Source: https://www.lawfirms.com/resources/north-carolina-s-tricky-situation-where-the-insurance-company-pays-benefits-but-might-still-deny-the-claim.html
Timestamp: 2020-05-28 03:33:02
Document Index: 598707535

Matched Legal Cases: ['§ 97', '§ 97', '§ 97', '§ 97', '§ 97', '§ 97', '§ 97', '§ 97', '§ 97']

North Carolina’s Tricky Situation Where The Insurance Company Pays Benefits But Might Still Deny the Claim. | LawFirms.com
Home Legal Topics Employment Compensation and Benefits
Injured workers that receive medical and wage loss benefits after a workplace accident typically feel secure in the idea that their employer’s workers’ compensation insurance company has accepted their workers’ compensation claim as compensable. However, the injured workers’ feeling of security is misplaced. This article will help explain how some situations in the North Carolina workers’ compensation system create confusing and frustrating positions for injured workers.
A. Injured Worker Reporting Requirements
Any time there is an injury at work in the State of North Carolina an injured worker needs to report the injury (at least verbally, but preferably in writing) to the employer within 30 days of the date of injury or else the employer or the employer’s workers’ compensation insurance company may deny any claim for benefits per N.C. Gen. Stat. § 97-22.
An injured worker also needs to make sure to file a claim for workers’ compensation benefits by filing a Form 18 with the N.C. Industrial Commission within 2 years of the date of injury or else the employer or the employer’s workers’ compensation insurance company may deny any claim for benefits per N.C. Gen. Stat. § 97-24.
The North Carolina Industrial Commission is the legal body created by the North Carolina Workers’ Compensation Act for the purposes of overseeing and addressing the administration of all of North Carolina’s work injuries. The North Carolina Industrial Commission can rule on motions or hold hearings concerning injured workers’ entitlement to medical treatment or disability compensation that results from a workplace injury or occupational disease. However, the North Carolina Industrial Commission will not oversee an injured worker’s claim until they have notice of the injury. The North Carolina Workers’ Compensation Act places the burden on the injured worker to report their claim.
B. The Employer’s/Carrier’s Response To A New Claim
When an injured worker files a claim for workers’ compensation benefits with the North Carolina Industrial Commission, the N.C. Workers’ Compensation Act (N.C. Gen. Stat. § 97-18) sets forth three different ways in which an employer or the employer’s workers’ compensation insurance company may respond to the claim for workers’ compensation benefits:
1. An employer or the employer’s workers’ compensation insurance company may accept responsibility for the work injury by filing a Form 60 per N.C. Gen. Stat. § 97-18(b). (see attached copy of Form 60)
When the claim has been accepted with a Form 60, generally any issues that arise regarding the injured worker’s entitlement to ongoing medical treatment or disability checks may be addressed via the filing of a motion with the North Carolina Industrial Commission.
2. An employer or the employer’s workers’ compensation insurance company may deny responsibility for the work injury by filing a Form 61 per N.C. Gen. Stat. § 97-18(c). (see attached copy of Form 61)
When the claim has been denied with a Form 61, a full evidentiary hearing before the North Carolina Industrial Commission is the only way in which the North Carolina Industrial Commission may order any benefits that are owed to the injured worker due to the work injury. The injured worker will need to prove that they have a compensable claim and that the medical treatment and disability compensation they are seeking are related to their workplace injury.
3. An employer or the employer’s workers’ compensation insurance company may initiate payment of compensation without accepting or denying responsibility for the work injury by filing a Form 63 per N.C. Gen. Stat. § 97-18(d). (see attached copy of Form 63)
Generally, when payments of compensation are initiated without a formal acceptance or denial of responsibility for the work injury, the employer or the employer’s workers’ compensation insurance company must be forced to either accept or deny the claim for benefits. If the claim is ultimately accepted, any issues may be addressed via a motion to the North Carolina Industrial Commission. If the claim is ultimately denied, a hearing before the North Carolina Industrial Commission is the only way for the Industrial Commission to order benefits that are owed to the injured worker due to the work injury.
