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Home / Testifying Expert / Claims Handling Review / Defense of TPAs, Agencies, and Counsel
Claims handling review

Defense of TPAs, agencies, and counsel.

The defense of claims professionals when their own handling is the allegation: third-party administrators, insurance agencies, and defense counsel, often on defense timelines.

Defense of TPAs, Agencies, and CounselCarrier claims-practice reviews & audits
About this practice area

When the claims professional is the defendant.

Third-party administrators handle claims on behalf of insurers, self-insured employers, public entities, and risk pools, under a claim service agreement that sets out their authority, service standards, and reporting duties. When results disappoint, the client may sue the TPA for breach of that agreement or for negligence, alleging late investigation, incorrect coverage decisions, inadequate reserves, or poor documentation.

Similar claims are brought against other claims professionals: insurance agencies accused of errors and omissions or of violating the state insurance code, and defense counsel accused by an insurer or excess carrier of mishandling a defense or failing to give timely notice. These cases are usually decided file by file, measured against the agreement, the applicable regulations, and customary industry practice, and often on tight defense timelines.

Three allegation arrows stopped at the expert's report, which stands between them and the claims professional it defends
Engagements

Matters handled.

The record is scored file by file, and each opinion is tied to the standard the professional was held to.

Testifying expert · Report

TPA suit over a workers compensation deductible recovery: random 52-file audit

100files reviewed, 52 selected at random
100+page rebuttal report
379citations, 23 exhibits

Defense of TPAs, agencies, and counsel

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Retained by counsel representing a third-party administrator being sued for negligence and breach of contract. Allegations against the third-party administrator included erroneous coverage interpretation and application as well as conducting an untimely investigation and inadequate reserving. The dispute arose from a workers compensation carrier’s recovery action against a policyholder for paid benefits subject to the policy’s deductible. GIC selected at random 52 files for review and utilized a proprietary score sheet to aggregate the results. In all, 100 files were reviewed. GIC authored a rebuttal report of over 100 pages containing 379 citations and 23 exhibits.

Also listed under: Claim audits and file scoring · Expert Testimony · Testimony record

Testifying expert · Report

Workers compensation bad-faith allegations against a TPA (South Dakota)

42-pagereport, 118 citations
16 daysfrom retention to report

Defense of TPAs, agencies, and counsel

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Engaged by a major claim third party administrator to address allegations of bad faith for their handling of a South Dakota workers compensation claim. Mr. Bingham’s 42-page report contained 118 citations. This report was completed 16 days from the date of retention.

Also listed under: Fair claims practices and standards of care

Testifying expert · Report

Homeowner claim-file audit in a TPA service-agreement dispute

112files reviewed in the quality control re-audit
Dismissedafter opposing expert was stricken

Defense of TPAs, agencies, and counsel

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Retained by counsel representing a third-party administrator being sued for alleged breaches of a claim service agreement. This assignment included completing an audit of homeowner’s claim files. GIC repeated the TPA’s internal quality control audit and verified their file scoring and conclusory report. This portion of the audit reviewed 112 files. Deliverables included an expert’s report, rebuttal report, and accompanying claim file score sheets. Case was dismissed after opposing expert was stricken.

Also listed under: Claim audits and file scoring

Other matters

Negligence claims against defense counsel in a maritime caseTestifyingDefense of TPAs, agencies, and counselRead moreShow less

Retained by a law firm being sued by an excess carrier for negligence in defense of an insurance action. The excess carrier alleges that the defense of a maritime claim was flawed and that the lawyer inadequately prepared the case for trial and that counsel was responsible for providing late notice to the excess carrier. Mr. Bingham authored a report disputing the allegations and has provided testimony via deposition.

Also listed under: Testimony record

Federal breach-of-contract action against a TPATestifyingDefense of TPAs, agencies, and counselRead moreShow less

Third-party claims administrator: defense of a federal action alleging breach of contract and incompetent claim handling. Relying on GIC’s analysis, the client disposed of the case by dispositive motion.

Failure to settle multi-fatality death claimsTestifyingFair claims practicesRead moreShow less

Retained by decedent’s estate in a bad-faith/breach-of-contract action against a self-insured for failure to settle death claims resulting from a driving while intoxicated accident involving multiple fatalities; Expert opinion report; sworn deposition.

U.S. District Court, District of South Carolina

Also listed under: Fair claims practices and standards of care · Testimony record

Agent misrepresentation of policy termsTestifyingCoverage and policy interpretationRead moreShow less

Retained as an expert for policyholder suing agent for misrepresentation of policy terms and other errors and omissions allegations.

Also listed under: Coverage and policy interpretation

Day-to-day representative of a court-appointed supervisorConsultingSupervisionRead moreShow less

Retained by the Oklahoma Insurance Department’s Receivership Office to be the day-to-day representative of the court-appointed supervisor of an insurance company: conducting a reserve audit, analysis of the claim operation, and approval of claim payments, with responsibility for a number of other tasks including compliance, reinsurance recoveries, and financial statements, reporting to the supervisor the results of the examination of the company’s operations.

Also listed under: Claims & Reserve Auditing · Regulatory Consulting · Receivership & Insolvency Issues

Claim service agreement dispute involving a TPATestifyingDefense of TPAs, agencies, and counselRead moreShow less

GIC was retained by a prominent New York-based law firm which represents a third-party administrator being sued for alleged breaches of their claim service agreement. Glynloen Insurance Consulting aided in the defense of a third party administrator, with Rick Bingham of GIC serving as an expert witness. Rick and his team conducted a thorough analysis of the record and subsequently reviewed the third-party administrator’s management information system. Upon completion of the team’s investigation, Rick provided a 176-page report of his findings and opinions.

Related

Elsewhere in Claims Handling Review.

Back to the Claims Handling Review overview, or see its other sub-categories.

Carrier claims-practice reviews & audits

Reviews of a claims operation as a whole: staffing, policies & procedures, reserving, controls, and settlement practices, across a book of files rather than a single claim.

View Carrier claims-practice reviews & audits →
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