https://wp-api.bajajfinservhealth.in/wp-content/uploads/2022/01/44-1-1903x687.jpg

Role of TPA in Health Insurance: What are its Benefits for a Policyholder?

B
Bajaj Finserv Health
February 16th, 2022
7 mins read

Key Takeaways

  • TPA helps in processing claims both via reimbursement and cashless modes
  • In cashless mode, TPA settles hospital expenses directly with the hospital
  • For reimbursements, you need to submit medical bills and records to TPA

There may be situations in life where you or your loved ones may need immediate medical care. This usually includes hospitalization and, in such cases, having insurance helps. A health insurance policy protects your finances while granting access to quality care. This is why it is important that you are equipped with the right policy. There are umpteen health insurance providers in the market, and you should buy a policy that suits your requirements. 

Just like these insurers, you can also find third party administrators or third-party administrators. A TPA is a company that provides a service to solve common problems related to health insurance claims. The process begins whenever you or your loved ones are admitted to the hospital. Third party administrators are given an intimation and are authorized by the IRDA to process your claims. Founded in 2001, the main purpose of a TPA is to act as a mediator between the insured and the insurance provider [1]. To learn more about the role of third party administrators in health insurance, read on.

Additional Read: 6 Types of Health Insurance Policies in India: An Important Guide

What Is a Tpa in the Health Insurance Sector?

A TPA is an organization involved in processing insurance claims. Though it is an independent organization, it can also function as an entity representing the insurance provider. In India, there are many people availing health insurance policies and different types of health products. This increasing number makes it difficult to keep a track of policies and this affects the quality of services. To tackle this, the IRDA formed TPAs or third-party administrators. Their role is to ensure quality and consistent services. They are involved in processing a huge number of health insurance claims. 

third party administrators

Why Are TPAs Important in Health Insurance?

The role of TPAs is vital as they help in processing health insurance claims. Some of the important functions performed by TPAs are as follows

When the insurance company approves your policy, your TPA conducts a validation procedure. The next step is to provide you with an authorized health card. This card contains important policy details like the policy number and name of the TPA responsible for processing your claims. During hospitalization, you can produce this card to raise a claim and intimate your insurer or TPA. This is an important document required at the time of processing claims.

  • TPAs expedite the claims process

The TPA checks the submitted documents and cross-verifies all particulars. The settlement is either done by reimbursement or in cashless mode. If it is a cashless mode, the TPA collects required documents from the hospital. In case of reimbursement mode, you need to submit medical records and bills to the TPA.

  • TPAs provide value-added services

This includes ambulance services and so on. TPAs also have a hand in ensuring you get treatment at a network hospital, where you can get proper treatment. They further ensure that their network offers the best features, which include the cashless facility [2].

How Can TPAs Benefit You as a Policyholder?

A TPA functions like an intermediary between you and the insurer. They make sure that a simplified procedure is followed for claim settlement. Whether it is a reimbursement or cashless claim, TPAs assist people to settle claims easily. Contacting a TPA is usually the first step when you require hospitalization. 

To get started, just intimate your TPA or your insurance provider about your hospitalization. The TPA then informs the hospital to begin the cashless facility. In this mode, payment will be directly made to the hospital. This way, TPAs ensure that proper procedure is followed and your claim is settled without any problems. If the cashless facility is not available, the TPA will follow the procedure for reimbursement. In this option, your bills and medical records will be scrutinized by the TPA and then claims will be settled. 

benefits of TPA

Is it Possible to Cancel my TPA?

TPA is a facilitator and if you are not happy with their services, you can cancel a particular TPA or change to a different TPA. All you need to do is discuss your concerns with your insurer. Follow these simple steps if you want to change your TPA.

  • Step 1: Contact your insurance provider
  • Step 2: Give your policy details
  • Step 3: Mention your reasons for TPA cancellation
  • Step 4: If your insurance company approves it, choose another TPA from the list

What are the Different Challenges Faced by TPAs?

TPAs normally function efficiently but there are numerous challenges they face as well. A few of them include:

  • Weak networking
  • Lack of proper reporting of claims across hospitals
  • Lack of awareness among policyholders about TPAs
  • Little information about the functioning and role of the TPA
  • Absence of standard procedures in billing

How do TPAs Earn Revenue?

A majority of revenue for TPAs comes from commission or fees on the policy premiums as per IRDA regulations. The other streams of revenue for TPAs are:

  • Claim administration
  • Data management
  • Benefit management
  • Medical management

Additional Read: Looking for Medical Insurance Plans? Check Out Complete Health Solution Plans

Besides these facts about TPAs you should know that you do not have to pay any money separately to your TPA as you will be dealing with your insurance provider. The team of TPA comprises eminent professionals like legal experts, doctors, IT professionals, and insurance consultants to name a few. Your health insurance provider decides which TPAs they work with. With the help of TPA services, they can reduce the number of fake claims. 

This is why it is important to choose the right health insurance policy. One great option is the diverse range of Complete Health Solution plans on Bajaj Finserv Health. Browse through their comprehensive benefits such as total coverage of up to Rs.10 lakh and reimbursements on doctor consultations. Find a plan that suits your needs and manage your medical emergencies without any hassles.

Role of TPA in Health Insurance: What are its Benefits for a Policyholder?-banner

Related Articles

View All

All About Apex Medicard: 5 Variants and Their Benefits

Aarogya Care

All About Apex Medicard: 5 Variants and Their Benefits

18 Aarogya Care Benefits that Enhance Your Health Insurance

Aarogya Care

18 Aarogya Care Benefits that Enhance Your Health Insurance

Prepaid Health Care: 7 Benefits of Aarogya Care Health Plans

Aarogya Care

Prepaid Health Care: 7 Benefits of Aarogya Care Health Plans

6 Reasons to Choose an Aarogya Care Personalized Health Plan

Aarogya Care

6 Reasons to Choose an Aarogya Care Personalized Health Plan

Aarogyam A Health Test: 5 Important Things for You to Know

Aarogya Care

Aarogyam A Health Test: 5 Important Things for You to Know

background-banner
Mobile Frame
Download our app

Download the Bajaj Health App

Stay Up-to-date with Health Trends. Read latest blogs on health and wellness. Know More!

Get the link to download the app

+91
Google PlayApp store

CIN

U85320PN2019PLC185286

Registered Office

Bajaj Auto Limited Complex, Mumbai – Pune Road, Akurdi, Pune – 411 035

Corporate Address

Phoenix Fountainhead, 4th floor, Nagar Road, Clover Park, Viman Nagar, Pune, Maharashtra - 411014

© 2021, Bajaj Finserv Health Limited.
All rights reserved.