It is the filing of a Form 63 which allows an employer or the employer’s workers’ compensation insurance company to initiate payment of compensation without accepting or denying responsibility for the work injury which often creates confusion. The injured worker will not know if the claim will be accepted or denied and will therefore be left not knowing what benefits they may be entitled or what benefits they will need to prove before the Industrial Commission.
C. Form 63 Filings
The North Carolina Industrial Commission Form 63 is the form that allows the employer to deny a claim after initially paying compensation. The Form 63 is allowed by the statutory framework of the North Carolina Workers’ Compensation Act. The statutory provision that provides authority for its use is N.C. Gen. Stat. § 97-18(d). N.C. Gen. Stat. § 97-18(d) states [with commentary]:
1. In any claim for compensation in which the employer or insurer is uncertain on reasonable grounds whether the claim is compensable or whether it has liability for the claim under this Article, the employer or insurer may initiate compensation payments without prejudice and without admitting liability.
[This statutory provision is what allows the employer or the employer’s worker’ compensation insurance company to begin paying benefits to the injured worker without accepting or denying liability for the work injury.]
2. The initial payment shall be accompanied by a form prescribed by and filed with the Commission, stating that the payments are being made without prejudice.
[The form noted here is a Form 63.]
3. Payments made pursuant to this subsection may continue until the employer or insurer contests or accepts liability for the claim or 90 days from the date the employer has written or actual notice of the injury or death, whichever occurs first, unless an extension is granted pursuant to this section.
[This portion notes a 90-day time period beginning the date the employer received notice of the injury within which the employer or the employer’s workers’ compensation insurance company may accept or deny responsibility for the work injury.]
4. Prior to the expiration of the 90-day period, the employer or insurer may upon reasonable grounds apply to the Commission for an extension of not more than 30 days.
[This portion notes the ability of an employer or the employer’s workers’ compensation insurance company to request an extension to the 90-day time period, not to exceed an additional 30-days, within which the employer or the employer’s workers’ compensation insurance company may accept or deny responsibility for the work injury.]
5. The initiation of payment does not affect the right of the employer or insurer to continue to investigate or deny the compensability of the claim or its liability therefor during this period.
[This simply clarifies that the employer or the employer’s workers’ compensation insurance company’s payment of compensation to the injured worker does not prevent the further investigation of the claim by either of these parties nor does it prevent either of these parties from denying the claim during the 90-day period or extended period if granted.]
6. If at any time during the 90-day period or extension thereof, the employer or insurer contests the compensability of the claim or its liability therefor, it may suspend payment of compensation and shall promptly notify the Commission and the employee on a form prescribed by the Commission.
[This is what allows the employer or the employer’s worker’s compensation insurance company to deny the injured worker’s claim for benefits and stop payment for any further benefits by the filing of a Form 61 within the 90-day period or extended period if granted.]
7. If the employer or insurer does not contest the compensability of the claim or its liability therefor within 90 days from the date it first has written or actual notice of the injury or death, or within such additional period as may be granted by the Commission, it waives the right to contest the compensability of and its liability for the claim under this Article.
[This portion notes that if an employer or the employer’s workers’ compensation insurance company does not deny the claim for benefits within the 90-day period or extended time period if granted, then these parties waive the right to deny the claim for benefits thereafter.]
8. However, the employer or insurer may contest the compensability of or its liability for the claim after the 90-day period or extension thereof when it can show that material evidence was discovered after that period that could not have been reasonably discovered earlier, in which event the employer or insurer may terminate or suspend compensation subject to the provisions of G.S. 97-18.1.
[This portion notes that an employer or the employer’ workers’ compensation insurance company may file a Motion to Terminate the injured worker’s entitlement to benefits if, after the 90-day period or extended time period if granted by the Industrial Commission, there was evidence discovered at a later date which would support the termination of benefits and which was not reasonable available to the employer or the employer’s workers’ compensation insurance company during the 90-day period or extended time period if granted.]
