Workers' Compensation Dispute Process
The Massachusetts workers’ compensation dispute process can be an arduous one.
We recognize that while some benefits may take a longer time to secure than others, the claims are no less legitimate.
If your injury or illness is fairly straightforward and the insurer approves your claim right away, you’ll probably receive benefits in about three-to-four weeks. However, if your claim is in dispute, the insurer could handle it one of a couple ways:
- Insurer may deny the claim and refuse to pay benefits.
- During the first 180 days, known as the “Pay-Without-Prejudice” period, the insurer may pay benefits without issuing a final decision or conceding liability. Insurer may reduce or stop benefits at any time during this period with a seven-day notice to the employee. The insurer can extend this period for up to one full year.
If your claim is denied for any reason, it’s advisable to contact an experienced law firm who can evaluate your claim and whether there are any major deficiencies in the evidence you have provided. Disputing an insurer denial of workers’ compensation benefits in Massachusetts involves filing a claim with the state’s Department of Industrial Accidents. We can help.
The process involves several necessary steps:
- Conciliation Session
- Review Board
All of it starts with the initial denial.What Happens When the Insurer Denies a Claim?
An insurance company issuing a denial must send an employee an “Insurer’s Notice of Denial (Form 104)” by certified mail.
Workers at this point can reach out to the insurer’s claim representative with questions about lack of payment or denial, but don’t expect those conversations to be especially helpful.
When an employee hires an attorney, he or she will call the representative and ask those questions on behalf of the worker. Once a worker retains a lawyer, the claim representative will no longer be able to talk to the worker.
If the attorney advises filing a claim with the Department of Industrial Accidents, a completed copy of the Employee’s Claim (Form 110) is submitted to their offices, with a copy on file for the worker and another forwarded to the insurer.
When the state receives this form, it will schedule the Conciliation, usually within a couple of weeks.Conciliation
This is an informal, sit-down meeting that involves:
- The worker
- The worker’s legal representative
- The insurance company’s attorney
- A conciliator with the Department of Industrial Accidents
At this time, the conciliator tries to facilitate a voluntary agreement between the worker and the insurance company. If no agreement is reached the claim status stays the same and the claim is referred to a department judge for Conference.Conference
The second phase of the dispute process is “Conference.” It’s an informal legal proceeding involving that involves an administrative law judge with the Department of Industrial Accidents.
This meeting usually takes place between two-to-four months from the date of the Conciliation.
At this informal legal proceeding, the judge considers evidence from both sides. This includes:
- Medical documents
- Wage statements
- Witness affidavits
At this phase, there are no witnesses called to testify. There are only sworn statements that detail the facts to which witnesses have attested.
Claimants at this proceeding need to show:
- Worker was disabled
- The cited injury/ illness was related to work
- Any medical bills in dispute were for treatment that was necessary
At the conclusion of the conference, the judge issues an order in which the insurer is either told it has to pay or it doesn’t. This order can be appealed by either the insurer or the worker within two weeks.
If the appeal is based on a medical issue, a fee is charged to cover the cost of an “impartial medical physician,” as chosen by the state. Workers who are indigent can have the fee waived.
On appeal, the same judge who presided over the conference will preside over the “Hearing,” but this time, the proceeding will be formal rather than informal.Hearing
This is the first formal legal proceeding in the process. State rules of evidence will be applicable, witnesses testify under oath and are cross-examined and the hearing is recorded.
Upon the close of the hearing, the administrative law judge will issue a ruling regarding benefits. Here again, either side can file an appeal, and that must be received within 30 days. Again, there is an appeal fee that amounts to one-third the current State Average Weekly Wage.Review Board
An appeal at this level is considered by a panel of six administrative law judges.
These judges will review the hearing transcripts, request oral arguments or additional legal briefs. The board will then decide whether to:
- Affirm the decision
- Reverse the decision
- Remand the case to the lower judge for further fact-finding or consideration
These decisions too may be appealed within 30 days.Additional Appeals
Any additional appeals beyond the review board must go before the Massachusetts Court of Appeals.
Contact the Law Offices of Jeffrey S. Glassman today for a free and confidential consultation.
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