A Third Party Administrator (TPA) is an entity that acts as an intermediary between the hospital and the insurance company in the context of health insurance. TPAs play a crucial role in facilitating both cashless and reimbursement health insurance claims.
Their primary responsibility is to ensure a seamless and hassle-free claim process, providing support to policyholders throughout. TPAs can either be independent organizations or entities affiliated with the insurance company.
In simple terms, a third-party administrator (TPA) is a person, an organisation, or an entity that serves as an administrator between the two parties. Under health insurance, a TPA is any entity that is not an insurance provider or a policyholder. In this article, we’ll take a closer look at what role it plays in health insurance.
Bajaj Allianz Health Guard Policy
1.Individual and family plan options
2.Covers medical costs with sum insured from ₹2 lakhs up to ₹1 crore
3. Extensive protection including organ donor expense, in-patient hospitalisation, daycare procedures, etc.
4. Pre- and post-hospitalisation cover
5. Covers the expenses incurred in the organ donor’s treatment.
6. Covers 130 daycare treatments.
7. Covers in-patient Ayurvedic/Homoeopathic treatment costs.
Bajaj Allianz Extra Care Plus Policy
1.Top-up health policy that covers higher medical expenses once your core insurance is exhausted.
2. Includes road ambulance cover, free medical check-ups, coverage against maternity expenses and organ donor expenses, in-patient hospitalisation and more.
3. Pre- and post-hospitalisation cover
Care Health Insurance Plan
1.Sum insured goes up to ₹75 Lakhs, with daily cash allowance of ₹500 (up to 5 days of hospitalisation)
2. Sum insured is recharged once a year if multiple claims have exhausted coverage.
3. No upper limit on the applicant’s entry age, covering the entire family at ease.
4. Maternity cover of ₹1 Lakh if sum insured is ₹50 Lakhs, ₹60 Lakhs or ₹70 Lakhs.
Individual Health Insurance
1.Sum insured of up to ₹1 crore
2. Offers complete medical coverage against major health risks
3. 10% of the total sum insured is offered as a No-claim Bonus
4. 586 daycare treatment cover available
5. Sum insured is reloaded up to 150%
Family Floater Health Insurance
1.Sum insured of up to ₹2 crores
2.Covers an entire family in a single plan.
3. Offers No-claim Bonus, in-patient hospitalisation cover, daily cash allowance, ambulance cover, etc.
Disclaimer: The premium rates are indicative. The actual premium that you may have to pay may change depending on various factors. Please check the prevailing premium rates before purchasing your Health policy.
The major objective of a TPA is to ensure a smooth processing of your health insurance claims and to help insurance companies provide top-of-the-class services for all policyholders. They are licensed entities by the Insurance Regulatory Development Authority of India (IRDAI) to facilitate the processing of the health insurance claims on behalf of the concerned insurance company.
They can be affiliated with one or more insurance companies, or be an independent organisation altogether.
Here are some of the roles that the TPA plays when it comes to health insurance policies:
Right from handling paperwork and presenting documents during the insurance claim process to offering end-to-end support, a TPA is very integral for the entire procedure.. These entities can help policyholders process both reimbursement and cashless forms of claim settlements. TPA also makes the communication between the insurance company and the policyholder easier. This improved communication enhances and fastens the insurance health insurance claim settlement process. The TPA offers a unique ID number to the policyholder, which is essential for the claim settlement process
TPAs are also responsible for keeping a track of all the documents related to the insurance policy of the insured. This is crucial especially during the claim settlement process, when the insured files for a reimbursement or cashless claim with a network hospital.
It’s the job of the Third Party Administrator to review the hospitals with due diligence to see if the hospital in question meets the criteria passed on by their affiliated insurance company. Once the review is satisfactory, the TPA then onboards them as an empanelled hospital with their insurance company, and adds it to their list of network hospitals for policyholders to avail of claim settlement.
