What Is Workers’ Compensation?

The Massachusetts Workers’ Compensation system is in place to make sure that workers are protected by insurance if they are injured on the job or contract a work-related illness. Under this system, all employers are required to provide Workers’ Compensation (WC) insurance coverage to all their employees by Massachusetts General Laws Ch. 152, Sec.25A. This insurance pays for any reasonable and necessary medical treatment related to a job related injury or illness, pays compensation for lost wages after the first five calendar days of full or partial disability, and in some cases provides retraining for employees who qualify.The Department of Industrial Accidents (DIA) is the agency responsible for administering the Workers’ Compensation law in Massachusetts.

The DIA is primarily a court system responsible for resolving disputed Workers’ Compensation claims. If your injury or illness claim is denied by the insurer or if you do not receive all the benefits you think you are entitled to your should contact an experienced attorney who can answer your questions about Workers’ Compensation benefits and let you know the correct procedures to follow to receive these benefits. It is important that you keep any documents your employer or its insurer sends you, as well as copies of any forms they have you fill out for them. It might be helpful to write out your questions in advance so you don’t forget to ask any questions you might have. The law requires that the insurer pay the
attorney’s fee if you win your case. In certain cases the insurer may reduce your payments to help pay your attorney. If you lose, the attorney can charge you only for very specific expenses. You do not necessarily need an attorney to file a claim, and you may represent yourself for any proceedings before the DIA. However, this is not recommended in most cases.

What Happens If You Have A Work-Related Injury Or Illness?

If you have a work-related injury or illness which results in lost work time of at least five full or partial days, your employer must file the Employer’s First Report of Injury or Fatality (Form 101). One copy is filed with the DIA, a second with the employer’s Workers’ Compensation insurance company, and a third provided to you. The Form 101 must be filed within seven days (not including Sundays and legal holidays) from the fifth day of lost time due to injury or illness. Once the insurance company receives the form from your employer, they have 14 days to investigate the claim and determine whether to pay the claim or not. IMPORTANT: If your employer does not send the Form 101 to the insurer within 30 days of your injury, report the injury in writing to the insurance company yourself, or complete the DIA’s Employee’s Claim (Form 110) and send the insurer a copy of the completed form.

What Happens When The Insurer Decides To Pay The Claim?

If the insurer agrees to pay the claim, they will send you an Insurer’s Notification of Payment (Form 103).

When will the benefits or check start?

You should start getting a check within three to four weeks after your injury or illness. You will receive compensation for lost wages for any days you are disabled after the first five full or partial calendar days. You are not compensated for the first five days of incapacity unless you are disabled
for 21 calendar days or more. The first 180 days after your initial injury are considered a “Pay-Without-Prejudice” period. This means the insurer may pay benefits to you for up to 180 days without making a final decision on your case. Paying you during this period DOES NOT mean they have accepted liability. During this initial period, the insurer may stop or reduce your payments by giving you seven days written notice via an Insurer’s Notification of Termination or Modification of Weekly Compensation During Payment-Without-Prejudice Period (Form 106). The insurer must give the reasons for taking this action. If the insurer continues paying you past this period, they will, in most cases, need permission from you or a judge to stop or reduce your benefits. If you receive a Form 106 and you receive notification of termination of benefits, be sure to consult an attorney to discuss your rights and responsibilities.

The insurer may ask you to extend the initial 180-day “Pay-Without-Prejudice” period for up to a year, with your written consent, on an Agreement To Extend 180 Day Payment Without-Prejudice Period (Form 105). The DIA must approve the form. You should make sure you are aware of all your rights before giving your consent or signing any other document.

What Happens When The Insurer Denies Your Claim? 

If the insurer decides to deny your claim, they must send you by certified mail an Insurer’s Notification of Denial (Form 104), including the reasons for denial and must inform you of your right to appeal. If you have questions about a denial or lack of payment on these forms, contact the insurer’s claim representative. Their phone number will be listed on the form. If you have hired an attorney, have the attorney call the claim representative about your denial. The claim representative cannot speak with you about your claim once you retain an attorney.

