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Health Insurance TPA

Medical emergencies can arise at any time and without prior warnings. While it is an unavoidable aspect of our lives, it is wise to be prepared for it in advance. Any health emergency requires immediate care. Knowing that hospitalisation and treatment costs can be expensive, it is best to have a health insurance plan in place.

An adequate health insurance policy ensures that yours and your family’s sudden medical expenses are taken care of without you having to dip into your life savings. Claiming on your health insurance plan can be a tedious and time-consuming process, especially when you are in the middle of a medical emergency. That is when a Third Party Administrator (TPA) comes into picture.

In this section, we have shed some light on TPA in health insurance plans in India.

What is TPA in Health Insurance?

A TPA or Third Party Administrator acts as an independent establishment or entity belonging to an insurer to process the health insurance claims. Typically, TPAs are licenced by the Insurance Regulatory and Development Authority of India (IRDAI).

It is hired by the insurance providers to process the health insurance claims in a cost-effective, timely, and hassle-free way. While most TPAs work alongside a health insurance provider, some of them also act as an independent establishment.

In simple words, if you have health insurance to claim, a TPA will offer you the necessary assistance during the process along with cashless/reimbursement facilities.

Role of Third Party Administrator in Health Insurance

As mentioned earlier, the primary responsibility of the TPA is to process health insurance claims. Other ways the TPA can come in handy in health insurance are as follows -

  • Issuing health cards to the insured

Before issuing a health insurance plan to any applicant, the insurer carries out a validation process. Once proper validation is done, the insurer issues an authorised health card to the newly insured. The health card possesses details of the health policy and the TPA responsible for managing future claims.

When the insured seeks treatment at any hospital, the claim process can be initiated by producing this card to the TPA or the insurer. The health card is one of the essential documents to be provided when making health insurance claims.

  • Hassle-free claim settlement process

The primary objective of having the TPA in place is to manage health insurance claims. Their responsibility is to check the claim application and documents provided for the said claim request. Moreover, they can ask the insured to provide more information to verify the details regarding the claim. The claim settlement is done either via a cashless method or on a reimbursement basis.

No matter what the claim settlement method is, the TPA has to check the documents provided for the said claim thoroughly. In the case of cashless claim settlement, the TPA gathers documents from the hospital directly; whereas, in the reimbursement methods, the insured has to submit the documents and hospital bills along with the claim application to the TPA.

  • Arrange for additional services (if needed)

Besides processing health insurance claims, the TPA also arranges for services such as ambulance, well-being programs, and more.

  • Provide helpline facility

The insured can gain insights and assistance on the claim process by getting in touch with the TPA on their helpline facility, which is available for service 24x7.

  • Build a strong hospital network

If the insurer has a TPA enlisted in the health insurance section, do make use of its benefits. The TPA encourages the insured to seek treatment at the best network hospital available near them. That way, the insured can access cashless claim settlements and seek high-quality medical services at affordable rates as well.

How TPA in Health Insurance Helps Policyholders?

The TPA is a mediator between the insured and insurer. The main responsibility of the TPA is to simplify the claim settlement process for the health insurance policyholders. As we know, there are two ways in which your insurer settles your health insurance claims -

  1. Cashless claim settlements

  2. Reimbursement

When the insured is admitted in the hospital for more than 24 hours, a claim becomes admissible. In such a situation, the insured has to inform the responsible TPA regarding hospitalisation and treatment.

The TPA will get in touch with the hospital facility and arrange for a cashless settlement of the expenses incurred. Once the insured’s treatment is done, the hospital sends across the bills to the TPA in case the cashless claim settlement is approved. If not, the insured has to submit the claim application and the supporting documents by themselves for reimbursement.

When the documents are received by the TPA (either sent by the hospital or submitted by the insured), they will verify each document post which the claim request will be approved. In case of reimbursement, the insured has to pay the medical bills from their pocket, and the compensation will be sent to them upon claim approval.

Benefits of TPA in Health Insurance

Some of the top advantages of TPA in health insurance are as follows -

  • The TPA customer service portal is available 24x7. So, if you have any query related to your health insurance claim, you can get in touch with the TPA right away.

  • The TPA team follows a standard process when assessing the claim application. The protocols developed by them help streamline the verification of the claim request and quick claim settlements.

  • The audience has become more aware of the health insurance benefits offered by their insurer due to the involvement of TPA.

  • TPA facility helps reduce the chances of fake claims and minimises expenditure for the insurer.

Conclusion

Not many people are aware of the TPA facility in India. Through this article, we believe that you have gained insights on the same and can be confident to approach the TPA enlisted by your health insurance provider for timely and cost-effective health insurance claim processing.

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