Common Challenges and Disputes in Workers' Comp Cases

If your claim is denied, don’t panic – you have the right to appeal that decision. In North Carolina, when an insurance carrier denies a claim (often by sending you a Form 61 denial notice), you can request a hearing before the NC Industrial Commission to have the dispute resolved.To do this, you usually file a Form 33 (Request for Hearing) with the Commission. This starts a legal process similar to a court proceeding, where you (often with an attorney’s help) can present evidence and make your case for why the injury is work-related and you are entitled to benefits. Before a formal hearing, the Commission will typically schedule a mediation – a meeting where a neutral mediator tries to help you and the insurance company reach a settlement or agreement. If mediation doesn’t resolve it, your case will go before a Deputy Commissioner (a judge) who will hear testimony (from you, doctors, etc.) and review evidence, then make a ruling.

During this process, it’s wise to gather strong evidence: prompt reporting (hopefully), eyewitness statements, medical reports linking the injury to work, etc. Consulting an attorney at this stage is highly recommended, because the appeals process can be complex. There are no fees upfront for filing a hearing request, and if you win, the Commission can order the insurer to pay benefits (sometimes even back pay with interest). Remember, a claim denial is not the end – many initially-denied claims are later won on appeal or settled. Act promptly, though, because waiting too long can complicate your case. While there’s no hard deadline to request a hearing after a denial in NC, it’s best to appeal within two years of the date of injury at most (since that’s the general claim deadline) and preferably much sooner.

Common reasons for denial include disputes over whether the injury was truly work-related (e.g., no witnesses and the employer contests your account), whether it was reported on time, or whether a medical condition is indeed caused by work. Sometimes insurance companies also deny claims if there’s incomplete information or if they believe you had a pre-existing condition not aggravated by work. Insurers might claim an injury didn’t occur in the “course of employment” (for example, an injury on a lunch break off-site). They could also assert you violated a safety rule or the injury was due to intoxication (grounds to deny benefits under NC law). Importantly, the denial letter must state a specific reason – it cannot be a generic rejection. If you receive a denial, read the stated reasons carefully. That will guide what evidence you need to overturn it (for instance, an eyewitness statement if they doubt it happened at work, or a doctor’s causation letter if they doubt it’s related to work). Many times, denials are essentially the insurance company “putting up a fight” – they might hope you don’t appeal. But if you believe your claim is valid, pursue it. The burden will be on you (and your lawyer if you have one) to prove the claim in a hearing, but workers’ comp is ultimately decided on the facts and law, not the insurance adjuster’s initial opinion.

Unfortunately, delays can be a common frustration in workers’ comp cases. Some insurance companies are slow in processing benefits, or even “slow-walk” payments hoping the worker will become desperate and settle for less. If your weekly checks are coming late or irregularly, know that NC law penalizes late payments: if a payment is more than 14 days late, a 10% penalty is added to that installment. That penalty should automatically be included in the late check (though you might have to remind the adjuster). If late checks are persistent, you or your attorney can file a motion with the Commission to compel timely payments. The Commission can order the insurer to pay on time and include penalties.

For medical treatment delays, like the insurance stalling approval for a surgery or specialist referral, you again have recourse. Your doctor can contact the adjuster or the NCIC to emphasize the urgency. If the insurer outright refuses a treatment recommended by your authorized doctor, that’s essentially a dispute about medical care – you can request a hearing (Form 33) on that issue, or sometimes request an administrative order from the Commission for necessary treatment. Involving an attorney cab press an insurer to act, because they know delays could lead to penalties or legal fees against them. Also, keep your communication in writing when possible – email the adjuster asking “when can I expect my check dated X?” or “has the MRI for my back been approved yet?” so there is a paper trail. The bottom line: you do not have to simply endure unjustified delays. The NCIC expects insurers to pay weekly benefits on schedule and promptly authorize reasonable medical care. If they don’t, you can use legal remedies to enforce your rights.

Insurance companies sometimes employ tactics to minimize payouts. They may delay payments or deny certain treatments, and they might conduct surveillance and search your social media to find evidence to reduce your claim. Always be honest and follow your doctor’s restrictions, so they have no excuse to cut off your benefits.

