• Role of TPA in Health Insurance
  • How does TPAs work?
  • Benefits & Limitation of TPA
TPA in Health Insurance
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TPA in Health Insurance

In an emergency, third-party administrators for health insurance are useful. When it comes to hospitalization claims, it might be difficult if you do not have health insurance coverage, but for those who do, a third-party administrator can help with hassle-free claim settlement. Because health insurance policies cover a wide range of services, it is critical to comprehend the technical jargon. TPA Insurance is not a phrase that everyone is familiar with, which is why this article seeks to explain the concept of Third Party Administrator in depth.

Read along to find more about TPAs.

What is a Third Party Administrator in Health Insurance?

Third-Party Administrator is an organization who came in effect since 2001, and, is IRDAI approved to act as a channel between the insurer and the policyholder. TPA helps the policy bearers in smooth filing of claims, submitting the correct documents, and other insurance-related issues. Health insurance companies hire these TPAs on behalf of them so that the customers can reach out to them in times of confusion. Network hospitals of the insurance companieshave a separate TPA desk where the policyholders can go to get assistance for their insurance related issues.

What is the Role of TPA in Health Insurance

TPAs play an important role in the health insurance industry and provide excellent service to policyholders. Policyholders can always rely on Third Party Administrators for all pertinent information about their health insurance policy. Here are a few examples of how a TPA can assist you.

  • Provides Hassle-free claim settlement
    Third-party administrator in health insurance offers hassle-free claim settlement guidance. While individuals purchase health insurance plans via insurance providers, a settlement between the hospital and the insurer is done by third-party administrators for health insurance.
  • Reimbursement Treatment
    When a policyholder files a reimbursement claim in case of availing treatment in a non-network hospital due to any emergency, the role of TPA in health insurance is to settle the claim smoothly and without any hassle.
  • TPA offers value-added services
    The role of TPA in health insurance is not just in claim settlements and reimbursement claims but also in providing additional services such as wellness programs, ambulance services, and more.
  • TPA serves as a connecting link
    When an insurance holder wants to make a claim for hospitalization or other treatment expenses, the claim process is handled by a TPA. Insurance holders are given a health insurance card that contains their unique Identity number or policy number, which a TPA uses to navigate the claim process and settle it with the hospital with minimal involvement from the insurance holder, making it a hassle-free experience.
  • Consistent Service Providers
    Third-party administrator in health insurance provide 24x7 service for grievance redressal, claim settlement, or health insurance policy queries, making it easier for customers to navigate a sea of health insurance policies and make the right decision. TPAs assist customers in determining how much sum insured is adequate for them and their families, what features are appropriate within a health insurance policy for them, and whether any optional covers are required.
  • Cashless network hospital
    TPAs are also responsible for monitoring cashless hospitals and determining whether they meet the criteria for being designated as a cashless network hospitals. To provide a smooth claim settlement process to insurance holders, cashless network hospitals must have an efficient and robust claim settlement system in place.
  • TPA database
    TPA keeps a separate database of its customers in order to better serve them in the event of a planned hospitalization or a medical emergency. All medical records, unique identification numbers, health insurance policy cards, and information about the policy purchased by the customer should be available in order to provide the proper service to the insurance holder.

Advantages of TPAs in Health Insurance

Following table demonstrates how TPAs help the policyholders at every step of their insurance journey:

Advantages Explanation
Claims Settlement Process TPA in medical insurance specialises in handling claims efficiently, ensuring a hassle-free reimbursement for policyholders.
Establishing Network Third party administrator in health insurance has well-established networks of healthcare providers, which makes it easier for customers to access quality medical services.
Customer service TPA in medical insurance has dedicated 24*7 customer service support, which helps to assist policyholders with their queries, claims, and other policy-related matters.
Affordable administration Outsourcing administrative tasks to TPAs can be cost-effective for insurance companies, as it reduces their operational expenses.
Transparency and reporting TPAs offer transparent processing of claims and provide reports on usage, costs, and any new changes.

