The Four Stages of a Contested Workers Comp Claim

If you are receiving a weekly check and your medical bills are being paid, you may expect everything to continue going smoothly. At some point, however, your case may be contested and have to be resolved at the Department of Industrial Accidents. Some cases are contested from the beginning, with the employer refusing to take any responsibility for the injury. In other cases, insurance companies wait to see if you will recover and return quickly to work. If you don't, they may contest the claim. You will receive a letter in the mail with the date and time that you must appear at your local office of the Department of Industrial Accidents.

Stage 1: Conciliation

Don't worry too much about this step. A conciliation is an informal meeting at which your lawyer, the insurance company's lawyer and a conciliator from the DIA try to reach an agreement about your claim. In most cases, you say nothing during the conciliation. In our experience, very few cases are resolved at this stage.

Stage 2: Conference

If nothing is resolved at the conciliation, your case advances to the conference. The letter that notifies you of your conference date will also tell you the name of the judge to which your case has been assigned. The name of the judge may be significant. Some judges are sympathetic toward people who are ill or injured; others have the same negative views of injured workers as the general population. They may be looking for malingerers or believe that "everyone can do something." Asked your lawyer or other injured workers to find out what type of judge is handling your case.

At the conference, you will most likely sit in silence while the lawyers for each side speak to the judge. It can be very difficult to listen to the attorney representing the insurance company talk about you without being able to respond. Your lawyer will present the judge with your medical evidence. The other lawyer will present whatever medical evidence the insurance company has, including the report of an independent medical examiner (a physician hired by the insurance company to examine you). The strength of your own medical evidence will play a major role in the judge's decision at this stage. That is why it is so important to have a doctor who believes you and supports your case. The report of the independent medical examiner often does not carry a great deal of weight with the judge. Judges understand that these reports are written by a physician hired by the insurance company, and they take that into consideration when judging their credibility.

The judge must make a decision within seven days of the conference. You will be notified of the decision by mail. If you prevail, you have won only one battle in the war. The insurer can appeal the decision. If you lose at the conference stage, you can appeal the decision. The appeal will take you to the next stage in a contested claim.

Stage 3: Hearing

The same judge who heard your case at the conference will conduct the hearing several months later. A very important step, however, will happen before the hearing. You will be sent to be examined by an impartial medical examiner. This is a physician chosen by the judge. The impartial medical examiner will receive a copy of all the medical reports that have been submitted to the judge. He or she will write a report, including an opinion as to whether or not your medical condition is related to your work and how seriously disabled (if at all) you are as a result of the injury.

The impartial medical examiner's report is the ONLY medical evidence that will be allowed at the hearing. By law, the judge must rely heavily on the impartial medical report in deciding your case.

Suppose your own doctors have provided strong documentation to support your workers compensation claim, but the impartial disagrees and says in his report that your injury is not related to work or you are not disabled? To put it bluntly, your own doctor's opinions no longer matter. You cannot say to the judge at the hearing that the impartial medical examiner must be wrong be your own doctors had different opinions. Your own doctors' opinions become irrelevant. Strong cases have been destroyed and weak cases revived by the opinion of an impartial medical examiner's report. This is one of the most unfair parts of the workers compensation law in Massachusetts.

At the hearing, you will testify as well as any witnesses for you. You will be cross-examined by the attorney for the insurance company. You will be notified of the judge's decision by mail.

Sometimes cases are settled before the hearing or the day of the hearing. Many injured workers have to decide whether or not to accept a settlement or take their chances before a judge.

Stage 4: Reviewing Board

You may have to wait years to get a decision from the reviewing board. The board will reverse the hearing judge's decision only if the decision was beyond the scope of his authority, arbitrary or capricious, or contrary to law.