What to Do If Your Workers’ Compensation Claim Is Denied

Why Are Workers’ Compensation Claims Denied in North Carolina?

Employers and insurance carriers may dispute workers’ compensation claims for several reasons. Sometimes the disagreement concerns whether an accident occurred in the course of employment. In other cases, the insurer may accept that an accident happened but question whether a particular medical condition resulted from it.

Understanding the specific reason for the denial is an important first step because it helps identify the evidence and legal issues that may need to be addressed.

Common Reasons for a Denial

• The injury is disputed as work-related. The insurer may argue that the accident did not arise out of and occur in the course of employment or that the condition does not meet the legal requirements for coverage.
• There is insufficient medical evidence. The available records may not establish a connection between the claimed injury and the workplace accident or occupational exposure.
• A pre-existing condition is involved. The insurer may contend that symptoms are attributable to a condition that existed before the workplace incident. A pre-existing condition does not automatically prevent a compensable claim, but the medical and legal questions can be complicated.
• The accident was reported late. North Carolina generally requires written notice of an accidental workplace injury within 30 days, subject to statutory exceptions.
• The claim was not formally filed. Reporting an injury to an employer or having the employer submit an accident report is not necessarily equivalent to filing the employee’s claim with the Industrial Commission.
• Eligibility or employment status is disputed. Questions may arise about coverage under the Workers’ Compensation Act or whether the injured person was an employee rather than an independent contractor.

A denial should be evaluated based on its stated grounds and the available evidence. It is not necessarily the final determination of the employee’s entitlement to benefits.

Look for Form 61 or a Written Explanation

An employer or insurance carrier denying a claim may issue Form 61, Denial of Workers’ Compensation Claim. This form is intended to identify the grounds for denying compensability or liability.

Keep the denial notice and any related correspondence. Those documents can help an attorney understand which issues the insurer disputes and what steps may be appropriate.

If the denial involves an earlier medical condition, see our article on workers’ compensation for a pre-existing injury in North Carolina.

How to Challenge a Denied Workers’ Compensation Claim in North Carolina

If your employer or its insurance carrier denies your claim, you may be able to pursue the dispute through the North Carolina Industrial Commission. The process involves identifying the issues, ensuring that the underlying claim has been properly filed, and requesting a hearing when appropriate.

Step 1: Review the Reason for the Denial

Begin by reading the denial notice carefully. Determine whether the insurer disputes the accident itself, your employment status, the relationship between your injury and your job, or another aspect of the claim.

For example, a denial based on inadequate medical evidence may require a different response from one based on whether an employee was acting within the scope of employment.

Step 2: Confirm That Your Original Claim Was Filed

North Carolina employees commonly use Form 18, Notice of Accident to Employer and Claim of Employee, to file a workers’ compensation claim with the Industrial Commission.

An employer’s submission of Form 19 does not, by itself, satisfy the employee’s obligation to file a claim. For an accidental workplace injury, North Carolina generally establishes a two-year filing limitation, subject to applicable statutory rules. Occupational disease claims have separate provisions.

If you are uncertain whether a claim was properly filed, address that question promptly. A dispute over insurance coverage does not eliminate filing requirements or extend deadlines automatically.

Our guide to filing a North Carolina workers’ compensation claim explains the initial process in greater detail.

Step 3: Request a Hearing Using Form 33

When an employer or insurance carrier denies a claim, an injured employee may request a hearing before a Deputy Commissioner by filing Form 33, Request That Claim Be Assigned for Hearing.

The request identifies the dispute to be considered by the Industrial Commission. Filing Form 33 is a way to seek a hearing concerning the denied claim; it is not an appeal from an existing Deputy Commissioner’s decision.

The proper filing and service requirements should be followed. An attorney can help identify the issues that need to be raised and determine whether additional procedural steps are required.

Step 4: Gather Evidence Supporting Your Claim

The evidence needed depends on the reason for the denial. Medical records may be central to a dispute about whether an injury is work-related, while accident reports and witness statements may be important when the employer disputes what happened.

Information about job duties, employment status, work restrictions, and lost earnings may also be relevant.

Evidence should be preserved promptly, particularly when workplace conditions or witness recollections may change over time.

Step 5: Participate in Mediation or a Hearing

Many workers’ compensation disputes proceed through mediation, where the parties attempt to resolve their disagreements with the assistance of a neutral mediator. Mediation does not guarantee a settlement, and the appropriate procedure depends on the case.

If the dispute is not resolved, it may proceed to a hearing before a Deputy Commissioner of the Industrial Commission. The parties may present evidence and legal arguments, and the Deputy Commissioner issues a decision based on the applicable law and record.

Some disputes resolve before a hearing, while others require additional proceedings. The time involved varies with the issues, evidence, and procedural history.

What Evidence Can Help Challenge a Workers’ Compensation Denial?

There is no single document that automatically overturns a denied claim. The strongest evidence generally addresses the specific reason the employer or insurer disputes the injury.

Medical Records and Opinions

Medical documentation can help establish the nature of an injury, its relationship to a workplace accident, and the treatment or work restrictions it requires.

Relevant evidence may include emergency treatment records, diagnostic results, specialist evaluations, physician opinions, and records showing how symptoms developed after the incident.

When a pre-existing condition is involved, medical evidence may be particularly important in determining whether workplace events caused or aggravated a compensable condition.

Accident Reports and Workplace Evidence

If the circumstances of an accident are disputed, preserve documents that help explain what occurred. These may include:

• Copies of incident reports and written injury notifications.
• Emails or text messages exchanged with supervisors.
• Names and contact information for coworkers who witnessed the incident.
• Photographs of relevant equipment or workplace conditions.
• Work schedules, job descriptions, and records of assigned duties.

