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What Happens If My Massachusetts Workers’ Compensation Claim Is Denied?

The workers’ compensation system in Massachusetts is intended to compensate eligible workers who have been injured while on the job in Massachusetts. If your claim is approved, your medical expenses associated with the injury will be covered and you will receive wage replacement income for any time that you are unable to work as a result of the injury. Filing a claim is the first step, but what happens if the claim for workers’ compensation benefits is denied?

Receiving a Denial

The Department of Industrial Accidents, or DIA, is responsible for handling workers’ compensation claims in Massachusetts. All claims must originate with Office of Claims Administration, or OCA, within the DIA. Your claim may be filed with the OCA by you, by your employer’s insurance carrier, by your attorney, or by a third party provider. Your employer’s insurer, however, may decide to deny the claim. The insurer has 14 calendar days from the time the claim is received in order to investigate the claim and decide whether to approve or deny the claim. If the insurer denies the claim, they must notify you in writing, by certified mail, of the denial and explain why they denied the claim. In addition to explaining why the claim was denied, the insurer must also include an explanation of your rights, including your right to appeal the denial. All of this should be sent to you on an Insurer’s Notification of Denial – Form 104.

Appealing a Denial

Once you have been officially informed that your claim has been denied, or if the time frame within which the insurer had to respond to the initial claim has elapsed and you have not received a response, you are entitled to appeal the denial. The appeal process requires you to submit an official appeal form known as the Employee’s Claim – Form 110 to the DIA. Along with the completed appeal form, you must also send any medical evidence or documentary evidence that you have that supports your claim to the DIA. You are also required to send a copy of the completed Employee’s Claim – Form 110 to the insurer. After the DIA receives all of this, you will be scheduled for what is referred to as a “Conciliation” meeting.

Conciliation, Conference, Hearing and Review Board

The conciliation meeting is an informal meeting that takes place between you and the insurer. The only way that any decision reached at a conciliation is binding is if both you and the insurer agree to the decision. If the insurer is still not willing to approve your claim after the conciliation meeting, then a Conference is scheduled in front of an Administrative Law Judge. Although this is also relatively informal in nature, an Administrative Law Judge does have the authority to issue a temporary order if you and the insurer are still not in agreement. The judge will either order the insurer to pay the claim or not. If the judge does not issue the temporary order in your favor, you have 14 days to appeal that order. The insurer can also appeal if the judge orders that benefits be paid.  If either you or the insurer appeal the temporary order, then a formal hearing is scheduled in front of an Administrative Law Judge. This hearing is more like a formal trial where evidence is admitted and testimony given. The judge will then enter a formal, permanent order approving or denying your claim. The final level of review for a denial is to the Review Board. Either party may appeal the Administrative Law Judge’s decision to the Review Board within 30 days after the order is entered. The Review Board is made up of three Administrative Law Judges who will review the transcript of the formal hearing and may ask for additional arguments by the parties involved. The Review Board only reverses the standing order if the Administrative Law Judge clearly had no basis for the decision, the decision conflicts with the law, or the judge did not have the proper authority to make the decision that was made.

Representation During the Appeal Process

As you can clearly see, the appeal process for a Massachusetts workers’ compensation claim can be long and complicated. At each stage of the claims process it becomes harder to reverse a decision and get a claim approved. Retaining the assistance of an experienced Massachusetts workers’ compensation attorney at the beginning if the claims process can help avoid the need to get caught up in the appeals process altogether. Contact the Massachusetts workplace injury lawyers at Kantrovitz & Associates, P.C. if you need assistance with filing a claim or appealing a denial by calling 800-367-0871 or by using our online contact form.