Facts about Third Party Administrator (TPA) of Health Insurance

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.

 

41 Comments

  1. Max Bupa is not having any TPA , they settle the claims themself. Is it advisable to select their medi claim which does not have TPA ?

    Reply
  2. Is there any dental insurance available in india .

    Reply
  3. Basu thanks for wealth of information ,commendable job!
    Hi,
    I am looking for health Insurance plan with minimum premium payable for to avail an ac bed during time of emergency in mumbai city.(even common ac bed is also fine).
    What policy is suited and to whom ?
    Should i buy group medical insurance?
    I don’t know if i should put money into it as the broker advised in spite of having group insurance you should not discontinue your personal policy?
    Is insurance from public or private bank advisable(from claim settlement perspective and cat from the bag scenarios) for example canara bank or icici bank
    Currently i have policy for 2.5 lakhs for me and my mom in New india assurance but they are saying the 2012 policy is closing and so you have to migrate to 2017 policy
    Is there term plan like mediclaim policy?
    Should i continue with any mediclaim policy after claiming once?(current age 33 claimed at 30 for Hernia)

    Reply
  4. Dear sir, I am planning to buy health insurance in Andhra bank. Whose insurance provider is United India and TPA is ghpl. My question is what if TPA changes in between? Will my insurance also stands cancelled or will it be continued with new TPA which ever United India chooses?

    Reply
    • Satish-Your insurance will continue with new TPA or in-house TPA as per the insurance company’s policy.

      Reply
  5. DEAR BASU,YOUR GUIDANCE ARE VERY PERFECT.SINCE I AM WORKING WITH NATIONALISED BAND AND HAVING MEDICLAIM POLICY OF UNITED INDIA INSURANCE CO. And WHOSE TPA IS HERITAGE.WE ARE NOT GETTING BILLS PASSED FOR TWO TO THREE MONTHS EVEN MORE.THEY ARE REJECTING BILLS ON SILLY REASONS WHAT TO DO.CAN WE APPROACH COMPLAINING REGARDING TPA TO OUR ONSURANCE CO.KINDLY GUIDE

    Reply
    • Sheikh-You have to first approach insurance company. If insurance company also not heed, then knock the door of ombudsman IRDA.

      Reply
  6. Dear Sir,

    I have taken 5L; Happy Family Floater from a PSU . In the product catalog the PSU company put an offer, if i go without TPA- 5% less premium .
    What is the Pros & Cons of TPA services?
    Is it necessary to have a TPA service in between the insurance company & me?
    Kindly advise.
    Thank you,
    Loyit.

    Reply
      • If we opt out of TPA services ? Could we still use cashless mediclaim services ?

        I mean, would the insurance company provide me cashless cards ?

        Also I have Oriental – Happy Family Floater policy. Me and my parents were covered. Could I also add my sister to it as dependent sibling, as father is no more ?

        Last time while purchasing policy four years ago, I could not add her.

        Thanks,

        Reply
        • Pushkar-“If we opt out of TPA services ? Could we still use cashless mediclaim services ?”-YES.
          Regarding adding members, check with the concerned insurance company.

          Reply
  7. Dear Sir

    I had the LIC health policy since 2010. But after enrolling, I went abroad. My family do not remember or recall receiving any communication regarding / from TPA. How to find who is my TPA and what happened to my Welcome kit and ID cards?

    Reply
  8. Which one is best religare group care or lombard

    Reply
    • Siddharth-If your question is related to TPA then it does not matter while buying an insurance.

      Reply
  9. Sir, Need your advise. I am tempted to go for Apollo Munich Optima restore based on the various web readings done so far. My family consists of 2 adults and 2 kids [37 / 32/ 5/ 1 ]

    However after reviewing your article and the claim settlement ratio, I am not sure about my move

    Would you please guide me through
    which is the best health Insurance provider for a 10 L family floater
    Also, is the IRDA report available for 2014

    Reply
  10. hello sir,
    I am going to take health insurance from national insurance through BOI. In that claim would be settled by TPA. I want to know,should i go through from that?or should i buy health insurance which has not TPA? or any pls suggest. Even i heard that TPA deducted 10% from total claim.

