TPAs in Health Insurance – All You Need to Know

What are TPAs in Health Insurance?

TPA or Third Party Administrator refers to a person or an organization that helps to process claims raised under a health insurance policy. They are independent third parties who may act on behalf of the insurance company to assist in the settlement of claims. Basically, TPAs are a bridge between the insurance company and the policyholder.

Under health insurance, the scope of coverage is wide and its claim settlement involves verifications and internal processing. TPAs keep a track of health insurance claim settlement work on behalf of insurance companies and maintain quality of services. All in all, TPAs look after the payment of your hospital bills and claims made under a health policy.

All TPAs are licensed by the Insurance Regulatory & Development Authority of India (IRDAI). Moreover, one TPA can be associated with multiple insurance companies at the same time.

Role of TPA in Health Insurance

Take a look at the key role of third party administrators in health insurance:

Smooth Settlement of Claims

The major role of a TPA is to expedite the processing and settlement of claims. In case of a cashless claim, the network hospital coordinates with the TPA to seek pre-authorization for treatment of the insured. It is the TPA’s job to cross-check if the documents submitted by the policyholder are sufficient to administer the claim. The TPA can ask the policyholder to provide information if need be.

Issuance of Health Cards

A TPA is responsible for issuing the authorized health card to the policyholder to validate the issuance of the policy. This card contains details of the policy & the policyholder and needs to be shown at the hospital during hospitalization to intimate a claim.

Maintenance of Records

TPAs are also responsible to keep a record of crucial information related to the insured while he/she is hospitalized. Doing so unburdens the insurance company from maintaining these records for future references.

Arrangement of Value-Added Services

A third party administrator also assists in arranging value-added services for the policyholder, such as ambulance service, wellness programmes, referral to surgeons/specialists, etc. The insured can call his/her TPA to avail value-added services covered under the policy.

Claim Assistance

Policyholders can call their TPAs in case they require any kind of claim-related assistance, such as claim intimation, document submission, claim status, etc. TPAs must provide full-fledged customer support and answer the queries of the policyholders. A person can reach out to his/her TPA 24x7 from any part of the country.

Build a Strong Network of Empanelled Hospitals

A TPA also helps the insurance company to build a strong network of empanelled hospitals. It tries to enrol the best hospitals with the insurance company that can arrange cashless services quickly and allow rate negotiation.

Benefits of TPA in Health Insurance

Here are the key benefits of third party administrators in health insurance:

• They ensure smooth hospitalization of the insured.
• They facilitate in efficient settlement of cashless claims.
• They help in submitting the right claim documents.
• They improve the claim service quality.
• They are available for customer assistance 24x7.
• They do not charge for the services offered.
• They help to efficiently process a large number of health claims.

Cancellation of TPAs in Health Insurance

A TPA is chosen by the insurance company and the TPA itself does not have a say in being appointed or dismissed. However, a policyholder can cancel the existing TPA and request the insurance company for another TPA. Follow the steps given below to cancel your health insurance TPA:

• Get in touch with your insurance company over the phone or email
• Share the details of your policy, including your policy number
• Request for cancellation of the existing TPA with the reasonfor cancellation
• The insurance company will either approve or reject the cancellation request.
• If approved, choose another IRDAI-licensed TPA.

Whom to Contact for TPA Service-related Issues?

In case you are facing any service-related issues with your third party administrator, then you need to contact your insurance provider instead of your TPA. This is because insurance companies are responsible for informing their customers about any changes related to TPAs. For instance, if the TPA is taking more than two days for processing your claim even after submitting all your documents, then you need to contact your insurer.

In a Nutshell

TPAs are a mediator between the policyholder and the insurance company. They assist the insurance company in handling claims while maintaining service quality. Besides, they are easily accessible and act as a representative of the insurance company. So if you want to contact your TPA, you can check out the list of IRDAI-licensed third party administrators mentioned in the aforementioned table.