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What to do if Your Workers’ Comp Claim is Denied?
If you were injured at work, you might not be able to return to your job for an extended period. During this time, the combination of medical expenses and lost wages could be financially disastrous. Fortunately, workers’ compensation insurance exists to protect injured workers from extreme financial loss due to a work injury or illness. If, however, your claim for workers’ comp is denied, the stress can be overwhelming. Don’t panic! Initial denials are surprisingly common. Even minor reporting errors can lead to reduced, delayed, or denied workers’ comp benefits. But what should you do if your claim was denied by the insurer?
If you have received a denial letter (Form 104 – Notification of Denial) it is best to consult with your workers’ comp lawyer ASAP! However, in some cases, a quick meeting with your employer can resolve the dispute. It is not uncommon for a simple clerical error or misunderstanding to result in a denied claim. If a formal appeal is necessary, however, you should consult with your lawyer before moving forward. Your attorney can help you navigate the complex legal process of an appeal, which would be filing a formal claim before the Department of Industrial Accidents.
So, why were you denied? The notification – which is from your employer’s workers comp insurer, will spell it out. Please remember that this denial is NOT from the Department of Industrial Accidents (court), so it’s not a final decision. It’s simply a preliminary decision. There may be several reasons, but these four are among the most common reasons why a claim has been denied:
1. Late Reporting:
When you are injured at work, you should notify your employer immediately. An injury or incident report is completed and typically, your employer files your workers’ compensation claim. Massachusetts law requires that a Form 101, the Employer’s First Report of Injury, be filed within seven days following the fifth day of your inability to work because of an injury. If the employer fails to do so, or if your claim has been denied, you must complete and file a Form 110, Employee’s Claim. The statute of limitations for filing a workers’ compensation claim in Massachusetts is “within four years from the date the employee first became aware of the causal relationship between his disability and (his) employment.”
2. Disputes About Whether Your Injury Was Actually Work-Related:
If you are an employee who was injured at work, or while performing a task or completing a duty that was for your employer’s benefit, chances are you have a viable claim. That is also true if you have a medical condition that is a direct result of your employment (for instance, a repetitive stress trauma such as carpal tunnel syndrome). In short, a condition or injury “arising out of employment and occurring during the course of employment” should be covered. Injuries that occurred during commuting to and from work are not covered, but if you were traveling for business reasons and were injured, they generally are. While some medical conditions may be clearly the result of the work environment or job, such as black-lung disease among coal workers, lung cancer may not be easily attributable to your employment.
3. Disputing Employment Status:
If you are an independent contractor, you are not eligible for workers’ compensation coverage by the business or company for whom you are providing services. An independent contractor is defined as doing work that is outside of the employer’s direction and control; is performed outside the employer’s usual course of business; and is done by someone who has their own, independent business or trade doing that kind of work. Other workers who are not typically covered include seaman engaged in interstate or foreign commerce, salespeople who work on commission or buy/sell basis other than in a retail establishment, with a written contract stating they are not treated as an employee under federal tax law; and Persons engaged in interstate/foreign commerce who are covered by federal law for compensation for injury or death.
4. Injury Reported After Leaving a Job
Even legitimate claims are viewed with suspicion by insurers and employers when they are filed after an employee quits, is laid-off or fired from a job. It’s always important to have a written statement about any injury for which you file a claim, including medical reports and corroborating statements from coworkers who witnessed the accident.
How Can Chisholm Law Help?
If your claim for workers’ comp benefits has been denied, the legal team at Chisholm Law, LLC can help you determine your rights and options and obtain your workers’ compensation benefits in a timely manner. We will thoroughly review your case materials to determine what steps need to be taken to ensure a successful outcome. Your Peabody, MA workers’ comp attorney will gather necessary evidence, file required paperwork within the allotted time frames, and deal with the insurance company and other relevant parties on your behalf. If you have been injured on the job, the only thing you should be focused on is healing. Let Chisholm Law handle everything else!
