do when an injury occurs?

        A: Report the injury to the employer, in writing, immediately and in any event within 30 days. Print out a Form 18, fill it out, sign it, and make two copies.

        Mail the original Form 18 to:

        N.C. Industrial Commission
        Statistics Section
        4334 Mail Service Center
        Raleigh, NC 27699-4334

        Mail the first copy of this Form 18 to your employer certified mail, return receipt requested, and keep the receipt when it comes as proof of mailing.

        Keep the second copy of this Form 18 for your file.



        Q: What should be done if the employer fails or refuses to report an injury?

        A: Telephone the Claims Administration Section at (919) 807-2506 to make sure that your Form 18 has been received by the Industrial Commission, and to get the file number assigned by the Industrial Commission to your claim.


        If this other injury was just 2 weeks ago, you can still file it with the commission.
        I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

        Comment


        • #5
          Originally posted by ElleMD
          OK, I can understand your employer not reporting it if you fell, but didn't seek treatment for the fall, even if you said your knee hurt. Only those claims which result in outside medical care or lost time from work need to be reported to the WC carrier. When you later sought treatment for your knee, did you inform your employer that you had?

          You also can file a claim whether your employer "wants" you to or not. From the state website
          Q: What must an employee do when an injury occurs?

          A: Report the injury to the employer, in writing, immediately and in any event within 30 days. Print out a Form 18, fill it out, sign it, and make two copies.

          Mail the original Form 18 to:

          N.C. Industrial Commission
          Statistics Section
          4334 Mail Service Center
          Raleigh, NC 27699-4334

          Mail the first copy of this Form 18 to your employer certified mail, return receipt requested, and keep the receipt when it comes as proof of mailing.

          Keep the second copy of this Form 18 for your file.



          Q: What should be done if the employer fails or refuses to report an injury?

          A: Telephone the Claims Administration Section at (919) 807-2506 to make sure that your Form 18 has been received by the Industrial Commission, and to get the file number assigned by the Industrial Commission to your claim.


          If this other injury was just 2 weeks ago, you can still file it with the commission.
          Ok to clear up a few things it happend july 12 2006 that when I slipped on the ramp that was connected to the work truck

          2nd I did not know that you could or had to file any of this yourself
          also has no one been told about this other that a little note at the time clock that says report all injurys to your employer.

          I am pretty sure my employer should of posted it and all information to this But it has not been done
          also this note was only posted after a few days after my first injury that was 2 years ago I really don't see why they should make this so hard to resolve. It is a case that happend on the job and I was hurt on the clock in a work truck
          I can not understand WHY I am BEING MADE OUT TO BE THE BAD GUY I am at the point that I think that all these insurance co are a bunch of crook's out to recieve money from a employer and give them a hard time when they have a case This is far from being fair that a hard working 11 year employer has to put up with this.

          I GUESS everyone thinks I should just let this go and return back to work and take the lose and pay the doctors But that cant and will not happen I am flat out broke and still have pain from day to day and at this time does not know what is wrong with my knee.Like I said NO one has told me or anyone before how to go about this other than report any injury to my employer.
          Last edited by robbg316; 09-20-2006, 09:28 AM.

          Comment


          • #6
            When you sought treatment after the first accident, did you tell your employer that you had?
            I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

            Comment


            • #7
              Originally posted by ElleMD
              When you sought treatment after the first accident, did you tell your employer that you had?
              yes he knew I was going to the doctor but nether him nor I knew if it was going to get worse later

              No one really even thought it would get as bad as it did but yes they knew I went and I even told them the shot seem to help but what my doctor I have now said that shot should of never been giving because it just mask the real injury.

              My employer even thinks that this insurance co is just being hard to work with he has told me over the phone 2 weeks ago that its not right for them to not to work this out because a mix up on the first time it happend. But at this time I have call both the wc and my employer yesterday and No return call from anyone.It should not be this hard for anyone to have to put up with this and get in this kind of mess and just about come down to losing everything by getting hurt while trying to make a living.But one thing is I exspect if the pressure gets on my employer and they think that this might cost them in out of money of them This will all be changed and they will find away to make me out to be the one that made the mistake.I HOPE they stick to the truth and everything should work out.

