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What is a Third-Party Administrator (TPA) and Its Relevance in Health Insurance?

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Health insurance is a vital financial tool that can protect you and your family from the rising medical costs and uncertainties of life. However, buying a health insurance policy is not enough; you also need to understand how to use it effectively and efficiently. This is where a third-party administrator (TPA) comes in handy.

A TPA is an entity that acts as a 3-way bridge between you, the policyholder, and the insurance company. It helps you access many health insurance policy benefits. A TPA receives a license from the IRDAI and works as an outsourcing partner of the insurance company.

Here, we will explain the role and benefits of a TPA in health insurance, how to choose a suitable one for your policy, and how to change your TPA if needed.

Role of TPA in Health Insurance

A TPA performs various functions to facilitate the smooth functioning of your health insurance plan. Some of the significant roles of a TPA are —

  • Issuing health cards: A TPA issues a health card to you when you buy a health insurance policy. The health card contains your personal details, policy number, TPA name and contact details, and network hospital list. You need to show this card at the hospital to get cashless treatment or claim reimbursement.
  • Processing claims: A TPA processes your claims on behalf of the insurance company. It verifies the documents submitted by you or the hospital, checks the eligibility and coverage of your policy, and approves or rejects the claim accordingly. It also coordinates with the hospital for cashless claims and settles the bills directly with them.
  • Maintaining records: A TPA maintains records of all your transactions related to a health insurance plan for your family, such as premium payments, claims, renewals, endorsements, etc. It also updates the insurance company about any changes in your policy or personal details.
  • Providing customer support: A TPA provides customer support to you for any queries or grievances related to health insurance for senior citizens. You can contact the TPA through toll-free numbers, email, website, or mobile app for any assistance or information.
  • Empanelling network hospitals: For your convenience and benefit, a TPA empanels network hospitals. A network hospital has a tie-up with the TPA and the insurance company to provide cashless treatment to you. You can choose any network hospital from the list provided by the TPA for your medical needs.
  • Offering value-added services: A TPA may also provide value-added services to you, such as health check-ups, wellness programs, discounts on medicines and diagnostics, health tips and advice, etc. Depending on your policy’s terms and conditions, these services may vary from one TPA to another.

Benefits of TPA in Health Insurance

A TPA offers several benefits to you as a policyholder. Some advantages of having a TPA are —

  • Ease of access: A TPA makes accessing your health insurance policy benefits easy. You do not have to deal with the insurance company directly for any claim or service-related issues. You can simply contact the TPA through various modes of communication and get prompt and hassle-free service.
  • Quick settlement: A TPA ensures quick settlement of your claims within the stipulated timeframe as per IRDAI norms.
  • Transparency: A TPA provides transparency in your claim process by giving you regular updates on the status of your claim through SMS, email, or online portal. You can also track your claim online or through a mobile app anytime and anywhere.

How to Change Your TPA in Health Insurance?

You may want to change your TPA in health insurance if you are not satisfied with its service or performance or if you find a better option. You can change your TPA in health insurance at the time of renewal of your policy by following these steps —

  • Inform your insurer: Notify your health insurance plan provider about your intention to change your TPA at least 45 days before the expiry date of your policy. You must fill out a request form and submit it with the required documents to your insurance company.
  • Select a new TPA: You must select a new one from the list of TPAs empanelled by your insurance company. You need to ensure that the new TPA meets your expectations and requirements and is compatible with your health insurance policy.
  • Get approval from your insurance company: You need approval from your insurance company to change your TPA. Your insurance company will verify your request and documents and approve or reject it accordingly. If approved, your insurance company will issue a new policy document with the name of the new TPA.
  • Receive a new health card: You need to receive a new health card from your new TPA. The new health card will contain your updated details, policy number, new TPA name and contact details, and network hospital list. You need to use this card to get cashless treatment or claim reimbursement.

Conclusion

A TPA is an important entity that can make a difference in your health insurance experience. Your TPA can help you to avail the benefits of your health insurance policy smoothly and efficiently. Therefore, you should choose a suitable TPA for your health insurance policy carefully and wisely. You should also keep yourself updated about the services and performance of your TPA and switch to a different one if needed.

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