A third-party administrator (TPA) in long-term care insurance is a company hired by an insurance company to handle administrative tasks like processing claims, managing payments, and communicating with policyholders, rather than the insurance company handling these functions directly.
Some of the largest third-party administrators in the long-term care insurance industry include companies like CHCS Services and Long Term Care Group (LTCG), both of which are frequently involved in handling claims and appeals for major insurance carriers.
If you’ve received correspondence from one of these companies, you can learn more about their role and what to expect:
- CHCS Services
- Long Term Care Group (LTCG)
- Helper Bees
When claims are denied or delayed, understanding the role of the TPA becomes crucial for fighting against unfair decisions.
For many policyholders, dealing with a TPA can be confusing and frustrating. Unlike working directly with the insurance company that issued the policy, TPAs often create additional complexity in the claims process.
The long-term care insurance claim attorneys at Sandstone Law Group understand how TPAs operate and can help policyholders challenge improper claim handling when these administrators fail to fulfill their responsibilities.
Legal insights about TPAs can reveal important rights and options that policyholders may not realize they have, particularly when dealing with claim denials or delays that seem unjustified.
Interested in learning more about your legal rights and options when third-party administrators are a factor in long-term car insurance? Schedule a free case evaluation with Sandstone Law Group online or at (602) 615-0050 to explore your legal rights and options.
Key Takeaways About What Is a Third-Party Administrator in Long-Term Care Insurance
- Third-party administrators manage claims processing for insurance companies, but often create obstacles that delay or deny fair claim resolution.
- TPAs must comply with state and federal regulations, such as prompt payment laws and fair claims handling standards. Violations of these rules can provide strong grounds for appeals or legal action.
- In states like California, consumer protection laws offer additional safeguards for policyholders dealing with TPAs.
- Arizona’s insurance statutes require TPAs to act in good faith and adhere to policy terms, making it possible to challenge improper claim handling under state law.
- Understanding TPA responsibilities under these laws helps policyholders recognize when claim handling crosses the line into bad faith or contractual violations, creating opportunities to consult a bad faith lawyer for legal recourse.
How TPAs Fit Into the Long-Term Care Insurance World
Third-party administrators (TPAs) manage long-term care insurance claims, but their involvement often complicates the process, delays claims, and creates confusion.
Legal professionals can help policyholders overcome these and other issues they may create, such as:
- Divided responsibilities: Oftentimes, TPAs manage daily claim operations, while the insurance company makes final coverage decisions. This division often creates confusion when claims are mishandled.
- Cost-cutting priorities: Insurers hire TPAs to reduce administrative expenses, which can lead to practices that prioritize saving money over fair claim handling.
- Accountability gaps: Policyholders often face a TPA that denies responsibility and an insurance company that shifts blame, leaving them without clear answers.
A long-term care attorney can identify the root of the problem, whether it involves TPA mismanagement, insurance company misconduct, or regulatory violations. With legal guidance, policyholders can hold the right parties accountable and pursue the full benefits they may be entitled to under their policies.
Common Problems With TPA Claims Administration
Third-party administrators (TPAs) often focus on cutting costs instead of handling claims fairly, which creates recurring issues for policyholders. These problems include:
- Delays in claims processing: TPAs frequently fail to maintain adequate staffing or implement efficient systems, causing unnecessary delays. These delays can severely impact individuals who rely on timely care.
- Communication breakdowns: TPAs may provide incomplete or conflicting information about claim requirements, ignore important documents, or fail to explain the appeals process clearly. These missteps can harm policyholders and create grounds for legal action.
- Excessive documentation requests: Some TPAs demand more paperwork than the policy requires or repeatedly ask for the same information. These tactics create unnecessary obstacles and may violate administrative obligations.
- Flawed medical reviews: TPAs sometimes rely on superficial file reviews instead of thorough assessments, leading to denials overlooking critical evidence about a policyholder’s care needs.
These administrative failures can violate state insurance laws or policy terms, opening the door for legal challenges. A long-term care attorney can identify these violations, document the issues, and build a strong case to challenge unfair claim handling.
The Appeal Process With Third-Party Administrators
Many policyholders assume they must only work through the TPA, but this isn’t always the case. Depending on the policy, direct communication with the insurance company may also be an option.
Legal professionals can help with key factors in the process, including:
- Evolving documentation requirements: The evidence needed for an appeal may differ from what was required for the initial claim. TPAs often handle appeals differently, so addressing the specific reasons for denial with the help of a lawyer may be necessary to secure a favorable outcome.
- External review options: Some policies and state laws allow for independent reviews of TPA decisions, which can provide an unbiased evaluation of the denial. Depending on the conduct and laws, you can hold the TPA accountable for aiding and abetting bad faith.
- Legal representation: Attorneys can identify wrongdoing, present evidence effectively, and address coverage issues and bad faith to strengthen your case.
A well-prepared appeal can challenge unfair TPA decisions and protect your rights under the policy. With legal guidance, you can navigate the complexities of the process and focus on securing the benefits you deserve.
When TPA Problems Become Legal Issues
When a third-party administrator (TPA) seems to complicate your claim, it’s likely a good time to explore your legal rights and options during a free case evaluation with Sandstone Law Group.
Other scenarios that may indicate it’s time to speak with our insurance claim denial lawyers include:
- Receiving conflicting or false information about your coverage or appeal rights that does not align with your understanding of the insurance policy.
- Facing repeated delays or excessive requests for documentation.
- Discovering financial incentives that encourage the TPA to deny claims.
- Experiencing claim denials based on incomplete or biased medical reviews.
- Noticing skipped steps in the claim investigation or appeals process.
- Dealing with misrepresented policy terms or unclear claim requirements.
- Suffering financial harm due to administrative failures beyond the denied benefits.
If any of these situations sound familiar, legal guidance can help you hold the right parties accountable and fight for the benefits your policy provides.
TPAs in Long-Term Care Insurance FAQ
How long should I wait for a TPA to process my claim?
State prompt payment laws typically require claim decisions within 30-45 days of receiving complete claim information. If the TPA exceeds these timeframes without valid reasons, they may be violating state regulations.
Can a TPA deny my claim if the insurance company would approve it?
TPAs generally cannot override coverage decisions that fall within policy terms, though the division of authority varies by arrangement. If you suspect the TPA is exceeding its authority, legal review can clarify the proper roles and responsibilities.
What records should I keep when dealing with a TPA?
Document all communications, maintain copies of submitted paperwork, and track response times. This documentation becomes crucial if disputes arise about what was submitted or when decisions were made.
Contact Sandstone Law Group For Help With Third-Party Administrators in Long-Term Care Insurance Claims
Understanding TPA operations helps policyholders recognize when administrative problems are affecting their claims. While TPAs serve legitimate functions in insurance administration, their involvement should not create unnecessary barriers to fair claim handling.
When TPA problems interfere with rightful claim payments, legal action may be necessary to hold all responsible parties accountable.
In most circumstances, insurance companies remain liable for TPA actions, and regulatory violations by TPAs can strengthen legal claims.
Dealing with TPA delays, denials, or administrative problems that seem unfair? Contact Sandstone Law Group to discuss your long-term care insurance claim and explore legal options for challenging improper TPA decisions.
Our attorneys are available to provide legal support when you message us online or call (602) 615-0050.