- Role of TPA in Health Insurance
- How does TPAs work?
- Benefits & Limitation of TPA
TPA in Health Insurance
When we talk about health insurance, TPA is one of the components of it. TPA in health insurance helps in buying and processing your health insurance policy, its renewal, and getting your policy claim approved and settled in times of emergency. Their role is not just limited to your policy settlements. They are also helpful in saving your time and efforts while raising a claim request during a medical emergency as well as becoming a mediator between the policyholder and the insurer to create a seamless customer experience for both parties.
This article covers the role a TPA plays between you and your insurance provider, the benefits of getting their assistance, and how they work. Read further to know more about a TPA and its benefits being a policyholder.
What is a Third Party Administrator in Health Insurance?
Third-Party Administrator is an organisation that came into effect in 2001, and, is IRDAI approved to act as a channel between the insurer and the policyholder. TPA helps the policy bearers in the smooth filing of claims, submitting the correct documents, and other insurance-related issues. Health insurance companies hire these TPAs on their behalf so that the customers can reach out to them in times of confusion. Network hospitals of the insurance companies have a separate TPA desk where the policyholders can go to get assistance for their insurance-related issues.
How do TPAs work?
TPAs play an important role in the easy settlement of health insurance claims. They are the major support system of the insurer as they undertake crucial responsibilities on behalf of them. Let's understand the workings 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.
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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.
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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.
Difference between TPA and Insurance Providers
Third-party administrators or TPAs in health insurance act as the foundational block of insurance administration in bridging the gap between a policyholder and the health insurance provider. On the other hand, a health insurance provider offers an individual or group of people the best available health insurance plans. TPAs are capable of making the claim process, policy renewal and other policy-related activities easy and hassle-free for both the parties. There are prominent features to a TPA that give you an effective and smooth transition with a 24/7 customer care facility, managing your policy premium payments, and to optimise the gateway of policy upgradation, etc.
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.
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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 claim 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
TPAs tend to keep their customers’ important data that helps them get a smooth hospitalization procedure. Any kind of records related to health, identity, policy documents, and other information to receive an appropriate service at the networking hospital are preserved in TPA’s database.
Advantages of TPAs in Health Insurance
The following table demonstrates how TPAs help the policyholder at every step of their insurance journey:
| Advantages | Explanation |
| Claim Settlement | TPAs can help the policyholder receive the claim against their policy. |
| Establishing Network | TPAs have a list of a wide range of networking hospitals that help the policyholder to receive advanced and best-quality treatment without wasting time searching for better facilitation. |
| Customer service | The policyholder can reach out to the customer support of their TPA at any hour for any of their queries related to policy, renewal, claim or reimbursement settlement, etc. |
| Affordable administration | Insurance providers elect TPA outsourcing to get help with the administration of their customers’ concerns effectively. Assigning them to the customer saves the insurer’s operational costs. |
| Transparency and reporting | You can see all the changes made to your policy, the validation of your policy claims, and usage of the sum insured limit, etc through the guidance of your health insurance TPA. They are also transparent to report to you about the expenses. |
Disadvantages of TPAs in Health Insurance:
The TPA needs 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. |
| Barriers 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 TPAs Help Policyholders?
TPA in health insurance provides many 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 a 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 empanelled under the health insurance provider list are fulfilling all the necessary criteria 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.
What's the importance of third-party administrators 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 more 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.
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 Email:cao[at]mediassist[dot]in 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 Email:nayan[dot]shah[at]paramounttpa[dot]com 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]parkmediclaim.co[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]grandtpa.co[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]hitpa.co[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 |
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.
Summing It Up
Third Party Administrators or TPAs are known to provide service and facilitation for customers who have elected a health insurance policy from particular insurance companies. However, some of the insurance providers act as TPAs themselves. A TPA can help the policyholder get every inch of information without getting confused and agitated. In a growing market of the health sector, the demand for health insurance policies is growing as well. So the possibility of getting help from TPAs is increasing rapidly. If you have any queries regarding your health insurance TPA, reach out to us at Policyx.com.
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TPA in Health Insurance: 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.
11. Do I need a TPA for the hospitalization claim?
TPAs make it easy for the policyholders, to make hospitalization claims, and get proper treatment and high-end services at the networking hospital without any fail. So, choosing a TPA is always considered to be a good practice in the insurance sector.
12. Can I cancel my TPA?
Yes, you can cancel your health insurance TPA anytime you wish, given that you clarify the reason for your TPA’s cancellation to your insurer.
13. How many types of TPAs are there?
There are two kinds of TPAs in common:- Commercial Liability Insurance TPA and Retirement Plan Administration TPA.
14. How to change TPA in my health insurance?
The following is the process through which you can change your TPA: Reach out to your insurance provider Submit them your relevant unique identification and policy-related documents Tell them the accurate reason and request to change your TPA Once your request is approved, you’ll be given a list to choose one of the following TPAs from the list.
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Written By: Simran Nirala
Lives In: Delhi, NCR Expertise: Health & Term Insurance Simran has an experience of 4 years in content writing. She transitioned from hospitality and digital marketing to the insurance industry after her emerging interest in how vast insurance is. With her ability to write complex insurance concepts in a simple, relatable manner, she keeps her audience hooked and solves their doubts smoothly.
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