The Dispute Resolution Process

What To Expect When Your Claim Is Denied Or Disputed

If your workers’ compensation claim is denied or disputed, your case may be referred to the dispute resolution process — and an experienced workers’ compensation lawyer can ensure your claim is successful.

For a free case evaluation of your workers’ compensation claim, please contact us online or call us toll free at (800) 367-0871 to speak with an experienced workers’ compensation attorney at Kantrovitz & Associates, P.C. We have more than 20 years of experience fighting for the rights of individuals injured in the course of their employment.

Based in Boston, Massachusetts, the workplace injury lawyers at Kantrovitz & Associates, P.C. help injured workers across Massachusetts, including but not limited to Boston, Essex, Middlesex, Norfolk, Suffolk, Plymouth and Merrimack River. We also represent Rhode Island and New Hampshire residents whose injuries occurred in Massachusetts or who were hired in Massachusetts but who were injured out of state.

More About the Dispute Resolution Process

Either you or your employer’s workers’ compensation insurer can begin an organized dispute resolution process, administered by the Massachusetts Department of Industrial Accidents, if there’s disagreement about whether you’re entitled to benefits, or about the types and amounts of benefits that you ought to receive. You can begin the dispute resolution process by filing an Employee’s Claim using Form 110. The insurance company can begin the process by filing a “complaint to modify or discontinue compensation” with the Department of Industrial Accidents. If you receive notice of such a complaint by your employer’s workers’ compensation insurer, it means that the company wants to reduce the amount of benefits that you’re receiving, or even stop your benefits entirely.

Once the dispute resolution process starts, it can go through up to four separate stages: Conciliation; a Conference before an administrative judge; a Hearing before an administrative judge; and consideration of the dispute by a Reviewing Board made up of three administrative law judges.

At any time during the process, it is possible that the parties can settle the dispute by utilizing a “lump sum settlement.” When that happens, it means that an injured worker and the employer’s workers’ compensation insurer have agreed that the employee will be paid a single, one-time payment rather than receiving weekly workers’ compensation benefits. Any medical and vocational rehabilitation benefits must remain open and available to the employee if needed.

Stage 1 – Conciliation

The first step in the workers’ compensation benefits dispute resolution process is called “Conciliation.” You should be scheduled for a Conciliation within about two weeks after the Department of Industrial Accidents accepts your Form 110 or the insurance company’s complaint. The scheduling is done automatically by computer within the Department.

The Conciliation is an informal meeting between you, a representative of the workers’ compensation insurer, and a representative of the Department of Industrial Accidents. In the Commonwealth’s fiscal year 2010, there were over 13,000 cases scheduled for Conciliation, and about 45% of those were resolved.

The Conciliation is an opportunity to discuss whether you and the insurance company can reach a voluntary agreement about your benefits. The conciliator may encourage the parties to reach an agreement, but he or she has no authority to order the parties to come to a resolution.

The benefits that you are receiving at the time of the Conciliation cannot be changed as a result of the Conciliation unless you and the workers’ compensation insurer both agree.

If, at the conclusion of the Conciliation, you and the workers’ compensation insurer have not reached a voluntary agreement about your benefits, then the claim will be referred by the conciliator for the next stage of the dispute resolution process, the conference.

Alternatively, you and the workers’ compensation insurer can agree to a voluntary arbitration of the claim, but this is rare.

Stage 2 – Conference

The second stage in the workers’ compensation benefits dispute resolution process is the “Conference.” Like the Conciliation, this is an informal proceeding, but it is held before an Administrative Judge. Where possible, the same Administrative Judge will retain your case throughout any later proceedings.

Conferences are scheduled by the Department of Industrial Accident’s Central Scheduling Unit. In fiscal year 2010, there were almost seven thousand workers’ compensation conferences scheduled. Almost 5,500 of those were resolved in one way or another.

At the Conference, you and the attorney representing the workers’ compensation insurance company will have the opportunity to make presentations to the Administrative Judge regarding your work-related injury or disabling condition and the benefits to which you’re entitled. The Administrative Judge will receive documents regarding your claim, such as your medical records and proof of income, and also testimony from any witnesses in the form of affidavits or statements. No witnesses appear to give live testimony, but the parties can tell the Administrative Judge what their witnesses’ testimony would be.

If discussions between the parties and the Administrative Judge do not result in a voluntary agreement about your workers’ compensation benefits, then the Administrative Judge will issue a temporary order called a Conference Order. In the Conference Order the Administrative Judge will either instruct the workers’ compensation insurer to pay benefits to you, or that it need not pay your benefits.

