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Third Party Administrator (TPA) & It’s Role in Health Insurance

What Is TPA (Third Party Administrator)?

Third Party Administrators (TPA’s) are IRDA approved organizations or entity that facilitates settlement of claims. Usually, Government Insurance companies outsource their claim settlement task to these specialized firms. They facilitate the entire claim management task.

In case we are not happy with claims settlement process then we can always challenge the TPA’s keeping IRDA in the loop. The entire process is elaborated step by step in subsequent paragraphs. In case of private firms there is in-house team for claim settlement. To begin with, we should know list of companies and contact details of people who are working as TPA’s.

Some of the Latest Details As Fetched From IRDA Site Is As Follows

Sr. NoName of TPA Contact PersonContact details Email
1Medi Assist Insurance TPAGanesh k080-49698036ganeshk[@]mediassistindia[dot]com
2Paramount Health ServicesSuresh Karandikhar020-25300000Skarandikar[@]mdindia[dot]com
3Emeditek Insurance TPA LimitedDr. Dheeraj Kumar0124-4466600drdhiraj.singh[@]emeditek[dot]com
4Heritage Health Insurance TPA LimitedSurendra Kumar Tiwari033-22482784/22486430stiwari[@]bajoria[dot]in
5United Health Care Parekh InsuranceShiva Belawadi022-28532400shiva.belavadi[@]uhcpindia[dot]com
6Medicare Insurance TPA ServicesDipankar Roy9831184120/033-22812826medicareho[@]medicaretpa[dot]co[dot]in
7Raksha Health Insurance TPA Pvt LtdPawan Bhalla0129-2564057pawan[@]rakshatpa[dot]com
8Family Health Plan Insurance TPA LimitedG.Bharathamma040-23556464bharatig[@]fhpl[dot]net
9Vidul Health Insurance TPA Private LimitedSudha Sahar080-40125678sudha[@]vidalhealth[dot]com
10Health Insurance TPA of India limitedSK Mehra020-4765800sk.mehra[@]hitpa[dot]co[dot]in

Role of TPA in Insurance Sector

TPA plays a vital role for both insurance companies and policyholders.

Their role is varied as mentioned below.

  1. Acts as a mediator between Insurers; policyholders & hospitals.
  2. Claims Processors.
  3. Claim Settlement.
  4. Cashless Approvals
  5. Inpatient treatment from hospitalisation to discharge.
  6. Stakeholder’s management.

How to Manage Claim Settlements through TPA (Third Party Administrators)

TPA helps in faster settlement of claims by acting as mediators. In case any our claim is rejected due to some reason then we can either catch hold of Insurance companies or TPA’s. Details of third party administrators are freely available on company’s website. One Insurance company can have many TPA’s as well based on the network hospital for cashless treatments.

The first step in availing any health policy is to check their list of network hospitals for cashless treatment. We can easily check the same from the website of insurance firm as shown below.

Never Pay Any Additional Cost to TPA

This is most important aspect of insurance that we should be well versed of. At time’s lots of mis-selling happens by agents in order to mint some money by charging additional for TPA service.

However as per rule of IRDA; TPA’s are sole discretion of insurance provider within the cost of the premier of the policy. At times they may have in-house team or they may choose to outsource it without any additional payment from our side.

TPA is facilitators who assist in the process of speeding up the process of claims settlement.

In fact they are additional benefits for the policyholders and offers following benefits.

  • Database Management
  • Speedy Claim Settlement
  • Offers additional Wellness Programmes
  • Assists in settlement of Claims
  • Manages any claims rejections

Why do Insurance Companies Need TPA’s?

We may wonder that within the same cost paid by us how do some insurance companies able to provide us the benefits of TPA’s.

This is due to the following reasons.

  • To make the process faster
  • Have dedicated institute to facilitate claims settlement.
  • Make process organised and smooth.
  • Coordinating the complete process from patience admission; treatment; discharge to claim settlement.

The above details not only help Insurance firms maintaining their branding but prove cost savvy as well for them.

How Does TPA Works?

Usually these third party administrators  referred as TPA are experts in managing the documentation and making the claim settlement convenient.  This can be very well explained through a short case study.

Step 1 – Cashless Treatment

Ramesh works in Genpact. His wife   is diagnosed from Kidney stone; doctors suggested to get it operated. He has taken health insurance policy from Apollo Munich Health Insurance Company.

He plans to go for cashless treatment. First thing he’s going to do is check the list of network hospital.

Once he selects the suitable hospital. Next step is to visit it and get in touch with insurance department; rest is taken care by them. TPA’s plays significant role here by faster settlement of claims. They are often well connected with insurance department of hospital. Our role is limited to sharing our policy numbers with the Insurance department of hospitals. At max we can contact our Insurers and rest is taken care by Third party Administrators.

Step 2 – Non-Cash Treatments

At times we may not be able to take treatment from empanelled hospital due to any personal reason. In that case the process remains the same .Only difference is we need to pay ourself initially and settle the claims later through our insurers. Usually if all our documents are in place than claim settlement should not take more than 30-45 days. TPA plays vital role in processing it as well.

Why there’s Need of TPA and How the Organisations Get Benefitted?

TPA’s are separate entity as they need to perform couple of tasks and further ads lots of benefits as elaborated below.

  • Managing Documentation
  • Coordinating the complete process from patience admission; treatment; discharge to claim settlement.
  • Information Management
  • Specialised services by  Information Management

Limitation of Using TPA

  • Since TPA are not the actually policy providers they may not have adequate information.
  • Customers often gets confused between agents & TPA’s
  • At the time of emergency policyholder may not trust TPA completely for claim settlement during rejections.
  • If any documents of policyholders is pending then TPA may not be able to help much.
  • If insurance provide doesn’t provide appropriate information of policy holders than there may be delay in settlement of claims.

How Can We Overcome Limitations and Avail Complete Benefits of Our Policy?

  • It’s prudential to keep all the details handy specially contact details of insurance agents.
  • We must check empanelled list of hospitals providing cashless facilities and concerned TPA to manage rejections.

Health Insurance policy is also synonym to our prestige and dignity as it saves us from extending hands in front of anyone. So we should buy policy that suits our health conditions and budget.

Alternatively we can compare different health policies and choose the best one as well. Policy X is proactively engaged in providing the best plans out of many.

You may check the quotes before deciding from the website.

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