There are TPA executives appointed with the intent to offer 24x7 service and support to policyholders. For any insurance claim-related doubts, details on non-network and network hospitals, ideal type of claim settlement, etc., policyholders can directly connect with the customer support team of their appointed TPA.
Additional services of the TPA can also include but are not limited to offering ambulance support, supplying medicines, helping with exit paperwork, etc., for the policyholders.
Third Party Administrators in health insurance can make the claim process easier for policyholders. Here are the major benefits of TPAs in health insurance:
Since health insurance TPAs follow a standard procedure to process and verify health insurance claims, the whole process becomes more streamlined. This leads to the swift settlement of claims, which is beneficial for both the insurer and the insured.
Another benefit of TPAs in health insurance is that policyholders can seek their support through a 24x7 helpline number. Therefore, any doubts that policyholders may have vis-a-vis the claims process can be readily addressed.
Policyholders can become more aware of the various benefits in health insurance policy with the help of TPAs by communicating with them to help understand the policy terms and conditions better.
With the expertise of health insurance Third Party Administrators, fake and fraudulent claims can be identified during the processing of the claims. This can be beneficial for the insurer in terms of savings of time and cost alike.
The Third Party Administrators offer a smooth and hassle-free claim settlement process to the insured, be it cashless or reimbursement claim settlement. They play a crucial role in simplifying thehealth insurance claim settlement ratio requests, thereby helping both the policyholders as well as the concerned insurer. Here’s how the TPAs work in both the types of claim settlements –
When a policyholder directly allows the insurance company to settle the medical bills and hospital expenses, it is known as a cashless claim settlement. In this case, the policyholder has to contact their TPA for their claim settlement. The TPA then offers end to end support, from choosing the right network hospital to closing the paperwork and settling expenses on behalf of the policyholder.
When an insurance policyholder pays their medical bills and hospital expenses by themselves, and then raises a reimbursement request with the insurer, it is known as a reimbursement claim settlement. In some cases, the policyholders decide to opt for non-network hospitals for their treatment, and they inform the TPA accordingly. Post discharge, when the insured files for a reimbursement claim, the TPA guides the policyholder with the set of required documents and the claim approval process. The insurance company finally transfers the claim amount to the insured’s bank account once the settlement process is complete.
Health Insurance TPAs (Third Party Administrators) provide several benefits for policyholders. Some of the key advantages of having a TPA in health insurance are:
Efficient Claims Processing: TPAs assist in managing and processing health insurance claims on behalf of insurance companies. They ensure timely processing of claims, reducing the administrative burden on policyholders.
Network of Healthcare Providers: TPAs have tie-ups with a wide network of hospitals, clinics, and healthcare providers. This network helps policyholders in availing cashless treatments, where the insurance company settles the bills directly with the healthcare provider.
Expertise in Health Insurance: TPAs specialize in health insurance claims management. They possess extensive knowledge and expertise in handling various insurance processes, including claim settlement, pre-authorization, and policy administration. This expertise helps in streamlining the claims process and resolving any related issues.
Support Services: TPAs provide additional support services to policyholders, such as customer helplines, online portals, and mobile apps. These services enable policyholders to access information, track claims, and get assistance for any queries or concerns related to health insurance.
Cost Control: TPAs play a crucial role in cost control by managing claims and ensuring that they are genuine and reasonable. They conduct checks and audits to prevent fraud and overcharging. This helps in controlling insurance premiums and maintaining the overall affordability of health insurance plans.
Enhanced Customer Experience: With their expertise and efficient processes, TPAs contribute to a better customer experience. They handle the administrative tasks related to health insurance, allowing policyholders to focus on their health and well-being.
It's important to note that the specific benefits of Health Insurance TPAs may vary depending on the policies and agreements between the insurance company and the TPA.
The Third Party Administrator (TPA) is licensed by the Insurance Regulatory Development Authority of India, i.e., IRDAI. They are either selected by the health insurance company themselves or some health insurance companies also allow customers to select from a list of TPAs registered with them. The TPAr also has the liberty to be linked with more than one insurance company at the same time. Here are a few important pointers you must keep in mind to enhance your understanding:
The Third Party Administrator is an intermediary between the insured (the policyholder) and the insurance company. In simpler words, the TPA is the bridge between these two parties, at the time of insurance claims’ filing.