Although the proceedings in a workers’ compensation Conference are informal, in reality the Conference is the critical stage in the workers’ compensation dispute resolution process in Massachusetts. The purpose of the Conference is to bring together the important evidence about your claim and to pinpoint what issues are in dispute in your case. In the Conference, you must be prepared to establish your eligibility for each form of workers’ compensation benefits that you claim. In addition, the outcome of the Conference will be an order from the Administrative Judge determining whether you will or won’t receive benefits; if you lose at the Conference, then you will not receive benefits for the remainder of the dispute resolution process, which can be quite lengthy and extend up to a full year or more. Finally, because the same Administrative Judge will likely handle the next stage of the dispute resolution process, the Conference is your prime opportunity to make a strong presentation establishing the best possible “first impression” with the judge for your case.

Once the Administrative Judge issues a Conference Order in your case, either party has up to 14 days to appeal. If an appeal is filed, then your case will be scheduled for a formal Hearing.

Stage 3 – Hearing

If either you or the workers’ compensation insurer appeal the Conference Order issued by the Administrative Judge, then your case will be assigned to the Hearing stage. The Hearing is a formal proceeding before the Administrative Judge that resembles a trial. The proceedings will be recorded by a stenographer, and the Massachusetts Rules of Evidence will govern the calling of witnesses to give sworn testimony and the admission of documents into evidence by the Administrative Judge.

In 2010, some 4,500 hearings were scheduled, and almost 4,200 cases were resolved at the hearing level.

Based upon the evidence and argument presented by the parties at the Hearing, the Administrative Judge will issue a formal decision on your workers’ compensation insurance claim.

Either party can appeal the final decision of the Administrative Judge, but only on the basis that the Administrative Judge made an error of law during the Hearing on in the judge’s final decision. That is, a party cannot appeal the factual findings made by the Administrative Judge, but must show instead that the decision exceeded the Administrative Judge’s authority, was contrary to law, or lacked any justification (meaning it was arbitrary or capricious).

An appeal of the Administrative Judge’s final decision after the Hearing must begin within 30 days after the date of the decision. The case then will be forwarded to The Review Board.

Stage 4 – The Reviewing Board

The Reviewing Board consists of six Administrative Law Judges, who are divided into two panels of three ALJs each. As such, the panels function much like a court of appeals. When a Hearing decision is appealed, it is assigned to one of the two panels.

Two hundred hearing decisions were appealed to the Reviewing Board in the Commonwealth’s fiscal year 2010. The Reviewing Board resolved 255 cases (including some from the prior year).

The Administrative Law Judges will examine the transcripts recorded during the Hearing as they begin the process of deciding whether the Administrative Judge made an error of law. The Administrative Law Judges also review written briefs submitted by the parties explaining why the Administrative Judge did, or did not, make an error of law during the Hearing or in the resulting decision. They also can ask the parties to present oral argument on the case.

Massachusetts law permits the Reviewing Board judges to reverse a decision of an administrative judge only if the decision was beyond the scope of the administrative judge’s authority, was contrary to law, or was arbitrary or capricious.

Based on their decision the Administrative Law Judges assigned to your case can affirm the decision of the Administrative Judge, reverse the decision, or possibly send the case back to the Administrative Judge for further proceedings on your claim.

Injured on the Job? Contact Our Workplace Accident Lawyers

The Massachusetts’ workers’ compensation system is designed to ensure that workers who are injured on the job receive paid medical treatment and compensation for lost wages after being fully or partly disabled for five days or more. The experienced workers’ compensation lawyers at Kantrovitz & Associates, P.C., based in Boston, Massachusetts, can help you obtain your full benefits after a workplace accident.

For a free case evaluation of your workers’ compensation claim, please contact us online or call us toll free at (800) 367-0871 to speak with an experienced workers’ compensation attorney at Kantrovitz & Associates, P.C. We have more than 20 years of experience fighting for the rights of individuals injured in the course of their employment.

Our workplace injury lawyers at Kantrovitz & Associates, P.C. help injured workers across Massachusetts, including but not limited to Boston, Essex, Middlesex, Norfolk, Suffolk, Plymouth and Merrimack River. We also represent Rhode Island and New Hampshire residents whose injuries occurred in Massachusetts or who were hired in Massachusetts but who were injured out of state.