If your workers’ comp claim has been denied, or you have a dispute with the insurance company about your benefits, you can challenge the decision with the Maine Workers’ Compensation Board. (For an overview of eligibility and benefits, see our article on filing a workers’ comp claim in Maine.)
If your employer’s insurance company denies your claim, it will file a Notice of Controversy with the Maine Workers’ Compensation Board. The notice will state the specific reason for the denial of your claim. Your case will then be sent to a Board representative called a “troubleshooter.”
Within a couple of weeks, the troubleshooter will contact you and the insurance company to discuss the claim. The troubleshooter will try to help you and the insurance company resolve the dispute informally, usually over the phone. If you can’t reach a resolution, your case will be sent to mediation.
Mediation is another attempt to help you and the insurance company resolve the dispute informally. A mediation is a meeting held in an informal setting, in which a neutral third party (the “mediator”) will try to help you and the insurance company reach a voluntary settlement agreement. The mediator does not, however, make a decision in your case. If you can’t resolve the dispute, you will need to attend a formal hearing.
To request a formal hearing, you will need to file a petition with the Maine Workers’ Compensation Board. The Board has different petition forms depending on what issue is in dispute. For example, if you believe you are entitled to wage loss benefits, you would file a Petition for Award of Compensation (Form WCB-140). Other petition forms are available if the dispute is about medical treatment or the extent of your permanent disability.
You must file your petition within two years of your accident or the date your employer filed a first report of injury, whichever is later. However, if the insurance company paid some benefits to you within two years of your injury, you have six years from the last payment to file a petition. Either way, it’s usually best to file your petition as soon as possible.
The hearing will be held before a workers’ compensation judge, who will listen to the arguments of the parties, consider testimony from witnesses, and review relevant documents. Both you and the insurance company will have an opportunity to present your cases. After the hearing, the judge will mail a written decision to the parties.
If the judge doesn’t rule in your favor, you can appeal to the Appellate Division of the Maine Workers’ Compensation Board within 20 days. To appeal, you must file a Notice of Intent to Appeal (Form WCB-240) with the Appellate Division and send a copy to your employer and its insurance company. You’ll also need to request a written transcript of the hearing, along with any documents presented as evidence, from the Workers’ Compensation Board. You must send a copy of these documents to the Appellate Division, along with your employer and its insurance company.
Once the Appellate Division receives your request, you will be asked to submit a written brief explaining why you believe the judge’s decision was incorrect. A panel of three workers’ compensation judges will generally decide your case based on the documents it receives. However, either party can request to appear in person to make oral arguments.
If you disagree with the panel’s decision in your case, you can appeal through the state court system. You must file your appeal with the Maine Supreme Court within 20 days. (For more information on these appeals, see the Appellate Division’s page on appeals.)
The Maine Workers’ Compensation Board has a Worker Advocate Program, which provides free legal representation to injured workers without attorneys. A worker advocate can help you file a petition, prepare for mediation, and represent you at a formal hearing. To take advantage of the program, you must participate in the state’s troubleshooting process first.
You might also want to consider hiring an experienced workers’ compensation lawyer, especially if your injuries are serious and will have a significant impact on your ability to work in the future. A lawyer will be able to represent you at all stages of the appeals process, including before the Appellate Division and through the state court system. To find an experienced workers’ compensation attorney in your area, see our online lawyer directory.