Understanding Workers’ Compensation Claim Denials in Massachusetts
Workers’ compensation laws are designed to protect employees who suffer injuries on the job. But, in reality, workers’ compensation insurance companies often prioritize their profits. They might deploy tactics to minimize payouts, questioning the severity of your injuries or the validity of your claim, or to prematurely terminate benefits.
Why Are Initial Workers’ Compensation Claims Are Commonly Denied in Massachusetts?
An insurance company may deny a workers’ compensation claim for any number of reasons. They will try to poke holes in your case any way they can. To ensure that your claim is strong, you will need an experienced workers’ compensation attorney on your side who knows how to navigate the workers’ compensation claim and appeal process.
The Injury Is Not Reported Immediately
The most common reason that workers’ compensation claims get denied is often due to the simplest mistakes: the injury was not reported immediately.
When injured on the job, the first thing you should do is seek immediate medical attention. You should then notify your employer of the accident as soon as possible. Employers and insurance companies are far more likely to deny a claim that has been postponed or delayed. It is best to submit this notice in writing, although verbal notification is also acceptable. A written notice can serve as proof that you acted in a timely manner if an insurance company tries to argue against your claim.
Even more important than timeliness is accuracy. When informing your employer (and your doctor) of a workplace injury, provide as much detail as possible. This includes:
- Time and place of the injury
- The extent of the injury
- What you were doing when the accident occurred
- How and why the injury happened
- The names of any witnesses
Sometimes your employer will have you fill out an accident report. Once again, make sure to be accurate. Any inconsistencies can hurt your claim.
The Injury Is A Pre-Existing Condition
Many denied workers’ compensation claims occur because the injury or illness is deemed by the insurance companies to be a pre-existing condition, meaning that the injury originated before the accident. You cannot claim compensation for a pre-existing condition. However, some pre-existing conditions are further aggravated by duties on the job. If this is the case, you may be eligible to receive compensation for your injury.
Jobs that require repetitive movement can cause significant trauma and stress on the body, which builds up over time. Conditions such as arthritis and repetitive stress injuries cannot usually be linked to one specific incident, which means you can still receive compensation for your injury as long as you can prove it was work-related.
The Injury Is Not Work-Related
Another common reason for denied workers’ compensation claims is because the injury is deemed to be not work-related. Therefore, it is important to know what exactly constitutes the “workplace.”
- For example, injuring yourself on the way to work would not be considered an injury sustained on the job. However, if you were to injure yourself while performing an outside task specified by the job (not necessarily on the job site), this could be the grounds for a successful workers’ compensation claim. It is best to consult an attorney before moving forward.
Other Grounds for Workers’ Compensation Benefit Denials
In addition to these common issues, workers’ compensation benefits are also commonly denied if:
- An injured worker did not miss at least five days of work due to the accident;
- An individual is not an employee within the definition of the law; or
- Paperwork and forms were filled out incorrectly.
Whether you are just beginning your workers’ compensation case or have already received a denial, having an attorney on your side can make all the difference. From gathering all necessary information and evidence for your initial application to assisting you with the appeal process, as a leading workers’ comp law firm, we can guide you every step of the way.
The Tactics of Insurance Companies: Premature Termination of Benefits
Even if a claim is initially approved, insurance companies, in their quest to maximize profits, often employ strategies that aren’t in the best interests of injured workers. One of the most distressing tactics is the premature termination of workers’ compensation benefits. Here’s how they might attempt this and why you need a vigilant workers’ comp attorney for claim denials on your side:
- Questioning the Severity of Injuries. Insurers may argue that an employee’s condition has improved enough for them to return to work, even if medical reports suggest otherwise. By downplaying the severity or duration of injuries, they aim to cut off benefits sooner.
- Frequent Medical Evaluations. To build their case, insurance companies might require injured workers to undergo repeated medical evaluations, hoping to find a report that supports their claim that the worker is fit to return to work.
- Misinterpreting Work Restrictions. Even if a doctor recommends light-duty or modified work, insurers might misconstrue this as an all-clear sign, pushing for the cessation of benefits.
- Surveillance and Monitoring. In some cases, insurance companies resort to having injured workers surveilled to gather evidence that they are engaging in activities that might contradict their claims.
- Relying on Administrative Oversights. Minor errors in paperwork or missed deadlines can be seized upon by insurers to halt benefits. They bank on the possibility that injured workers, overwhelmed by the system’s intricacies, might make mistakes.
What Steps Should I Take If My Massachusetts Workers’ Comp. Claim Was Denied or Prematurely Terminated?
A claim needs to be filed with the Massachusetts Department of Industrial Accidents (DIA). An injured worker can file the claim themselves, but I would not recommend it. The Massachusetts Workers’ Compensation System is very complicated. It consists of the laws or statutes, regulations that help define how the laws are put into action; case decisions that interpret how the laws and regulations apply to specific cases or facts; and circular letters that explain procedures that the DIA follows. And then there are the individual Judges who hear the cases and have different ideas on how to decide a case.
