Most people have heard of workers’ compensation insurance, but very few know when an injured employee is eligible to receive weekly benefits under North Carolina Workers' Compensation.
There are so many myths and misconceptions about North Carolina workers’ compensation benefits, especially concerning weekly cash benefits.
We must first look at accepted versus denied WC claims.
Accepted vs. Denied Workers' Compensation Claims
After an employee files the Form 18 with the North Carolina Industrial Commission, an employer (their workers' compensation insurance carrier) must notify the Industrial Commission if it accepts or denies the claim.
Accepted Workers' Compensation Claims
If the employer accepts the claim, a Form 60 or Form 63 is filed with the NCIC.
In an accepted claim, the employer pays for and thus controls medical treatment, but that does not mean that they will pay weekly benefits.
In NC Workers' Compensation, the term "accepted" is not as straightforward as it sounds.
It would seem logical that in accepted workers’ compensation cases, the injured worker should receive weekly wage-loss benefits from the workers’ compensation insurance carrier when they miss time from work due to accident-related injuries.
Unfortunately, the workers' compensation insurance carrier can accept a case but will pay only for medical expenses (Form 63, Section 2).
Also, according to North Carolina General Statute §97-29, an injured worker must be completely written out of work by their authorized treating physician to receive NC Workers Compensation Weekly Benefits after being out of work for at least seven (7) days.
Please note that the "authorized treating physician" is a physician whose services are paid for by the Workers' Compensation insurance company.
So, you can only receive weekly workers' compensation benefits if your claim is accepted AND the doctor paid for by the insurance company says you can not work.
How are weekly workers' compensation benefits calculated?
Why is my workers’ compensation check so low? Unfortunately, weekly workers' compensation benefits are less than your normal wages.
The injured worker is paid a compensation rate equal to 66 2/3% (sixty-six and two-thirds percent) of his/her pretax average weekly wage.
A simple example: an injured worker has worked for the same employer for many years. Over the last year, they grossed $40,000.00. Dividing that number by 52 weeks ($769.23) and then multiplying by 66 2/3% would equate to an average weekly wage of $512.85.
Average weekly wage is a hotly debated topic, but the law requires that AWW be computed in the fairest way for the worker.
Can the insurance company stop my workers’ compensation checks?
Yes, but not abruptly. There are two common ways that benefits can be terminated: 1. the injured worker returns to work, or 2. the insurance company files a Form 24, and the NCIC approves the request to terminate benefits.
Also, note that failing to cooperate with your employer's workers' compensation insurer can lead to suspension of your workers' comp checks.
What happens if my doctor says I can return to work, but I still hurt? If the authorized treating physician opines that you can return to work, but you feel that you can not return to work, a 2nd opinion under North Carolina § 97-25 may help you.
Denied Workers' Compensation Claims
In denied workers' compensation claims (Form 61), weekly wage loss benefits are not paid.
It is common for workers' compensation insurance to accept certain body parts and deny others, so an injured worker may have a partially accepted claim.
In a partially accepted claim, you must use strategies for accepted and denied claims in order to attain full recovery.
If the insurance company is denying that you have a viable work injury claim (or denying a specific body part), the injured worker will need to request a hearing before the North Carolina Industrial Commission to get any benefits (for the denied parts or everything if it all was denied).
We have seen various reasons for these denials:
- Employees are classified as independent contractors and thus are not eligible for workers' comp.
- pre-existing condition not caused by work accident;
- occupational disease not caused by work;
- The accident did not happen at work.
- refusal of workers' comp insurance to accept all injuries from the work accident;
- and the list goes on.
Insurance companies can cite various reasons to deny, partially approve, or refuse to pay weekly benefits on a claim. This puts the injured worker in a particularly difficult situation.
If this is happening to you or someone you care for, we offer free case reviews by phone and online.
What about Doctors' Restrictions on Reduced Work Hours?
Another lost-wage scenario may involve an injured worker who has returned to work but is under a doctor’s restrictions limiting their hours.
If the injured worker’s ability to earn wages has been reduced because of their on-the-job accident-related injury, then they are eligible to receive wage loss compensation in an accepted workers’ compensation case.
The injured worker will be paid based on a wage loss compensation rate that equals sixty-six and two-thirds percent (66 2/3%) of the difference between his/her average weekly wages before the date of injury and the average weekly wage he/she is able to earn after the injury.
NC Workers' Compensation Weekly Benefits
In accepted claims, an injured worker can receive weekly workers' compensation benefits if their claim has been accepted and the authorized treating physician takes them out of work for more than seven days.
However, the insurance company's goal is to get you back to work as soon as possible to avoid paying lost-wage compensation or additional medical expenses.
If you are healed and ready to return to work at full capacity, you should. The problem arises when an injured worker is not healed but is expected to return to work at full duty. If this is happening to you, you should consult an NC Workers' Compensation lawyer as soon as possible.
There are many confusing issues surrounding an injured worker’s workers’ compensation claim, which at times can be quite overwhelming for a North Carolina injured worker.
The injured worker who is out of work due to their accident-related injury has enough on his/her plate. He/she should not have to worry or be concerned with wage loss compensation issues with their workers’ compensation claim.
The Bishop Law Firm helps Workers' Compensation clients in Raleigh, Durham, Rocky Mount, Wilson, Smithfield, Louisburg, Fayetteville, Chapel Hill, Roanoke Rapids, and surrounding areas in North Carolina. Contact us today at (919) 615-3095 for a free evaluation or start online now.
