If your employer’s insurance company has denied your workers’ comp claim for a work-related injury or illness, you may be wondering how you can challenge that decision. This article explains common reasons that insurers deny claims and how to file an appeal with the Massachusetts Department of Industrial Accidents (DIA), the agency that oversees the state's workers’ comp system and reviews disputes.

Common Reasons for Denied Workers’ Comp Claims

Your workers’ comp claim can be denied if you delay in reporting your injury or illness. You should notify your employer immediately (or as soon as it's practical) after you're injured on the job or learn that you have an occupational disease. Once you've given this notice, your employer should file report of the injury with its insurance company and the DIA. But if your employer won't do that, you need to notify the insurer and DIA yourself by filing Form 110. (For more information, see How to File a Workers’ Compensation Claim in Massachusetts.)

The insurance company may also deny your claim if it decides your injury or illness doesn’t meet the requirements for “arising out of and in the course of employment.” This is legal jargon for injuries that were caused by your work and happened while you were doing your job. Here are a few situations in which workers’ comp won’t cover your injury in Massachusetts:

• the injury resulted from your own serious and willful misconduct
• the injury happened while you were participating in a voluntary athletic event, party, picnic, or other recreational activity (even if your employer sponsored the event)
• you developed a mental or emotional condition as a result of a legitimate transfer, promotion, demotion, or termination
• you lied about the injury or illness
• before you were hired, you didn’t tell the employer the truth about a physical condition that would make an injury likely while you were doing the job, and you were hurt because of that condition; or
• you were injured while commuting to or from work.

See Denied Workers Compensation Claims to learn about other common reasons that insurers deny workers’ comp claims.

How to Appeal a Denied Workers’ Comp Claim

You can file an appeal with the DIA if the insurance provider denies your workers’ comp claim. First, you need to file an official claim (Form 110) and include the following information:

• the date of your injury, the date of your first day of missed work, and the date of your fifth day of missed work

• the name of the insurance provider

• your injuries and the benefits that you’re claiming

• medical treatment you’ve received and the name of your doctor, and

• how much work you expect to miss.

In addition, you must provide copies of unpaid medical bills, medical records, witness names and statements, and any documents that explain how the injury happened. You must file this claim form within four years after the date of your injury, the date you learned that your medical condition was related to work, or the date you received notice of the insurance company’s denial. If you haven’t already done so, you should also consider hiring a workers’ comp attorney to guide you through the appeals process.

There are several possible steps in the workers’ comp dispute resolution process in Massachusetts:

• Conciliation. First, you’ll have an informal meeting with the insurer and DIA. The conciliator will try to help you and the insurance company reach a voluntary agreement.
• Judicial conference. If conciliation fails, your claim will be referred to an administrative judge. (You can also request an independent arbitrator up to five days before the conference.) Within 28 days, the judge will hold a conference and give you and the insurer an opportunity to explain what happened. Within seven days after the conference, the judge will issue a written order denying your claim, requiring the insurer to provide compensation, or changing the compensation.
• Hearing. If you’re unhappy with the judge’s initial decision, you have 14 days to file an appeal for a full evidentiary hearing before the judge. (The insurer and employer also have the right to appeal.) You’ll be able to submit evidence, call witnesses, and testify on your own behalf.
• DIA Review. If you’re still unhappy with the judge’s decision, you can appeal within 30 days to the DIA’s Reviewing Board. The administrative judges on the board will review the hearing transcript and decide whether to reverse the hearing judge’s decision. The board may also ask for additional briefing and oral argument.
• Court appeals. Your next option is appealing to the Massachusetts Appeals Court. After that, you can petition for review before the Massachusetts Supreme Court.

Reach Out to a Lawyer

The workers’ comp appeals process can be complicated and requires detailed knowledge of Massachusetts workers’ comp law and the Department of Industrial Accidents. An experienced workers’ comp attorney can explain the legal procedures involved and guide you through the appeals process.

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