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Health Insurance May 28, 2021
Health Insurance claim settlement is done in two ways – first by third-party administrators (TPA) and second through the in-house claim settlement. A TPA is a company registered with the Insurance Regulatory and Development Authority of India (IRDAI) that acts as an intermediary between policyholders and the insurance company. You have the advantage of choosing a TPA at the time of policy purchase and if you aren’t satisfied with its services, you can change it at the time of renewal. Continue reading this page further and learn more about the TPA services in claim settlement.
Table of Contents
How to Choose a TPA?
You’ll not get the in-house claim settlement service by every insurer, so you may have to choose a TPA while buying health insurance. While choosing a TPA, you must consider the following –
- List of network hospitals under the TPA
- Healthcare services offered by the TPA
However, if you don’t choose a TPA while buying the policy, the insurer will allot a TPA of its choice.
What TPA Do?
TPAs key role is to process and settle claims with the help of documents provided by you. A TPA issues health cards through which you can receive cashless medical treatment at the network hospital. They also maintain the policy database and help you track claim status.
Note: TPA is not responsible for claim rejection or acceptance.
Important Things to Know About TPA
- The policyholder can choose a TPA of their choice from the list of TPAs engaged by the insurer
- The policyholder can choose a TPA at the time of buying or renewing the policy
- The policyholder does not have any right to seek dispensing of the TPA services and request the insurer to to render the health service directly
- In case a TPA service is terminated during the policy term, the insurance company must provide an alternate TPA
- If the insurer has only one TPA, no option will be provided to policyholders
- The insurer has the right to engage or terminate the TPA
TPA vs In-house Claim Settlement Which is Best?
Compare the Pros and Cons of TPAs and In-house claim settlement below –
| TPA | In-house Claim Settlement |
|---|---|
| TPA provides a large hospital network compared to the in-house claim settlement department of an insurance company. TPA provides a streamlined claim process TPA handles the day-to-day operations of health insurers TPA employs professionally qualified doctors to review claims as well as commercial charge TPA builds good relationships with network hospitals to ensure you’ll get the best rates. TPAs doesn’t accept any judgment on claims | You have to call the customer care and go through the complete claim procedure In-house claims processing is done within the insurance company and takes less time as compared to TPAs. |