Form 63, “Medical Only” Gives the Worker no Rights under NC Workers’ Compensation Law!

If you get hurt at work and report your injury to your employer, you may receive from their insurance company a “Form 63, Medical Only.” The block marked “2.” will be checked on this Form 63. A “medical only” Form 63 provides no rights that you or your lawyer can enforce. It is legally worthless!

The Form 63 is an Industrial Commission form designed to allow employers and workers compensation insurance companies to pay benefits to injured workers for up to 90 days voluntarily, without accepting legal responsibility for the claim. This is called a “pay without prejudice” form and the insurance company can pay for both medical expenses and out of work benefits for up to 90 days, and still deny the claim during that period. The 90 days counts from the day on which the employer had notice of the on the job injury, and not from the date the Form 63 is created and sent.

The Form 63 was designed by the Industrial Commission several years ago when the law was changed by the legislature to allow a “pay without prejudice” period, so that insurance companies could begin paying benefits, which helped the injured worker, without having to accept liability for a claim that they were still investigating. The idea was, let the insurance company take care of the worker for a period of time but do not penalize the insurance company if, after they start paying, they discover evidence that justifies a denial of the claim as not being covered under workers compensation law.

Unfortunately, and apparently at the urging of the insurance industry, the Commission added a “medical only” block (#2) to the Form 63. This “medical only” option was not authorized by the North Carolina General Assembly so there is a good argument that it is ultra vires or outside the legal authority of the Commission. However, because the Commission created it on its official form, the Commission allows insurance companies to use it. The problem with it is simply this: it does not accept liability for someone’s accident or injury when the insurance company uses the Form 63, “medical only” provision on the form. The insurance companies use it to “direct the medical treatment” of the injured worker without accepting liability for the claim. The law otherwise clearly requires the insurance company to first accept liability for the claim using Form 60 before it has the legal right to “direct the medical care” for the injury. Directing the medical care is really important to the insurance company because they get to choose the doctors and can deny authorization for tests and treatment, so they can control their costs. They get to steer the injured worker to doctors that the insurance companies know are either less expensive or who will send the client back to work quicker or otherwise keep the insurance company’s expenses as low as possible. But the insurance companies are not supposed to have this benefit of the law-“directing medical treatment”- without a corresponding obligation contained in the law, which is, accepting liability, or legal responsibility, for your injury. Unfortunately, the Commission’s creation of the form 63 “medical only” allows the insurance companies to sidestep their obligation to accept responsibility for your claim, but lets them direct your medical care anyway, to the benefit of the insurance company.

When a new client comes to see me and they have a Form 63 “medical only,” I look to see whether at least 14 days have passed since the employer got notice of the accident and injury. If it has, then the statutory period allowed to accept or deny a claim has passed. Because the Form 63, medical only is not an acceptance of the claim, I can then file a motion to the Commission requesting an order that compels the insurance company to “admit or deny” the claim. The Commission will routinely enter this order and typically gives the insurance company 30 days to either admit or deny the claim, even though the law only provides 14 days. I recently had a case in which the insurance company filed a Form 63 medical only and was sending my client to a back specialist in Hickory, and when I mentioned to the defense lawyer that I was thinking about filing a motion to force his client to admit or deny the claim, he advised that if I filed such a motion, they would just deny the claim. I therefore held off on filing the motion because I did not want to put my client in the position of having to litigate a denial for a year when she was in fact getting reasonable treatment for her injury at the insurance company’s expense. So, it is a judgment call based on the facts of each individual case, as to whether or not a “motion to admit or deny” is appropriate.

This whole “Form 63 medical only” practice is insidious, really. The state legislature has never approved it or authorized it, and the insurance companies use it to avoid their legal obligations while still trying to take advantage of the legal and economic benefits of directing medical care. The problem has been brought to the attention of the Industrial Commission but as of yet, nothing has been done to address the practice.

If you get hurt and receive a Form 63 “Medical Only” then you should contact Bob Bollinger, a Board Certified Specialist in North Carolina Workers Compensation law, to discuss your legal rights and obligations and what might be done to improve your situation under the Workers’ Compensation Act.

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