Do you know who is TPA in your health insurance ? Lot of us, especially the salaried think that TPA is insurance company. This situation I faced two three times when few of my clients name their TPA as if the insurance company.
In reality TPA is the service provider or you may say as mediator between policy holder and insurance company. Usually health insurance companies outsource their claim settlement process to these TPAs. What role and responsibility they play in your insurance claiming?
Once policy is issued then insurance company will pass policy holder’s all information to their respective TPAs. Future communication will be between policy holder and TPAs. TPAs usually issue the identity card which consists of unique identification number and details about policy holder. You must know your TPA contact details as they are the future communicator for you.
When policy holder get hospitalized in any of network hospitals then the claim process and payment directly to hospital will be maintained by these TPAs. Below are the few must known facts about your TPA after new IRDA (Health Insurance) Regulations, 2013.
1) As told above TPAs are mere mediators between insurance company and policy holder. So either accepting or rejecting the claim is totally right of insurance company not the TPAs. I heard from media that few insurance companies pay incentive to TPAs based on rejection of claims. To abolish this bad practice this new guidelines clearly specify the responsibility of claim settlement must be of insurer not the TPAs. So in case of claim repudiation, you need to go against insurance company but not TPAs. But their is a fault in procedural submission then TPAs may reject the claim with reasons.
2) But if you have any issue related to service part of insurance then you need to go against TPAs only not your insurance company.
2) TPAs will process your claims within 2 days or receiving complete set of claim documents.
3) If their is any change in TPA by insurance company then it is the onus of insurance company to inform it’s customers about this change in 30 days advance.
4) Their will be a separate channel to from TPAs as well as your insurance companies to address the issues related to senior citizen claims and grievances.
5) TPAs will run 24/7 call center to address the grievances of policy holders. They usually provide claim status issues, E-Card and assistance related to cashless claims.
6) This call center will be in language of English, Hindi and local languages.
7) TPAs need to run toll free numbers for general quarries on cashless, claims and card status. Auto mailers and auto generated SMS facilities for updating claims status and updated email facilities.
8) Responsibility of sharing this toll free number to all policyholder is of insurance company.
9) It is the responsibility of TPAs to send the guide book and related information within 7 working days of receipt of information regarding issuance of policy to the insured. This guide book will contain SMS service details, Cashless request forms, Specimen Certificate, list of network hospitals, cashless hospitalization process, reimbursement process and list of branches and their contact numbers.
10) As told above it is the responsibility of TPAs to issue the ID card. This ID card consists of following details.
- A unique alpha numeric identification number
- Name of the insured and relationship with policy holder
- Age of the insured
- Photograph of the insured
- Emergency contact number of insurer and TPA
- Name of the insurer
- Date of policy issue
- Date of inception of first policy without break
11) TPAs can’t charge anything from the policy holders regarding the service they provide.
12) TPAs can’t demand or accept any benefits from the insured.
Hope these few facts make you aware about the service offered by TPAs.