What You Should Do When the Insurer Denies Your Claim, or You Do Not Receive All Benefits You Are Entitled To?

If an insurer denies your claim, you have the right to file a claim with the DIA. If you wish to file a claim with the DIA, legal representation is strongly advised at this point in the process. Let your attorney complete and submit an Employee’s Claim (Form 110) to the DIA. Once the DIA receives your completed Form 110, you will be scheduled for a Conciliation within two weeks or so. This will start the dispute process. You will be notified in writing of the date, time and location of this meeting.

The Dispute Process

1. Conciliation

The first stage of the Dispute Resolution process is initiated when the DIA receives either of the
following forms:
1.   Employee’s Claim (Form 110), which is filed by an injured employee or their legal counsel
against the Workers’ Compensation insurance carrier.
2.   Insurer’s Complaint for Modification, Discontinuance or Recoupment of Compensation
(Form 108), which is filed when an insurance company requests permission to stop or
change your benefits.

Upon receiving either of these forms, an informal meeting will be automatically scheduled
between you (or your legal representative), the insurer’s attorney, and a conciliator from the DIA.
This meeting, called a “Conciliation,” normally takes place within 12 business days of filing a
Form 110 or Form 108. At the Conciliation, an effort is made to reach a voluntary agreement
between you and the insurer. If a voluntary agreement cannot be reached, the status of your claim
would remain the same as before, and your case could be referred to one of our judges for a
Conference.

2. Conference

The Conference is an informal legal proceeding before an Administrative Judge, and usually will
take place between 8 and 12 weeks from the date of the Conciliation. The judge learns about the
case from presentations by both parties and the submission of documents, such as medical reports,
wage statements and affidavits from witnesses. Witnesses are not called. You or your attorney
indicates to the judge what the witnesses would have said.

At the Conference you need to show:
(A) you were disabled;
(B) the injury or illness was work related; and
(C) That any disputed medical bills were for necessary treatment.
After the Conference the judge issues an order, either telling the insurer to pay your benefits or
ruling that they are not required to pay your benefits.
The Conference Order can be appealed by either party on an Appeal of a Conference
Proceeding (Form 121). You have 14 days to appeal from the date of the order. There is a fee to
appeal the Conference Order if your appeal is based on a medical issue. This fee pays for you
to be evaluated by an impartial medical physician. This fee may be waived if you can prove you
cannot afford to pay the fee by filing an Affidavit of Indigence and Request for Waiver of Sec.11A
(2) Fees (Form 136). If either party appeals the Conference Order, a formal hearing before the
same judge will be scheduled.

3. Hearing

The Hearing is a formal legal proceeding. It is usually held before the same judge who presided at the Conference.
Massachusetts Rules of Evidence will apply and sworn testimony is taken.Witnesses are called and cross-examined by the opposing party.
A stenographer records the proceedings.
The judge will render a Hearing decision in which you will either be awarded benefits or not.
The decision can be appealed to the Reviewing Board by either party on an Appeal to Reviewing Board (Form 112).
This appeal can only be made if the party contends that the judge made an error of law in issuing their decision or during the Hearing.
The appeal must be received within 30 days from the date of the Hearing decision. There is an appeal fee equal to 30 percent of the State Average Weekly Wagein place at the time of the appeal.

The Industrial Accidents Review Board

If one or both of the parties wishes to appeal the Hearing decision, that appeal is heard and decided
by the Review Board. This board is comprised of six Administrative Law Judges, three of whom
will examine the hearing transcripts. They may ask for additional written legal briefs or oral
arguments from the parties. The Review Board can reverse or uphold the decision of the
Administrative Judge, or can determine that more work needs to be done, and remand (send back)
the case to the Administrative Judge for further finding. Either party may appeal Review Board
decisions to the Court of Appeals within 30 days of the Review Board decision.