What is TPA in Health Insurance?

Imagine a situation in which you, or any of your dear ones, are facing a medical emergency and desperately seeking medical help or hospitalisation. You keep reminding yourself that you have a good health insurance plan that will take care of your expenses. But can you picture yourself handling all the paperwork and nitty-gritties of the claim process in such an emergency? No. You want to be with your family and take care of them. But who would take care of the procedure to claim insurance?
The answer is Third-Party Administrators, or TPAs as they are popularly called. TPAs are those invisible middlemen who come to your rescue in such testing times and handle all the formalities and paperwork as you look after your family.
Let’s understand in detail what is a TPA in health insurance.
A TPA is actually an intermediary between you and your insurance company. It is an entity that has been appointed by the insurer to facilitate the processing of health insurance claims.
When you avail the service of these TPAs, you do not pay them anything. They are directly compensated by the insurance company.
You can trust these TPAs with all the paperwork and formalities as they are bodies that are licensed by India’s insurance regulator IRDAI (Insurance Regulatory and Development Authority of India) and are fully trained for the job they are doing. Now that you know what is TPA in Mediclaim policy, let us understand why we need it.

Why do we need TPAs?

Now, you would have got an idea about what is TPA in health insurance. But you must be wondering why such big insurance companies need TPAs at all to facilitate health insurance claims. That’s because, given the size of India’s population, the number of people buying health insurance in the country has increased exponentially, and so has the number of claims. The number of private insurers and the variety of products they offer have also expanded.
In such a situation, it is extremely difficult for insurance companies to handle the paperwork of each and every insurance claim themselves. Not only would it make the process cumbersome but also would delay the settlement of claims.
It is helpful for them if they get a ready claim file with all the necessary documents and forms in place. They can make a quick decision on the claim and, if approved, the funds can be disbursed to the policyholder quickly.
So, it is actually the TPAs that make it possible for insurance companies to deliver quality services at a fast pace all while helping you with the necessary paperwork.

What is the role of TPA in health insurance?

When you or one of your family members need hospitalisation and you want to use your health insurance, the first person you should get in touch with is your TPA. But it is important to understand what exactly would the TPA do.
You should first know that there are mainly two types of claims – cashless claims (where the insurer pays the hospital directly) and reimbursements (where you make the payment at the hospital and the insurer reimburses you later). Now, we will take a look at the role of a TPA in both such type of cases.

Cashless claims: Suppose your doctor recommends you sudden hospitalisation for the treatment of a disease that is covered under your health insurance policy. And you plan to go the cashless route for raising a claim. Then you should first get in touch with the TPA associated with your insurance company and get information on the suitable network hospital of your insurer.
After choosing the hospital, the TPA representative should meet you at the hospital insurance desk and help you in submitting the required forms and documents to avail of the cashless facility.
The TPA then coordinates with the hospital and keeps track of all the bills and certificates which need to be submitted to the insurer. Once the claim is approved, the TPA settles the treatment expenses with the hospital.

Reimbursements: Suppose you choose a hospital that is not a part of your insurer’s network hospitals. Then you can’t avail the cashless facility. In such a situation, you first inform the TPA about your choice of hospital. The TPA at this stage would just guide you on which documents and bills you should keep with you to raise a claim later.
You get your treatment done and pay the bills from your own pocket. Now the TPA would help you with your application for reimbursement. The TPA would guide on the complete list of documents, bills and certificates that you need to submit along with your claim application. Once your claim is approved, the insurance company would transfer the claim amount to your bank account.

What are the other responsibilities of a TPA?

Besides facilitating the settlement of claims, TPAs also help in providing other services such as:

• Issuing health cards: Whenever you buy a health policy from an insurer, the TPA is responsible for issuing a health card to you. This card has to be compulsorily presented when filing a claim. It contains information like the policy number, name of the insured person, etc.

• Value added services: TPAs can provide additional value-added services like a 24x7 helpline facility for policyholders, ambulance services, wellness programmes, etc.

• Strengthen the hospital network: TPAs help in getting the best hospitals enlisted on the insurer’s hospital network so that policyholders can avail the cashless facility.

So, if you are planning to use your health insurance in the near future, find your TPA with the help of your insurer and get in touch with it now.

Disclaimer: The above information is indicative in nature. For more details on the risk factor, terms and conditions, please refer to the Sales Brochure and Policy Wordings carefully before concluding a sale.