The workers’ compensation system compensates employees who are unable to work due to job-related injuries. Employers are required by state law to obtain workers’ compensation insurance for their employees to pay for their medical treatment and lost wages if they suffer debilitating injuries or illnesses from a work accident.
If your workers’ compensation claim is denied, you may receive an Insurer’s Notification of Denial in the mail. This should explain the insurance company’s rationale behind your denial and should include steps on how to appeal the decision. Appealing a workers’ compensation decision in Boston with the help of an experienced attorney could make a significant difference in the outcome of your case.
Level of Appeals for Workers’ Compensation Cases
When an injured worker appeals a denial of a claim, he or she may need to go through five levels of appeal, including:
- Impartial Exam
- Review Board
- Court of Appeals
Conciliation is an informal proceeding with a nonbinding outcome. While it may be informal and nonbinding, Conciliations are very important. At this meeting, an appointed conciliator meets with the employee’s attorney and insurer’s attorney to discuss a mutual resolution for the claim. The resolution could settle the entire claim, but, more often, the resolution resolves the current dispute.
Why would an insurance company agree to resolve a claim after they denied the claim or terminated workers’ comp benefits? The short answer is to save them money and legal costs if it looks like the employee has a strong case with compelling medical evidence and doctor reports. The insurance adjuster may not have had all the medical records supporting the employee’s claim at the time that the claim was denied. If both parties cannot reach an agreement to pay compensation, the claim would proceed to the conference level.
A Conference is an informal proceeding before an Administrative Judge that is conducted pursuant to Massachusetts General Laws Chapter 152 §10A. There is no recording or stenographic record of the proceeding. A workers’ comp Conference is similar to a motion hearing in civil court. The employee’s attorney and insurer’s attorney will submit medical records and reports for the Administrative Judge to review. Sometimes the parties will submit non-medical documents as well such as accident reports, accident photos, wages records. The insurance lawyer may submit investigative reports and video showing the employee’s activities on certain days, which the insurer may argue demonstrate that the employee is able to perform work.
After submitting their medical and non-medical records, both lawyers present a brief oral argument as to why the Administrative Judge should rule in their client’s favor. Following the Conference, the Administrative Judge issues an Order.
A party aggrieved by the conference order may file an appeal within fourteen (14) days from the date of the Order. Sometimes the Administrative Judge does not order everything that one party or the other requested and, as a result, both parties may appeal. If the claim presented at Conference involved a medical issue that is in dispute, which is usually the case, then the DIA will schedule an Impartial Exam with a doctor who is on the DIA’s list of impartial physicians. The impartial physician will review the medical records and reports that were submitted by the parties at Conference and examine the injured worker.
Afterwards, the impartial physician will file a written Impartial Report at the DIA. Pursuant to Massachusetts General Laws Chapter 152 §11A, the impartial physician’s opinions concerning issues such as causation, disability, and work capacity are prima facie evidence at Hearing unless the Administrative Judge finds that the Impartial Report is inadequate or the case involves issues that are medically complex. If the Administrative Judge opens up the medical record at Hearing, then the parties may submit additional medical records and reports, which will be admitted into evidence.
A formal hearing is the third level of appeal, which often involves the presentation of evidence by both sides. At the Hearing, the judge hears testimony from witnesses such as the employee, the employer, co-workers, investigators who conducted surveillance and vocational experts. If the parties so choose, they have the right to cross examine the impartial physician, which is conducted at a deposition before a court reporter at the impartial physician’s office.
The court reporter will file the original deposition transcript and deposition exhibits with the Administrative Judge. The lawyers for the injured worker and the insurance company will usually file a written closing argument with the judge that summarizes their view of the evidence and how they request the judge to rule. The Administrative Judge will then issue a written Hearing Decision. The Hearing Decision may be appealed to the Department of Industrial Accidents Reviewing Board within 30 days.
Reviewing Board and Court of Appeals
The Reviewing Board consists of a panel of three administrative law judges. These judges can review the hearing transcripts and request oral arguments or additional legal briefs, but do not accept new evidence. The parties submit written briefs outlining their arguments with reference to the Hearing testimony and evidence and citations to legal authority such as Reviewing Board or appellate court decisions that support their legal argument.
The board typically only changes a judge’s decision if they find that the decision was not factually justified, violated the law, or fell outside the judge’s legal authority. Any additional appeals beyond the Review Board must go before the Massachusetts Court of Appeals. In some cases, an appeal could go before the Massachusetts Supreme Judicial Court.
How Long Does an Injured Plaintiff Have to File a Claim?
The statute of limitations for a workers’ compensation claim in Boston is four years. However, the sooner the victim communicates his or her injury, the more time he or she may have to work with an attorney in case the insurer denies him or her benefits.
It is in the injured worker’s best interest to make a report and file a claim as soon as possible. This could help him or her avoid the insurance company raising the defense of late filing and lack of notice. As a practical matter, since the injured worker has no source of income while out of work due to a work injury, the need to start the workers’ compensation claims process quickly will require the injured worker to hire a lawyer.
Appealing a Boston Workers’ Compensation Decision with a Skilled Attorney’s Help
Appealing a workers’ compensation claim in Boston can be challenging and may be a lengthy process. If an insurer has denied your claim, it is highly advisable to consult an experienced employment lawyer for legal advice and representation. To learn more, call now.