What To Expect In Workers’ Compensation Hearing And Appeals

Nearly all employers in Massachusetts must purchase workers’ compensation insurance. When a worker gets hurt, employers file a claim and the insurance company decides if it’s covered and what benefits the worker is entitled to.

But filing a workers’ compensation claim is not always easy or straightforward. And oftentimes, claims get wrongfully denied. Sometimes it’s due to an honest clerical mistake. But unfortunately, many employers and workers’ compensation insurance companies take deliberate steps to deny workers’ compensation claims. And in other instances, everyone agrees that the worker’s injuries should be covered by workers’ compensation insurance, but they disagree on the specific benefits the worker should receive.

If there is a disagreement between a worker and workers’ compensation insurer regarding a claim, the Massachusetts Department of Industrial Accidents (DIA) has four steps available to help reach an agreement: conciliation, conference, hearing and the Reviewing Board.

Claims Process Disagreements: Conciliation

Conciliation consists of an informal meeting between the worker, the worker’s attorney (if he or she has one), an attorney for the workers’ compensation insurance company and the DIA conciliator. The conciliator serves as a neutral third party to try and help negotiate a settlement.

Conciliation meetings take place at the DIA regional office closest to the employee. If the worker is out of state, the conciliation will automatically take place in Boston. In some circumstances, the location of the conciliation meeting can be changed.

Before the conciliation, the worker should gather the necessary medical documentation to support his or her position. It’s not required of the worker to have an attorney for the conciliation process, but it is a good idea to have one by the side. If the parties cannot resolve their disagreement during conciliation, the conference process is the next step.

Claims Process Disagreements: Conference

The second step is the conference (sometimes referred to as a proceeding). And while the worker still isn’t required to have an attorney, it’s strongly recommended they have an experienced workers’ compensation hearings and appeals attorney with them for this process.

This is because even though a conference is an informal meeting between the workers’ compensation insurance company and the worker, instead of being before a conciliator, it’s in front of an administrative judge.

This administrative judge has much more power than the conciliator because the administrative judge can make a decision as to whether the workers’ compensation insurance company must pay benefits to the worker. If the worker or the workers’ compensation insurance company disagrees with the administrative judge’s order, they must file an appeal within 14 days. Appeals are decided at a hearing.

Claims Process Disagreements: Hearing

A hearing is a formal legal proceeding and is a lot like a trial. A hearing is held before an administrative judge and many rules from a regular courtroom apply, such as the Massachusetts rules of evidence.

At the hearing, both sides present evidence in support of their position and may call witnesses to testify. In certain situations, either side may be required to submit new evidence before the administrative judge issues a decision. If either side is unhappy with the administrative judge’s decision, they can appeal it to the Reviewing Board.

Claims Process Disagreements: Reviewing Board

At this level of the workers’ compensation settlement process, the parties may only present legal arguments in support of their position. Generally speaking, no new evidence may be presented to the Reviewing Board. If the Reviewing Board feels additional evidence is necessary, they will usually remand the case back to the administrative judge for further consideration of additional evidence.

No matter what, the parties must present legal briefs to the Reviewing Board. These legal briefs will explain the basis for their legal position. The Reviewing Board will sometimes ask for more from the parties, such as coming before the Reviewing Board to present their legal arguments in person.

If either side is still unhappy with the Reviewing Board’s decision, they may file another appeal with the Massachusetts Court of Appeals. A workers’ compensation appeal to the Massachusetts Court of Appeals is a fairly rare occurrence.

Workers’ Compensation Claim Denial

If the workers’ compensation insurance company makes a decision to deny the worker’s claim (and none of the above settlement steps are taken), the worker has the option of appealing the denial directly to the DIA by filing a claim.

The worker has two ways to file their claim: by mail or in person. Either way, the worker must get certain documents to the DIA’s Boston office. This includes the completion and submission of Form 110. Additionally, the worker must provide the following documents and information:

• Medical reports
• Unpaid medical bills
• Witness names and statements
• Anything else that explains how the injury occurred

After submitting Form 110 and relevant documentation to the DIA, the worker will need to give notice of the claim to the workers’ compensation insurance company by providing them a copy of all documents sent to the DIA. A common method of providing these documents is by sending them via certified mail.

The DIA will do one of two things after the worker files a claim. First, the DIA might reject the claim on procedural grounds due to the worker improperly completing Form 110. If this happens, the DIA will send everything back to the worker with an explanation of what is incorrect or incomplete. The worker can try and file the claim again.

Second, the DIA will accept the claim and set up a conciliation meeting. This is the same conciliation meeting that takes place during the claims dispute resolution process.

Get Help From An Experienced Workers’ Compensation Attorney

If you are refused workers’ compensation benefits, all is not lost. To learn more about the workers’ compensation dispute resolution and appeals process, please contact our office for a consultation with a dedicated workers’ compensation attorney. Let our experience work for you. Call 978-216-1152.