1. Filing a Workers Comp Claim in Massachusetts (Form 110)
If you are out of work because of an on-the-job injury, you expect that your lost wages and medical bills will be covered by workers’ compensation. Every day you go without your benefits is a financial hardship – and if your claim has been denied, it just compounds the economic and emotional stress.
There are steps you can and should take as soon as you receive an Insurer’s Notification of Denial-Form 104, or if you have not heard from the insurer within 30 days of the accident:
- Make sure you have all information on hand, including:
- a. The date you were injured;
- b. Your first calendar date of missed work;
- c. The fifth calendar date of missed work;
- d. The name of your employer’s workers’ compensation insurance;
- e. The type of injury and on what part of your body you were injured (for instance, a compound fracture of the right tibia);
- f. What benefit you are seeking;
- g. If you know it: how long you’re expected to be out of work;
- h. Where you initially went for treatment;
- i. The contact information of the physician who is currently treating your work-related injury.
- Obtain and complete a copy of Form 110-Employee Claim
- Be as thorough and accurate as possible and attach copies of medical evidence such as physician’s notes, doctor or hospital bills that support the work injury;
- make sure a copy of the claim is sent to the insurer via certified mail;
- Make sure you keep copies of everything.
2. What Happens After a Claim Has Been Filed?
Now that you have completed the steps above, what happens next? The claim filing process can be complex and time consuming, but the help of an experienced Peabody, MA workers’ comp attorney can dramatically increase the likelihood of a speedy, successful award of benefits. The steps below provide an outline of what you can expect during the claims process.
Conciliation: If the paperwork and documentation is accepted, a Conciliation is scheduled. This is a meeting which involves your attorney, the insurer’s attorney, and a Conciliator from the Department of Industrial Accidents. The purpose of the meeting is to come to an agreement. The Conciliation is typically scheduled for 12-14 days after the processing of your claim. Although few cases are actually resolved during this initial step, the meeting is a required part of the appeal process. If a voluntary agreement cannot be reached, the Conciliator will determine whether or not to move your case to a judge. To ensure that this happens, it is essential to provide as much evidence as possible to substantiate your claim.
Conference: If an agreement cannot be reached, the next step is a Conference before an Administrative Judge. This also involves you, your attorney and the insurer’s attorney and an administrative judge. An administrative judge will a brief oral argument from your attorney and the insurer’s attorney, review the submitted medical documentation from both sides, and then issue a temporary Conference Order – hopefully to have the insurer pay you benefits. All parties have 14 days to appeal the order. You will use Form 121 Appeal of Conference Order to appeal the administrative judge’s order on your case. There is a one-time fee to file this order. Once the Department of Industrial Accident (DIA) has received your appeal, you will receive a letter requesting your attendance at an impartial medical exam. If an impartial medical exam is ordered, once it is completed and the doctor’s report filed, a full evidentiary hearing will be scheduled before an administrative judge. If the parties agree that an impartial exam is not needed, your case will be placed in line for hearing date.
Hearing: If a conference order is appealed, the case goes to a Hearing. This is basically a bench trial in which evidence is submitted and witnesses heard. The administrative judge makes a hearing decision based on the evidence and testimony. Either party may appeal the decision within 30 days.
At the hearing, each party is permitted to give both an opening statement and closing argument. Either party may also submit additional information and requests, including briefs and motions, and requests for rulings and findings of facts. The administrative judge may or may not grant these requests. As the judge’s decision is based on new evidence introduced at the hearing, it is essential to come prepared.
Reviewing Board: If either party disagrees with the Hearing Decision, the next appeal goes to the Department of Industrial Accidents Review Board. The board may accept the administrative judge’s decision or send a decision back to the administrative judge for more fact-finding. The board only overturns a decision if they believe the decision was arbitrary or capricious, outside the scope of the judge’s authority or contrary to law.
Contact a Knowledgeable Massachusetts Workers’ Compensation Lawyer Today
At Chisholm Law LLC, we are dedicated to helping injured workers obtain compensation throughout the Peabody, Massachusetts area. For a consultation, contact us online, or call (978) 703-0700 to speak with an experienced workers’ comp lawyer today.