If you’ve been injured on the job, you may be wondering, “What are the two factors that determine workers’ compensation claims?” If you are a North Carolina worker, there is a good chance that you have, at some point, suddenly found yourself in a flurry of medical bills, lost wages, and insurance forms.
Although each situation has its own complexities, most workers’ comp cases are about two key factors: causation and proof of claim. If you can understand these two simple principles, you can better defend your rights and avoid the common errors that are made, resulting in denied or underpaid workers’ compensation claims.
About M. Reid Acree Jr., Attorney at Law, P.A.
Mr. Acree is a Winston-Salem workers’ compensation lawyer and is a Board Certified Specialist in the area of workers’ compensation law. He has over 35 years of experience representing injured and sick workers in North Carolina. Although he started his practice in defense, a pivotal case early in his career inspired him to dedicate himself to the rights of workers who have been mistreated by their employers and their insurers.
He has tried over 3,500 occupational disease cases, including complex asbestos-related and toxic exposure cases, as well as representing workers who have sustained serious injuries to their spine, joints, and extremities.
Whether the Injury Is Work-Related
The first important issue is whether your injury is legally considered to be work-related. In North Carolina, this is determined by two interrelated legal tests: whether the injury “arose out of” your employment and whether it happened “in the course of” your employment. “Arising out of your work” focuses on what caused the injury. The question is whether you were exposed to a specific risk at work that resulted in the injury. For instance:
- A back injury sustained by a warehouse employee while lifting large boxes
- A construction worker tumbling off a scaffold
- An assembly line worker in a factory suffering from repetitive stress injuries
This factor is typically satisfied if the risk was caused by the job itself. In 2023, there were 68,600 occupational injury and illness cases in North Carolina in the private industry. Of these, 40,900 were severe, with 24,100 needing days away from work.
The phrase, “in the course of your employment,” takes into account the injury’s location, time, and circumstances. In general, you have to be:
- On the job site or carrying out duties
- Working during the hours that are designated for work, or
- Working on a project that will help your employer
For instance, getting hurt while making a delivery or slipping in the employer’s parking lot on the way to work may still be eligible. These differences are fundamental to North Carolina’s workers’ compensation laws and frequently serve as the main point of contention in contested claims.
The Claim Must Be Properly Documented
Whether the claim is handled appropriately from an administrative and medical perspective is the second crucial component. If necessary actions are not taken, even a valid injury may be denied. This comprises:
- Notifying your employer of the injury as soon as possible
- Seeking approved medical care
- Submitting the necessary paperwork to the North Carolina Industrial Commission
- Adhering to recommended medical and occupational restrictions
Many workers’ compensation cases fail due to errors or gaps in the documentation, not because the injury wasn’t real. These technical problems are frequently used by insurance companies to withhold or postpone benefits.
Hire a Workers’ Compensation Lawyer
If your health, income, and future are at stake, you need a strong advocate on your side. When you are hurt on the job, workers’ compensation can become an overly complex, exhausting process. Your employer and their insurance company may be more focused on saving money than paying your benefits, and may delay, deny, or underpay your claim.
An experienced workers’ compensation attorney can help ensure your rights are protected and all necessary evidence is compiled to prove your claim for benefits. A lawyer can also handle all communications with the insurance company for you, giving you more time and peace of mind. If you have the right legal help, you are more likely to obtain the full medical benefits and wage replacement you need now and in the future.
FAQs
Q: What Are the Two Factors That Determine Workers’ Compensation Claims?
A: The two criteria that establish a workers’ compensation claim are whether the injury/illness was work-related and the severity of the injury. The injury must have arisen out of and in the course of employment. Benefit amounts are affected by the seriousness of the injury, the duration of time the worker is unable to work, and the type of medical treatment needed.
Q: What Are the Factors Determining Employee Compensation for Workers’ Comp Benefits?
A: The factors that determine the compensation that is paid to an employee for workers’ compensation benefits depend on the wages of the employee, the type of injury sustained, the degree of disability, the duration of treatment, and the ability to return to full or modified duty, which may also have an impact.
Q: What Are the Two Parts of Workers’ Compensation?
A: The two main components of workers’ compensation are medical benefits and wage replacement benefits. Medical benefits can include coverage for doctor visits, hospitalization, prescriptions, surgery, and rehabilitation, as well as any other treatment necessary due to the work injury. Wage replacement benefits offer employees partial wage compensation during periods when they are unable to work or when their work capacity is restricted.
Q: What Are the Major Factors to Determine an Employer’s Workers’ Compensation Rates?
A: An employer’s workers’ compensation rates are based on the risk level of their industry, the amount of payroll, their claims history, safety programs in place at the workplace, and an experience modification factor (EMR) unique to each employer.
Employers with workforces that have higher-risk job duties or with a higher frequency of claims tend to have higher premiums. Companies with better loss histories and lower frequency of claims may be able to qualify for lower rates.
Contact M. Reid Acree Jr., Attorney at Law, P.A., Today
M. Reid Acree Jr., Attorney at Law, P.A., can help you with your workers’ compensation matters. Contact us today and hire a workers’ compensation lawyer for help with your legal process.