Successful Appeals of Denied Workers’ Compensation Claims for Repetitive Stress Injuries

Successful Appeals of Denied Workers’ Compensation Claims for Repetitive Stress Injuries

By: Perry Morrison

Workers’ Compensation Claims in North Carolina

North Carolina Workers Compensation insurance is a system of laws and regulations providing financial benefits to injured workers who experience work-related injuries and occupational illnesses.

The system, administered by the North Carolina Industrial Commission (NCIC), protects against accidental and repetitive stress injuries (RSI). RSI develops at the workplace over time due to repetitive motions or overuse of specific muscles, joints, tendons, bones, and nerves. The most common are carpal tunnel syndrome, trigger finger, tenosynovitis, rotator cuff injuries, and tennis elbow.

Average Compensation Workers Get for Repetitive Stress Injuries

The statistics on compensation for repetitive stress injuries look promising. Most workers (75%) claiming RSI receive reimbursement via settlement or award. On the other hand, 25% of workers end up without compensation (with their claims denied).

The median recovery workers receive is between $13,600 and $22,100 through settlements and awards as compensation for repetitive stress injuries. However, most workers (57%) received $10,000 or less, while 29% got between $10,000 and $40,000. Only 14% of workers were lucky enough to receive over $40,000.

How Long Does the RSI Claims Process Last?

Repetitive stress injury claims take longer to get resolved. On average, getting compensation for RSI lasts 16.1 months – slightly longer than an average of 15.7 months for other compensation claims.

One of the reasons it takes longer to get fair compensation for repetitive strain injuries is the nature of the claim. These claims get denied more often (due to more complex proving), meaning you have to request a hearing or file an appeal.

What is the Percentage of Denied Compensation Claims for RSI?

Compared to other types of claims, repetitive stress injuries claims get denied more often. Almost half of those claims (48%) faced initial denial by the insurance companies.

Despite the high percentage of denials, it is not an unusual initial outcome in repetitive stress injury claims. RSIs develop gradually, almost unnoticeably. Because there is no traumatic event (a workplace accident) directly contributing to the occupational illness, proving repetitive stress injuries occurred at work is more complex. After receiving an initial denial, about 40% of workers file an appeal or request hearing with the NCIC seeking compensation.

The most typical reasons for claim denials are the following:

• Preexisting condition. Among all compensation claims, repetitive stress injury claims usually get denied because of alleged preexisting conditions. The nature of these injuries (progressing slowly over time) gives rise to suspicion, causing the initial denial. Insurance companies tend to ascribe the illness to aging or an old injury. About 28% of RSI claims receive denial due to such conditions.

• Missed deadlines. Failing to meet deadlines is another common cause of RSI denials. In North Carolina, you must notify your employer within a reasonable time of experiencing the first signs of repetitive stress injury, and file your Form 18 with the NCIC within two years of your medical diagnosis where a doctor says that is arises from your employment. Missing these time limits is a reason for denial.

• Off-site or off-duty injuries. Insurance companies often deny compensation claims because injuries occurred off-site or off-duty. They argue that the injury occurred while the worker was away from the workplace or during off-hours. RSI claims are specific. You do not have to be at work when you feel the first symptoms of repetitive stress injury. Because RSIs are unrelated to an individual traumatic event, you will most likely experience the first symptoms when you are away or on weekends. However, insurance companies will use that against you, claiming you have prior health issues or your symptoms occurred due to off-duty injury.

Appealing your Denied Compensation Claim for Repetitive Stress Injuries in North Carolina.

As mentioned, 40% of workers receiving a denial for repetitive stress injury claim file an appeal.

In North Carolina, the insurance company should send you a notice within 30 days of submitting your claim explaining the reasons for the denial.

An appeals procedure consists of a formal hearing and (if necessary) further appeals.

• Formal Hearing

To initiate an appeal process, you must file a Request for Hearing using Form 33. The deadline is two years, starting from the date of your injury. In case of repetitive stress injury, the deadline starts from the day you first experienced the symptoms of your illness.

By submitting Form 33, you will start the procedure before the North Carolina Industrial Commission. The process resembles a civil trial – both parties present evidence (medical documentation, photographs, etc.) and interrogate witnesses. The deputy commissioner issues a final decision based on the available evidence, awarding compensation or denying your claim.

Without professional legal help, you are less likely to navigate the complex evidentiary process. Hiring an attorney to represent you at a formal hearing is highly recommendable.

• Full Commission Review

If the Deputy Commissioner denies your claim following a formal hearing, you can appeal the decision to the Full Commission – a panel of three compensation judges. The Commission reviews the hearing record and the briefs you and the other party submit, sometimes even hearing oral arguments. Filing an appeal is possible through Form 44 (an Application for Review). You must send it to the NCIC within 15 days of receiving the first-instance decision.

• Further Appeals

The decision denying your claim does not mean you lost your chances of getting RSI compensation. You can appeal further – first, to the North Carolina Court of Appeals and then possibly further to the North Carolina Supreme Court.

What does a successful appeal look like?

Succeeding with your appeal requires addressing and refuting each ground for the denial.

Since most repetitive stress injury claims denials rely on prior condition arguments, you must present evidence proving otherwise. Include medical documentation showing you do not have such a condition, or your condition is not related to the current repetitive strain injury. Alternatively, you must prove that (despite having prior health issues) your recovery is complete, so a new work-related injury should be considered a new RSI. In addition to presenting evidence, you should include signed statements from coworkers or family members, witnessing how your repetitive strain injury worsened over time due to work-related conditions.

Increase Your Chances of Success with Perry Morrison

Having an experienced Workers Compensation attorney on your side will increase your chances of success when appealing denied repetitive stress injury claims. The statistics on compensation amounts are convincing – workers without lawyers received between $8,700 and $14,700 (through settlement or award), while workers with lawyers received between $8,700 and $27,800.

Perry Morrison has been practicing Workers’ Compensation law since 1989. His profound knowledge of insurance policies, trial practice and appellate procedures will doubly enhance your chances of a successful outcome.

Do not let the insurance companies take advantage of complex appeals procedures, leaving you without the compensation you deserve – reach out today to schedule your appointment at 252-243-1003.