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.
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.
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TPA very bad service
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 ?
Dear Joe,
Yes, you can.
Is there any dental insurance available in india .
Dear Siddhant,
I think NO.
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)
Uday-Refer my post "Health Insurance by Banks – Should you buy?".
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?
Satish-Your insurance will continue with new TPA or in-house TPA as per the insurance company's policy.
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
Sheikh-You have to first approach insurance company. If insurance company also not heed, then knock the door of ombudsman IRDA.
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.
Loyit-Not necessary to opt TPA.
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,
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.
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?
Krishnakumar-There is no TPA for LIC health plan. It is typical plan managed by LIC itself. Please read my view on this plan at "Jeevan Arogya-Do you know this LIC’s Health or Medical Insurance Policy?".
Which one is best religare group care or lombard
Siddharth-If your question is related to TPA then it does not matter while buying an insurance.
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
Jestine-Please go ahead.