It is the employer’s insurance company that makes the decision on whether to approve or deny a worker’s compensation claim. As such, not every person who applies for workers compensation will be approved. Although there are valid denials of benefits, sometimes the system gets it wrong.
When a claim is denied the worker will receive an “insurer’s notification of denial form 104” in the mail. The form will have an explanation of why the worker’s insurance claim was denied. Many worker compensation claims are denied because of documentation errors, disagreement over the worker’s status and whether the injury was actually work related. A worker has four years from the date of the letter to file an appeal to the denial.
If a worker decides to file an appeal they must send forms to not only the Department of Industrial Accidents, but to their employer’s insurance company as well. At this stage the injured worker and the employer’s insurance company have an informal sit down called a “conciliation” where the parties attempt to reach an agreement. If no agreement is met then the parties again meet informally, but with an administrative judge present who will issue an appealable order. Parties who disagree at this stage move on to formal proceedings that can be appealed all the way to the Massachusetts’s court of appeals.
Pursing an appeal of worker compensation benefits can be a timely and complex endeavor. While parties are allowed to work with doctors to compile evidence of their injury, presenting a case in a formal setting can be difficult. Getting the right information about the options will not only increase the chances of a positive outcome, but will allow the injured worker to focus on their recovery and not legal jargon.
Source: mass.gov, “What To Do If You Wish To Appeal Your Denied Claim,” Accessed Oct. 28, 2014