Disadvantages of TPAs in Health Insurance:

It is essential for the TPA to match the expectations and demands of the insurance company and the customers at a time but sometimes mismatch in both can lead to discrepancies. Here are a few disadvantages of TPAs in Health Insurance:

Disadvantages Explanation
Control over the claims process Insurers have minimal control over the claim settlement process, which TPA primarily manages, this impacts service quality.
Barrier in Communication Miscommunication or delays in communication between the TPA, and policyholders, can lead to annoyance and insufficiencies.
The Conflicts of Interest TPAs may bond financially with specific healthcare providers, which could influence how they manage their networks and handle claims efficiently.
Reliance on the external service providers Insurance companies are dependent on TPAs for their essential tasks, and any interruption in the services could negatively impact customer experience.
Limited options for customisation TPAs offer a standard process, which may sometimes differ from the expectations of the particular insurance company.

How TPA helps Policyholders?

TPA in health insurance provides a plethora of services and advantages to insurance holders. PolicyX has curated a list of advantages offered by third-party administrators

  • Third-Party Administrators act as the touch-point between policyholders and hospitals when it comes to claim settlement during hospitalizations.
  • The key responsibility of Third party administrator is to make sure that policyholders do not undergo any issues during hospitalization or discharge
  • TPA Insurance has to make sure that the cashless network hospitals impaneled under the health insurance provider list are fulfilling all the necessary criteria in order to serve the insurance holders in need of any medical emergencies
  • TPAs are involved with policyholders during hospitalization and are coordinating with the cashless network hospital to make the experience of a policyholder hassle-free.
  • TPAs arrange the necessary value-added services such as road ambulance, wellness programs, doctor schedules, and more.

Difference between TPA and Insurance Providers

Third-Party Administrators are responsible for handling various aspects of insurance provided by insurance providers. Some of the examples are smooth and hassle-free claim process, premium payment management, and efficient customer service. The role of TPA in health insurance is that of a bridge between insurance providers and insured lives. Meanwhile, health insurance providers are responsible for providing the best health insurance plans to individuals, families, groups, and others. Third Party Administrators in health insurance are the administrative foundation in the health insurance system.

Whats the importance of third-party administrators (TPA) to insurance companies?

Insurance companies partially rely on TPAs for smooth settlement of claims. Other reasons as to why health insurance companies need TPAs are listed below:

  • Having a dedicated institute to facilitate claim settlement.
  • Co-ordinating the complete process (from treatment to discharge).
  • Proper management and investigation of claim requests.
  • Better quality of services.

What are the Benefits of TPA to a Policyholder?

A policyholder can profit from a TPA in the following manner:

  • Avail faster and focused claims management.
  • Ambulance services.
  • 24-hour toll-free helplines.
  • Grab a list of trusted network hospitals of a respective insurer.
  • Tracking claims.
  • Increase the knowledge base of healthcare services.

Health Insurance Companies

How does TPAs work?

TPAs play an important role in an easy settlement of health insurance claims. They are the major support system of the insurer as they undertake crucial responsibilities on behalf of them. Lets understand the working of a TPA with the help of the below example:

Ramesh works in Genpact. His wife is diagnosed with a kidney stone and the doctor suggests an immediate operation. He has taken a health insurance policy from HDFC ERGO General Insurance Company. Below are two cases, which will showcase the role of TPAs in health insurance.

  1. Case 1: Cashless Treatment

    Ramesh plans to go for cashless treatment, gets in touch with the respective TPA of HDFC ERGO, and selects a suitable network hospital with their guidance. At the hospital insurance desk, the TPA guides Ramesh to submit the required documents to avail of the treatment. After approval, the assigned TPA settles the treatment expenses with the hospital.

  2. Case 2: Non-Cashless Treatment

    Due to some reason, Ramesh decides to visit a non-network hospital. He informs the assigned TPA regarding the same, gets the treatment done, and pays the bills. After discharge, Ramesh files for reimbursement. The TPA guides him with the list of required documents for submission. After the approval, the insurer transfers the claim amount to the registered bank account.

How TPA Works

List of TPAs in India.