An accident does not necessarily have to result from an employer’s negligence to qualify for workers’ compensation. The purpose of gathering this evidence is to establish the circumstances of the injury and address the disputed legal requirements.

Wage and Employment Records

If your claim involves disability compensation or disputed earnings, payroll records, pay statements, employment history, and documentation of missed work may become important.

Keep records of any attempts to return to work, restrictions imposed by your physician, and changes in your ability to earn wages.

Accurate and Consistent Documentation

Keep an organized record of appointments, conversations, correspondence, and claim developments. If you discover an error in an earlier report, address it accurately rather than attempting to make the records appear artificially consistent.

Clear documentation can make it easier to identify disagreements, explain what happened, and prepare for mediation or a hearing.

What If the Industrial Commission Rules Against You?

Challenging an insurance company’s denial is different from requesting review of an unfavorable decision issued after a workers’ compensation hearing.

Once a Deputy Commissioner has issued an Opinion and Award, a party seeking further review must follow the Industrial Commission’s appellate procedures and applicable deadlines.

Requesting Review by the Full Commission

Under N.C. Gen. Stat. § 97-85, a party generally has 15 days from notice of the award to apply for review by the Full Commission.

The Industrial Commission provides Form 44, Application for Review, for the review process. Additional requirements, including those concerning the notice of appeal, Form 44, and supporting submissions, are governed by the applicable procedural rules.

The Full Commission reviews the matter under its statutory authority and may address the evidence and legal conclusions as permitted by law.

Appealing to the North Carolina Court of Appeals

After a final Full Commission decision, a party may seek review in the North Carolina Court of Appeals under N.C. Gen. Stat. § 97-86 and the applicable Rules of Appellate Procedure.

The statute provides a 30-day appeal period, with specific provisions governing when that period begins. Court review generally concerns legal errors rather than an entirely new hearing of the workplace accident.

Additional review in the North Carolina Supreme Court may be possible in limited circumstances, subject to the applicable rules and requirements.

Why Deadlines Matter

Different deadlines apply depending on whether you are filing an original workers’ compensation claim, requesting a hearing about an insurer’s denial, or seeking review of an Industrial Commission decision.

These deadlines should not be treated as interchangeable. If you have received an Opinion and Award or another formal decision, obtain advice promptly about the specific procedure that applies.

When Should You Contact a Workers’ Compensation Attorney?

A denied claim can involve medical evidence, employment records, filing requirements, and questions about coverage under North Carolina law. These issues may become especially difficult when you are recovering from an injury and unable to work.

Consider obtaining legal guidance if your employer disputes the accident, the insurer questions whether your condition is job-related, your medical care is being challenged, or you have received an unfavorable Industrial Commission decision.

An attorney can help evaluate the reason for the denial, identify the appropriate procedure, and prepare evidence supporting your position. Legal advice is also important when a filing or appeal deadline may be approaching.

At Kellum Law Firm, our workers’ compensation attorneys assist injured employees throughout North Carolina with disputed claims and other issues involving workplace injuries.

Visit our Workers’ Compensation practice-area page or request a free case evaluation to discuss your situation.

When to Contact a Workers’ Compensation Attorney

While some claims are straightforward, most denials involve complexities that can be difficult to navigate alone — especially once the appeal process begins. If your benefits have been cut off, your employer is disputing the facts, or the insurance company is downplaying your injury, it’s time to get professional help.

You should strongly consider speaking with an attorney if:

• Your claim has been denied or delayed without a clear reason
• You’ve been pressured to return to work against medical advice
• Your employer is disputing how or when the injury occurred
• You’re being offered a low settlement or feel your case is being undervalued
• You’ve been terminated, retaliated against, or cut off from benefits

At Kellum Law Firm, we’ve been fighting for injured workers across North Carolina for over 50 years. From appealing denied claims to negotiating full settlements, our legal team is here to protect your rights and ensure you’re treated fairly at every stage of the process.

There’s no cost to talk to us — and no obligation to move forward. Visit our Workers’ Compensation practice area page to learn more about how we can help, or schedule a free case evaluation today.

Frequently Asked Questions About Denied Workers’ Compensation Claims

Official Resources for Disputed Workers’ Compensation Claims

The North Carolina Industrial Commission provides the forms and procedural information used in workers’ compensation disputes. These resources may help you understand the process:

• North Carolina Industrial Commission — Information for Injured Workers: General filing guidance and information about denied claims.
• Industrial Commission Forms: Official forms, including Form 18, Form 33, and Form 44.
• Industrial Commission Frequently Asked Questions: Answers about claim denials, medical treatment, and other workers’ compensation procedures.
• North Carolina Workers’ Compensation Act: Statutory provisions governing claims, hearings, and appeals.

These resources provide general information. The applicable procedure and deadlines depend on the facts and procedural status of each claim.

Practical Tip: Keep a Complete Record of Your Claim

If your workers’ compensation claim has been denied, organize the documents relating to your injury and the insurer’s decision. Keep copies of your accident report, medical records, work restrictions, denial notice, and correspondence with the insurance company.

Maintain a dated record of important conversations and appointments. If new medical evidence becomes available or your employer changes its explanation of the accident, preserve that information as well.

Good records cannot guarantee a favorable outcome, but they can help an attorney identify the issues in dispute and prepare a clearer presentation of your claim.

For assistance reviewing a denial, request a free workers’ compensation case evaluation.