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Aggregate Stop Loss Claims

for Traditional Products

  1. WHAT IS AN AGGREGATE STOP LOSS CLAIM?
    • This type of claim occurs when the Employer Group’s total claims for all covered persons (less any Specific Stop Loss Claim) are in excess of the Aggregate Deductible for covered services as stated in the Excess Loss Policy.
  2. MONTHLY REPORTING REQUIREMENTS
    • The Administrator is required to submit a Monthly Aggregate Stop Loss Report for each stop loss self-funded case. The Monthly report is a cumulative form and provides both monthly and year-to-date totals. This report should be submitted to TPAC as soon as possible following the end of each month.
  3. SUBMISSION OF AN AGGREGATE STOP LOSS CLAIM
    • Aggregate Stop Loss coverage is issued on a policy year basis and the loss fund is calculated on a policy year basis, consideration of an aggregate claim takes place at the end of the policy year. An Aggregate Stop Loss claim should be submitted as soon as possible after conclusion of the policy year.
    • The Administrator should forward the following information:
      1. Completed Monthly Aggregate Excess Loss Report for the policy year. Since it is a cumulative report, which is completed each month, it only requires addition of the 12th month and addition of all totals.
      2. Completed Aggregate Claim Form signed and dated by the Administrator.
      3. A claim report showing the name of claimant, incurred date of each loss, date of payment, amount of each payment and the payee
      4. A list of all Specific Stop Loss claims for the policy year under consideration. Such listing should indicate whether or not these claims have been submitted to TPAC for consideration and if not submitted, an explanation should be provided.
  4. SPECIAL HANDLING, COMMENTS AND RECOMMENDATIONS
    • When an Aggregate Stop Loss Claim is submitted, an audit of paid claims will be performed usually at the Administrator’s office.
    • All files and records which may affect either Specific or Aggregate coverage are subject to personal and/or mail audit.
    • In order for claims to be considered, they must be properly documented with fully completed claim forms and itemized bills.
    • TPAC must be advised in writing as soon as possible of any law suit in which they are named or could become involved because of Excess Loss coverage.