A denied workers’ compensation claim does not mean your case is over. In Massachusetts, a denial is the insurer’s position, not a final decision. Injured workers can challenge it through the Department of Industrial Accidents (DIA), the state agency that resolves workers’ compensation disputes.
The catch is time. Some appeal windows are only 14 days long, so what you do in the first few weeks matters. Below, we explain why claims get denied, what to do first, how each stage of the DIA process works, and when it makes sense to bring in a workers’ compensation attorney.
Why Workers’ Compensation Claims Get Denied in Massachusetts
Most denials come down to a short list of disputes. Knowing which one applies to you tells you what evidence you need to fight it.
- The insurer says the injury is not work-related. The insurer argues the injury happened outside of work, or that your job did not cause it. This is common with back injuries, repetitive strain, and illnesses that develop over time.
- The medical evidence is thin. Your records may not clearly connect the injury to your job, or there may be gaps in treatment that the insurer reads as a sign you recovered.
- The insurer blames a pre-existing condition. The insurer points to an old injury, arthritis, or wear and tear and argues that work is not the real cause of your current problem.
- Notice to your employer was late. You are expected to tell your employer about the injury in writing as soon as possible. A late report gives the insurer an opening to question the claim.
- The insurer disputes your employment status. The insurer argues you were an independent contractor rather than an employee, so workers’ compensation does not apply.
A denial for any of these reasons can be challenged. The rest of this article explains how.
Read the Denial and Mark Your Deadlines
Start by reading the denial closely. In Massachusetts, once the insurer receives your employer’s first report of injury, it generally has 14 calendar days to pay or deny the claim. A denial comes by certified mail on Form 104, the Insurer’s Notification of Denial, which must list the reasons and explain your right to appeal. Those reasons tell you which dispute you are facing and what evidence you need. If 30 or more calendar days pass with no word from the insurer, you can move forward as if the claim were denied.
Write down the date of your injury, the date you gave your employer written notice, and the date the denial arrived. Then note the deadlines ahead: 14 days to appeal a conference order, 30 days to appeal a hearing decision to the Reviewing Board, and a general four-year window to file a claim from when you first became aware the injury was work-related. These are general timeframes, so confirm the dates in your own case with an attorney.
Gather Your Evidence
The evidence you collect now is what the DIA will rely on later. Focus on records that show you were hurt, that it happened at work, and that the injury limits your ability to work.
- Medical records. Every visit, test, and treatment note since the injury.
- Your doctor’s opinion. A written statement explaining how the injury is connected to your work. This is often the most important document in a denied claim.
- Accident or incident reports. Any report filed at work, plus photos if you have them.
- Witness statements. Names and contact details for coworkers who saw the injury happen.
- Proof of written notice. A copy of how and when you reported the injury to your employer.
- Pay records. Recent pay stubs or W-2s that show your average weekly wage.
- Insurer paperwork and unpaid bills. Keep the Form 104 and every letter from the insurer.
Keep copies of everything in one place, and keep going to your medical appointments. Gaps in treatment are one of the first things an insurer uses to argue you have recovered.
File Form 110 With the DIA
Form 110, the Employee’s Claim, is the form that formally starts your dispute with the Department of Industrial Accidents. You file it after you receive a Form 104 denial, or after 30 or more calendar days have passed without hearing from the insurer.
A few points trip people up at this stage:
- You must attach copies of supporting documents, such as medical reports or unpaid medical bills.
- The insurer must also get a copy of the form and all attachments by certified mail, even if it already has those records.
- The DIA can reject a form that lists the wrong insurer, leaves out the type of benefits you are claiming, or skips the first and fifth days you missed work.
Once the DIA accepts the form, it sends a notice scheduling the first step, a conciliation. Attorneys file the claim through the DIA’s online system.
If you have not filed a claim yet, our guide on how to file a workers’ compensation claim in Massachusetts covers the filing steps in detail.
What Happens at Each Stage of the DIA Process
A denied claim can move through up to five stages at the DIA, and it can be resolved at any one of them.
- Conciliation. An informal meeting with you, your attorney, the insurer’s attorney, and a DIA conciliator, who tries to help both sides reach an agreement. If they cannot, the claim goes to an administrative judge.
- Conference. Another informal discussion, this time before an administrative judge. If the issues are not resolved, the judge issues a temporary order on whether the insurer must pay benefits. Either side can appeal the conference order within 14 days.
- Hearing. The trial phase of the case. Beforehand, you are examined by an impartial medical examiner, and both sides file a Joint Pre-Hearing Memorandum. At the hearing, Massachusetts rules of evidence apply and witnesses testify. Either side can appeal the judge’s hearing decision within 30 days.
