An insurance provider’s claim-settlement ratio is one of the most crucial factors buyers consider while purchasing their insurance policies. To provide policyholders with a seamless claim application and settlement experience without straying away from their core business operations, insurers appoint entities known as TPAs.
TPA in health insurance stands for third-party administrators. These are organisations, individuals, or entities that are not the insurance providers (first party) or beneficiaries/clients (second party) of an insurance contract. TPAs are instead intermediaries (third parties) who serve as the link between the first and second parties. They specialise in providing efficient administrative services, particularly concerning the claim settlement process. Outsourced by health insurance companies, TPAs’ duties include claim verification, settlement, and establishing tie-ups with hospitals, among other things.
TPA In Health Insurance – Expectations and Services Rendered
The following are the standard services or facilities that a third-party administrator in health insurance is entrusted with by the insurance provider.
- IRDAI Verification
The Insurance Regulatory and Development Authority of India (IRDAI) overlooks all insurance-related matters in the country. TPAs must register themselves with the IRDAI and obtain a license to operate. The IRDAI verification is necessary to protect the rights of policyholders.
- Policy Implementation, Claim Processing and Settlement
TPAs typically comprise a group of highly qualified medical and non-medical personnel, legal experts, IT professionals, etc. They implement policies to help make the claim process as easy as possible. They are also responsible for processing your claims on behalf of your insurer.
- 24×7 Customer Care
Medical emergencies can knock on your door at any time. TPAs are thus expected to provide assistance 24×7. You can call their toll-free number to initiate the claim process. TPAs also facilitate services like interactive voice response (IVR) and call-backs to offer efficient and prompt services.
- Widening the Hospital Network
TPAs in health insurance have tie-ups with thousands of hospitals across the country. One of the primary services they offer insurance providers is getting hospitals to sign up with the insurer’s network. This service later proves to be a boon for policyholders as it facilitates cashless claims.
What Is The Role Of TPA In Health Insurance?
To understand what is the role of TPA in health insurance, it is vital to note that they do not and cannot issue insurance policies. However, they can do the following things.
- Issue Health Cards
After you buy a medical insurance policy, the insurer sends your policy details to the appointed TPA. Based on the provided information, the TPA enrols you and other insured members within a policy and issues member ID cards. Also known as health cards, the member ID card allows you to receive cashless treatments across nationwide network hospitals.
- Facilitate Pre-authorisation for Cashless Claims
When receiving treatment at a network hospital, you must inform your insurer and the TPA before seeking admission. You must fill out a pre-authorisation form before a planned treatment and within 24 hours after emergency treatment. Through pre-authorisation, the insurer conveys to the healthcare facility and the TPA whether the claim is admissible.
- Process Reimbursement Claims
You may be eligible for reimbursement if you choose to receive treatment at a non-network hospital. The role of TPA in health insurance in such cases is to investigate the claim thoroughly. Professionals employed under TPAs check for discrepancies in the submitted documents and verify whether the claim request is legitimate or not.
- Provide 24×7 Customer Support
It is nearly impossible to predict the occurrence of a medical emergency. Therefore, TPAs must have a solid customer support department to provide efficient services to callers facing medical crises. The TPA helpdesk is available 24x7x365 and offers services through IVRs or text messaging. You can call the TPA’s toll-free number available on the health card.
- Tie Up With Hospitals
Third-party administrators in health insurance are expected to build relationships and tie-ups with hospitals. TPAs generally assess the hospitals’ track records and quality of service before adding them to the network hospital list. TPAs need to expand their hospital network so that policyholders can choose from a vast network of hospitals and utilise the cashless claim facility. TPAs may form a three-way agreement between the insurer, the hospital and themselves.
- Make Timely Reports
TPAs are also responsible for maintaining all records of policyholders’ applications – from hospitalisation to claim settlement. The TPA must provide management information systems (MIS) reports at fixed intervals to the insurance company and their stakeholders. The IRDAI permits TPAs to share the reports daily, weekly, monthly, half-yearly or yearly.
- Offer Additional Services
Besides claim settlement, TPAs also provide add-on services. As a policyholder, you can avail of services like ambulance transportation, extra beds, health check-ups, outpatient department (OPD) treatments, health talks, yoga sessions, etc., through your TPA. TPAs also tie up with wellness programme providers to facilitate wholesome treatments. You can use your member ID card to avail of such facilities.
