Most days, going to work is a routine action that, while perhaps difficult in some respects, ends with everyone going home safe and in one piece. Occasionally, though, accidents at work do happen, some because the work is inherently risky, and others because of unusual or freak circumstances that create a moment where an injury is possible. One of the benefits of working as an employee, compared with independent contractors or owner/operators, is the ability to access workers’ compensation benefits to cover medical bills and lost time at work during the period of recovery and recuperation. Unfortunately, many insurers will deny these claims, leaving the injured worker with large unpaid medical bills and lost income that places many workers in a financially precarious situation that is hard to overcome. Consequently, it is imperative to understand how to file a workers’ compensation claim for coverage, and what to do if the claim is denied.
Applying for Massachusetts Workers’ Compensation Coverage
Except for the largest employers, most businesses are insured through private insurance companies, with the whole system being regulated by the Massachusetts Department of Industrial Accidents (DIA). Fairly stringent rules govern how long an injured or ill worker has to file a claim, and which medical facilities may provide treatment, but it is not necessary to prove the employer was at fault for the injury. Rather, injuries that occur on the job, which are related to the person’s job duties, should be covered under a workers’ compensation policy. Reporting injuries to an employer promptly, ideally in writing, is critical to benefits being approved. At a minimum, an injured employee should explain:
- The date of the accident;
- How the accident occurred; and
- The symptoms being experienced.
Once notification is provided, the injured employee is typically asked to file out an accident report, another key piece of information used to approve or deny a claim, and instructed on how to obtain medical treatment. Following this report, the employer generally must file a claim with the insurance company and the DIA, though the employee may do so if the employer refuses. Once a claim is made, the insurance provider has 14 days to reject or approve benefits. If approved, some of the benefits injured employees may receive include:
- Payments for lost wages;
- Reasonable and necessary medical treatment;
- Money for permanent loss of function or disfigurement (disability); and
- The costs of rehabilitation therapy or training.
Responding to a Denied Claim
If a claim is denied, the injured worker has the right file an appeal with the DIA, but this process is extremely complicated and should be directed by an experienced workers’ compensation attorney. Workers’ compensation providers do not take a claimant’s report at face value, and they conduct their own investigation to see if enough evidence exists to demonstrate a covered injury occurred. Types of information insurance companies will use include:
- Medical records;
- Job duties and work experience;
- A medical exam by a doctor hired by the insurance company; and
- A functional assessment evaluation that looks at the worker’s ability to perform his/her duties after the injury.
Examples of reasons insurance companies routinely cite to deny claims are: the injury was due to employee misconduct, the claim is fraudulent, the injury occurred during the commute to/from work, or the employee was injured because a condition that increased his/her likelihood of being hurt, which was never disclosed to the employer. The appeals process, which must be triggered within four years, is multilayered and involves both administrative and judicial officials, the primary reason an injured employee needs the services of an experienced attorney to have a realistic chance at success.
Contact a New Bedford Workers’ Compensation Attorney
Suffering an injury while doing your job is a hard situation to accept, and receiving the necessary workers’ compensation benefits to cover the financial impact of this event is crucial to getting back to work. If your workers’ compensation claim was denied, contact the skilled attorneys at Goldberg Law Group, about challenging the insurer’s decision. You deserve these benefits, and Goldberg Law Group, will fight for your rights. Contact the New Bedford office for a free initial consultation.