    Thanks

    Reply
    • Pranav-TPA is just servicing entity and no authority to judge the claim or deduct the claim amount. If plan features matching your requirement then go ahead.

      Reply
  11. Hi Basu,

    I have an insurance policy with Royal Sundaram. RSA has changed my TPA from Medicare to Paramount without any information. I was not given Paramount Health Card also. Is there any guideline from IRDA on this. I am not comfortable having my policy with Paramount since I already have another policy with a PSU Insurance Company where Paramount is the TPA. Is there any remedy other than portability.

    Regards
    Dipanjan

    Reply
    • Dipanjan-What is problem with having two insurance policies with same TPA (when insurance companies are different or same)?

      Reply
  12. Dear Basu,

    A friend of mine has taken health insurance plan from National Insurance and he is not happy with the TPA assigned to him as major hospitals in Delhi deny cashless facility to them due to that TPA.
    Is it possible for him to opt for some other TPA associated with the same insurance company without nullifying the health insurance policy?
    Also, if possible please can you share how can he switch TPA?

    Regards,
    Amit

    Reply
    • Amit-Ideally one insurance company have tie up with one TPA. If you not satisfied with TPA then you can opt out of TPA (which creates claim hurdle) or use portability to move to other insurers.

      Reply
  13. So it is better to opt for TPA or not? eg. Oriental family floater insurance gives you 5% discount if you dont opt for TPA.

    Reply
  14. Dear Mr. Basu Nivesh,

    I am looking to buy health insurance for my parents from a long time but I am not able finalize or even shortlist few. Can you provide me names of few good health insurance companies or TPAs which are professional, ethical and customer friendly(during claim process).

    Looking forward for your reply 🙂

    Reply
    • Vinay-None 🙂 Because it depends on case to case. So hard to name few.

      Reply
  15. so I think there is nothing to worry about loss of my investment, shall I submit my complaint with sebi complient register site www score website or I have to wait till maturity period.

    Reply
  16. so I think there is nothing to worry about loss of my investment, shall I submit my complaint with sebi complient register site http://www.score. website or I have to wait till maturity period.

    Reply
    • Rajik-Go ahead and complain.

      Reply
  17. Dear Sir,
    It is Sahara q shop Plan fix deposit bond and I dont think it related anyway to secondary market and it given lock period of six years i.e 2018 and i didnt find any clue to get back my invested money immediately. but what we hearing about the sahara company in recent news is it the company will refund their investor value on redemption dates in future or we go legal in this matter.
    Advice

    Reply
    • Rajik-Yes either Sahara need to refund or SEBI will collect the amount from Sahara and will give it to investors. Process is going on, you may get delayed payment but will definitely they will pay you.

      Reply
  18. sir I have querry regarding the news we are hearing about sahara india & Supreme court judgement in daily news paper.
    Like a number of small investers who invested in sahara India, the agent misguided me & invested my money in sahara q shop last year and the bond redemption is 2018. and once I tried to cancel and claim for my reimbursement but it couldnt work out the head office regected my application of cancelling the bond.so there is only option I had I need to wait till my bond get mature. Do you have any suggestion regarding whare I can get by money back as soon as possible legally.
    Awaitin g to hear from you.

    Reply
    • Rajik-Please go through the rules and regulations of the bond which they published on the same bond paper. You need to concentrate on the lock in period of the bond, any call back option of the bond is mentioned or not, is it listed on any secondary market or not. Check these things and let me know. I will definitely guide you.

      Reply
  19. Thanks for the information Dear Basu

    Reply
    • Gopal-Pleasure to see your appreciation 🙂

      Reply
  20. rare information…a good article…

    Reply
    • Sudhanshu-Thanks for your comment 🙂

      Reply

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