In order to navigate the pitfalls of this complicated system, and ensure that you are getting all the benefits you are entitled to, you should retain an experienced workers’ compensation lawyer to handle your case. I have been handling these types of cases almost exclusively since I started as a lawyer in 1986.
Filing the Claim
The first step is to actually file the claim. In this virtual world today, that has to be done online. A claim cannot be filed within 30 days of the injury unless there has been a denial by the insurer. With the claim, supporting medical documents have to be submitted to the DIA. These medical records have to contain certain information, including a causal connection opinion from the medical provider that the injury was work related. They will also need to contain an opinion on the level of the injured worker’s disability. If these opinions are not included, the claim may be rejected.
Once a claim is filed, the first step of the proceedings is a Conciliation. This is a meeting between the Conciliator, the insurance representative (usually a lawyer), and the employee’s attorney. In some instances, the employee must attend (usually if the claim is for scarring or disfigurement). The purpose of the Conciliation is to see if an agreement can be worked out between the parties. The Conciliator cannot order benefits to be paid. If the parties cannot reach an agreement, the Conciliator’s job is to make sure there is enough medical evidence to send the case on for a Judge to hear it. It usually takes a couple of weeks from the initial claim filing to the Conciliation. If the Conciliator deems it necessary, they can continue the matter for several weeks.
If the case is forwarded on by the Conciliator, a Conference is scheduled. The time between the Conciliation and the Conference being held is roughly two to three months currently in Massachusetts. At the Conference the lawyers for both parties make summary arguments to the Administrative Judge. Medical records and other documents are submitted electronically prior to the Conference date. The injured worker is usually required to be present at the Conference but does not have to testify or participate.
The Judge then will issue an Order, usually within a couple of days to a week, to either pay or deny the claim. Sometimes the Judge will issue a modified payment or denial Order. At this proceeding, having an experienced workers’ compensation attorney, who knows what medical and other evidence is persuasive, goes a long way to getting a favorable Order.
If either party is not happy with the Order, they can then appeal it within fourteen days. If the Order is one that requires the insurer to pay benefits, they must make those payments even if they appeal the Order.
Impartial Physician Exam
If there is an appeal, and the case involves a medical issue, the next step is for the injured worker to be examined by an Impartial Physician. This is a doctor who is assigned and paid through the DIA and not by either party. The doctor will do an exam of the injured worker and is provided with medical records that were submitted at the Conference. The Impartial Physician will then do a report. The report is supposed to answer specific question such as whether there was a work injury, is the injured worker incapacitated either partially or totally. This report is then supposed to be the only medical evidence at the next proceeding which is a Hearing. There are exceptions to the Impartial Report being the only medical evidence. Generally, if the report is inadequate (the physician did not address all of the issues) or the case is medically complex.
A Hearing is scheduled after the Impartial Exam is done. It is like a trial in that the injured worker and other witnesses will testify. There is cross-examination of the witnesses. The rules of evidence also apply. A stenographer records the proceedings. The Judge (usually the same one who presided at the Conference) will then write a decision which includes finding of facts and conclusion of law. The time between the Conference and the Hearing is usually many months depending on the scheduling of the Impartial Exam and other factors.
If either party feels that the Judge did not apply the law correctly or the decision was beyond the scope of his authority, arbitrary or capricious, they can appeal the case to the Reviewing Board. Administrative Law Judges, usually three, will, hear cases at this level. There are legal briefs submitted, and there also may be oral arguments by the parties’ attorneys. The Administrative Law Judges then issue a decision which may uphold or overturn the Administrative Judge’s Hearing decision. They might also send the case back to the Administrative Judge to clarify part of the decision.
Parties can appeal a Reviewing Board decision to the Massachusetts Appellate and possibly the Massachusetts Supreme Judicial Court. I have been handling workers’ compensation case from Conciliation to the Massachusetts Appeals Court since 1986, and I can tenaciously advocate for your rights and the fair and full compensation to which you are rightfully entitled.
Protect Your Rights – Schedule A Free Consultation With An Experienced Workers’ Comp. Attorney Today!
With over three decades of legal experience in workers’ compensation, I’ve witnessed firsthand the challenges injured workers face when confronting insurance company denials. By hiring a workers’ compensation attorney with extensive experience handling rejected claims, you can efficiently navigate the system, ensuring your rights are protected and you receive the compensation you rightfully deserve.
Each stage of a workers’ compensation claim requires strategic planning, evidence presentation, and a deep understanding of the workers’ compensation landscape. As an experienced workers’ comp attorney for claim denials, I can guide you through each step, ensuring optimal outcomes. Call my office today to schedule a free consultation – I am only entitled to a fee if benefits are secured.