WHAT MAKES A CLAIM COMPENSABLE AND WHAT BENEFITS ARE YOU ENTITLED TO UNDER THE NORTH CAROLINA WORKERS’ COMP ACT
I. In North Carolina, a person must have either sustained an “injury by accident" or have an “occupational disease" to have their claim be deemed compensable.
You Must Show that You Sustained an "Injury by Accident". The North Carolina Workers’ Compensation Act defines an "injury by accident" as an unlooked for or untoward event such as a slip, trip, fall or other unexpected event that interrupts your usual work routine. If the injury occurs while you are performing a task in the same way you always perform it (bending down to lift a box and your knee pops), chances are that the claim is not going to be compensable.
The one exception to this rule is for back injuries. Back injuries are compensable if the injured person can show an injury as a result of a “specific traumatic incident". A back injury by a specific traumatic incident is compensable regardless of whether or not the “normal work routine" is interrupted or not.
The Injury by Accident Must also "Arise Out of and in the Course and Scope of" your Employment. Basically, the phrase "arising out of" refers to the origin or cause of the accident. You must show a causal connection between your employment and the injury. The phrase "course and scope of employment" refers to the time, place and circumstance surrounding your injury. For the injury to occur during the course and scope of your employment, you must be engaged in an activity which you are authorized to undertake and which furthers the employers business.
"Occupational Diseases" are specific conditions which are listed in the North Carolina Workers Compensation Act. These conditions include asbestosis, silicosis, synovitis, tenosynovitis, bursitis, and chemical exposure.
There is also a "catch all" provision which defines an "occupational disease" as any disease where your job exposed you to a greater risk of contracting the disease than members of the public generally and that your exposure significantly contributed or was a significant causal factor in the disease’s development. A common "occupational disease" that is included under this provision is carpal tunnel syndrome.
II. Once an injury has been deemed compensable or the carrier has admitted to your right to compensation, your benefits can be broken down into 2 categories, Compensation and Medical Compensation.
A. Compensation can be essentially be broken down into two separate categories: Lost Wages and Permanent Disability.
Lost Wages: An injured employee is entitled to 66 2/3% (.6667) of their average weekly wage after the first seven (7) days of disability. The average weekly wage is usually calculated by looking at the gross (pre-tax) wages earned in the 52 weeks preceding the injury. Once calculated, the average weekly wage is multiplied by .6667, which yields the weekly compensation rate. An injured employee will receive weekly checks at this rate until their period of disability is over.
Permanent Disability: Sometimes an injured body part does not heal 100%. When this occurs, you doctor will assign an "impairment rating". Benefits for this rating are calculated using the "Schedule of Injuries; Rate and Period of Compensation" set forth in N.C.G.S. § 97-31. Benefits under this schedule will vary depending on the body part injured and the rating assigned by the treating physician. If you are not satisfied with the rating, you have the right to obtain a second opinion on the rating as set forth in N.C.G.S. § 97-27(b).
*There is a third option for benefits when a person returns to a job earning less than they were prior to the injury. If this occurs, the injured person has a right to chose between the rating and 66 2/3 the difference of their average weekly wage and the weekly check they currently receive. This is limited to 300 weeks of benefits from the date of injury.
B. Medical compensation is defined as “medical, surgical, hospital, nursing and rehabilitative services and medicines, sick travel and other treatment…as may reasonably be required to effect a cure, give relief or lessen the period of disability." N.C.G.S. 97-2(19). Medical Compensation: If the insurance company has accepted your claim, all medical bills related to your workers’ compensation claim, including prescriptions, and travel to and from your doctor’s office should be paid by the insurance company.
In regard to travel expenses, you are currently entitled to collect for mileage for travel to treatment facilities at the rate of 50 Cents ($0.50) per mile, provided that travel is 20 miles or more per round trip. In addition, injured workers with special needs may be provided with transportation to and from their medical appointments.
Vocational Rehabilitation: Sometimes, an injured employee is unable to return to his/her previous job because of physical restrictions that have resulted from their workers’ compensation injury. In those instances, the employee can seek vocational rehabilitation. Vocational Rehabilitation can assist in finding a new job that meets the restrictions imposed by the treating physician or even help the employee get the training and education needed to find work in a new field.
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