How To Make Claims Via TPA in Health Insurance?
Now that you know what is TPA in health insurance, here’s how you can use their claim services.
Firstly, you need to inform your insurer and the TPA of your planned medical treatment as early as possible. Planned treatments are surgeries or treatments for which you are undergoing proper diagnosis, and the medical professional has confirmed the need for the procedure. In case of unplanned treatments like heart attacks, strokes, accidents, etc., you must inform your insurer and TPAs within 24 hours of hospitalisation.
Steps to File Claims When Receiving Treatment at Empanelled Hospitals
TPAs usually tie up with a vast network of hospitals. They spot-check to ensure the healthcare facility offers the best medical care. Since the TPA has already verified the hospital, you can enjoy cashless claims, where the insurer and TPA directly settle your bills. The steps to follow to file cashless claims are as follows:
- Fill out and submit the pre-authorisation and cashless claim form at the earliest before getting admitted to a network hospital for planned treatment. In case of emergencies, you can fill out the form after admission within 24 hours.
- The hospital sends your medical reports and bills to the TPA.
- The TPA verifies the data and determines whether or not to approve the claim.
- If the claim is approved, the TPA settles your medical bill with the hospital on the insurer’s behalf.
Steps to Follow When Receiving Treatment at Non-empanelled Hospitals
You also have the choice to receive treatment at non-network hospitals and file reimbursement claims. Once you are discharged from the hospital, you can begin the claim reimbursement process. Just follow these simple steps.
- Reserve the original copies of all medical reports, documents, and medical bills.
- After being discharged from the hospital, you must send these documents along with a copy of your medical insurance policy in either physical or electronic form to the TPA within 30 days of the discharge date.
- The TPA can take anywhere between two weeks to a month to review your documents and ask for additional documents if required.
- The insurer approves the claim and credits the claim amount to your registered bank account.
Note that you must bear non-medical expenses like food, water, toiletries, etc. Also, the insurer may reject your claim if your documents are not in order. Discrepancies like non-disclosure of pre-existing conditions, received treatment for excluded conditions or diseases, filing a claim after the time limit has passed, etc., are also instances wherein the insurer can reject your claim.
Benefits Of Third-Party Administrators In Health Insurance
By appointing TPAs, insurance companies are at an obvious advantage. TPAs help insurers streamline the claim process and reduce the number of fake claims. However, when it comes to understanding what is a TPA in health insurance, you should also know how a TPA’s role impacts policyholders.
- You can avail of customer support, right from hospitalisation to discharge, through the TPA.
- You can receive proper guidance for documentation and claim settlement procedures.
- The TPA member ID cards aid you in receiving cashless treatments.
- The TPA is at your service round-the-clock.
- TPAs can offer prompt and efficient claim settlements as that is their sole business module.
- You can receive treatments under government schemes as well.
Government Schemes & TPAs
In recent years, the Government of India has rolled out numerous healthcare schemes to empower marginalised communities. Numerous TPAs may also offer claim settlement services for such schemes. A few popular government schemes include the Rashtriya Swasthya Bima Yojana (RSBY), Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) and state-wise health insurance schemes.
What You Should Know About TPAs In Health Insurance
TPAs are individual companies licensed by the IRDAI to settle claims on behalf of the insurance company. However, there are certain limitations that you, as a policyholder, should know about when understanding what is TPA in health insurance:
- They are not the decision-makers.
TPAs cannot decide whether your claim gets approved or rejected. They are only responsible for verifying your medical documents and processing the claim. The final decision falls on the insurance company.
- They cannot charge you money.
Since TPAs are employed by the insurance company, you are not liable to pay any additional charges for settling claims. You should report such payment requests to your insurer.
- They are independent of the insurance company.
TPAs cannot issue health insurance policies. You should take up any grievances against the insurer with the insurer’s grievance redressal cell.
- Insurers often employ multiple TPAs.
Depending on their claim settlement process and network hospitals, some TPAs may be more influential in some cities than others. Therefore, insurance companies may hire more than one TPA.
- You may have the option to change TPAs.
If your current TPA is unable to meet your requirements, you can inform your insurance provider. Your insurer may let you select another TPA from the list of available TPAs.
