Health Insurance 288 views April 7, 2020

Can You Choose Your TPA for Your Health Insurance Plan?

Third-Party Administrator (TPA) can be an agency or a company or an organisation that holds a license from the Insurance Regulatory and Development Authority of India (IRDA) for processing of the claims of the corporate as well as retail insurance policies. TPAs also provide cashless facilities to the policyholders as an outsourcing authority of insurance company. TPAs acts as intermediaries between the insured individual and the insurance company playing an important role in claim processing under the mediclaim policy.

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Insurance Regulatory and Development Authority (IRDAI) of India has now allowed the holder of the policies to choose their of their choice third party administrators (TPA) when they buy or renew their health insurance plan. The third-party administrators play a vital role in the processing of the health insurance claim and they make the process easier and simple.

Choose your TPA for your health insurance plan

The health insurance providers will provide a host of third party administrators to the policyholders while selling the plan and the buyers will select a TPA as per their requirement. The policyholder is only allowed to change the TPA at the time of renewal of the health insurance plan. The insurance company may limit the number of third party administrators based on the health product and the location of the holder of the policy.

Points to remember while choosing a third-party administrator for your health insurance plan as stated by the IRDAI are as follows:

  1. The holder of the policy can choose a TPA for their health insurance plan as per their choice from the TPAs engaged by the insurance company.
  2. TPA can be selected only from the names provided by the insurance company when the individual is buying the health insurance plan or renewing the plan
  3. The policyholder will not have any right to seek services of TPAs services and he/she can make a request to the insurance company to render the health insurance services directly to the insured.
  4. The insurance company will select a TPA for the policyholder is he/she does not select one. The insurance company will allot a TPA of its choice to the policyholder for his/her health insurance plan
  5. The policyholder will be allowed a right to choose alternate TPA in case the services of his/her TPA are terminated.
  6. No option will be provided to the policyholder if the insurance company has service of one TPA only.
  7. The insurance company will have the last option for engaging or terminating the services of the TPA. For engaging or terminating the TPA’s services for a particular health product will be the insurer’s choice.

Role of Third Party Administrators

TPAs play a vital role in both the insured and the insurer. It ensures reduction of administration cost, the false claim ratio, standardized the cost of treatment, etc of the insurer and also guides the policyholder through the claim process. The key role of the third party administrators are as follows:

  1. TPAs works as intermediaries between the insurance company and the holder of the policy. It works with the insurance company, the policyholder and healthcare provider.
  2. TPAs help the policyholders for claim settlement as they can get in touch with the insurance company directly and made the claim process quick and easy.
  3. TPA makes its easier for the policyholder to opt for cashless treatment as they have their list of network hospitals with which they have a direct link.
  4. TPAs not only smooth out the procedure of claim for the policyholder but also help him/her pick choose a health insurance plan. Hence a TPA provides buying, renewing and claiming of a health insurance plan.
  5. TPAs have a unique identification number which is provided to them to ease the claim settlement process and to handle the entire claim settlement procedure. The TPAs also have a helpline facility accessible to them to help them through any claim issues of the health insurance plan.
  6. TPAs also process and provide the specific factors of the employee benefits policy acquired for different entities such as underwriting, additional services which are customer-oriented, etc
  7. Most of the TPAs have medical practitioners in their list of employee which help to assist the TPAs and the insured individual to take better decisions despite any particular ailment is provided coverage in the health insurance plan or not.
  8. TPAs shall be well aware of all the latest and recent medical developments with the policyholder and will have all the relevant and necessary medical records of the holder of the policy thereby making communication much easier.

How claims are settled with the help of TPAs

The claims of health insurance plans are wither settled by your chosen TPA or in house processing department of the insurance company. The holder of the holder is required to inform the respective TPA in case of any claim of the policy. The TPA will seek all the details, bills and the required documents provided by the hospital in order to process the claim with the insurer. They complete the entire process like form filling with the insurance provider, submitting the documents, etc. However, the TPAs are however not responsible for any rejection of the claim by the concerned insurance company.

Conclusion

IRDAI has made health insurance policies more attractive and accessible by offering the benefit of choosing the third party administrator for health insurance plan as per their choice at the time of buying or renewing the health insurance plan. Some private companies like Max Bupa, HDFC Ergo and Bajaj Allianz have in the house claiming process which provides efficiency in settling and processing of the claims. If you have already availed services of a TPA in one of your insurance plans and want the same TPA then you have the benefit to choose that one for your other insurance plans. This will make you stress and burden-free. Third-party administrators are of great advantages guiding you towards your process of purchasing, renewing and claiming of health insurance plans.

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