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Appeal your denied workers’ compensation claim

If the workers' compensation insurer denied your claim, find out how to appeal it and what you need to appeal the denial.
You should get a notice within 1 – 2 weeks after submitting your claim form.

Department of Industrial Accidents

The Details

What you need

To appeal a denial of your workers’ compensation claim to the Department of Industrial Accidents (DIA) you will need to know:

  • Your date of injury
  • The 1st calendar day of work missed
  • The 5th calendar day of work missed
  • The workers’ compensation insurance carrier
  • The body parts and types of injuries
  • What type of types benefits you’re looking for
  • How long you may be out, if known
  • Where you first went for treatment
  • Your current treating doctor

You are required to attach copies of at least 1 item below to the Form 110 – Employee Claim and bring the rest with you to the conciliation - the first step in the dispute process.

  • Unpaid medical bills
  • Medical reports
  • Any reports that support how the accident happened
  • Witness names
  • Witness statements

How to appeal

To file a claim, download and complete Form 110 – Employee Claim. You will need 3 copies of this form and all other materials:

  • 1 copy for the DIA
  • 1 copy for the workers’ compensation carrier
  • 1 copy for your records, or in case you hire an attorney later

Send your original signed Form 110 - Employee Claim with copies of your supporting documents to:

                 Department of Industrial Accidents
                 Dept. 110
                 1 Congress St., Suite 100
                 Boston, MA 02114

Bring your original signed Form 110 - Employee Claim with copies of your supporting documents in person to the DIA Boston office:

                  Department of Industrial Accidents
                  1 Congress St., Suite 100
                  Boston, MA 02114

Next steps

What you need to do after completing the appeal

Once you have completed the form and have your attachments, you will need to make 3 copies:

  • Send a copy for the Form 110 – Employee Claim and all supporting documents to the workers’ compensation carrier by Certified Mail
  • You must attach copies of the medical reports, bills, etc. to the form you send to the insurer even if you know they already have them. If these documents aren’t attached, the insurer’s attorney will ask the DIA to withdraw the claim because it wasn’t filed correctly.

The DIA will review your claim and respond in 2 ways:

  • The DIA can reject the form for several reasons and send everything back to you. A rejection letter will be attached to the form stating what information is missing or incorrect.
  • If the information is correct, we’ll send a notice to you, the insurance company, and your employer setting up a meeting with a conciliator to discuss your claim. This informal meeting is called a conciliation.
    • Your employer gets a notice as a courtesy. They don’t need to appear unless the insurance company wants them to.

More info

If you don’t know the name of your employer’s workers’ compensation insurance company, look at Box 1 on the Form 104 – Insurer’s Notification of Denial that the insurer sent you. Their name and address will be located in that box.



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