A TPA is an outside agency appointed by a health insurance company who helps in settlement of a health insurance claim. TPAs help you (the insured) process your health insurance claim using various hospital bills and documents. Although insurers can deal the health claims directly but in most of the cases they have appointed a third party called TPA to handle their claims to the agencey to transfer their work load & bring more efficeny in the service.
At the time of illness, the insured is required to intimate the TPA about the problem & submit all the required docs & medical bills & in turn the TPA arrange the quick payments to your hospital at the time of discharge of the patient.However, they are not responsible for claims rejection or acceptance.. Instead of solely depending on the insurer, policyholders can now choose third-party administrator at the time of buying a health insurance policy or at the time of renewal.
According to a circular of IRDA , “For the purposes of this sub-regulation, the choice of the policyholder to choose a TPA for rendering health services is limited to the TPAs with whom the insurer is having Service Level Agreements in place. The insurer will provide the policy holder a list of TPA’s empaneled with them, from amongst whom he may choose a TPA of their choice. Based on the health insurance product and geographical location of the policyholders, the insurer may also limit the number of TPAs amongst whom the policyholder may choose a TPA of their choice.
For example, a policyholder has had a prior good experience with a specific TPA, he may choose to use the same TPA for any health insurance claim. & that gives the customer flexibility,
For all the TPA regulation amendments-2019, Pl. click over the link below & go through the IRDA circular.