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Appeals Court Rules Insurer Must Follow Established Process With Massachusetts Workers’ Compensation Claim

The Massachusetts Workers’ Compensation Act was designed to provide prompt financial relief to an injured worker or deceased worker’s family if a work-related accident occurs. Workers’ compensation claims and appeals are handled through a separate system and do not go through any of the standard civil court processes until all the administrative portions are concluded. Recently, the Appeals Court in Merchants Insurance Group vs. Spicer (14-P-798) ruled in favor of the injured worker after an insurance company attempted to stop benefits through an action in Superior Court.

Thumbnail image for log-pile-1336025.jpgThe worker was seriously injured while working as a landscaper and sought workers’ compensation. His hand was dismembered by a log splitting machine. His medical bills were over $700,000, and his treatment was ongoing. The insurer for the employer providing the benefits contested the claim, but the administrative judge for the Department of Industrial Accidents (DIA) granted the injured landscaper temporary total incapacity and medical benefits, pending a formal hearing and ruling. The insurer, following an appeal of that order, also sought to have the policies rescinded in Superior Court, claiming the injured worker’s employer materially misrepresented the information provided on the applications for policies. The insurer claimed it had no duty to indemnify the employer and sought damages of the amounts already paid to the injured worker.

The injured worker and the employer did not formally object to the proceedings in Superior Court, and the judge entered a summary judgment in favor of the insurer. As part of the order, the judge ruled that the insurer did not have to pay any of the sums on the claims arising out of the injured worker’s claims. The insurer took the judgment to the DIA, which denied the insurer’s motion to dismiss the suit. As its reasoning, the administrative judge ruled that the Superior Court did not have jurisdiction, that the employee was not a party to the initial application (and alleged misrepresentation) with the insurer, that the insurer did not terminate the policy according to statute, and that as a matter of public policy the judge did not want to encourage insurers circumventing the administrative process by going to the Superior Court.

In its discussion, the Appeals Court went through the steps of workers’ compensation claims. Four steps occur before any appeal reaches their court, none of which includes the Superior Court. The first is when the parties try to reach an agreement between themselves. The next is an informal conference in front of an administrative judge. The third step is a formal hearing before the administrative judge, and the fourth step is an appeal to the reviewing board. Since the insurer only made it halfway through the administrative process, the Appeals Court determined it had not appropriately exhausted its administrative remedies. While the court found that the insurer could still find relief related to the claim against the employer, it was not an appropriate mode of recourse for its complaints related to the employee. The Appeals Court affirmed the prior determination of the administrative judge, which continued the worker’s benefits.

The Massachusetts workers’ compensation attorneys at Karsner & Meehan have the experience you need to pursue your claim and defend against an insurer’s aggressive tactics. For a free, confidential consultation, call 508-822-6600.

More Blog Posts:

U.S. First Circuit Court of Appeals Reviews Massachusetts Home Renovation Injury, Massachusetts Injury Lawyers Blog, August 21, 2015
Massachusetts Appellate Medical Malpractice Case Expands Injureds’ Ability To File Suit, Massachusetts Injury Lawyers Blog, August 12, 2015