How The Workers’ Compensation Benefits Process Works

work-comp-process

After you filed your claim, the case will get marked as a conciliation. The best way I describe that is an informal meeting between the attorneys and a conciliator. It doesn’t take place in a courtroom, it takes place in an office. At that point, if you are the moving party, we file the claim. Our job is to put on a prima facie case or a minimal amount of evidence to sustain the burden that you have suffered in industrial accident, and the disability or treatment is causally related to that. If you establish that burden, the conciliator then will refer the case up to an administrative judge to be heard. The conciliator has no authority to get the insurance company to pay or even deny a claim any further.

They may encourage a resolution or an agreement short of the judge, but if they don’t, it gets referred out to the judge. At that point, the next stage is a conference. The conference is an oral argument between the attorneys. Most employees don’t come to the conciliation. You don’t need to, but when there’s a judge involved, you must be present. We then present all of our evidence and an oral argument to the judge why you’re entitled to benefits or treatment, give an overview of your history, and a history of the injury and the treatment.

The attorney from the other side will get up and indicate why they believe your case should be denied at that time. Whichever party doesn’t get what they want, or only gets part of what they want, will file an appeal of the conference order. What’s important, is that even though that appeal is being filed, if you get an order for benefits or treatment, the insurance company has to pay you under that order. This is required even though the appeal is pending. At that point, it would be scheduled for a hearing, which is essentially a trial where witnesses are put on the stand, and a testimony is taken. Prior to the trial, you get marked up for a medical examination. It’s an 11A exam. It’s the court’s doctor.

That court’s doctor looks at the insurance company’s medical evidence, our medical evidence, and renders an opinion to the court. All of those things are utilized at the time of a trial. At the time of a trial, a decision, a written decision, is issued by the judge in a timely manner. The appeal process at that point is, if one of the attorneys feel that the hearing decision is deficient as a matter of law, filing an appeal to the reviewing board. The reviewing board composes of six judges, and they have the right to either overturn the hearing decision. They may also remand it back down for further hearing.

If a party is not happy with the decision of the reviewing board, you have the right to refer it up to the Massachusetts Court of Appeals for further oral argument.