With certain exceptions, all employers in Massachusetts are required to have workers' compensation insurance coverage. If your claim is accepted, your employer's worker's comp insurance carrier will pay for all claim-related medical expenses, as well as disability benefits while you are off work.
To determine the identity of your employer's workers' compensation insurance carrier, talk to your employer. There also should be a poster in your break room or other common area with information about workers' compensation and the insurance company's name. You can also check your employer's coverage with the Massachusetts Labor and Workforce Development.
Under Massachusetts law, injuries and diseases sustained due to workplace activity are covered, as long as they arose in the course and scope of employment. This means you had to be performing an aspect of your job or be present at your employer's premises when the injury or illness occurred. Injuries that occur on the way to or from work are usually not covered. (For more information, see What Injuries Aren't Covered by Workers' Comp?)
You must report your injury or illness to your employer as soon as possible. If you are out of work for five or more days, your employer is required to report your work-related injury or illness to its insurance company and the Department of Industrial Accidents within seven days of the injury. This is the official start to your workers' comp claim.
Massachusetts workers' compensation law provides for a variety of benefits to assist injured workers while they are recovering from their injuries, including medical benefits and disability benefits.
Medical treatment. The insurance company will pay for all reasonable and necessary medical treatment related to your industrial injury or occupational disease. This includes doctors' visits, surgeries, hospital stays, prescriptions, and medical devices. You can also receive reimbursement for travel to and from doctors' visits. Your employer can choose your medical provider for your first visit. After that, you can treat with your own doctors.
Temporary disability benefits. If you are unable to work due to your injury or illness for six or more days, you will receive temporary total disability benefits. These benefits are 60% of your average weekly wage at the time of your injury, subject to a maximum set by law ($1,338.05 as of October 2017). These benefits can last up to three years. If you have to take a lower paying job or work fewer hours due to your injury or illness, you will partial benefits for up to five years.
Permanent partial disability benefits. Once your condition has improved as much as it is likely to with treatment, your doctor will give you a permanent disability rating. If you have a partial disability, but you can still do some work, you will receive permanent partial disability benefits. This compensation is 60% of your average weekly wage at the time of your injury, but no more than 75% of what you received for temporary total disability. Partial disability benefits are usually available for a maximum of five years. However, there are a few exceptions that allow benefits to continue for up to ten years, including for employees who have suffered a loss of 75% or more of any bodily function.
Permanent total disability benefits. Permanent and total disability benefits are available for workers who cannot return to work in any meaningful capacity. If you qualify, you will receive two-thirds of your average weekly wage, subject to the same maximum as temporary total disability benefits.
A Massachusetts workers' compensation claim may be denied for many reasons. The most common reasons are reporting or filing a claim too late, improper paperwork, and lack of medical evidence establishing that your condition was caused by work. Claims may also be denied if you refuse medical care for your injury.
If your employer's workers' compensation insurance carrier denies your claim, you will receive an Insurer's Notification of Denial (Form 104). This form will include the reasons for your denial and describe the process of appealing denial of your claim. You have four years from the date of denial to file an appeal.
To appeal, complete and file an Employee's Claim form (Form 110) with the Department of Industrial Accidents. Along with the form, submit all medical evidence and other evidence establishing your claim. Your doctor can assist you in gathering the medical documentation necessary to prove your workers' compensation claim. You must also send a copy of the Form 110 to the insurance company.
After filing your claim, you will receive notice of a conciliation. This is an informal meeting during which you and the insurance company will attempt to reach a settlement agreement. A conciliator from the Department of Industrial Accidents will lead the meeting and encourage you and the insurance company to discuss a resolution. You should bring all evidence supporting your case to the conciliation, including your medical records. If you do not reach an agreement with your employer's insurance company, the next step of the appeals process is called a conference.
If no agreement is reached at the conciliation stage, the conciliator will refer your case for a conference with an administrative judge. This is another informal proceeding, during which the judge will review all of the evidence from both parties. However, no witness testimony can be given. You should be prepared to present evidence about what caused your injuries, the extent of your medical treatment, your physical inability to work, and your wage loss.
The administrative judge will issue a decision called a Conference Order. Either party can appeal this order by completing an Appeal of a Conference Proceeding (Form 121). The case then proceeds to a formal hearing involving the same administrative judge.
A hearing is much like a trial, in which witness testimony is given and evidence is formally presented to the administrative judge. You will have the opportunity to present witnesses on your behalf, such as your doctors and any coworkers who witnessed the industrial accident. You may also cross-examine (ask questions of) your employer's witnesses. Both you and the insurance company will present documentary evidence to the judge, such as doctors' reports, diagnostic studies, and medical bills. After all of the evidence is presented, the administrative judge will issue a written final decision.
If the administrative judge denies your claim, you may appeal to the Reviewing Board by filing an Appeal to Reviewing Board (Form 112). You must file this appeal within thirty days of the administrative judge's decision.
Three administrative law judges will review your case, but they will review only the hearing transcript and evidence submitted at the hearing. New evidence is typically not allowed. The Review Board will alter a hearing judge's decision only if the decision:
The Review Board will issue a written decision. This decision may be appealed to the Massachusetts Court of Appeals.
If your worker's compensation claim was denied, you should consult with a Massachusetts workers' comp attorney. An attorney can help you navigate the complex rules and procedures you must follow in order to successfully appeal or settle a claim. Attorneys' fees in Massachusetts cases are governed by the Workers' Compensation Act, and your attorney can charge legal fees only if you win your case. (For more information, see How Much Will I Have to Pay a Worker's Compensation Lawyer?)