What to Do If Your Workers’ Compensation Claim for Surgery is Denied in North Carolina? 2025

A workplace injury requiring surgery can leave you facing serious physical and financial hardships. Workers’ compensation is designed to ease the burden by covering medical expenses, including surgery, but denials can leave injured workers feeling uncertain and frustrated. If your claim for surgery has been denied, you are likely wondering what to do if your workers’ compensation claim for surgery is denied in North Carolina.

Don’t lose hope. There are steps you can take to challenge the decision and fight for the care you need.

Understand Why Your Claim Was Denied

The first step in addressing a denial is understanding the reason behind it. Common reasons for denying surgery claims include disputes over medical necessity, arguments that the procedure is unrelated to the workplace injury, or inadequate documentation from the treating physician.

Review the denial letter carefully, as it will explain the specific reasons for the decision. This document is critical for formulating your next steps. If the denial involves a disagreement about the necessity of the surgery, additional medical evidence may be required to support your case. For example, obtaining a second opinion from another physician can strengthen your claim.

File a Request for a Hearing

If your surgery claim is denied, you have the right to appeal the decision. In North Carolina, this process begins by filing a Form 33, officially requesting a hearing before the North Carolina Industrial Commission (NCIC). This form notifies the Commission of your intent to challenge the denial and outlines the issues to be addressed.

At the hearing, a Deputy Commissioner will review your case, including medical evidence, accident details, and testimony from relevant parties. Thorough preparation is essential to presenting a strong argument. Medical records, medical opinions, and documentation linking the surgery to your workplace injury will play a crucial role in convincing the Commission to overturn the denial.

Participate in Mediation

Before your case proceeds to a formal hearing, the NCIC may require mediation. This process involves a neutral third-party mediator who works with you and the insurance company to resolve the dispute. Mediation is often less adversarial and time-consuming than a hearing, making it an opportunity to reach a fair agreement more quickly.

During mediation, ensure that you present clear evidence supporting the necessity of your surgery. This includes a doctor’s recommendation, diagnostic test results, and any other documentation that highlights the damage of the injury on your life and the benefits of the procedure. An experienced attorney can represent you during mediation, helping you negotiate effectively with the insurance company.

Prepare for a Formal Hearing

If mediation does not resolve the issue, your case will proceed to a formal hearing before a Deputy Commissioner. During this process, both sides will present evidence and arguments, after which the Deputy Commissioner will issue a ruling.

To prepare, gather all relevant evidence, including medical records, treatment history, accident reports, and testimony. A strong legal strategy is crucial, as insurance companies often present their own consultants to argue against the surgery. Your attorney can cross-examine these witnesses and highlight the medical necessity of the procedure.

Understand the Importance of Timely Action

In North Carolina, it’s essential to act quickly after receiving a denial. Failing to meet deadlines for filing a hearing request or submitting necessary documentation can jeopardize your claim. For instance, filing Form 33 must occur within a specific time frame, and missing this deadline may result in losing your right to appeal.

By taking immediate action, you preserve your ability to challenge the denial and ensure your case remains active. Prompt action also allows more time to gather evidence and consult with doctors if needed.

How Legal Representation Can Help in in North Carolina

Navigating a workers’ compensation denial for surgery can be complex and stressful, especially while recovering from an injury. A skilled workers’ compensation attorney can provide invaluable support by reviewing your denial, gathering additional medical evidence, and representing you during mediation or hearings.

Attorneys understand the tactics used by insurance companies to dispute claims and can counter these arguments effectively. They also ensure all deadlines are met and that your case complies with North Carolina’s workers’ compensation rules. With legal representation, you have a stronger chance of securing the benefits you need for surgery and recovery.

FAQs

Can Workers’ Compensation Deny Surgery in North Carolina?

Yes, workers’ compensation can deny surgery if they dispute its necessity or claim it is unrelated to the workplace injury. Common reasons include disagreements between the treating physician and the insurance company’s doctor. Workers can challenge the denial by requesting a hearing through the North Carolina Industrial Commission and providing detailed medical evidence supporting the need for surgery to reverse the insurance company’s decision.

What Should You Do If Surgery Is Denied by Workers’ Compensation in North Carolina?

If surgery is denied, request an explanation from the insurance company. Then, file a hearing request with the North Carolina Industrial Commission. Submit medical records, including your physician’s recommendation, to prove the surgery is necessary. Consulting an experienced workers’ compensation attorney ensures your case is presented effectively, helping to protect your rights and improve the chances of overturning the denial.

Why Would Workers’ Compensation Deny Surgery in North Carolina?

Surgery may be denied if the insurance company argues it is unnecessary, unrelated to a workplace injury, or conflicts with their medical guidelines. A lack of sufficient evidence from the treating physician can also result in denial. Strengthening your case with additional medical opinions and detailed documentation is critical to challenging the denial effectively.

Can You Appeal a Workers’ Compensation Surgery Denial in North Carolina?

Yes, you can appeal by filing a request for a hearing with the North Carolina Industrial Commission. During the hearing, you must present medical evidence, such as records and testimony from your physician, to show the surgery is essential. Acting promptly is crucial, as appeals must be filed within specific deadlines to ensure your claim remains valid.

Schedule Your Workers’ Compensation Appeal Consultation Today

Law Office of Lyndon R. Helton, PLLC, is proud to serve injured workers in Burke County, Catawba County, and Caldwell Counties. Our experienced team is committed to helping you challenge denials, navigate the complex appeals process, and secure the benefits you need for recovery. Contact our trusted legal team today to schedule your consultation and take the first step toward ensuring your rights are protected.