No – firing or retaliating against an employee for filing a workers’ comp claim is illegal in North Carolina. The state’s Retaliatory Employment Discrimination Act (REDA) specifically prohibits employers from taking adverse action (“retaliation”) because you exercised your rights under the Workers’ Compensation Act. This means your boss cannot lawfully fire you, demote you, cut your pay, or otherwise punish you simply for reporting an injury or filing a claim. If they do, you have grounds to file a retaliation complaint with the NC Department of Labor or take legal action under REDA.

However, it’s important to understand the nuances: North Carolina is an “at-will” employment state, so employers can fire employees for many reasons (or no reason at all) – just not an illegal reason. Filing a workers’ comp claim makes you a protected worker for that activity. But if an employer can prove they fired you for a legitimate unrelated reason (like company-wide layoffs or serious misconduct on your part), that might be considered lawful. The timing and circumstances matter. If you suspect retaliation, document everything – write down comments or threats, keep copies of performance reviews, etc. The law places the burden of proof on you to show that your claim was a “substantial factor” in the employer’s action.

Also note: there are time limits to act. Generally, you must file a complaint about workers’ comp retaliation within 180 days of the retaliatory action (roughly 6 months) or you lose the right to do so. So don’t delay if you believe you were fired or mistreated for filing a claim. In practice, if you get fired while out on workers’ comp (or right after filing), talk to an employment or workers’ comp attorney immediately. They can help assess if it’s retaliation and guide you in filing a REDA claim or negotiating a resolution. Many employers know not to overtly fire someone for filing a claim, but subtle retaliation (like cutting hours or creating a hostile environment) can also be challenged. The key point: the law is on your side – you shouldn’t be punished for seeking benefits you’re entitled to.

This is a delicate situation. Under workers’ comp rules, if your authorized treating physician releases you to light duty or restricted work, and your employer offers a suitable light-duty position within those medical restrictions, you are generally expected to attempt it. Refusing a suitable job offer can put your benefits at risk. In fact, if you turn down suitable work, the employer/insurer may file to terminate your wage benefits on the grounds that you’re not cooperating.

However, “suitable” is the key word. The job must accommodate the restrictions the doctor gave. For example, if the doctor said “no lifting over 10 lbs, limit standing to 1 hour,” the light-duty job should honor that. If the offered work ignores your medical limits or is essentially a token job meant to push you out, you may have grounds to object. The proper course if you truly believe the job exceeds your abilities is to communicate with your doctor and employer. Go back to the doctor, explain the job duties, and see if the doctor will adjust your restrictions or state that the job is not suitable. Do not just stay home without saying anything. Ideally, the doctor will support you if the job demands too much.

If your doctor still okays it, you should at least try the job if possible. Keep a log of tasks that you struggle with or pain you experience. If you physically cannot do it, report that to your employer and doctor. In some cases, a trying to perform the job responsibilities will show it’s not feasible and then your doctor might take you back out of work. Remember, the goal of workers’ comp is to get you healed and back to work, so there’s an expectation to cooperate with return-to-work efforts that are safe. Just know that if you flat-out refuse a light-duty job that fits your restrictions, you could jeopardize both your job and your benefits. When in doubt, seek advice – a lawyer can petition the Commission if there’s a dispute about whether a job is appropriate. But as a rule: if the job truly fits within what your doctor says you can do, you should accept it, or at least attempt it under the doctor’s guidelines.

It’s not uncommon for injured workers to feel they aren’t getting the care they need – maybe the company doctor is rushing your appointments, or you disagree with a treatment plan or an impairment rating. Here are some steps and rights you have in NC if you’re unhappy with your medical care:

• Request a Change of Treating Physician: If you believe your doctor isn’t helping or you need a specialist, you (or your attorney) can request the Industrial Commission to order a change of doctor. You would typically file a motion or Form 33 to request a hearing for a change of physician (Form 33 is also used, but often these issues can be handled via a motion or administrative appeal to the Commission). You’ll need to show a good reason, like you’re not improving under current care or the doctor-patient relationship is problematic. The Commission will consider whether a new doctor is in your best interest and not an undue burden on the employer/insurer. If approved, the Commission may authorize you to see a different doctor (sometimes they’ll give a panel of options or let you choose).
• Second Opinions: If the issue is a permanent disability rating (PPD rating) that you think is too low, NC law gives you the right to a second opinion evaluation by a doctor you choose, at the expense of the insurance carrier. For example, if the company doctor says you have 5% impairment to your back and you believe it’s more like 15%, you may be able to pick another doctor (often a specialist) to perform an independent rating exam. The insurance must pay for that one-time exam. They don’t have to accept that second doctor’s rating outright, but if it’s higher, you can use it as evidence to negotiate or at a hearing, and the Commission often gives weight to a well-supported second opinion.
• Independent Medical Examination (IME): For other disagreements – say you feel you need an MRI or surgery that the current doctor is downplaying – you have the option to get an IME on your own. You would have to pay for it (unless the Commission orders the insurer to pay, which happens in some cases). An IME means you consult an independent doctor for their opinion on your diagnosis and treatment. Sometimes, presenting a strong IME report to the insurance company can persuade them to approve a treatment or change doctors. If not, you can present that evidence at a hearing.
• Talk to Your Adjuster (or Nurse Case Manager): Sometimes communicating your concerns can help. In some claims, a nurse case manager might be assigned and you can express that maybe a different type of specialist is needed. The insurance might agree to a second opinion or referral without a formal fight, especially if your doctor also recommends it.
• File for a Hearing if Necessary: If the insurer flat-out refuses necessary treatment or a doctor change and it’s truly harming your recovery, you can file Form 33 to bring the issue to a Deputy Commissioner. The Commission can order the insurer to provide a different doctor or approve a procedure if the evidence shows it’s medically needed.

The key is not to silently endure subpar treatment. You have a right to proper medical care. If you’re in pain and not getting better, or you doubt the doctor’s conclusions, exercise your rights to second opinions and Commission review. Just remember to stay within the legal process (don’t just start treating on your own outside workers’ comp, or you might have to pay for it). Follow the procedures: request approval or a hearing, and gather medical evidence supporting your position. It can be helpful to consult an attorney in these situations, as they deal with these disputes often and know how to navigate the Commission’s process.

It may surprise you, but yes, workers’ comp insurance companies in NC do sometimes hire private investigators to surveil injured workers. Their goal is to catch evidence that you are not as injured as claimed or are violating your work restrictions, so they can reduce or terminate your benefits. Surveillance can involve an investigator discreetly following you in public places, videotaping or photographing your activities. They might watch you doing things like grocery shopping, driving, or yard work – any activity that could indicate your injury isn’t severe or that you can work more than you’ve said. Insurers use this tactic to combat fraud, but often it’s just to create doubt about your disability.

Legally, if you are in public view, you can be recorded – there’s no expectation of privacy on public streets, in stores, etc. Investigators are not allowed to trespass on your property or peek inside your home (peeping tom and trespass laws protect you there). But they can stake out nearby and observe what you do outside. They may also monitor your social media for photos or posts that suggest you’re more active than your injury should allow. This is all legal as long as done within certain bounds.

How to handle it: Assume that at any point while your claim is open, especially if you have significant benefits at stake, you might be under surveillance. This doesn’t mean you have to live in fear – it means be truthful and consistent. Follow your doctor’s restrictions in real life, not just at appointments. For example, if you’re told not to lift more than 10 pounds, don’t decide to help a friend move furniture or carry heavy grocery bags. If you have a bad back injury, don’t go out and attempt to play sports. Even seemingly innocent activities like bending to pick up your child could be misconstrued on video if you claimed you can’t bend at all. Also, be mindful of social media; avoid posting videos of you doing physical feats or even overly upbeat claims of feeling “great” if that contradicts your injury claims. Insurance investigators may review Facebook/Instagram if they can find them.

If you suspect someone is surveilling you (unfamiliar car outside home repeatedly, etc.), it could be true. Usually, they are professionals and you may never notice them. In any case, the best defense is to always be honest – if you truly are as injured as you say, then surveillance should not be able to show you doing something you shouldn’t. Don’t exaggerate symptoms, because if you’re caught in even a small lie, it will seriously damage your credibility. Note that surveillance must still show something meaningful – if they see you walking to the mailbox, that’s not grounds to cut off benefits if your injury didn’t forbid walking. It’s typically used if they film you doing manual labor or strenuous hobbies while you claim you’re too hurt to work. If the insurer does reduce or stop your benefits citing surveillance, you have the right to challenge that and present your side (maybe the activity was approved by your doctor, etc.). But it’s better to avoid that fight by not giving them evidence in the first place. When in doubt, stick to your prescribed restrictions 100%. Remember, you don’t have to be bedridden to deserve benefits – but you do need to be consistent about what you can and can’t do.