DEPARTMENT OF INDUSTRIAL ACCIDENTS FORM 104
INSURER’S NOTIFICATION OF DENIAL
1. What does this form mean:
THE WORKERS’ COMPENSATION INSURANCE COMPANY IS DENYING YOUR CLAIM AND WILL NOT PAY YOU ANY BENEFITS VOLUNTARILY.
2. How long does a workers’ compensation insurance company have to notify me that my claim is being denied?
The workers’ compensation insurance company only has 14 days to notify you that your claim is being denied. The time period begins to run from the day it receives notice of your injury from your employer or 14 days from the date a claim is filed for benefits on your behalf.
3. Why can a workers’ compensation insurance company deny my claim when it is clear I was injured at work as there were witnesses to my injury and I received medical treatment right away.
Even if there were witnesses to your injury and you saw a doctor right away a workers’ compensation insurance company still can deny your claim because the law allows them to do it.
4. What does it mean when the box is checked for:
a. No personal injury: The insurance company does not think you were injured.
b. No injury arising out of and in the Course of Employment: The insurance company is arguing that you were not hurt on the job or doing any job related duties.
c. No disability: Even if you were injured at work, you are not disabled by that injury and could work.
d. No causal relationship between the personal injury and disability: The insurance company may agree that you had an injury and that you are disabled but is arguing that your injury did not cause your disability.
In most cases, a workers’ compensation insurance company will claim that you have a pre-existing condition which is what is causing your problem and not your work injury.
NOTE: EVEN IF YOU DO HAVE A PRE-EXISTING CONDITION IT DOES NOT MEAN THAT YOU ARE NOT ENTITLED TO BENEFITS.
1. Lack of Jurisdiction: Your claim is not covered under the Massachusetts Workers’ Compensation law.
2. Lack of Notice: You did not report the injury within a reasonable period of time.
NOTE: Your obligation is to report an injury when you become aware of it even though it may not be at the time the accident occurred or when you started to have symptoms.
3. LATE CLAIM: Similar to lack of notice, you must make a claim against the workers’ compensation insurer as soon as practicable. However, you cannot be expected to make a claim if you are unaware you have one because you did not realize you were injured.