Denied Workers' Compensation Claims

Massachusetts employers are required to notify their workers’ compensation insurance companies whenever one of their employees is injured on the job. The insurance company reviews the circumstances of the incident and then makes a decision on whether to provide workers’ compensation benefits to the injured worker.

If your claim is denied, your case isn’t necessarily over, and all hope is not yet lost when it comes to obtaining workers’ compensation benefits. Contact an attorney who regularly handles workers’ compensation claims as soon as possible to go over your options. They can explain how to maximize your chances of obtaining a full and appropriate workers’ compensation benefits award.

In fact, the Commonwealth of Massachusetts, the Executive Office of Labor and Workforce Development (EOLWD) advises all claimants to obtain legal representation to assist with the claims process. Injured employees who choose to file workers’ compensation claims without consulting an attorney may run into significant issues or become lost in legal language. Often times, their claims will be denied.

As our Boston workers’ compensation attorneys at the Jeffrey Glassman Injury Lawyers can explain, when your employer’s insurance company denies your claim for workers’ compensation benefits, certain steps must be taken right away to preserve your rights. The assistance of an experienced attorney can be invaluable during this process.

For example, after the insurance company denies your workers' compensation case, an Employee’s Claim Form must be submitted to the Department of Industrial Accidents (DIA), to start the court process. The DIA is the Massachusetts agency that oversees the workers’ compensation system. Medical evidence supporting your workers’ compensation claim must be submitted to the DIA along with the claim form. Documentation such as medical bills and physician’s reports, as well as statements from co-workers or any other witnesses to your on-the-job accident will help substantiate your claim. An attorney will be able to assist you in determining which information is beneficial to getting your case started.

Once the DIA receives your claim package, the agency will process your paperwork and schedule a Conciliation. They typically are scheduled to occur within two to three weeks of your claim being submitted.

In addition to a claim by an injured worker, Conciliations can also develop as a result of a workers’ compensation benefits insurer filing a complaint for modification, discontinuance or recoupment of compensation benefits. An insurance company will file these complaints when they want to stop or change your benefits, but require court permission to do so.

Conciliation is the first meeting that takes place in the workers’ compensation dispute resolution process. Your experienced workers’ compensation attorney will attend an informal meeting with a court conciliator and a representative of the insurance company. During the conciliation process, the parties will discuss possible ways to resolve the claim that was filed. Some options include a 19 agreement, reaching a settlement, or withdrawing the claim. Typically, it is best not to attend this meeting without first consulting with an attorney. Your attorney can also attend this meeting on your behalf and may recommend that you remain at home.

If a resolution can’t be reached, the case will be referred to a DIA judge for the next stage of the process, a Conference.

A workers’ compensation Conference in the Commonwealth of Massachusetts is a formal meeting before an Administrative Judge. Conferences are more formal than Conciliations. Typically, the injured employee attends the Conference. However, in some circumstances, the injured workers’ attendance is excused.

During the Conference, attorneys for the injured worker and the insurance company present arguments as to why a worker should or should not receive workers’ compensation benefits. Witnesses will not testify, but your attorney can present other evidence that supports your claim. For example, medical records, accident reports, witness statements, or photographs may be used to prove your case. The Administrative Judge will listen to the arguments, review the materials submitted, and ask any questions they may have. Within a week, the judge will then issue an order deciding the claim.

If either party is unhappy with the judge’s decision, an appeal can be filed. The judge’s decision remains in place while the case is sent forward for a formal legal hearing.

If either party appeals a judge’s decision, the workers’ compensation case will be sent forward for a Hearing. A Hearing is somewhat similar to what you see on television. Your attorney will present evidence, cross-examine witnesses and argue for your rights to workers’ compensation benefits. You will likely be called to testify about the accident as well as your injuries. The rules of evidence for the Commonwealth of Massachusetts apply during a Hearing. Injured workers are strongly urged to seek legal representation prior to this stage in the process.

After hearing all the testimony, reviewing the evidence and rereading the proceeding transcripts, the Administrative Judge will make a formal written decision on the case. The judge’s decision will address all issues and decide what benefits, if any, an injured employee is entitled to.

In some rare situations, the judge’s final Hearing decision can be appealed to the Department of Industrial Accidents Reviewing Board. Both you and your employer’s insurance carrier have will have 30 days to appeal the judge’s decision to the Reviewing Board.

Appeals before the Reviewing Board are heard before six Administrative Law Judges. The review board can uphold the prior order or reverse it. The board also has the option of sending the case back to the prior Administrative Judge for additional proceedings.

You can access and read the review board’s decisions on their website, DIA Reviewing Board Decisions.

In even rare situations, a Reviewing Board decision can be appealed to the Massachusetts Court of Appeals, which is the state appellate court. Like a Hearing decision, the parties have 30 days to appeal a decision issued by the review board.

When you receive a denial of your workers’ compensation claim, it will come on a 104 Form that may have all the check boxes marked off. It may not provide much information as to why your claim is being denied. However, there are a number of common reasons an insurance company may use to deny your claim for workers’ compensation benefits. They include:

• Your employer may dispute that your injury occurred at work
• The insurance company may argue that you have a preexisting condition that is causing your problems
• They may claim your injury isn’t as severe and debilitating as you say
• You may have failed to report your injury in a timely manner
• No one saw your injury
• The accident report from the accident may not match your medical records
• Your medical records show illegal drugs in your system when you reported to the emergency room following your work accident

It’s important to keep in mind that insurance companies are often focused on one thing—their own financial wellbeing. Insurance companies often deny claims to save themselves money.

Hiring a skilled workers’ compensation attorney is the best and most effective action that you can take to maximize your chance of obtaining adequate compensation after a claim denial. The workers’ compensation attorneys at Jeffrey Glassman Injury Lawyers are experienced with all the reasons an insurance company may come up with to deny your claim and know how to overcome them.

If you’re dealing with a denied workers’ compensation claim in Massachusetts, contact the Boston workers’ compensation lawyers at Jeffrey Glassman Injury Lawyers today at (617) 777-7777 for a free and confidential consultation.