The Workers' Compensation system, which was adopted during the second decade of the 20th Century, is based on an agreement between employers and employees. Ideally, treatment is to be provided promptly, however the experience of injured workers in California varies based on how responsive employers and their insurance claims representatives are.
Workers' Compensation benefits are insured and adjusted primarily by insurance companies and those employers secure enough to self-insure their liability. Many Workers' Compensation insurance carriers in California have their claims adjusted by a Third-Party Administrator (TPA), a company that administers injury claims and related services under contract with an insurance company, insurance fund and/or self-insured employers.
The TPA earns income by commissions from insurance premiums or by charging specific fees for services. The concept is a specialized TPA will be more efficient and cost effective in their administration versus a larger insurance carrier that is focused on national or international coverage in multiple specialties (auto, business, health, etc.).
"A well run TPA can expedite claims and provide an improved level of services and benefit delivery," says Adam Dombchik, managing partner of the Workers' Compensation law firm of Gordon, Edelstein, Krepack, Grant, Felton & Goldstein, LLP (GEK). "However, as with most for-profit services, TPAs will focus on cost cutting and savings over service. This means the needs of injured workers often are ignored or intentionally delayed and denied as part of cost containment or by the lack of available services, such as access to medical specialists or diagnostic imaging."
TPAs will often delay and deny injury claims or requests for medical treatment to avoid the cost of properly investigating an injury claim or providing adequate medical care, forcing an injured worker to litigation to obtain basic benefits.
Such delay/denial tactics require the assistance of an attorney simply to obtain basic benefits such as medical treatment and time-loss coverage. Having legal counsel anticipating and pushing back on the TPA from the onset of the claim is necessary to avoid substandard care and forced return to work before the person has recovered from the injury. An attorney can properly set up the claim from the very beginning, navigate the "delay" period, obtain relevant records to support the claim, and help expedite benefits and obtain treatment.
At GEK we are dedicated to ensuring injured workers receive the full range of benefits to which they are entitled. Contact us via our website--www.geklaw.com--or call us at 213-939-7000; we're here to help.
FAQs
Many Workers' Compensation insurance carriers in California have their claims adjusted by a Third-Party Administrator (TPA), a company that administers injury claims and related services under contract with an insurance company, insurance fund and/or self-insured employers.
Which of the following would not be entitled to workers' compensation benefits? ›
While workers' compensation is rather comprehensive, some individuals are exempt from workers' comp in California. Under California Labor Code, Division 4, Part 1, Chapter 2, Section 3352, these workers include the following: Sole Proprietors and business owners (excluding roofers) Business owners.
Which situation qualifies a worker for workers' compensation coverage? ›
If you get hurt on the job, your employer is required by law to pay for workers' compensation benefits. You could get hurt by: One event at work. Examples: hurting your back in a fall, getting burned by a chemical that splashes on your skin, getting hurt in a car accident while making deliveries.
Can I lose my health insurance while on workers' comp in California? ›
Big businesses generally cannot cancel your health insurance coverage. However, if you work for a small business, it could legally stop your coverage. You have protections in California against retaliation. For example, your employer cannot discontinue your coverage because you filed a workers' compensation claim.
What is TPA settlement? ›
A TPA is basically a middle man who facilitates the settlement of a health insurance claim. A TPA is appointed by the insurer. TPAs help you (the insured) process your health insurance claim using various hospital bills and documents. However, they are not responsible for claims rejection or acceptance.
Who benefits from TPA? ›
TPA helps the policy bearers in the smooth filing of claims, submitting the correct documents, and other insurance-related issues. Health insurance companies hire these TPAs on their behalf so that the customers can reach out to them in times of confusion.
Which scenario would apply for a workers compensation case? ›
If you get hurt on the job, your employer is required by law to pay for workers' compensation benefits. You could get hurt by: One event at work. Examples: hurting your back in a fall, getting burned by a chemical that splashes on your skin, getting hurt in a car accident while making deliveries.
Which of the following is not covered in the workers' compensation system? ›
Intentional acts: When a worker intentionally causes their workplace injuries or illnesses, they are not covered under a workers' comp insurance policy. Illegal activities: Employee injuries due to illegal activities at the worksite are not covered by an organization's workers' compensation insurance policy.
What is the most common workers' comp claim? ›
Cuts and Punctures
For example, sprains and strains are the most common types of injuries for all industries except for small businesses. For small businesses, however, cuts and punctures are the most frequent type of workplace injury, followed by sprains and strains.
How long can you stay on workers comp in California? ›
Once verified, you can receive benefits such as medical treatment and income replacement for up to 104 weeks or two years, in most cases. However, you may not be aware that these 104 weeks of temporary disability (TD) workers' compensation payments can be stretched out over five years in most cases.
For instance, your medical care and recovery should be covered for as long as you need it, even if you left your job. However, your right to receive temporary disability (wage replacement) benefits could be lost, and your ability to collect permanent disability benefits could be compromised as well.
Can you work another job while on workers comp in California? ›
The short answer is no, you usually can't work while you're getting workers' comp in California. But there are possible exceptions depending on your injury. Workers' comp benefits are only available for workers who can't return to their job because of their illness or injury.
What is the main function of the TPA? ›
The roles of TPA as provided in the Act are to develop, manage, operate and promote the Port Sector in Tanzania. Social Impact Assessment (ESIA) for rehabilitation of berth 8-11.
Why do insurance companies have TPA? ›
A third-party administrator (TPA) provides administrative services for self-funded health plans, sometimes referred to as self-insured health plans, in the health insurance industry. A TPA can also provide access to healthcare networks and may be able to source additional vendors, such as stop-loss insurers.
What does TPA mean in HR? ›
Third Party Administrator (TPA) definition
Third-party administrators (TPA) are organisations that handle administrative duties for certain employee benefits, typically insurance. Businesses outsource to TPAs when they don't want to retain in-house responsibility for these administrative duties.
What is a TPA desk adjuster? ›
TPAs are skilled in fraud detection and prevention, to protect insurers from potential losses. They can access claims data and analytics and often have in-depth knowledge of specific industries, which ensures accurate assessments and fair claim settlements.
