What is a TPA in Health Insurance

Simply put, a TPA is an organization that processes your medical claim. TPA is like a bridge between the insurance company and its customers, meeting the needs of both. They have their own separate existence, but for a customer, it is like a representative of the insurance company. Just the way IRDAI (​​Insurance Regulatory and Development Authority) gives a license to the insurance company and its agents, the TPA also has to get the license from IRDAI itself.

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Today, many health insurance companies are present in the country that offer different types of policies. As the number of companies and plans offered have increased, awareness about insurance has spread and the number of customers has gone up. In such a situation, there may be problems in providing good service to the customers. IRDAI also ensures that the customers get the best service in the shortest possible time. Keeping this in view, IRDAI started licensing third-party administrators and made them continuously responsible for the highest level of service. Apart from this, the responsibility of settling many health insurance claims was also entrusted to the TPA.

If a family member or friend is hospitalized, your job is to take care of them, spend time with them and motivate them to get well as soon as possible. The TPA takes care of other things like the hospital bills and other expenses. 

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Most health insurance companies appoint TPAs. You are not required to pay anything to the TPA. The TPA settles your cashless claim if you go for treatment in a network hospital and reimburses your bills later if you go for treatment in a non-network hospital. The TPA is in direct contact with the customer and assists them with the claim. Apart from this, it is also the responsibility of the TPA to investigate fake claims or any irregularities. Overall, the following are some things to know about the TPA:

• TPA shares its information about health services with customers
• TPA improves the quality of services of the insurance company
• TPA itself handles the investigation and management of claims
• TPA checks cashless and reimbursement claims

The TPA plays a vital role in processing health insurance claims. Some of the major functions of a TPA are mentioned below:

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Issuance of health cards to the insured: Every health insurance policy is issued after a thorough verification process. After this process is completed, a health card is provided to the insured. On this health card, the name, age and policy number of the insured as well as the name of the TPA who will be responsible for processing your claim at the time of need are recorded. At the time of hospitalization, the insured has to show this card at the hospital. On the basis of this card, information about your claim is sent from the hospital to your insurance company or TPA. Always keep this card with you, as it is one of the most important documents for any claim process.

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Easy settlement of claim process and settlement: As soon as an insured makes a claim, it is the responsibility of the TPA to verify all the documents submitted for the claim and then settle it at the earliest. If the TPA is not satisfied with the documents submitted by you, they can ask for additional documents and information from you. In case of a cashless claim, the TPA collects the documents directly from the hospital. In case of reimbursement, they demand original bills along with all necessary documents from the insured.

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Arranging value-added services: Apart from settling the claim process and making the health card of the insured, the TPA has many other responsibilities, like helping arrange an ambulance, wellbeing programs and many other services.

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Helpline facility: For any help or information related to the claim, the insured can call the helpline of the TPA. The helpline services work 24x7 and these numbers can be called from any part of the country. Many TPAs ​​also provide toll-free calling to their customers. The insured can call the TPA's helpline to inquire about the status of his claim.

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Strengthening the network of hospitals: The role of the TPA is crucial in taking full advantage of the health insurance policy. One of the responsibilities of the TPA is also to strengthen and expand the network of the hospital so that the insured can get prompt treatment at the appropriate time. The TPA tries to add the best hospitals to its network so that the insured can get cashless treatment and have to pay the least amount to the health insurance company for the same.

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The TPA acts as an intermediary between the health insurance company and the insured. It is the responsibility of the TPA to simplify the claim process under the health insurance policy. We already know that there are two types of claims, cashless and reimbursement.

As soon as there is a need for any medical or emergency treatment, the insured reaches the hospital immediately. If the insured needs to be hospitalized for more than 24 hours, then they can claim health insurance cover. However, the rule of 24-hour admission does not apply for day-care treatments such as cataract operations.

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In case of hospitalization, the insured needs to inform the TPA or the insurance company. As soon as the TPA gets this information, it asks the hospital to provide the cashless facility, if possible. Once the insured is treated, the hospital sends all the bills and required documents to the TPA for cashless approval. If cashless treatment is not available then all these bills and documents are given to the insured and they can get reimbursement done later.

The TPA closely scrutinizes all the bills and documents and then approves the claim settlement. If cashless treatment is being done then the bill is paid directly by the hospital. Whereas, in the case of reimbursement, the amount is transferred to the bank account of the insured.

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Before you decide to remove the TPA from your health insurance policy, let it be known that it is there for your convenience. If there is any time-lag or discrepancy between the services being offered to you then you can talk to your insurance company. The insurance company will contact the TPA in this regard and you will be informed about the progress of the entire process in this regard. Despite this, if you feel that you do not want the facilities of the TPA or you are not happy with your TPA and want to take the services of any other TPA, then you can inform the insurance company about it. Following are the steps of removing the TPA from your health insurance policy:

• Contact your insurance company through email or phone
• Share your policy details with the company and provide your unique ID, if any
• Explain in detail why you want to remove your existing TPA
• If the insurance company allows changing the TPA, then you can choose the TPA of your choice from a list.

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There are thirty insurance companies in India that sell health insurance policies. Many insurance companies also require the TPA to help in the claim process in every nook and corner of the country. There are many TPAs offering their services ​​all over the country. The same insurance company enlists the services of multiple TPAs ​​and the same TPA provides services for multiple insurance companies. Below is a list of some of the major TPAs, but there are many other TPAs ​​available in the country as well:

• Medi Assist India TPA Pvt. Ltd.
• United Healthcare Parekh TPA Pvt. Ltd.
• Paramount Health Services & Insurance TPA Pvt. Ltd.
• Med Save Health Care TPA Ltd.
• Medicare TPA Services (I) Pvt. Ltd.
• Defense TPA Pvt. Ltd.
• Vipul Made Corp TPA. Pvt. Ltd.
• E Meditech (TPA) Services Limited
• MD India Healthcare (TPA) Services (Private) Limited
• Anyuta TPA In Healthcare Pvt Ltd
• East-West Assist TPA Pvt. Ltd.
• Genins India Insurance TPA Limited
• Alankit Insurance TPA Limited
• Family Health Plan (TPA) Limited
• Focus HealthServices TPA Pvt. Ltd.
• Vidal Health TPA Private Limited
• Health India TPA Services Private Limited
• Good Health TPA Services Limited
• Heritage Health TPA Pvt. Ltd.
• Park Mediclaim TPA Private Limited
• Anmol Medicare TPA Limited
• Dedicated Healthcare Services TPA (India) Pvt Ltd
• Grand Health Care TPA Services Pvt Ltd
• Health Insurance TPA of India Limited
• Rothshield Healthcare (TPA) Services Limited
• Dedicated Healthcare Services TPA (India) Pvt Ltd
• Spurthi Meditech TPA Solutions Pvt. limited number
• Ericsson TPA Healthcare Pvt. Ltd.
• Shree Gokulam Health Services TPA (P) Limited
• Safeway TPA Services Pvt.Ltd

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