Deception by the Insurance Adjuster: Why You May Need a Lawyer!

A new client showed me a letter today that was sent to the client by the workers’ compensation insurance adjuster.  She received this letter a few days  after the client reported her injury to her employer.

But first, a little background is needed.  In North Carolina, the injured worker needs to report the accident and injury to the employer, in writing, within 30 days.  But the worker also needs to file the claim with the NC Industrial Commission within two years of the incident, in order to preserve the claim and protect her legal rights under the Workers’ Compensation Act.  The “Form 18” is the worker’s claim form to obtain workers’ compensation benefits.

After the injured worker reports her accident and injury to her employer, the employer is required to file a “Form 19” with the NC Industrial Commission.  This form is called the “Employer’s First Report of Accident” and is used by the Commission as a statistical reporting form.  It does NOT constitute a claim by the injured worker for workers’ compensation benefits.

The Commission rules require the insurance adjuster or the employer to send a copy of the Form 19 to the injured worker along with a blank Form 18 to facilitate the ease of the employee in filing his or her claim for workers’ comp benefits.  This rule exists because injured workers would get the Form 19 and think their claim had been properly filed, and not find out differently until the statute of limitations had run.  You see, an insurance company can pretend to cover a case and pay for medical treatment for two years, then deny the claim as soon as the two year statute of limitations runs, without any recourse on the part of the employee.  So the rule requires the carrier to send the employee the Form 18 blank.

The letter my client got from the adjuster stated this:

“I have received your claim for worker’s compensation benefits. …..

If we accept your claim as compensable, any …. inpatient treatment requires pre-authorization.

As required by the NC Industrial Commission please find enclosed your Form 19 (the employer’s report of your injury) as well as a blank Form 18 (the employee’s report of injury).  If you choose, you have the option to complete the Form 18 and file it yourself with the North Carolina Industrial Commission to the address at the bottom of the form.”    

There, that was what the letter advised.  I put the really bad parts in italics.

Now, the adjuster knows full well that the injured worker has two years to file the Form 18 with the Commission in order to preserve her rights and make her claim.  If the adjuster has accepted the claim as compensable and filed the proper paperwork with the Commission (a Form 60) then the failure of the worker to file the Form 18 will not matter.   Otherwise, it is critical to the worker.  Here, the adjuster tells the injured worker that she has not accepted the claim yet, but then tells her that filing the Form 18 is an “option.”  At this point in the case, because the claim has not yet been accepted as compensable, it is absolutely necessary and crucial that the injured worker file the Form 18 with the Commission!  It is not an “option” if the worker wants file a workers’ comp case!

My new client told me she had no idea that the Form 18 needed to be filed by her to protect her rights until she talked to me.  She said this letter led her to believe that it was optional and she did not really have to do it or need to do it.

Basically, we have an insurance adjuster here who appears to have intentionally misled an unrepresented injured worker about the significance of the Form 18 Claim form.   To add insult to injury, my client is a State employee, and the insurance company that the State of NC has engaged to manage its claims is pulling this crap.  You would think the State would treat its employees a little better.

This letter illustrates why injured workers cannot trust the adjusters and insurance carriers to take care of them.

If you get hurt at work, it is a good idea to call a Board Certified Specialist in Workers’ Compensation Law for a free consultation before you talk to an adjuster, sign anything, or file anything with the Commission.