According to the IRDAI circular, the policyholder can choose a TPA of his/her choice from a list of TPAs engaged by the insurer. Below is the list of TPAs available in India:

Name of TPA Contact Person/Address Contact Details
Medi Assist Insurance TPA Private Mr. Ganesh K
Chief Administrative Officer
Tower D, 4th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore, 560029
Toll-free for senior citizens: 1800 419 9493
Toll-Free No.: 1800 425 9449
Website: www[dot]mediassist[dot]in
Paramount Health Services & Insurance TPA Private Limited Dr. Nayan Shah
Chief Executive Officer
Plot No. A-442, Road No. 28, Ram Nagar,
MIDC Industrial Area, Wagle Estate, Thane (W) - 400 604
Senior Citizen Helpline No.: 022 66629813
Toll-Free No.: 1800 22 66 55
Website: www[dot]paramounttpa[dot]com
United Health Care Parekh Insurance TPA Private Limited Mr. Shiva Belavadi
Chief Executive Officer,
3B/1 Gundecha Onclave, Kherani Road, Saki Naka, Andheri (East), Mumbai – 400 072
Toll-Free No.: 1800 209 8884
Email: shiva[dot]belavadi[at]uhcpindia[dot]co
Website: www[dot]uhcpindia[dot]com
MD India Health Insurance TPA Private Mr. Suresh V. Karandikar
Chief Executive Officer
S.No. 46/1 E-space A-2 Building,
3rd Floor, Pune-Nagar Road,
Vadgaon Sheri, Pune – 411 014
For senior citizens: 020-25300126
Toll-Free No.: 1800 233 1166
Fax : 1860 233 4449
Email: skarandikar[at]mdindia[dot]com
Website: www[dot]mdindiaonline[dot]com
Heritage Health Insurance TPA Private Limited Mr. Manash Chakraborty,
Chief Administrative Officer
NICCO HOUSE, 5th Floor, 2, Hare Street, Kolkata-700001
Toll-Free No.: 1800 345 3477
Email: mchakraborty[at]bajoria[dot]in
Website: www[dot]heritagehealthtpa[dot]com
Family Health Plan Insurance TPA Limited Ms. G. Bharathamma
Chief Executive Officer
No: 8-2-269/A/2-1 to 6, 2nd Floor, Srinilaya Cyber Spazio, Road No. 2, Banjara Hills, Hyderabad – 500 034
Senior Citizen Helpline No.: 1800 102 4273
Toll-Free No.: 1800 102 4033
Email: bharathig[at]fhpl[dot]net
Website: www[dot]fhpl[dot]net
Raksha Health Insurance TPA Private Limited Mr. Pawan Kumar Bhalla
Chief Executive Officer
C/o Escorts Corporate Centre 15/5, Mathura Road, Faridabad, Haryana – 121 003
Toll Free No.s: 1800 180 1444, 1800 220 456, 1800 425 8910 Email: pawan[at]rakshatpa[dot]com
Website: www[dot]rakshatpa[dot]com
Vidal Health Insurance TPA Private Limited Ms. Sudha Suhas Kulkarni
Chief Administrative Officer
First Floor, Tower No. 2, SJR iPark, EPIP Zone, Whitefield, Bangalore - 560 066.
Toll-Free No.: 1860 425 0251, 080 46267018
Email: sudha[at]vidalhealthtpa[dot]com
Website: www[dot]vidalhealthtpa[dot]com
East West Assist Insurance TPA Private Limited Dr. Atul Arora
Chief Executive Officer
38, Golf Links, New Delhi - 110003
Ph. No.: 011-47222666 FAX: 011-47222640
Email: ceo[at]eastwestassist[dot]com
Website: www[dot]eastwestassist[dot]com
Medsave Health Insurance TPA Limited Mr. S. Aravamuthan
Chief Administrative Officer
F-701A, Lado Sarai, Mehrauli, New Delhi - 110030
Senior Citizen Helpline No.: 9319810070
Toll-Free No.: 1800 111 142
Email: s.aravamuthan[at]medsave[dot]in
Website: www[dot]medsave[dot]in
Genins India Insurance TPA Limited Mr. Subhash Chander Khanna,
Chief Administrative Officer
D-34, Ground Floor, Sector-2 Noida - 201301 (U.P.)
Toll-Free No.: 1800 345 3323
Ph. No.: 0120-4144100 Fax:0120-4144170-71
Email: sckhanna[at]geninsindia[dot]com
Website: www[dot]geninsindia[dot]com
Alankit Insurance TPA Limited Mr. Bodh Raj Punj
Director & Chief Executive Officer
Alankit House, 4E/2, Jhandewalan Extension, New Delhi - 110055
Toll-Free No.: 1800 11 3300
