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Workers' Compensation - Claims Administration - Massachusetts

Under the Massachusetts Workers' Compensation statute, when an employee is disabled or incapable of earning full wages for five or more calendar days as the result of a work related injury or disease, the employer must file a first injury report. This report must be sent to the Office of Claims Administration at the Department of Industrial Accidents (DIA), the insurer, and the employee within seven days of notice of the injury.

The insurer then has 14 days upon receipt of an employer's first injury report to either pay the claim or to notify the DIA, the employer, and the employee of refusal to pay. When the insurer pays a claim, it may do so without accepting liability for a period of 180 days. This is the "pay without prejudice period" that establishes a window where the insurer may refuse a claim and stop payments at its will. Up to 180 days, the insurer can unilaterally terminate or modify any claim as long as it specifies the grounds and factual basis for so doing. The purpose of the pay without prejudice period is to encourage the insurer to begin payments to the employee instead of outright denying the claim.

After a conference order is issued or the pay without prejudice period expires, the insurer may not stop payment without an order from an Administrative Judge. The insurer must request a modification or termination of benefits based on an impartial medical exam and other statutory requirements. A discontinuance or modification of benefits may take place no sooner than 60 days following referral to the division of dispute resolution.

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Information for this topic was drawn from:
http://www.mass.gov/wcac/wc-over.html

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Workers' Compensation - Claims Administration - Massachusetts

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