              Comment


              • #8
                Did you tell your employer that this treatment was the result of the fall sustained at work? Was this treatment less than 30 days from the initial fall? What is this underlying problem with your knee?

                The reason it matters is that your employer does not have a duty to report the injury until they know that you have sought medical treatment as a result. Before that, the WC carrier doesn't care and there isn't anything to report unless your employer keeps these incidents on file for some internal reason, though they are not required to.

                If you have a medical condition that caused the falls, it wouldn't be covered under WC. Not everything that happens at work is covered. There must be something about work that contributed to the accident. If you just happened to be at work when it happened, that is not enough.
                I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

                Comment


                • #9
                  Originally posted by ElleMD
                  Did you tell your employer that this treatment was the result of the fall sustained at work? Was this treatment less than 30 days from the initial fall? What is this underlying problem with your knee?

                  The reason it matters is that your employer does not have a duty to report the injury until they know that you have sought medical treatment as a result. Before that, the WC carrier doesn't care and there isn't anything to report unless your employer keeps these incidents on file for some internal reason, though they are not required to.

                  If you have a medical condition that caused the falls, it wouldn't be covered under WC. Not everything that happens at work is covered. There must be something about work that contributed to the accident. If you just happened to be at work when it happened, that is not enough.
                  yes I told them I was going to the doctor for my knee
                  my problem with my knee I can not tell you that because WC HAS not released me to go back to the doctor to find out what the MRI showed
                  There was no medical condition that caused it I have never had any problems with my knee before I FELL DOWN THE RAMP because it was wet and slick and I had a heavy load on the hadcart I was puishing that is it.I do not understand why this is picked to death I fell on the job when going down a ramp pushing a handcart and something happend to my knee bottom line I am not out to get anyone I am just want WHAT I should get and be released to go back to work thats all I dont even care about all the other things like milege and any of that just pay the doctor give me my 60% and send me back to work all done.But I am going to be so scared that if I get hurt again AND HAVE TO go back like this I probly will just keep working no matter how hurt I get this is just not worth the stress and hardship RIGHT now I am on the edge of lossing my home because of this MY water is going to be turn off this week my light will be turn off next mon and oct 9 I will be homeless if the morg is not payed on my house IT has got to the point that I just dont think NO ONE CARES WHAT HAPPENS TO ME.I do not know what to do I COULD NOT EVEN PAY A ATTORNEY if I had one in the shape I am in now.I am in the bigest trouble I have ever been in 41 years I been on this eart.I think I am slipping in a depression.

                  Comment


                  • #10
                    Time out a minute. It isn't that I'm not willing to try and work with you here but the answers make a huge difference. If you don't fully answer the question, I can't give you good advice.

                    Since your employer knew you received treatment for your knee, then they should have filed the claim at that time. You should have filed a claim as well. Since you can't turn back time, I would appeal the denial of your claim. From the regs 97-22. Notice of accident to employer.

                    Every injured employee or his representative shall immediately on the occurrence of an accident, or as soon thereafter as practicable, give or cause to be given to the employer a written notice of the accident, and the employee shall not be entitled to physician's fees nor to any compensation which may have accrued under the terms of this Article prior to the giving of such notice, unless it can be shown that the employer, his agent or representative, had knowledge of the accident, or that the party required to give such notice had been prevented from doing so by reason of physical or mental incapacity, or the fraud or deceit of some third person; but no compensation shall be payable unless such written notice is given within 30 days after the occurrence of the accident or death, unless reasonable excuse is made to the satisfaction of the Industrial Commission for not giving such notice and the Commission is satisfied that the employer has not been prejudiced thereby. (1929, c. 120, s. 22.)


                    If you can justify your reasoning for not filing the claim within the 30 days, it may be covered.

                    Q: What happens when the employer refuses to acknowledge the claim?

                    A: When liability for payment of compensation is denied, the Commission, claimant, his or her attorney (if any), and all known providers of health care shall be promptly notified of the reason for such denial. The denial Form 61 shall not be worded in general terms, but must detail the exact reason for the denial of liability.



                    (a) If a claim is denied by the insurance company or self-insurer, the employee may request a hearing before the Industrial Commission by submitting a Form 33, Request for Hearing.

