What Can I Do If My Workers’ Compensation Claim is Denied?
Workers’ compensation provides income and medical benefits to those who sustain work-related injuries. However, many times these claims will be denied or disputed by the workers’ comp insurance company that your employer carries. You may be wondering, “What do I do if the insurer denied my workers’ compensation claim?” If you need to fight a denied claim, you will need the legal guidance of an experienced Massachusetts workers’ compensation attorney.
What Steps Are Involved in Filing a Workers’ Compensation Claim? | Process
If a worker and workers’ compensation insurer disagree about a claim, the Massachusetts Department of Industrial Accidents (DIA) has basically four steps to the claims process: Conciliation, Conference, Hearing, and Reviewing Board. After a claim form is filed electronically with the DIA, a Conciliation is scheduled within a couple of weeks. This consists of an informal meeting usually between the worker’s attorney (if he or she has one), an attorney for the workers’ compensation insurance company and the DIA Conciliator.
The Conciliator serves as a neutral third party who determines what the issues in dispute are and tries to get the parties to reach an agreement. If an agreement cannot be reached, then the Conciliator makes sure there is the proper medical documentation to send the case to be scheduled for a Conference before a Administrative Judge.
The second step is the Conference. And while the worker still isn’t required to have an attorney, it’s strongly recommended they have an experienced workers’ compensation attorney with them for this process. Prior to the Conference all medical and non-medical documents are uploaded to the DIA system. At the Conference the lawyers for both parties make summary arguments to the Judge. The Judge will then issue an Order to pay the benefits asked for, deny them, or a some combination of payment and denial. If either party disagrees with the Order, they can appeal it.
Workers’ Compensation Hearing
A Hearing is similar to a civil trial, both sides present evidence in support of their position and may call witnesses to testify. Usually the same Judge that heard the Conference will preside over the Hearing. Prior to the Hearing, if there is a medical issue in dispute, an Impartial Exam is done. A doctor who is paid through the DIA and not the parties (thus supposedly being impartial) performs and exam of the injured worker and reviews the medical records submitted at the Conference.
The Impartial Physician then writes a report which is supposed to include certain opinions regarding whether the injury is related to work and the level of disability from gainful employment. This report is the only medical evidence at the Hearing. There are certain exceptions to it being the only medical evidence. Once the evidence record is closed, the Judge writes a full decision which includes Findings of Fact, Conclusions of Law and a what benefits are ordered or not. If either side is unhappy with the Administrative Judge’s decision, they can appeal it to the Reviewing Board.
At this level three Administrative Law Judges will decide if the Hearing Judge’s decision failed to correctly apply the law or the Judge’s decision was beyond the scope of his authority, arbitrary or capricious. At this level of the workers’ compensation process, the parties may only present legal arguments in support of their position.
Generally speaking, no new evidence may be presented to the Reviewing Board. If the Reviewing Board feels additional evidence is necessary, they will usually remand the case back to the Administrative Judge for further consideration of additional evidence. No matter what, the parties must present legal briefs to the Reviewing Board. These legal briefs will explain the basis for their legal position. The Reviewing Board will sometimes ask for more from the parties, such as coming before the Reviewing Board to present their legal arguments in person.
If either side is still unhappy with the Reviewing Board’s decision, they may appeal to the Massachusetts Court of Appeals. A workers’ compensation appeal to the Massachusetts Court of Appeals is a fairly rare occurrence.
Contact an Experienced Massachusetts Workers’ Compensation Attorney
To learn more about the workers’ compensation claims and appeals process, please contact my office for a consultation with a dedicated Massachusetts workers’ compensation attorney. Let my experience work for you.