Ph. No.: 011-42541621-24 Fax:011-42541620-30
Email: alok[at]alankit[dot]com
Website: www[dot]alankithealthcare[dot]com
Health India Insurance TPA Services Private Limited Mr. Kamaljeet Gupta
Chief Administrative Officer
Neelkanth Corporate Park, Office No. 406 to 412, 4th Floor, Kirol Road/Village, Vidya Vihar Society, Vidya Vihar (West), Mumbai-400086
Senior Citizen Toll-Free No.: 1800 2269 70
Toll-Free No.: 1800 2201 02
Ph. No.: 022-40881000
Email: kamaljeetg[at]healthindiatpa[dot]com Website: www[dot]healthindiatpa[dot]com
Good Health Insurance TPA Limited Ms. Saigeeta Dikshit,
Chief Administrative Officer
Suite 403 - 406A, 4th Floor, Ashoka My Home Chambers, Behind Ashok Bhoopal Chambers, Sardar Patel Road, Secunderabad, Telangana State - 500003
Senior Citizen Toll-Free No.: 1800 102 9919
Toll-Free No.: 1860 425 3232
Email: saigeeta[at]ghpltpa[dot]com Website: www[dot]ghpltpa[dot]com
Vipul Medcorp Insurance TPA Private Limited Mr. Rajan Subramaniam
Chief Executive Officer
515, Udyog Vihar, Phase 5, Gurgaon, Haryana – 122 016
Senior Citizen Toll-Free No.: 1800 120 3348
Toll-Free No.: 1800 108 7477, 1800 102 7477
Ph. No.: 0124-4833900 Fax: 0124-4699611
Email: rs[at]vipulmedcorp[dot]com
Website: www[dot]vipulmedcorp[dot]com
Park Mediclaim Insurance TPA Private Limited Mr. Anurag Bhatnagar
Chief Executive Officer
702, Vikrant Tower, Rajindra Place, New Delhi-110008
Toll-Free No.: 1800 11 55 33
Ph. No.: 011-43191000
Email: anuragbhatnagar[at][dot]in
Website: www[dot]parkmediclaim[dot]co[dot]in
Safeway Insurance TPA Private Limited Mr. Mahesh Sharma
Chief Executive Officer
815, Vishwa Sadan, District Centre, Janakpuri, New Delhi-110058
Toll-Free No.: 1800 102 5671
Ph. No.: 011-45451300
Email: ceo[at]safewaytpa[dot]in
Website : www[dot]safewaytpa[dot]in
Anmol Medicare Insurance TPA Limited Mr. P. S. Kshatriya
Chief Executive Officer
2nd Floor, NBCC House, Opp. Ahmedabad Stock Exchange, Ambavadi, Ahmedabad – 380015, Gujarat
Toll-Free No.: 1800 233 1999
Ph. No.: +91-79-61609926, 61609930
E-mail: prithvi[at]anmolmedicare[dot]com
Website: www[dot]anmolmedicare[dot]in
Grand Insurance TPA Private Limited Mr Bibhutosh Chattopadhyay Chief Administrative Officer Grand House, 45A, Hindustan Park, Kolkata 700 029 (West Bengal) Toll-Free No.: 1800 102 4747
Ph. No.: 033-40274747 Fax: 033-40043344
Email: cao[at][dot]in
Website: www[dot]grandtpa[dot]co[dot]in
Rothshield Insurance TPA Limited Ms. Janki M Bhate
Chief Executive Officer
402, Raheja Chambers, Nariman Point, Mumbai 400 021
Toll-Free No.: 1800 228 144
Ph. No.: 022-22048144 Fax: 022-22854415
Email: janki[at]rothshield[dot]co[dot]in
Website: www[dot]rothshield[dot]co[dot]in
Ericson Insurance TPA Private Limited Dr. Krishna P. Jaiswal, MD
11-C, Corporate Park, ST Road, Chembur, Mumbai - 400 071 (Maharashtra)
Senior Citizen Helpline No.: 022-25280208
Toll-Free No.: 1800 22 2034
Ph. No.: 022-25280280
Email: krishna[at]ericsontpa[dot]com
Website: www[dot]ericsontpa[dot]com
Health Insurance TPA of India Limited Mr. SK Mehra
Chief Executive Officer
2nd Floor, Majestic Omnia Building, A-110, Sector-4, Noida 201301 (Uttar Pradesh)
Toll-Free No.: 1800 180 3600, 1800 102 3600
Email: sk.mehra[at][dot]in
Website: www[dot]hitpa[dot]co[dot]in
Vision Digital Insurance TPA Private Limited Ms. Priyanka Jain
Chief Administrative Officer
Time Square Building 3rd & 4th Floor,
Sushant Lok-1, Block-B,
Gurugram - 122002
Toll-free no: 1800-419-9982
Ph. No.: 0124-4003171
Email: priyanka.jain[at]visiontpa[dot]in
Website: www[dot]visiontpa[dot]in
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What are the limitations of TPAs?

