Role of TPA in Health Insurance: Explained

Health emergencies are unpredictable and can occur without any warning. No one can be mentally prepared to handle the situation calmly as there is a lot of panic and rush during such situations. Getting immediate help, hospitalisation, and filling up the necessary paperwork are just some of the exhausting things associated with medical emergencies. However, you can be prepared for the financial expenses related to emergencies with the help of health insurance. While insurance provides much-needed financial assistance, how to use it properly can be confusing for many. In such situations, you can take the assistance of a third-party administrator. Who are they and what is their role? Here is more information related to them.

Who is a third-party administrator?

Health insurance is a type of policy that provides you with financial assistance during medical emergencies. If you or a family member falls sick and require hospitalisation, this insurance policy will help in covering the cost of hospitalisation and treatment. The sum insured offered in the policy takes care of the expenses. Reading the policy document carefully to know the inclusions and exclusions is critical. * The third-party administrator is an entity which acts as an intermediatory between you, the insured, and the insurer. When you file a claim during hospitalisation, it is the TPA assists you in processing the claim filed. These administrators are generally independent. However, at times they can also represent the insurer. Just like insurance companies, TPAs require IRDAI registration. You can visit the official website of IRDAI for further details.

Responsibilities of the third-party administrator

The following are the responsibilities of the TPA in insurance:

1. Issue health card

The health insurance card is provided by the insurer to the policyholder. This card has all the details related to the insurance policy that you own. The card is beneficial if the hospital has a cashless claim facility. It is issued to you by the TPA on behalf of the insurer. The health card can help quicken the claim settlement process.*

2. Assist in the claim process

Once you file a claim, the TPA is intimated. They assist in speeding up the claim process. They are responsible for gathering all the information related to the hospitalisation of the individual and other information related to them and their medical history. This helps in supporting your claim and increases the chances of its approval. *

3. Provide additional services

The TPA can assist you in more than just the claim settlement process. They can get you or your family member admitted to a network hospital, which can give you the benefit of a cashless facility. The administrator can also assist in arranging other services such as an ambulance to transport the patient.*  You can also get updates from them regarding your claim application.

Other responsibilities of the third-party administrator

1. Providing information related to health services that you can avail
2. Helping you understand different features of your policy
3. Strengthen the relationship between you and your insurer

Is the TPA necessary?

Absolutely not. If you are not satisfied with the TPA assigned to you, you can cancel their services. Alternatively, you also have the option of switching to another third-party administrator. This, of course, depends entirely on the discretion of the insurer. If they find your reason satisfactory, only then the cancellation or provision of another administrator will be approved. Also Read: 3 Reasons Why You Should Get Health Insurance in Today’s Changing Times

Why health insurance is a must?

Along with the administrator, there are various benefits of health insurance that you can enjoy. The other benefits you can enjoy are:

1. Coverage of the room rent for the period of hospitalisation*
2. Coverage of nurse charges during hospitalisation*
3. Cost of medical check-ups either during hospitalisation or prescribed by the doctor*
4. Provision of daily allowance to cover expenses other than those related to the hospitalisation*
5. Coverage of expenses related to pregnancy and birth of the child with the help of maternity cover
6. Financial compensation offered under the personal accident cover if the policyholder suffers partial or total disability in an accident. Lump-sum amount is given to the beneficiaries of the policyholder if they were to pass away

*Standard T&C apply

Conclusion

This is how the administrator functions in insurance. If you wish to provide better financial protection for you and your family from medical emergencies, you should invest in family health insurance which provides coverage to everyone under a single policy.

FAQs

How can I contact my TPA for assistance?

Your TPA contact details are mentioned on your health insurance card or policy document. They can be reached via helpline numbers, email, or mobile apps.

Can a policyholder choose their TPA?

In most cases, the insurance company assigns a TPA, but some insurers allow policyholders to choose from their empaneled TPAs at the time of policy purchase.

What documents are needed for a TPA claim?

Documents like a claim form, hospital bills, discharge summary, prescriptions, and diagnostic reports are required. Your TPA will guide you through the process.

How does a TPA differ from an insurer?

An insurer underwrites policies and bears the financial risk, while a TPA acts as a service provider to manage claims and policyholder assistance on the insurer’s behalf.

Are there any charges for TPA services?

TPA services are generally included in the policy premium. Policyholders don’t need to pay extra for availing of these services. Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.