                    (b) Medical providers may bill the employee only after it has finally been determined that it is not a compensable workers' compensation claim.


                    www.comp.state.nc.us/ncic/pages/form33.pdf

                    If you are planning to appeal, I would speak to a lawyer that handles WC. By law the lawyer may not charge you up front for any fees. The lawyers fees are set by statute and are paid out of any award you may receive. I would do so sooner rather than later. I never hurts to appeal unless you are committing fraud.

                    In the interium, your regular insurance should cover treatment as you have a denial letter from WC. Speak to your attorney about this as well. They should be able to assist you in getting care and the bills reimbursed.

                    Statute of limitation claims are tough to overcome but not impossible. Did your employer have posters up with the information about WC?
                    I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

                    Comment


                    • #11
                      Originally posted by ElleMD View Post
                      Time out a minute. It isn't that I'm not willing to try and work with you here but the answers make a huge difference. If you don't fully answer the question, I can't give you good advice.

                      Since your employer knew you received treatment for your knee, then they should have filed the claim at that time. You should have filed a claim as well. Since you can't turn back time, I would appeal the denial of your claim. From the regs 97-22. Notice of accident to employer.

                      Every injured employee or his representative shall immediately on the occurrence of an accident, or as soon thereafter as practicable, give or cause to be given to the employer a written notice of the accident, and the employee shall not be entitled to physician's fees nor to any compensation which may have accrued under the terms of this Article prior to the giving of such notice, unless it can be shown that the employer, his agent or representative, had knowledge of the accident, or that the party required to give such notice had been prevented from doing so by reason of physical or mental incapacity, or the fraud or deceit of some third person; but no compensation shall be payable unless such written notice is given within 30 days after the occurrence of the accident or death, unless reasonable excuse is made to the satisfaction of the Industrial Commission for not giving such notice and the Commission is satisfied that the employer has not been prejudiced thereby. (1929, c. 120, s. 22.)


                      If you can justify your reasoning for not filing the claim within the 30 days, it may be covered.

                      Q: What happens when the employer refuses to acknowledge the claim?

                      A: When liability for payment of compensation is denied, the Commission, claimant, his or her attorney (if any), and all known providers of health care shall be promptly notified of the reason for such denial. The denial Form 61 shall not be worded in general terms, but must detail the exact reason for the denial of liability.



                      (a) If a claim is denied by the insurance company or self-insurer, the employee may request a hearing before the Industrial Commission by submitting a Form 33, Request for Hearing.

                      (b) Medical providers may bill the employee only after it has finally been determined that it is not a compensable workers' compensation claim.


                      www.comp.state.nc.us/ncic/pages/form33.pdf

                      If you are planning to appeal, I would speak to a lawyer that handles WC. By law the lawyer may not charge you up front for any fees. The lawyers fees are set by statute and are paid out of any award you may receive. I would do so sooner rather than later. I never hurts to appeal unless you are committing fraud.

                      In the interium, your regular insurance should cover treatment as you have a denial letter from WC. Speak to your attorney about this as well. They should be able to assist you in getting care and the bills reimbursed.

                      Statute of limitation claims are tough to overcome but not impossible. Did your employer have posters up with the information about WC?
                      TO answer your question of the posters The only thing they have posted is a small paper up by the time clock with a note to report any injury no matter how small to them other than that there are no posters IF that is legal I don't know THE other places I worked way back had a big poster in 2 or more places where employers go like break rooms and time clocks I really do not know But that is the only thing they have posted And for years they didnt have anything till I hurt my back 2 years ago and I was told they were running around posting up papers

