back to main

Identifying Potential Third Party Liability Claims

Below are examples of potential third party claims that merit further investigation by the TPA.

Trauma cases

1. Prior to payment of the claims the TPA should send the SLG Liability Questionnaire (or their own form that requests the same information) to request exact details regarding the accident.
    

2. Claims should not be paid by the Plan until the questionnaire and applicable attachments have been completed and returned.
    

3. It can be advantageous to use a legal firm that specializes in the area of subrogation to review the information and if necessary to handle the subrogation related issues on behalf of the Plan.

Potential Medical Malpractice Claims

Medical malpractice claims are often very difficult to identify. Below are some indicators of potential medical malpractice situations.

1. Medical billings which are inconsistent with the initial diagnosis
    

2. Treatment for infections after surgery
    

3. Unusually large medication charges
    

4. Second surgical procedures within 24 hours of initial surgical procedures
    

5. Any surgery where a repair of an organ not related to the initial surgery is involved
   (nicks/lacerations of bladders, liver, colon, etc.)
    

6. Any complication related to the delivery of a child
    

7. Any re-admission to the hospital within two weeks after a surgical procedure
    

8. Any hospital stay that is more than five days beyond the usual and customary stay for the condition for which the individual was originally admitted
    

9. Any course of treatment where the total charges exceed the reasonably expected charges by more than 15%
    

10. Any cases involving infection such as sepsis
     

11. Any disease that could have resulted from a blood transfusion
     

12. Presence of billings for multiple surgeons when such bills are not indicated given the original procedure

If medical malpractice is suspected, we suggest that you order the patient's medical records (records and charts including the nursing notes and operating room notes) in addition to obtaining the Liability Questionnaire. Keep in mind that the Claimant is often unaware that malpractice has occurred. With this in mind, it may be up to the Plan or the Carrier to investigate the malpractice case.

Slip and Fall Cases:

This category of cases is typically the least likely to result in a substantial subrogation recovery. Trauma claims may be involved, therefore, these cases should be treated the same as any other trauma cases. Liability is often strongly contested by the property owner. The Plan and/or the Carrier should be prepared to negotiate the subrogation lien in these cases.

Dog Bites:

This category of claim involves trauma and these cases often make good candidates for subrogation, especially when the victim is a child. It is important to remember in cases involving young children (less than age 9) it is typically believed that they are not capable of being negligent. If they are not capable of being negligent then they can not be responsible under the doctrine of contributory negligence. Therefore, if any other party involved in the injury is negligent in any fashion and there is a source for recovery, a recovery should occur.

Injuries Involving Children:

In addition to dog bites, there are several types of injuries involving children where an argument might be made that the child was potentially at fault. It is important to note that young children (less than 9 years old) are generally not capable of negligence. Examples of this may be: children "darting out" in front of another motorist; children playing with dangerous instruments like fire or firearms; children falling into pools and ponds or other bodies of water. These cases are often successful subrogation cases. Again the procedures relative to trauma will apply.

Poisoning Cases:

This category of cases can encompass everything from food poisoning at a restaurant to chemical ingestion. An admission to the emergency room is generally involved with these cases. The TPA should flag ICD-9 and CPT codes that reflect food poisoning issues as well as claims for pumping the stomach, usage of antitoxins, charcoal and claims for anaphylactic shock.

Sports Activities:

Each sports injury should be reviewed on the basis of the sponsor of the event, the equipment used, supervision issues and individuals involved.

NOTE: There are multiple other categories of third party liability cases that we could mention. We are committed to assisting TPA’s as needed in these areas. Please keep in mind that in subrogation cases where the Carrier has made reimbursements to the Policyholder, we will expect to take the lead in the process.