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TPA in Health Insurance
Apr 2, 2021

What is TPA in Health Insurance?

Medical emergencies are unexpected and uncertain. They strike at the most inopportune times, leaving you stranded. The costs of availing medical facilities are skyrocketing. The soaring medical inflation makes it more and more necessary to have a health insurance cover.   Those who have a health insurance cover are somewhat covered from financial hassles whereas those who don't could find themselves in a debt trap. Here the importance of health insurance policies is established. But apart from the health insurance company, there is an intermediary organisation known as the third-party administrator, that you might need to interact with.   Fret not! Here we explain all you need to know about TPA, including the vital role it plays.   What is TPA?   Third-party administrator or TPA is an organisation that administers the claim handling process for an insurance company. Not only that, but any grievance or redressal process for the claimant is also taken care of by the TPA. Health insurance TPA is an independent organisation different from the insurance company. These bodies are also licensed by the Insurance Regulatory and Development Authority of India (IRDAI) to operate on behalf of the insurance companies. It is like an extended arm of the insurance company.   With more and more people availing a health insurance policy, the number of claims has also increased. It gets difficult for the insurers to manage all these claims single-handedly. Here comes health insurance TPA. By providing consistent and quality services, they help the insurers in processing the large number of claims made on a daily basis.   What is the relevance of a third-party administrator or TPA in health insurance?   A TPA ensures all your claim-related queries are taken care of and addressed. Moreover, the validity of a claim application is also checked by a health insurance TPA. Every insurance company appoints a TPA for servicing its policyholders. Under Insurance Regulatory and Development Authority of India (Third Party Administrators - Health Services) (Amendment) Regulations, 2019, every insurance company has to provide an option of selecting the TPA to the policyholders from the list of empanelled TPAs. Moreover, the policyholders can also change their TPA at the time renewal of their insurance policies.   Who all are part of the team of TPA or third-party administrator?   The TPA generally consists of a team of in-house medical professionals registered with the Indian Medical Council, insurance consultants, people having expertise in the legal field, management consultants, along with IT professionals.     What role does a TPA play in health insurance administration?   Apart from functioning as an intermediary between the insurance company and the policyholder, a health insurance TPA pay a crucial role as follows -   Maintain records of the policyholder: Once the insurance company issues the policy, these records are transferred to the TPA organisation. The TPA maintains the records and assumes most of the responsibilities for the insurance company. Identity cards with a unique number are issued to policyholders, including its beneficiaries under the policy.   Settlement of Claims: One of the crucial roles that a TPA plays is settlement of your claim applications. In case of a cashless claim settlement, the TPA directly coordinates with the hospital for settling of the medical bill. Moreover, in reimbursement cases, the TPA checks the validity of your claim application for admissible expenses under the policy terms. If there are any doubts regarding the claim filed, the TPA can investigate hospital records too.   Cashless claim facility: A third-party administrator assists the policyholder when it comes to claim related to cashless health insurance plans. Once you furnish the required forms to the hospital, it submits the details to your health insurance TPA. All further matters related to medical facilities availed at the hospital are taken care of by the TPA. You must note to avail a cashless facility, you need to avail treatment from a specified network hospital pre-defined in your insurance policy. Although it is a handy feature, it is the insured's choice as to where to opt for the treatment.   Empanelling network hospitals: TPAs are further responsible for monitoring as well as adding new medical facilities to the list of network hospitals for the insurance company. As stated earlier, a policyholder can avail a cashless medical facility at a network hospital. The facilities provided, the quality of services offered along with its proven track record are some of the factors accounted for when adding a hospital as part of the network chain. The general insurance policy document specifies the list of such network hospitals at the time of purchase or renewal.   Serves as a helpdesk: Along with the functions mentioned above, a TPA is responsible for maintaining a 24x7 helpdesk facility. It is done to address any emergency claims of the insured as well as any queries regarding claims. The services of such helpdesk facilities are over and above those maintained by your insurance company.   Add-on facilities: Lastly, a few TPAs also provide add-on services like ambulance facility, lifestyle management programmes, healthcare facilities, supplies related to medicines, and more.   To conclude, as crucial it is to select an insurance company, it is just as important to choose the right TPA. With a choice available to select the TPA of your choice, ensure you have a proper third-party administrator after careful evaluation of the alternatives at hand.

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