If you have received a denial letter (Form 104 – Notification of Denial) it is best to consult with your workers’ comp lawyer ASAP! However, in some cases, a quick meeting with your employer can resolve the dispute. It is not uncommon for a simple clerical error or misunderstanding to result in a denied claim. If a formal appeal is necessary, however, you should consult with your lawyer before moving forward. Your attorney can help you navigate the complex legal process of an appeal, which would be filing a formal claim before the Department of Industrial Accidents.

So, why were you denied? The notification – which is from your employer’s workers comp insurer, will spell it out. Please remember that this denial is NOT from the Department of Industrial Accidents (court), so it’s not a final decision. It’s simply a preliminary decision. There may be several reasons, but these four are among the most common reasons why a claim has been denied:

1. Late Reporting:

When you are injured at work, you should notify your employer immediately. An injury or incident report is completed and typically, your employer files your workers’ compensation claim. Massachusetts law requires that a Form 101, the Employer’s First Report of Injury, be filed within seven days following the fifth day of your inability to work because of an injury. If the employer fails to do so, or if your claim has been denied, you must complete and file a Form 110, Employee’s Claim. The statute of limitations for filing a workers’ compensation claim in Massachusetts is “within four years from the date the employee first became aware of the causal relationship between his disability and (his) employment.”

2. Disputes About Whether Your Injury Was Actually Work-Related:

If you are an employee who was injured at work, or while performing a task or completing a duty that was for your employer’s benefit, chances are you have a viable claim. That is also true if you have a medical condition that is a direct result of your employment (for instance, a repetitive stress trauma such as carpal tunnel syndrome). In short, a condition or injury “arising out of employment and occurring during the course of employment” should be covered. Injuries that occurred during commuting to and from work are not covered, but if you were traveling for business reasons and were injured, they generally are. While some medical conditions may be clearly the result of the work environment or job, such as black-lung disease among coal workers, lung cancer may not be easily attributable to your employment.

3. Disputing Employment Status:

If you are an independent contractor, you are not eligible for workers’ compensation coverage by the business or company for whom you are providing services. An independent contractor is defined as doing work that is outside of the employer’s direction and control; is performed outside the employer’s usual course of business; and is done by someone who has their own, independent business or trade doing that kind of work. Other workers who are not typically covered include seaman engaged in interstate or foreign commerce, salespeople who work on commission or buy/sell basis other than in a retail establishment, with a written contract stating they are not treated as an employee under federal tax law; and Persons engaged in interstate/foreign commerce who are covered by federal law for compensation for injury or death.

4. Injury Reported After Leaving a Job

Even legitimate claims are viewed with suspicion by insurers and employers when they are filed after an employee quits, is laid-off or fired from a job. It’s always important to have a written statement about any injury for which you file a claim, including medical reports and corroborating statements from coworkers who witnessed the accident.

How Can Chisholm Law Help?

If your claim for workers’ comp benefits has been denied, the legal team at Chisholm Law, LLC can help you determine your rights and options and obtain your workers’ compensation benefits in a timely manner. We will thoroughly review your case materials to determine what steps need to be taken to ensure a successful outcome. Your Peabody, MA workers’ comp attorney will gather necessary evidence, file required paperwork within the allotted time frames, and deal with the insurance company and other relevant parties on your behalf. If you have been injured on the job, the only thing you should be focused on is healing. Let Chisholm Law handle everything else!

1. Filing a Workers Comp Claim in Massachusetts (Form 110)

If you are out of work because of an on-the-job injury, you expect that your lost wages and medical bills will be covered by workers’ compensation. Every day you go without your benefits is a financial hardship – and if your claim has been denied, it just compounds the economic and emotional stress.

