When an employee is incapable of earning full wages for five or more full or partial calendar days due to an occupational injury or illness, the employer must file Form 101 - Employer's First Report of Injury/Fatality with the Department of Industrial Accidents (DIA) and send a copy to their insurance carrier, a copy to the injured worker and keep a copy for their records. This form must be sent within seven calendar days (not including Sundays and legal holidays) from the fifth day of full or partial disability.
STEP 2 - PAYMENT OR DENIAL OF CLAIM
Once the insurer receives the form, they have 14 calendar days to pay benefits on an Form 103 - Insurer's Notification of Payment or notify the employee and the DIA that they are denying the claim by sending an Form 104 - Insurer's Notification of Denial . The insurance company can pay on a claim for up to the first 180 days following the initial injury or illness without accepting liability for the claim. During this 180 day "Pay Without Prejudice" period, the insurer can stop or modify the payments after giving a seven calendar day notice to the injured worker and the DIA on an Insurer's Notification Of Termination or Modification Of Weekly Compensation During Payment-Without-Prejudice Period (Form 106) The insurer, with the consent of the injured worker and approval of the DIA, can extend the initial 180 day period for another 180 days on an Agreement To Extend 180 Day Payment-Without-Prejudice Period (Form 105) After the initial 180 day period has passed, the insurer can stop or reduce payment only for reasons specified by the Workers' Compensation Act and regulations. If the insurer denies the claim or stops or reduces payment once it has been initiated, the employee can file an Employee Claim Form -- With Instructions (Form 110) to request a Conciliation.
STEP 3 - CONCILIATION
The first proceeding scheduled on a contested claim is an informal meeting called a Conciliation, which is usually held within 12 business days of the Employee Claim - Form 110 being received by the DIA. Notification of the Conciliation date will be sent to your insurance representative. At Conciliation an attempt is made to settle the issues in dispute. If the case involves § 28, Willful Misconduct, then a notification of the Conciliation date and time will also be sent to the employer. If an agreement is not reached, the claim is referred to a Conference.
STEP 4 - CONFERENCE
The Conference is the first proceeding before an Administrative Judge. The insurer and the employee must be present at the Conference. The employer must attend the Conference if the claim involves § 28, Willful Misconduct of Employer. At the Conference the employee would need to show: (A) they were disabled; (B) the injury or illness was work related; and (C) that any disputed medical bills were for reasonable and necessary treatment. Following the Conference, the judge will issue an order of payment or denial. Either side may appeal this within 14 calendar days. The employer will receive notification for the date of the Conference. If the case is appealed, it will proceed to the Hearing stage.
STEP 5 - HEARING
At a Hearing, the same Administrative Judge who presided at the Conference considers all the evidence. The employer must attend the Hearing if the claim involves § 28, Willful Misconduct of Employer. Massachusetts Rules of Evidence apply and sworn testimony from witnesses is taken. After reviewing all the information available, the judge will then issue a written decision. A notification for the Hearing date will be sent to the employer. If either party to the case believes the judge made an error of law or exceeded their authority with the ruling, the party has 30 calendar days from the filing date of the decision to file an appeal to the Reviewing Board.
STEP 6 - REVIEWING BOARD
This board is made up of six Administrative Law Judges, three of whom will examine the Hearing transcripts. They may ask for oral arguments or written briefs from either party. The Reviewing Board can reverse or uphold the decision of the Administrative Judge. Decisions can be appealed to the Massachusetts Appeals Court. The employer must attend the oral arguments, or submit a brief, if the claim involves § 28, Willful Misconduct of Employer.
Please Note: If the Conference or Hearing is rescheduled, the DIA recommends that you check with your insurance representative for the new date and time.
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