List of TPA Agents
An organisation registered under the Companies Act, of 1956, with a share capital, can operate as a third-party administrator. TPAs must register for the license with the IRDAI and renew it every three years. As on 30th September 2022, the following TPAs can carry our administrative health insurance duties across the country.
|Reg. No||Company Name||Website|
|002||Medvantage Insurance TPA PVT LTD||www.medvantagetpa.com|
|003||Medi Assist Insurance TPA PVT LTD||www.mediaassist.in|
|005||MDIndia Health Insurance TPA PVT LTD||www.mdindiaonline.com|
|006||Paramount Health Services & Insurance PVT LTD||www.paramounttpa.com|
|008||Heritage Health Insurance TPA PVT LTD||www.heritagehealthtpa.com|
|013||Family Health Plan Insurance TPA LTD||www.fhpl.net|
|015||Raksha Health Insurance TPA PVT LTD||www.rakshatpa.com|
|016||Vidal Health Insurance TPA PVT LTD||www.vidalhealthtpa.com|
|018||East West Assist Insurance TPA PVT LTD||www.eastwestassist.com|
|019||Medsave Health Insurance TPA LTD||www.medsave.in|
|020||Genins India Insurance TPA LTD||www.geninsindia.com|
|022||Health India Insurance TPA Services PVT LTD||www.healthindiatpa.com|
|023||Good Health Insurance TPA LTD||www.ghpltpa.com|
|025||Park Mediclaim Insurance TPA PVT LTD||www.parkmediclaim.co.in|
|026||Safeway Insurance TPA PVT LTD||www.safewaytpa.in|
|027||Anmol Medicare Insurance TPA LTD||www.anmolmedicare.in|
|035||Ericson Insurance TPA PVT LTD||www.ericsontpa.com|
|036||Health Insurance TPA of India LTD||www.hitpa.co.in|
How do TPAs differ from health insurance providers?
Your health insurance provider promises to pay you the sum insured to cover medical expenses in exchange for premiums. Your insurer disburses your claims by paying the healthcare facility directly or reimbursing you after discharge. The insurer makes these payments to you via a TPA. You do not form any contract with the TPA. Essentially, the TPA is a link between you and your insurer to allow for a hassle-free claim settlement process.
Do I have to pay any fees or charges to the TPA?
No. As a policyholder, you can avail of services the TPA offers for free. Your insurer hires TPAs and pays for their services. If a TPA asks you to pay money, you should report the same to your insurer.
What are non-medical expenses?
Your hospital admission fees, extra bed, food and beverages, etc., are non-medical expenses that your insurer does not typically cover. Therefore, the TPA does not process claims made for non-medical expenses.
Can my insurer settle the claim directly without a third party?
Many medical insurance companies outsource TPAs as it streamlines their claim settlement process. However, a few insurance companies have their own in-house department for claims settlement. You can get in touch with your insurer to know if you can get your claims settled without the TPA's intervention.
Can I buy health insurance from a TPA?
No. Per IRDAI regulations, TPAs are prohibited from engaging in other businesses, including selling insurance plans. Hence, they can only assist you with the claim settlement process and have nothing to do with insurance sales.
Can my insurer let me select a TPA of my choice?
No. Your insurer forms a contract with more than one TPAs depending on the insurer's area of business operations. Therefore, you typically do not have a say when it comes TPAs. However, you can always talk to your insurer regarding if you have any specific requests or bad experience with your TPA.
My medical insurance policy was issued in Mumbai. Can I avail of the TPA services in another city?
Yes. Thanks to the TPA's wide network, you can avail of TPA services in any city across the country.
What is a TPA member ID?
The TPA member ID is a unique ID issued to policyholders. Your insurer shares your health insurance policy details with the TPA. The TPA then generates an ID for all the insured members under the policy. TPAs may dispatch the physical copy of the member ID to your mailing address. You can also request an electronic card.
Can I get a duplicate member ID after losing the card?
Yes. You can fill out a duplicate card issuance application form and submit it to the TPA. You need to pay additional charges for the same. You shall receive the duplicate card in your mail within one to two weeks. However, you can use your electronic card, which is valid across all network hospitals.
What happens if the TPA rejects my claim?
The TPA thoroughly verifies your insurance case while settling claims. Treatment for excluded diseases and conditions, invalid policy, policyholder's unresponsiveness to furnish shortfall documents, etc., are reasons for claim rejection. However, you can contact your insurer if you find the TPA's decision unsatisfactory.