N.C. Gen. Stat. § 97-18(d) lays out the employer’s and employer’s insurance company’s responsibilities after notice of a workers’ compensation claim and the investigation into the claim is ongoing. They may initiate payment of benefits to an injured worker via the filing of a Form 63, further investigate the claim for benefits, and then the employer and its carrier will have 90 days (if no 30 day extension is granted by the Industrial Commission) to accept the claim via the filing of a Form 60 or deny the claim via the filing of a Form 61. If the employer and its workers’ compensation carrier fail to deny the claim via the filing of a Form 61 during this time period, then they waive the right to deny the claim in the future.
D. Two kinds of Form 63
Where the issues in this situation arise though is the Form 63 itself. The Form 63 contains two sections from which the employer or the employer’s workers’ compensation insurance company may choose to complete noting what benefits they are providing via the filing of the Form 63.
Section 1 of the Form 63 addresses the employer’s or the employers’ workers’ compensation insurance company’s payment of both disability checks for lost time from work as well as payment for medical treatment resulting from the work injury. This section notes the ability for these parties to further investigate the claim. This section further notes these parties then have up to 90 days from the date the employer received notice of the injury or extended time period if granted within which to accept the claim via the filing of a Form 60 or deny the claim via the filing of a Form 61, and if these parties fail to deny the claim by filing a Form 61 during this time period they then waive the right to do so in the future. Section 1 of the Form 63 in essence notes the employer’s or the employer’s workers’ compensation insurance company payment of benefits as set forth in N.C. Gen. Stat. 97-18(d).
In contrast, Section 2 of the Form 63 addresses the employer’s or the employer’s workers’ compensation insurance company’s payment for medical treatment only and allows these parties to later deny the claim for benefits via the filing of a Form 61 at any point in the future. It is important to note that there is no 90-day deadline or extended time period if granted for the employer or the employer’s workers’ compensation insurance company to accept or deny the claim or else waive their right to do so in the future. This section of the Form 63 simply allows the employer or the employer’s workers’ compensation insurance company to pay for medical treatment (and not disability checks) for as long as they so choose, without formally accepting or denying the injured worker’s claim for benefits.
Section 2 of the Form 63 was challenged as invalid because it did not comply with the requirements set forth in N.C. Gen. Stat. 97-18(d). In the case of O’Neal v. Inline Fluid Power, Inc., the N.C. Court of Appeals decided on May 19, 2015, that Section 2 of the Form 63 was valid and could be utilized by the employer or the employer’s workers’ compensation insurance company in addressing the payment of benefits to an injured worker. The Court of Appeals noted that Section 1 of the Form 63 is governed by N.C. Gen. Stat. 97-18(d) as it addresses the payment of disability compensation. Whereas the Court of Appeals noted that Section 2 of the Form 63 is governed by N.C. Gen. Stat. 97-25, which allows the employer or the employer’s workers’ compensation insurance company to pay for medical treatment (and not disability checks) for so long as they so choose, without formally accepting or denying the injured worker’s claim for benefits, and with the ability to deny these benefits at any point in the claim moving forward.
The statutes, forms,
and cases lead to a conclusion that the specific form an employer or insurance
company files in response to an injured worker’s claim for workers’
compensation benefits has a significant impact on the benefits an injured
worker may receive and dictate which actions an injured workers must take to
obtain all of the benefits available pursuant to the North Carolina Workers’
Compensation Act. The statutory
framework is supposed to clarify whether an injured worker’s claim is accepted
and that benefits are due or whether the claim is denied and the injured worker
must seek a judgment from the Industrial Commission. However, that framework has been twisted to
allow the use of a Form 63 medical only to allow insurance companies to direct
medical treatment but yet choose to deny a claim at any time. Injured workers in North Carolina should be
aware that receiving benefits after a workplace injury is not always what it