- Reviewing Board. Three administrative law judges review the hearing transcripts and legal briefs. They reverse a decision only if it went beyond the judge’s authority, was arbitrary or capricious, or was contrary to law.
- Massachusetts Appeals Court. Hears further appeals from Reviewing Board decisions.
Because the Reviewing Board looks for legal errors rather than new evidence, the hearing is where your medical evidence and testimony need to be complete.
What the First Few Weeks Can Look Like
- Within 14 calendar days of receiving the injury report, the insurer pays or denies the claim.
- 30 calendar days after the injury with no response: you can file Form 110.
- About 1 to 2 weeks after filing Form 110: the DIA sends a notice scheduling your conciliation.
- Within 14 days of a conference order: the deadline to appeal it.
- Within 30 days of a hearing decision: the deadline to appeal to the Reviewing Board.
Why Medical Evidence Decides Most Denied Claims
In a denied claim, the medical record carries more weight than anything else. Most disputes turn on two questions: did work cause the injury, and how much does it limit you? Two medical exams are part of that fight, and they are easy to confuse.
- Independent Medical Examination (IME). An exam arranged by the insurer with a doctor it chooses. Insurers often use the IME report to support a denial or argue you can return to work.
- Impartial medical examination. Under Section 11A of the Massachusetts workers’ compensation law, when a disputed medical issue reaches the hearing stage, a physician from the DIA’s roster examines you and sends a report to both sides at least one week before the hearing.
The impartial report is treated as prima facie evidence, so the judge starts from it on the medical questions. Other medical evidence is generally allowed only if the judge finds the report inadequate or the issues complex. Missing the exam without good cause can lead to suspended benefits.
That is why steady treatment and a clear opinion from your own doctor matter so much. When your records consistently tie the injury to your work, the insurer’s IME does not go unanswered.
Should You Hire a Workers’ Compensation Attorney?
You are allowed to file a claim and start the DIA process on your own. Even so, the DIA itself recommends hiring an attorney for conciliation and strongly advises it for the conference stage.
There are practical reasons for that advice. The deadlines are short, Form 110 has to be filed and served correctly, and the impartial medical report can decide a hearing. An attorney can get the right medical opinions into the record and answer the insurer’s IME and legal arguments. The earlier that help starts, the less room there is for a missed deadline.
Cost is often the main worry for someone who is out of work. In Massachusetts workers’ compensation cases, attorney fees are set by state law, and with our office, you only pay a fee if you win a disability award. The first conversation is a free consultation, so you can learn where your claim stands before deciding anything. Learn more on our workers’ compensation page.
How the Law Office of Eva C. Ovalle Helps With Denied Claims
At the Law Office of Eva C. Ovalle, PLLC, we help injured workers file workers’ compensation claims, appeal denials, and pursue the wage and medical benefits they are entitled to under Massachusetts law. Our firm has over 12 years of experience.
When a claim has been denied, we review your case, gather the supporting evidence, and file the appeal on your behalf. We also deal with the insurance company so you can focus on your recovery.
Our office is in Medford, and we serve injured workers in Medford, Woburn, Burlington, Everett, Chelsea, and the Greater Boston area. Call (857) 203-0950 or schedule a free consultation to go over your denial and your deadlines.
*This article is provided for general informational purposes only and is not legal advice. Reading it does not create an attorney-client relationship. Every case turns on its own facts, and Massachusetts law changes. Please consult a licensed Massachusetts attorney about your specific situation.*
Frequently Asked Questions
It depends on the stage. The general window to file a claim with the DIA is four years from when you first became aware the injury was work-related. Inside the DIA process, you have 14 days to appeal a conference order and 30 days to appeal a hearing decision to the Reviewing Board.
Yes. The workers’ compensation insurer will not pay while the denial stands, but many workers use their own health insurance in the meantime. If the claim is later found to be covered, the health insurer can seek repayment from the award. Keep treating, since gaps in care can hurt your claim.
A pre-existing condition does not automatically end your claim. Under Section 1(7A) of the Massachusetts workers’ compensation law, when a work injury combines with an earlier condition that is not work-related, the result is covered as long as the work injury remains “a major but not necessarily predominant cause” of the disability or need for treatment. Your doctor’s opinion should address this directly.
The law does not require one, but the DIA recommends an attorney for conciliation and strongly advises one for the conference. With our office, attorney fees are set by state law, and you only pay a fee if you win a disability award.
Missing a deadline can mean the order or decision stands, and you lose the chance to challenge it at the next stage. Other options may exist depending on your facts, so speak with an attorney right away instead of assuming your case is over.