The Form 104 arrives by certified mail, and for most injured workers, it lands like a door slamming shut. The language is bureaucratic, the reasons can feel pretextual, and the immediate question is whether any of this is worth fighting. It is. A denial from an insurance company isn’t a judge’s ruling. It’s the insurer’s opening position in a process that Massachusetts law designed specifically to give injured workers a structured path to challenge it.
We’ve been representing injured workers in Massachusetts since 1994, and a denial is one of the most common places where our involvement begins. What follows is an honest explanation of why denials happen, what the appeals process actually looks like, and what it costs to fight back. The short version: the process is real, the timeline is defined, and the cost to you is often nothing.
Why Massachusetts Workers’ Comp Claims Get Denied
Under G.L. c. 152, the Massachusetts Workers’ Compensation Act, an injured worker carries the burden of showing that an injury arose out of and in the course of employment. Insurers have 14 calendar days from receipt of a claim to either pay benefits or issue a Form 104 denial. That tight window pushes insurers toward denial when documentation is thin or the facts are contested.
The most common denial grounds we see involve the insurer arguing the injury wasn’t work-related, that the worker delayed reporting to the employer, that medical records don’t explicitly connect the condition to a workplace incident, or that the worker was classified as an independent contractor rather than an employee. A particularly common and often beatable basis is the pre-existing condition argument, where the insurer claims symptoms stem from a prior condition rather than the job. Massachusetts law takes a different position on this than many workers expect: benefits can still be available when a work injury aggravated a pre-existing condition, even if that condition existed before the incident. Insurers deny on this ground precisely because workers don’t know it’s contestable with the right medical documentation.
What the Form 104 Actually Means
The Form 104, formally called the Insurer’s Notification of Denial, must explain the specific reasons for the denial and inform you of your right to appeal. Read it closely, because the denial language identifies the exact ground the appeal will need to address. A denial that says the injury wasn’t reported promptly requires a different response than one that disputes whether the condition is work-related at all.
What the Form 104 isn’t: a final ruling. It’s the insurer’s position, not an adjudicated order, and it triggers your right to file Form 110 with the Department of Industrial Accidents to initiate a formal appeal. There’s also one scenario that doesn’t require a Form 104 at all. If 30 days pass from the first date of disability and the insurer hasn’t responded, you can file Form 110 without waiting for a formal denial.
The DIA Appeals Process: From Conciliation to Hearing
Filing Form 110 with the Department of Industrial Accidents starts the formal process. The DIA then schedules the first stage: conciliation. For workers in Taunton and across Bristol County, proceedings typically take place at the DIA’s Fall River regional office.
The process moves through four defined stages:
- Conciliation: An informal, non-binding meeting between the parties and a DIA conciliator. Many cases resolve here. If not, the case advances.
- Conference: An Administrative Law Judge hears abbreviated arguments and issues a temporary order. If the order favors you, the insurer must send payment within 14 days.
- Hearing: A formal proceeding where both sides present full evidence and testimony. The Administrative Law Judge issues a permanent order.
- Reviewing Board: A panel of three Administrative Law Judges that can only reverse a Hearing decision if it was legally erroneous or lacked an evidentiary basis. Further appeal goes to the Massachusetts Appeals Court.
Either party can appeal a Conference order to a Hearing, and either party can appeal a Hearing decision to the Reviewing Board within 30 days. The insurer has the same right to push the case further that you do, which is one reason why consistent, knowledgeable representation from the start matters.
What Evidence Strengthens Your Appeal
Medical records are the foundation. Records that create a clear, documented link between the workplace incident and the injury give the Administrative Law Judge something concrete to work with. Gaps in treatment, or records that describe symptoms without connecting them to work, give insurers their strongest counterargument.
Beyond medical documentation, a strong appeal file typically includes:
- The First Report of Injury form filed with the employer and any incident reports completed at the time
- Witness statements from coworkers who saw the incident or its immediate aftermath
- Wage records establishing your pre-injury earnings for calculating benefit amounts
- All correspondence with the employer and insurer, including anything that touches on how or when the injury was reported
At the formal Hearing stage, the judge may order an impartial medical examination under G.L. c. 152. The impartial physician’s opinion carries substantial weight in the judge’s decision. Preparing for that examination and understanding what it covers is an area where legal guidance makes a concrete difference.
What a Workers’ Comp Attorney Actually Costs After a Denial
This is the question most workers don’t ask directly but need answered. Attorney fees in Massachusetts workers’ compensation cases are regulated by statute under G.L. c. 152, §13A and subject to DIA approval. In settlement situations where liability is established, fees are generally capped at 20% of the recovery. But here’s what most workers don’t know: when an insurer contests a claim and the employee prevails at a Conference or Hearing, the insurer is typically required to pay the attorney’s fee on top of the worker’s benefits. In many contested cases, you pay nothing out of pocket for legal representation. The insurer that denied your claim ends up paying your lawyer.
At Percy Law Group, PC, our workers’ compensation fees are paid by the insurer, not the client, and we offer free initial consultations. We also serve Spanish and Portuguese speaking clients, so language won’t be a barrier to getting your questions answered.
Don’t Wait to Get Representation
Each stage of the DIA process builds on what came before it. A weak conciliation record makes Conference harder. A poorly developed Conference record makes the Hearing harder. Errors at the Hearing level can be very difficult to reverse at the Reviewing Board, which can only correct legal errors. It cannot re-weigh the facts.
The workers’ compensation attorneys at Percy Law Group, PC have been fighting for injured workers across Massachusetts since 1994, with more than 100 years of combined experience across our Taunton team. We keep clients informed at every stage and treat you as a partner in the process, not just a file number. If your workers’ comp claim was denied, reach out to us at (508) 206-9900 to talk through where you stand and what the next step looks like.