Why Workers’ Comp Claims Get Denied in Massachusetts
If you’ve ever opened a letter to find your workers’ comp claim was denied, you already know how it feels. It’s frustrating. It feels like you’ve been judged harshly.
After decades of handling workers’ comp cases in Massachusetts, we know denials are commonplace. They’re simply a part of how the system operates. A denial doesn’t mean your injury isn't serious or that the case is over. It means the claim raised questions early, and now the process moves into its next phase, information gathering.
This blog post explains why denials happen, what insurers are really looking for, how appeals fit into the picture, and what matters once a claim gets some pushback. This is how the system works.
Why Do Workers’ Comp Claims Get Denied in Massachusetts?
Workers’ comp denials are more common than most people realize. According to data on claims nationwide, about 7% of workers’ comp claims are denied when they’re first submitted, and in some places that number can go as high as 20% depending on state rules and the claim details.
Making sure our clients understand that denials happen early and for predictable reasons helps them respond without panicking.
People who try to DIY their claims can miss important details and inadvertently turn in incomplete paperwork. It’s also hard to keep on top of all the moving parts when the process is entirely new to you. Maybe a report comes in late, and you didn’t realize it was an important one. Your description of what happened might be a little thin because you don’t know the clues adjusters look for. Now you’re going back and forth between the insurance company, your doctors, the police, witnesses, etc. The amount of backup documentation you need to make a successful claim takes a lot of work and time to gather and submit properly. That can become your side-hustle, or you can hire help.
What Does a Denial Truly Mean?
Luckily, a denial doesn’t mean the system thinks you’re trying to pull a fast one.
It’s more likely that the insurance company thinks the file isn’t strong enough yet. That difference matters, so don’t give up hope if you get that denial letter.
Let’s say you work in a field like construction or healthcare (think nurses, orderlies, and janitors). The culture says to “walk it off” and push through it. A couple of days later, you’re not better, so you go to see your doctor. They make notes about your pain, but don’t write down that it started at work. That oversight gives an adjuster permission to pump the brakes.
It’s important to know the system rewards consistency in your account of what happened. When that’s missing, denial is the default response. It’s the adjuster’s job to line up your injury report with medical notes in the context of what happened. If any pieces don’t match cleanly, the claim is paused and flagged.
Remember that denial isn’t the final word on your case. Often it’s the beginning.
How Do Reporting Delays Affect a Workers’ Comp Claim?
One delay won't end your case, but when you need more information, those answers take time.
Clients who come to our law firm sometimes assume there’s already an official record of what happened to them, somewhere. They hope that the system is designed to take care of it. That would be nice.
Assumptions and delays put more pressure on your case. I’m sorry to say there isn’t anyone taking care of this but you and your attorney. When paperwork shows up late or badly done, the adjuster’s job is to deny until you fill in the gaps.
Now the ball’s back in your court.
Why Do Medical Records Matter So Much in Denials?
Medical records carry so much weight in workers’ comp cases because they’re the main thing the insurance company relies on to decide what happened. Adjusters didn’t see the injury happen. They don’t know you or the environment where you work. They don’t visit the job site. They don’t watch how someone moves at the end of a long shift. They just read the file.
That file is expected to answer a few basic questions: what the injury is, when it showed up, and whether it clearly ties back to the work being done. When those answers are spelled out in the medical notes, the claim has footing. When they aren’t, the insurance company has room to step in and take control.
A lot of people go to their regular doctor, which makes sense. The care itself is fine. The documentation is the problem. Primary care doctors focus on symptoms, treatment, and recovery. They aren’t thinking about job duties, timelines, or how a workers’ comp adjuster reads a chart.
Doctors who specialize in work injuries chart things differently. They’re used to documenting how the injury happened on the job, what tasks were involved, and when symptoms first showed up. That kind of detail answers the questions the system is built around before the insurance company has to ask them.
A clear timeline of events and how they are connected is what keeps the insurance company from taking control of the narrative.
Are Workers’ Comp Denials Normal?
Yes, they are, even in legitimate cases.
In Massachusetts, denials are one of the ways the workers’ comp system manages volume and uncertainty early on. When a claim first comes in, the insurance company doesn’t yet know how strong it will become or how much documentation will eventually support it. Now, claims can be pushed back and tested.
From an adjuster’s point of view, a denial creates time. In the pause, missing information can surface. That’s not a judgment about the worker or the injury.
Once people understand that denials are built into the system, their reaction changes. A denial stops feeling like a wall and starts feeling like a checkpoint.
What Happens After a Workers’ Comp Claim Is Denied?
A denial opens the door to an appeal. It’s part of how the workers’ comp system is designed to work when there’s disagreement about a claim. Appeals prove the claim can stand up to scrutiny. Gaps, vague language, or inconsistencies matter more at this point than they did earlier.
Appeals take time, and that part catches people off guard. There may be hearings. There may be long stretches where nothing seems to move at all. For someone who’s hurt and out of work, that waiting is the hardest part of the process.
That’s why good preparation matters so much. The way a case is handled early on affects how it looks later, when the appeal is reviewed with a more critical eye. Experience matters because the system doesn’t forgive loose ends.
What Should Workers Take Away From a Denial?
A denial feels like a setback because, unless you’re working with a lawyer, it shows up without much explanation. All it really means is that the file, as it stands, didn’t answer every question the system asks at the start.
For some people, that’s discouraging. For others, it’s the first signal that the case needs to be handled more carefully from here on out.
Either way, a denial isn’t the moment everything falls apart. A denial doesn’t mean the system got it wrong. It usually means the system doesn’t have the full story yet.
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Disclaimer: This blog article is for informational purposes only and should not be considered a substitute for formal legal advice from Attorneys Jim and Steve Brady and Associates P.C. Please consult a qualified professional for personalized advice tailored to your needs.