The key objective of the TPA is to ensure that the insurance claim made by the insured is processed in a hassle-free manner.
It’s their job to make it easier for insurance companies by taking charge of the insured’s paperwork, settling hospital bills, offering end to end support in the claim process, etc.
With the help of TPAs, insurance companies can provide dedicated and timely claim settlement support to their policyholders. Hence, it is crucial for insurers to choose their TPAs wisely.
The TPAs provide the following valuable benefits to the policyholders:
Constant support during the hospitalisation process.
Provides the vita; unique ID numbers and cards to the policyholders for cashless claims.
Assistance related to gathering and storing the right documentation.
Support in the cashless claims process in case any issues arise.
Simplification of the entire claim settlement process.
The Third Party Administrators are generally provided by the health insurance companies or the policyholder is allowed to select from the list of TPAs that are registered with the insurer. Hence, it is important for the policyholders to keep a few things in mind:
The TPAs can be cancelled or changed by the insurance company at any time, and the insured can get in touch with them to know more details.
The insurance company keeps its policyholders updated on the active TPAs that are affiliated with their company, replacement or exit of a particular TPA, etc.
Your insurance company will be your primary point of contact for all queries. They can redirect you to your updated TPA as well, when you file for a claim.
Here is the list of the popular health insurance Third Party Administrators operating in India:
United Healthcare Parekh TPA Private Limited
Media Assist India TPA Private Limited
MD India Healthcare (TPA) Services Private Limited
Paramount Health Services & Insurance TPA Private Limited
E Meditek (TPA) Services Limited
Heritage Health TPA Private Limited
Focus Healthcare Services TPA Private Limited
Medicare TPA Services (I) Private Limited
Family Health Plan (TPA) Limited
Raksha TPA Private Limited
Vidal Health TPA Private Limited
Anyuta TPA in Healthcare Private Limited
East West Assist TPA Private Limited
Med Save Health Care TPA Private Limited
Genins India Insurance TPA Limited
Alankit Insurance TPA Limited
Health India TPA Services Private Limited
Good Health TPA Services Limited
Vipul Med Corp TPA Private Limited
Park Mediclaim TPA Private Limited
Safeway Insurance TPA Private Limited
Anmol Medicare TPA Limited
Dedicated Healthcare Services TPA (India) Private Limited
Grand Health Care TPA Services Private Limited
Rothshield Healthcare (TPA) Services Limited
Ericson Insurance TPA Private Limited
Health Insurance TPA of India Limited
You can check the list of the TPAs for your health insurance provider by visiting their official website or checking your health insurance card.
Third Party Administrators deal with the following main types of health insurance claims – (i) Cashless claims and (ii) Reimbursement claims.
Yes, a particular TPA can be cancelled by your health insurance provider or de-licensed by the Insurance Regulatory and Development Authority of India (IRDAI).
Yes, the role of TPA in health insurance is that they provide customer support through their 24x7 toll-free helpline number.
Usually, the insurance companies allow the customer i.e., policyholder to choose their Third Party Administrator (TPA) from a list of TPAs that are registered with them. These TPAs work as the intermediary between the insured individual and the company providing insurance. The TPA selected by the policyholder will then take charge of the claim settlement process of the insured, and not the insurance company itself.
Yes, it is possible for a single TPA i.e., Third Party Administrator to be affiliated with more than one insurance company at the same time.
No, every health insurance company does not necessarily have a TPA.
Yes, you can choose a TPA that has been registered with the insurance provider. This can be done at the time of purchasing or renewing your insurance plan. If this is not done by your own, your insurance provider will then choose the one that best fits your needs.
No, TPA is not mandatory for health insurance policies.
Yes, a TPA can help in reducing the number of fake claims.