Background
Workers’ Compensation is exactly that. It is a system designed to compensate workers who get injured on the job if they need to miss work or receive medical treatment. In North Carolina, Workers’ Compensation claims are governed by The North Carolina Workers’ Compensation Act. The North Carolina Industrial Commission has exclusive jurisdiction over the controversies that may arise while handling a claim. If a party wishes to appeal an adverse ruling, then the appeal goes straight to the North Carolina Court of Appeals. In order to ensure appropriate protection for employers and employees, North Carolina requires all businesses that regularly employ three or more employees to obtain Workers’ Compensation insurance or qualify as self-insured employers.
Starting the Process
Once there is an injury, an employer should file a Form 19 within five days after the employer has knowledge of the accident. This is the employer’s report to the employee and the Industrial Commission that there has been an injury on the job. Although the filing of a Form 19 is required by law, it is mainly administrative, and therefore any statement made by the employer about the injury is made without prejudice.
Along with the Form 19, the employee should also be sent a Form 18 by the employer. The Form 18 is effectively the employee’s legal “complaint” and helps to establish administrative facts and basic details about the claim. The Form 18 also prevents the statute of limitations (two years from the date of injury) from tolling, so it is an important measure for the employee to take.
Once the Form 18 is filed with the Industrial Commission, the employer will receive a letter with a copy of the Form 18 and written notice that the employer must do one of the following: 1) pay the claimant benefits without prejudice while investigating the claim; 2) accept the claim; or 3) deny the claim. The employer must respond to this letter within 30 days.
Forms 60, 61, & 63
The Form 63
If the employer wishes to investigate the claim, and in the meantime compensate the claimant, then it should file a Form 63. The Form 63 has two options. The first option, “Section One,” is the “temporary compromise” portion of the form that allows the claimant to have her medical treatment and/or her indemnity (lost time) benefits paid while the employer investigates the legitimacy of the claim. This is a temporary compromise because the employer is paying the benefits without prejudice (i.e. they are not forced to later accept the claim if their investigation reveals a disputable injury), but they are also limited to 90 days to make that decision. In other words, if the investigation is not completed within 90 days, the employer may be thereafter obligated to accept the claim as compensable (with prejudice).
Another option on a Form 63 is the lower portion of the form, or “Section Two.” This is generally used when the employee likely has an injury, but has not missed more than seven days from work. Thus, the employer uses a Section Two to acknowledge and pay for medical treatment, without paying indemnity benefits, and also without prejudice if the employer later chooses to deny the claim.
The Form 60
To accept the claim as compensable, the employer would file a Form 60 which details the claimant’s specific right to compensation. The Form 60 confirms when the injury occurred and how it happened, the claimant’s average weekly wage and compensation rate (this can be edited later if more information becomes available), and when the disability began. The employer files a Form 60 when all parties agree that the injury was sustained in the course and scope of the claimant’s employment with the employer and that it was an interruption of the claimant’s normal work routine (i.e. an accident). Importantly, however, if the employer ever wishes to end compensation, an employer’s admission of the compensability of the claim (by filing a Form 60) does not later give rise to a presumption of disability. In other words, the burden may later fall on the employee to prove continuing disability (the need for continued benefits), despite the employer’s acceptance of the claim.
The Form 61
To deny the compensability of a claim, the employer should file a Form 61. Much shorter than the Form 60, the only substantive section on the Form 61 is describing which alleged injury is being denied. Once the claimant receives the Form 61 denial, the claimant may choose to file a Form 33 Hearing Request to contest the denial, or accept the denial and move on with life.
Potential for Litigation
If the claimant is unhappy with the denial and files a Form 33 Hearing Request, the claimant must specifically state why she is requesting a hearing and which witnesses she intends to call. It is important to note that once a Form 33 is filed, the parties are ordered to have a mandatory mediation in an attempt to settle the claim. Also, the employer is required to file a Form 33R in response which allows the employer to indicate why the parties cannot agree, what witnesses it intends to call, and information about any benefits paid. After the parties participate in mandatory mediation, if the claim does not settle, they participate in a hearing with their witnesses and evidence before the Industrial Commission.
Claims are also often litigated when an employer endeavors to terminate or suspend compensation. This is typically done by the employer’s filing of a Form 24. The Form 24 gives the claimant 17 days to respond to explain and argue why the claimant’s benefits should continue. The parties then participate in a telephonic hearing with a Special Deputy Commissioner who makes a determination based upon the evidence and arguments. This decision is appealable.
All throughout the claim process, nothing prohibits the parties from voluntary settlement negotiations. In fact, most claims do not end up at a hearing and are instead settled through mediation or informal communications. Once the parties agree on the terms of settlement, the counsel for the employer will draft the settlement documents. Once the agreement is executed and then approved by the Industrial Commission, the employer/carrier will pay out any lump sum amount, and the claimant’s case is closed.
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What to Expect When You’re Expecting… a Workers’ Compensation Claim - JD Supra
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