Beverly Eaves
Perdue, Governor Pamela T. Young, Chair |
Bernadine S. Ballance,
Commissioner Laura K. Mavretic, Commissioner Danny L. McDonald, Commissioner Staci Meyer, Commissioner Christopher Scott, Commissioner Dianne C. Sellers, Commissioner |
North Carolina
Industrial Commission
Health Benefit Plans and Medical Costs
Internal Checklist
for the Review of Compromise Settlement Agreements
per N.C. Gen. Stat. §97-17 (amended 6/15/01)
1. Compensability of Claim
ڤ Admitted ڤ Adjudicated ڤ Denied
2. Was denial reasonable
ڤ yes ڤ no
3. All known medical expenses related to the injury have been listed
ڤ yes ڤ no
4. Expenses that are disputed are listed with adequate explanation
ڤ yes ڤ no
5. Medical expenses have been paid by (check all that apply)
ڤ a health benefit plan
ڤ a disability income plan
ڤ other health insurance plan
ڤ employee
ڤ workers’ compensation carrier/administrator/self-insured employer
ڤ not paid
6. Expenses paid or to be paid by the workers’ compensation carrier/administrator or self-insured are listed
ڤ yes ڤ no
7. CSA contains finding that the positions of parties to the agreement are reasonable as to the payment of medical expenses
ڤ yes ڤ no
8. There is a need for finality of litigation in this case
ڤ yes ڤ no
COMMENTS: ______________________________________________________
__________________________________________________________________
[For Commission Use] ________________Date:_________ |
Updated March 4, 2009
Chairman’s Memo
Health Benefit Plans and Medical Costs Internal Checklist for the Review of Compromise Settlement Agreements per G.S. §97-17 (former Chairman Lattimore’s August 14, 2001 memo).