Third Party Administrator (TPA)
Third Party Administrator is a company that manages insurance processes usually the service part on the behalf of insurer and receives commission in return. Insurance companies outsource some aspects of insurance business to make the process hassle free and efficient. TPA’s perform these services and acts as intermediary between the insurer and the insured. TPA’s could be division of insurers or completely autonomous.
TPA’s are regulated by IRDA and licence is granted for three years from date of issue until renewed.
TPA Services: TPA’s first role is to issue identity card with unique identification number and provide insured with a guidebook on claims process with a list of networked hospitals. The other functions performed by TPA are:
1. Claims Process: TPA primary role is to process claims both cashless and claim reimbursement.
- Cashless Claims- The insured needs to provide the network hospital with TPA issued identity card or policy number. The hospital sends pre authorization details with doctor’s certificate, treatment details etc. If found that claim is legitimate, TPA issues letter authorizing hospital to proceed specifying the maximum limit of cover.
- Claim reimbursement- The insured needs to contact TPA as soon as possible and intimate about the claim. Documents like claim form, hospitalization details, diagnostic tests, treatment bills, policy duplicate should be provided to TPA. If found legitimate, TPA will reimburse the claim.
2. Enlist Health Care Providers: TPA also ties up with hospitals to provide more comprehensive coverage to the insured. The selection criterion depends on location, infrastructure, facilities available etc.
3. Customer Support: TPA maintains dedicated call centre to provide quick access to policyholders, respond to their queries and update about claim status. TPA’s also have websites for online assistance.
4. What are documents required in absence of cashless facility by TPA?
- Claim form duly filled by claimant
- Original Discharge summary from the hospital
- Doctor’s consultation report, Specialist fees
- Laboratory tests undergone by patient along with doctor’s authorization.
- All medicals invoice along with doctor’s prescription
- Any other document related to hospitalization
- Policy copy if available
What if TPA rejects claim?
TPA rejects claims if it finds the claim not being genuine. Whenever TPA rejects claim, the reason for rejection is also stated. However if you feel that TPA rejection is unjustified, you can contact your insurer within few days of rejection to present your concerns.
List of TPA’s:
1. Alankit Health Care TPA Limited
2. Anmol Medicare TPA Ltd.
3. Anyuta Medinet Healthcare TPA in Healthcare Pvt. Ltd
4. Dedicated Healthcare Services TPA (India) Private Limited
5. E Meditek (TPA) Services Ltd.
6. East West Assist TPA Pvt. Ltd
7. Family Health Plan (TPA) Ltd
8. Focus Healthservices TPA Pvt. Ltd
9. Genins India TPA Ltd.
10. Good Healthplan Ltd
11. Grand Healthcare Services TPA Private Limited
12. Health India TPA Services Private Limited
13. Heritage Health TPA Pvt. Ltd
14. I Care Health Maangement & TPA Services Pvt. Ltd
15. MD India Healthcare (TPA) Services (Pvt.) Ltd.
16. Medi Assist India TPA Pvt. Ltd.
17. Medicare TPA Services (I) Pvt. Ltd
18. Med Save Health Care TPA Ltd
19. Paramount Health Services (TPA) Pvt. Ltd.
20. Park Mediclaim TPA Private Ltd
21. Raksha TPA Pvt. Ltd
22. Rothshield Healthcare (TPA) Services Limited
23. Safeway TPA Services Pvt. Ltd
24. Spurthi Meditech TPA Solutions Pvt. Ltd
25. Sri Gokulam Health Services TPA (P) Ltd
26. TTK Healthcare TPA Private Limited
27. United Healthcare Parekh TPA Pvt. Ltd
28. Universal Medi-Aid Services Ltd
29. Vipul Med Corp TPA. Pvt. Ltd
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