Dealing with a denied workers’ comp claim

Suffering from a work-related injury or illness in Massachusetts can be challenging, and workers’ compensation benefits provide essential financial support. However, sometimes an insurance company denies a workers’ comp claim, leaving the injured worker unsure of their next steps.

Understanding the reasons for the denial and the appeal process can help injured workers navigate the system more effectively and improve their chances of receiving the benefits they deserve.

Reasons for claim denial

Various reasons can lead to a workers’ comp claim denial. Common causes of denial include insufficient medical evidence, missed deadlines and disputes regarding whether the injury or illness is work-related. In some cases, the insurance company might argue that a pre-existing condition or an unrelated event caused the worker’s condition.

Appealing a denied claim

Injured workers have the right to appeal a denied workers’ comp claim. The first step in the appeal process involves filing a claim with the Department of Industrial Accidents within four years of the date of injury or the date the worker became aware of the work-related nature of the condition.

After filing the claim, the DIA schedules a conciliation, an informal meeting where the worker, the insurance company and a conciliator from the DIA try to reach a voluntary agreement. If they cannot reach an agreement, the case proceeds to a conference before an administrative judge. Both sides present evidence at the conference, and the judge makes a temporary order regarding the benefits.

If either party disagrees with the judge’s temporary order, they can appeal the decision and request a formal hearing. This hearing resembles a trial, with both sides presenting evidence and witnesses. The judge issues a final decision after the hearing. If either party remains unsatisfied with the outcome, they can file an appeal.

Understanding the reasons for the denial and the appeal process is crucial when a workers’ comp claim gets denied in Massachusetts. By following the appropriate steps and gathering sufficient evidence, injured workers can increase their chances of receiving the workers’ comp benefits they deserve.