                      OK update on this sept 28 last week I had a new interview with a new case worker with this workmans comp Insure co I answer all of her questions starting back when I first hurt my knee on the 7/12/06 and the last time on 7/26/06 she then made a return doctor visit with the last doctor I seen that did the MRI that was this past mon The doctor now says the MRI shows a torn cartilage in my knee and recommends surgery I was told by the doctor it was at a stage that he could repair it and would feel pretty good that I could go back and do my same type of work with min problems I also ask him does he think this came from my slip on the ramp he say no doubt the twist that I show him before was he said the time it weaking it and when the 1st doctor gave me the shot it just coverd up the real problem and I just over stressed it that day a week later at work and it let go and tore so I ask him when this could be done he said as soon as workman comp gives him the ok to move foward on the surgery So right back to the waiting game Plus No money still Not one cent I REALLY think there should be a time limit law on these workman comp insurance co on how long they have to tell you if your claim is accepted or not and also other things they take for ever on its just is very unfair to people that have bills that depend on a job to cover I am at a point of really getting up set But I just got a call from a family member lastnight saying they had this to happend to them and they have found me a local atty
                      So as soon as I hear from wc on this if it be another dropped claim I have a really good workman comp atty standing by I also have a friend that works in a local state law office that I ask who was the best wc atty and they gave me the same atty I have had him before in 1989 for a car crash I was in and he was good then so this where I am now but feeling alot better right now about all of this other than my vista card is about to hit its limit I do feel if working comp droppes this claim this time they will be hearing from my atty I am over this playing game with them.

                      Comment


                      • #12
                        Please, please use punctuation. It is very hard to read your post without it.

                        If the claim is being accepted despite not being filed in a timely manner, you should be receiving your first TTD check within 14 days. There are rules for how long it can take to get treatment authorized. If the claim is accepted, then authorization may not be sought more than 10 days in advance of the procedure and the insurer has 2 business days to authorize treatment (97-25.3.).

                        Much of your issues now are not because the insurer has failed to comply, but because you did not file the claim within the 30 days proscribed by law. In NC, the insurer can pay benefits for a maximum of 90 days without obligating themselves to the claim. Basically, there is a 90 day grace period allowed. However, the insurer isn't required to do this in every case.

                        After speaking with you they may decide to accept the claim, even though it is beyond the 30 days. If they do not, you will need to file with the Commission and let them decide whether you had a good reason for not meeting the deadline.

                        Your employer is required to have a poster with a WC notice. If they do not, it *may* be considered good reason to have missed the deadline, and or there may be a penalty assessed against them. However, that is for the Commission to decide and not having the poster is not an automatic guarantee that your claim will be covered.
                        I post with the full knowledge and support of my employer, though the opinions rendered are my own and not necessarily representative of their position. In other words, I'm a free agent.

                        Comment


                        • #13
                          Originally posted by ElleMD View Post
                          Please, please use punctuation. It is very hard to read your post without it.

                          If the claim is being accepted despite not being filed in a timely manner, you should be receiving your first TTD check within 14 days. There are rules for how long it can take to get treatment authorized. If the claim is accepted, then authorization may not be sought more than 10 days in advance of the procedure and the insurer has 2 business days to authorize treatment (97-25.3.).

                          Much of your issues now are not because the insurer has failed to comply, but because you did not file the claim within the 30 days proscribed by law. In NC, the insurer can pay benefits for a maximum of 90 days without obligating themselves to the claim. Basically, there is a 90 day grace period allowed. However, the insurer isn't required to do this in every case.

                          After speaking with you they may decide to accept the claim, even though it is beyond the 30 days. If they do not, you will need to file with the Commission and let them decide whether you had a good reason for not meeting the deadline.

                          Your employer is required to have a poster with a WC notice. If they do not, it *may* be considered good reason to have missed the deadline, and or there may be a penalty assessed against them. However, that is for the Commission to decide and not having the poster is not an automatic guarantee that your claim will be covered.

                          I am sorry you had a problem reading what I wrote.

                          This problem has been solved and its all taken care of.

                          Got the first check today and now The doctors found I have a tore cartilage in my knee,now surgery is set for OCT 18.

                          I found the key word to this insurance co and I should of used it the first time, I would not of had all these problems of them thinking I was out to lie about this.
                          As soon as I said atty, everything made a big turn around That really get's me that all these wc insur co are about is money and loop holes to find to get out of paying someone for something that was a 100% injury due to work accident.
                          My employer told me he will be looking into finding a different wc insurance co That is a not so quick into dropping a claim for a small mix up as this.

                          I have learned a big lesson from all of this and that is to make sure my boss reports any injury right then.And to inform wc that I will seek a atty if I am giving any problems.I hope this never happened again, I am really ready to get better and return back to work.

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