Workers who are injured on the job are entitled to compensation in Maine. But what are your options if you don’t receive the amount of benefits that you expected, or if your workers’ compensation claim is denied entirely? This article explains common reasons insurance companies deny claims, and how you can appeal a denial with the Maine Workers’ Compensation Board (WCB).
In Maine, your workers’ comp claim can be denied if you don’t report the injury to your employer within 30 days. (See How to File a Workers’ Compensation Claim in Maine for more information.)
The insurance company may also deny your claim if it thinks you don' have a work-related injury or illness. Workers’ comp only covers:
Maine law specifically rules out workers’ comp coverage for injuries in certain situations, including when:
See Denied Workers Compensation Claims to learn more about other common reasons that insurers deny claims.
If your employer’s insurance company denies your claim, it will file a Notice of Controversy (NOC) with the WCB, which oversees the state’s workers’ comp system and resolves claim disputes. The notice will explain why the insurer denied the claim.
The WCB has a four-part process for resolving disputes about claims: troubleshooting, mediation, a formal hearing, and board review.
After receiving the NOC, the WCB will refer it to a claims resolution specialist who will work with you and the insurance company to try to resolve the dispute informally. This process normally takes place over the phone. The specialist will help identify the disputed issues and, if necessary, collect additional information (like medical reports).
If you don’t reach a resolution during the troubleshooting stage, your case will be sent to mediation, an informal proceeding where you and the insurer will meet with a neutral mediator to try to resolve the dispute. Mediation usually happens in person, but it can be done over the phone if everyone agrees. Both you and the insurer will have the opportunity to present evidence. The mediator may also meet separately with each of you to gather additional information and address private concerns. At the end of the process, the mediator will complete a record of the mediation that discusses either the terms of an agreement or the issues that are still in dispute. If an agreement is reached, you and the insurance company representative will sign the record and will be obligated to follow what it says.
You can have a private workers’ comp attorney represent you during mediation. If you don’t have a lawyer, and you’ve participated in the troubleshooting process, the specialist may refer you to a Worker Advocate to represent you (for free) during mediation.
If you and the insurance company don't reach agreement after medication, you may request a formal hearing by filing a petition with the WCB. There are different petition forms depending on what the dispute is about. If the insurer denied your claim for workers’ comp benefits, you need to file a Petition for Award of Compensation (Form WCB-140). (Visit the WCB website for information on other petition forms.) You must file the petition within two years of the injury or the date when the employer filed a first report of injury. You have six years to file the petition if you received benefits within the first two years of the injury.
A workers’ comp judge will preside over the hearing. After hearing the arguments and reviewing the evidence, the judge will mail a written decision to the parties.
If you’re unhappy with the judge’s decision after the hearing, the next step is to file a Notice of Intent to Appeal (Form WCB-240) within 20 days of the decision. Send a copy of the form to your employer and the insurance company. A panel of three workers’ comp judges will consider your appeal, either by reviewing written briefs submitted by the parties or, if requested, by holding oral arguments.
If you disagree with the panel’s decision, your final option is to appeal to the Maine Supreme Court. You must file your appeal request within 20 days of the panel’s decision. This is only a request; the Supreme Court may decide not to consider your appeal.
The workers’ comp appeals process can be complicated and requires detailed knowledge of Maine law and the procedures of the state’s WCB. Insurance companies have their own lawyers. You can help tilt the scales in your favor by enlisting the help of an experienced workers’ comp attorney or Worker Advocate to guide you through this process. (Learn more about what a good workers' comp lawyer can do for you.)