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]
Medical Expenses Have Been Considered

________________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).


N.C. Industrial Commission ·   4340 Mail Service Center ·   Raleigh, NC 27699-4340
Main Telephone: (919) 807-2500 ·   Fax: (919) 715-0282
NCIC Home Page: http://www.ic.nc.gov/