Though TPAs are quite useful, they do struggle with a few limitations. Here they are-

  • Since TPAs are not the actual health insurance providers, they may not have adequate information.
  • Customers often get confused between agents and TPAs.
  • As TPAs are middlemen, they dont have a major say in claim settlement.

To sum it up…

TPAs not only make our claim settlement journey easier but also increase our knowledge base of healthcare services. Both the parties (insurer and insured) can easily profit from them if used correctly.

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Health Insurance TPA: FAQ

1. What is the role of a TPA In health insurance?

TPA in health insurance is not only responsible for claim settlement services between the insurance holder and cashless hospitals but also takes care of value-added services such as wellness programs, road ambulance, and more.

2. Who is responsible for hiring TPA in health insurance?

Health insurance providers are responsible for hiring the Third Party Administrators to help their insurance holders with a smooth claim settlement process.

3. If I take the help of an assigned TPA, do I need to pay them in return?

No. TPAs are hired by insurance companies and they only pay their fees/service charges.

4. Do TPAs play any role in the acceptance and rejection of the claims?

No, they are only responsible for managing the claim settlement process.

5. What documents are required for making a Health Insurance TPA Claim?

Below is the list of documents required for making a Health Insurance TPA Claim:

  • Aadhar Card of the policyholder.
  • Health Insurance TPA e-card copy or the insurance certificate copy.
  • Hospital and Pharmacy Bills.
  • Hospital Discharge Summary.
  • Doctor’s Prescriptions.
  • If required, the company may ask for further documents.

6. Can I trust the TPA of my insurer?

Yes, you can. TPAs are IRDAI approved and act as intermediaries between the insurance providers and the policyholders.

7. Do all health insurance companies have TPA?

No, it totally depends on the operational structure of the insurance companies. Not all health insurance companies are associated with TPAs, some insurance companies have in-house claim settlement services.

8. What happens if the TPA denies my health insurance claims?

You as a policyholder always have the right to challenge the decision of the TPA. Contact the health insurance company, provide the necessary information and submit the documents to support your claim. The company will review and make the final decision.

9. Can we change our TPA if we are unsatisfied with the service?

No switching the TPA is not possible, however, the policyholder can contact the health insurance company and express their concern, the rest action depends on the insurance company.

10. Can I choose my own third party administrator in health insurance?

Typically, the health insurance company chooses their own TPA for the policies. However, if the insurance provider permits, you can choose the TPA from the approved list of TPAs.

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Reviewed By: Naval Goel

Naval Goel is the CEO & founder of Naval has an expertise in the insurance sector and has professional experience of more than a decade in the Industry and has worked in companies like AIG, New York doing valuation of insurance subsidiaries. He is also an Associate Member of the Indian Institute of Insurance, Pune. He has been authorized by IRDAI to act as a Principal Officer of Insurance Web Aggregator.