There are steps you can and should take as soon as you receive an Insurer’s Notification of Denial-Form 104, or if you have not heard from the insurer within 30 days of the accident:

1. Make sure you have all information on hand, including:
   • a. The date you were injured;
   • b. Your first calendar date of missed work;
   • c. The fifth calendar date of missed work;
   • d. The name of your employer’s workers’ compensation insurance;
   • e. The type of injury and on what part of your body you were injured (for instance, a compound fracture of the right tibia);
   • f. What benefit you are seeking;
   • g. If you know it: how long you’re expected to be out of work;
   • h. Where you initially went for treatment;
   • i. The contact information of the physician who is currently treating your work-related injury.
2. Obtain and complete a copy of Form 110-Employee Claim
   • Be as thorough and accurate as possible and attach copies of medical evidence such as physician’s notes, doctor or hospital bills that support the work injury;
   • make sure a copy of the claim is sent to the insurer via certified mail;
   • Make sure you keep copies of everything.

2. What Happens After a Claim Has Been Filed?

Now that you have completed the steps above, what happens next? The claim filing process can be complex and time consuming, but the help of an experienced Peabody, MA workers’ comp attorney can dramatically increase the likelihood of a speedy, successful award of benefits. The steps below provide an outline of what you can expect during the claims process.

Conciliation: If the paperwork and documentation is accepted, a Conciliation is scheduled. This is a meeting which involves your attorney, the insurer’s attorney, and a Conciliator from the Department of Industrial Accidents. The purpose of the meeting is to come to an agreement. The Conciliation is typically scheduled for 12-14 days after the processing of your claim. Although few cases are actually resolved during this initial step, the meeting is a required part of the appeal process. If a voluntary agreement cannot be reached, the Conciliator will determine whether or not to move your case to a judge. To ensure that this happens, it is essential to provide as much evidence as possible to substantiate your claim.

Conference: If an agreement cannot be reached, the next step is a Conference before an Administrative Judge. This also involves you, your attorney and the insurer’s attorney and an administrative judge. An administrative judge will a brief oral argument from your attorney and the insurer’s attorney, review the submitted medical documentation from both sides, and then issue a temporary Conference Order – hopefully to have the insurer pay you benefits. All parties have 14 days to appeal the order. You will use Form 121 Appeal of Conference Order to appeal the administrative judge’s order on your case. There is a one-time fee to file this order. Once the Department of Industrial Accident (DIA) has received your appeal, you will receive a letter requesting your attendance at an impartial medical exam. If an impartial medical exam is ordered, once it is completed and the doctor’s report filed, a full evidentiary hearing will be scheduled before an administrative judge. If the parties agree that an impartial exam is not needed, your case will be placed in line for hearing date.

Hearing: If a conference order is appealed, the case goes to a Hearing. This is basically a bench trial in which evidence is submitted and witnesses heard. The administrative judge makes a hearing decision based on the evidence and testimony. Either party may appeal the decision within 30 days.

At the hearing, each party is permitted to give both an opening statement and closing argument. Either party may also submit additional information and requests, including briefs and motions, and requests for rulings and findings of facts. The administrative judge may or may not grant these requests. As the judge’s decision is based on new evidence introduced at the hearing, it is essential to come prepared.

Reviewing Board: If either party disagrees with the Hearing Decision, the next appeal goes to the Department of Industrial Accidents Review Board. The board may accept the administrative judge’s decision or send a decision back to the administrative judge for more fact-finding. The board only overturns a decision if they believe the decision was arbitrary or capricious, outside the scope of the judge’s authority or contrary to law.

Contact a Knowledgeable Massachusetts Workers’ Compensation Lawyer Today

At Chisholm Law LLC, we are dedicated to helping injured workers obtain compensation throughout the Peabody, Massachusetts area. For a consultation, contact us online, or call (978) 703-0700 to speak with an experienced workers’ comp lawyer today.

• https://www.mass.gov/how-to/appeal-a-workers-compensation-conference-order
• https://www.mass.gov/info-details/preparing-for-a-hearing
• https://www.mass.gov/how-to/appeal-a-workers-compensation-hearing-decision

If you are injured at work, it is essential that you file your claim correctly and in a timely manner. An experienced lawyer can assess your case and determine the appropriate amount of compensation you should receive based on your condition.

