Why Does the Insurance Company Need My Past Medical Records for a Workers’ Comp Claim?
If you’ve filed a workers’ compensation claim in NC, the insurance company will request your medical records and potentially communicate directly with your doctors. Get the facts in our blog.
If you’ve filed a workers’ compensation claim in North Carolina, the insurance company will request your medical records and potentially communicate directly with your doctors. For many injured workers, this raises valid concerns about privacy, fairness, and whether insurers are digging for reasons to deny benefits.
It’s important to understand that while insurance companies do have certain rights to medical information, North Carolina law places clear limits on what they can access and how they can obtain it. Those limits are stated in North Carolina General Statutes § 97-25.6, which balances an employee’s right to medical privacy with the need to resolve workers’ compensation claims fairly.
Why Are Medical Records Requested in Workers’ Compensation Cases?
Under North Carolina law, workers’ compensation insurance carriers are entitled to “reasonable access to all relevant medical information” necessary to evaluate a claim, meaning they are not entitled to unlimited access to your entire medical history.
Insurance companies typically review medical records to:
- Confirm that the injury or illness is work-related
- Understand the diagnosis and treatment plan
- Determine work restrictions and return-to-work ability
- Evaluate temporary or permanent disability
- Decide how long benefits should be paid
What Counts as “Relevant Medical Information” Under North Carolina Law?
Section 97-25.6 strictly defines what medical information is considered relevant. Insurers may only request records that fall into one of these categories:
- Records explicitly related to the evaluation, diagnosis, or treatment of the injury or disease being claimed
- Information reasonably related to the claimed work injury
- Records connected to an assessment of the employee’s ability to return to work
This means insurers cannot access records relating to unrelated medical conditions, past injuries, or private health issues unrelated to the workers’ compensation claim.
Can an Employer or Insurer Get My Medical Records Without Permission?
Yes, but only within the limits of the law.
North Carolina law allows employers and their insurance carriers to obtain relevant medical records from authorized health care providers without the employee’s express written authorization. However, if the claim is denied or the employer does not pay the provider, the employee must receive written notice of the request. Additionally, if the employee requests copies of the records received, the employer must provide them within 30 days. This ensures transparency and allows injured workers to see exactly what information is being reviewed.
How Are Insurers Are Allowed to Communicate With My Doctor?
Written Communications. Insurance companies may send written questions to your authorized treating provider, but they must notify you in advance. You are entitled to receive a copy of your doctor’s written response within 10 business days. These communications are limited to topics such as:
- Diagnosis
- Course of treatment
- Time out of work
- Work restrictions
- Whether the condition is related to employment
- Permanent impairment, if any
Oral Communications. Verbal conversations with your doctor are even more restricted. Before an insurer speaks with your provider by phone, you must receive advance notice and the opportunity to participate in the call. If you don’t participate, the insurer must provide a written summary of the conversation within 10 business days.
Your Right to Object and Seek Protection
If an employer or insurer wants to send additional information to your doctor, such as job descriptions, surveillance, or other materials, you have the right to:
- Review the proposed communication in advance
- Object within 10 business days
- Request a protective order from the North Carolina Industrial Commission
The Commission can block or limit improper communications and may even require the unreasonable party to pay attorneys’ fees and costs. However, North Carolina law makes it clear that the workers’ compensation system is not meant to eliminate the physician-patient relationship. The Industrial Commission has the authority to issue protective orders to prevent unreasonable annoyance, embarrassment, or oppression, and undue burden or expense. If an insurer oversteps, legal options may be available.
What Are My Legal Rights as an Injured Worker in North Carolina?
If you’ve been hurt at work, you have the right to:
- Necessary medical treatment for your work injury
- Wage replacement benefits if you cannot work
- Copies of medical records and provider communications
- Notice of insurer requests for medical information
- Object to improper disclosures or communications
- Legal representation at any stage of your claim
You do not have to accept an insurance company’s interpretation of your medical records or their conclusions about your ability to work.
Get Help from an NC Workers’ Compensation Lawyer at Daggett Shuler
If you’re worried about medical record requests, uncomfortable insurer communications with your doctor, or a workers’ compensation claim that’s been denied or undervalued, you don’t have to face the process alone.
We understand the law, the tactics insurance companies use, and how to push back when your rights are at risk. Our workers’ compensation lawyers are here to discuss your situation and to help you learn how we can help protect your benefits, your privacy, and your future after a workplace injury.
Contact us today by submitting an online form or calling our office at (336) 724-1234.
