By :Douglas A. Petho
If you have been injured at work your employer or health insurance company may have advised you to seek benefits under North Carolina workers compensation. If you have never had to file a claim before, you may be confused as to what workers compensation is, what benefits you are entitled to.
Entire books have been written on all the intricacies and nuances involved in pursuing workers compensation claims. My purpose here is to merely provide a simple understanding of the system.
The first thing to understand is that claims for compensation under Workmen’s Compensation do not require a showing of fault or negligence on the part of the employer. All that is required for injury to be compensable is that the injury must be(1) by accident,(2) arising out of, and (3) in the course and scope of employment.
North Carolina Courts have defined an accident broader than one might think of when thinking of “accident”. An accident has been defined by our Courts as an “unlooked for event and implies a result produced by a fortuitous cause”. It must involve more than employee’s performance of his or her usual and customary duties in the usual way. Put another way, it must result from an interruption of the employee’s normal work routine introducing unusual conditions.
There is also a very important exception when it comes to injuries to the spine.
In 1983, the definition of injury was amended to create a special rule for back injuries. The amendment allowed compensation for injuries sustained to the back as a result of a “specific traumatic incident“. As such, back injury does not need to be the result of an unlooked for or untoward event not expected or designed by the injured employee if the back injury arose from a “specific traumatic incident”.
An injury arises out of the””course and scope” of employment when it is a natural and probable consequence or incident of employment and as a natural result of one of its risks, so there is some casual relationship between the injury and the performance of some service of the employment. There must be a casual relationship between the accident and the employment. While many cases the relationship is clear, for example falling from a ladder other times it is less clear. Unexplained falls or death, personal medical conditions, assaults or robberies at work and acts of nature often present difficult issues in determining whether an injury arises out of the course and scope of employment.
Finally, the term employment includes employment by the state and all political subdivisions thereof, and any public and quasi-public corporations therein and all private employment in which three or more employees are regularly employed in the same business or establishment. There are various exceptions including those dealing with agricultural and domestic workers. There are also exceptions for independent contractors. There are also exclusions dealing with independent contractors.
Assuming that an employee has sustained an injury as a result of an accident in the course and scope of his or her employment then workers compensation will provide benefits. These benefits are limited to medical benefits wage loss benefits and death benefits.
Medical benefits provide rehabilitation and medical treatment to the injured worker that affect secure or reduces the extent of the disability and provides relief and treatment for permanent injuries. There is no limit on medical treatment the employer is to provide.
Wage loss benefits to encompass three different categories of benefits.
First,total disability is the complete inability to earn any wages after and because of a compensable accident or occupational disease. it may be temporary or permanent.
Second, partial disability is the inability to earn the same wages that an employee was earning prior to suffering a compensable injury. It may be temporary or permanent.
Partial disability applies if an employee is unable to return to either the same number of hours or at the same rate of pay prior to injury.
Third, death benefits are payable in the event employees killed as a result of the compensable accident or occupational disease. The injured worker’s dependents are entitled to death benefits and funeral expenses. North Carolina limits funeral expenses $10,000 and death benefits equal to 500 weeks of pay.
The amount of wage loss benefits are calculated at 66 2/3% of the injured workers pretax average weekly wage.