Below is a list of the different types of workers’ comp available to employees in Massachusetts:

• Temporary Total Disability Benefits — This type of workers compensation benefit is for employees who need to take more than five days off work due to their injuries. If you qualify, you will receive 60% of your gross average weekly wage for up to 156 weeks (3 years). In order to qualify for this benefit, an injured worker must be temporarily disabled from their job and any other.
• Temporary Partial Disability Benefits — If you can work but your earning capacity is reduced (such as reduced hours or limited duties), you may qualify for partial incapacity benefits for up to 260 weeks (up to 5 years). The maximum compensation under this section of the law is limited to 75% of your temporary total disability rate.
• Permanent and Total Disability Benefits — The most serious injuries can result in permanent and total disability. If a jobsite accident causes you to become permanently and totally disabled from any and all employment, you will likely qualify for permanent and total disability benefits which is two thirds of your average weekly wage. Under this type of workers’ compensation, you will receive benefits as long as your disability continues.

Workers’ compensation is there to provide you with the benefits you need to rebuild your life. If you suffer any type of injury or illness at work, a skilled workers’ compensation attorney can improve your chances of receiving just compensation.

Loss of Function and Disfigurement benefits

Should your work injury or illness result in severe disfigurement or loss of function, you may be entitled to receive additional benefits. This type of compensation is provided as a one-time payment and the amount is determined based on the extent of your scarring/disfigurement as well as the location and severity of function loss. Permanent loss and disfigurement benefits are paid out in addition to medical bills, lost wages, etc.

Contact an experienced workers’ compensation lawyer today!

Chisholm Law LLC is dedicated to helping injured workers obtain compensation in Danvers, Massachusetts and the surrounding areas through Massachusetts. For a consultation, contact us online, or call 978-703-0700 to speak with Eric today.

It’s a good question. First, let’s give a little background…

The first 180 days (six months) of an injured worker’s claim is referred to as the pay without prejudice period. This 6-month period, governed by M.G.L. Chapter 152 (the Massachusetts Workers’ Compensation Statute), allows the insurer to pay an injured worker weekly benefits without fully accepting liability for injury. During this period, they are supposed to investigate the claim, review medical records, discuss the facts and circumstances of the injury with the injured worker, their employer, etc., to determine if there is any factual basis to dispute the claim. If an insurer decides they want to deny a claim after having started payments, they can stop your benefits at any time during this six-month period. All that is required is that they provide 7-day advanced written notice that they are terminating benefits. That’s it! They do not require permission from anyone! It’s important to realize that the insurer holds all the power during this initial period.

So, what is this form?

The Form 105 (https://www.mass.gov/doc/form-105-agreement-to-extend-180-day-payment-without-prejudice-period/download) is a form that extends the pay without prejudice period from 180 days to 360 days. Insurers typically send out 105 extension letters early on in the process, i.e. 30-90 days rather than do what they should and investigate the circumstances around the injury. Insurers often send these extension letters under the guise that they are assisting you get an additional 180 days of benefits. “Wow! I’m going to get another 180 days of checks?” That’s not accurate, and grossly misleading. They can continue to pay benefits if they choose to. Essentially, they want injured workers to sign the Form 105 extension because they want the time frame extended where they have the power to stop benefits.

That leads to the next question. What happens it I don’t sign it?

If an insurer continues to pay benefits beyond the 180-day period, they have actually accepted liability for your injury as a matter of law, and can only stop your benefits under limited circumstances, such as a judge authorizing termination by way of a Conference Order; you return to work without a loss of earnings; your treating physician indicates that you can return to work with your employer and they’ve kept your job open for you; and a few other limited circumstances. What’s this mean? It means after the 180-day period they no longer have the power to stop your benefits without proper reason, and/or permission. So why should you allow an insurer to avoid accepting liability by signing the Form 105?

That is not to say that a Form 105 extension should never be signed. Every injured worker’s case is unique, and should be fully explored before making an assessment. If you have received an Agreement to Extend 180 Day Payment Without Prejudice Period, aka Form 105, from the workers’ compensation insurer, you should reach out to me right away. I’d be happy to discuss.

For a free consultation regarding the pay without prejudice form, or any other issue related to your work injury, contact the firm online here, or reach out by phone at (978) 703-0700 to speak with Eric today.