What is TPA in Health Insurance?

A health insurance TPA (Third-Party Administrators) are agencies licensed to aid and help the insurer in all their administrative responsibilities. TPAs consist of a team of experts:

• Medical professionals (having valid registration with the Indian Medical Council)
• Legal persons
• Insurance consultants
• IT professionals
• Customer service executives
• In-house management, and other members

Trustworthy health insurance TPAs have a valid association with the insurer and receive their license of affiliation from the Insurance Regulatory and Development Authority of India or the IRDAI.

The IRDAI is the authority that oversees the functioning of all the insurance companies, third-party agencies, and hospital networks. Thus, it would be wise that you only trust those health insurance TPAs that have been verified and registered with the IRDAI and your insurer.

A TPA is the backbone of any insurance company. Without it, handling a large number of health insurance claims, queries, and grievances on an everyday basis would be a near-impossible task for insurers. But thanks to TPAs, every process, from basic to advanced, runs smoothly. The given responsibilities explain what the role of a TPA in health insurance is:

• Administrative maintenance:

Now that you know what TPA in health insurance is, one of the main duties of a health insurance Third Party Administrator is taking care of and maintaining all customer information in systematic online and offline records. As soon as you get the insurance policy to your name, the insurer transfers the copy of the insurance form and other relevant documents to the TPA of your choice. Any changes made to the insurance policy at the renewal are also updated and transferred to the Third Party Administrator. Thereon, the responsibility of maintaining and updating these records is on the TPA. The health insurance TPA also issues a unique customer identification number to you and your beneficiaries once you purchase the insurance policy. This identification number consists of your insurance policy number and the complete name and information of the registered Third Party Administrator.

• Claim verification:

When you raise a health insurance claim, your insurer will forward the insurance claim form and details to your health insurance TPA. The TPA will check and verify the authenticity of your hospital bills, submitted documents, and claim form. To verify the genuineness of the insurance claim, they might even call the hospital you are admitted at or want to take admission in. They might also communicate with you and the insurer to get their facts straight. Even in other forms of insurance like motor insurance, for instance, Third Party Administrators coordinate with insurers and network agencies to verify every piece of information.

• Claim settlement:

A health insurance TPA is responsible for confirming the validity of a health insurance claim. The way they do this depends on the mode of claim settlement you choose. In the case of planned or emergency cashless claim hospitalization, they coordinate directly with your chosen network hospital and settle the hospital bills on your behalf. They are responsible for forwarding all the documents to your network hospital and getting your insurance claim settled. For reimbursement of health insurance claims, they check the genuineness of your insurance claim and documents through investigation and coordination with the hospital and reimburse the money within the given timeframe.

• Hospital empanelment:

Health insurance TPAs also have the authority to curate and track the workings of registered network hospitals and add more to their network hospital list. They check the proven track record of the potential network hospital and verify its quality of services, among other factors like brand name and customer satisfaction. If the hospitals clear the verification check, they are successfully added to the hospital network list. This rostering is a continuous and dynamic process, and the way Third Party Administrators take care of the entire thing is phenomenal.

• 24x7 customer helpdesk:

Health insurance TPAs are the core touchpoint for insured customers. For all the times the insurer cannot address your health insurance queries and problems, you get directed to your chosen TPA. The Third Party Administrator is fully equipped to tackle your issues and give you actionable solutions for the same. Their helpdesk doors are open round-the-clock to deal with customers. Sometimes, the health insurance TPA also provides additional services such as emergency ambulance assistance, wellness programs, lifestyle and disease management programs, and the like.

At Tata AIG, we do not have any Third-Party Administrators for our health insurance plans. We handle the entire process of our health insurance portfolio in-house, ranging from application for health insurance policies to claim settlement and extending customer support. There are several advantages of retaining every step of the process in-house, some of which have been discussed below.

• Adherence to quality standards

By not outsourcing any step of our health insurance process, we are able to ensure adherence to quality in each facet of the service delivery. We have complete control over the development, modifications, and administration of our health insurance policies. This allows us to keep the process centralised and scrutinised on a consistent basis, enabling us to deliver high-quality services to our customers which is our main goal.

• Competitive pricing

By not having to engage and pay third parties for performing parts of the process of the administration of our health insurance plans, we are able to provide said plans to customers at competitive prices. This way, our customers get excellent health insurance benefits at feasible prices.

• Differentiation

Keeping the entire process of administering our health insurance plans in-house is of great value in creating and maintaining product differentiation and a competitive advantage in the industry. With our unique health insurance plans that can be customised according to your health and insurance requirements, you can be assured of quality service and benefits.

A health insurance TPA plays an integral role in the quickening and smoothing of things up for an insurer. They are the behind-the-scenes superstars that take care of the on-stage show. As crucial it is to choose your insurer, choosing your health insurance TPA is too, as you will be handing over your personal care to them both. Getting your health insurance policy and the associated Third Party Administrator from us will not only ensure that you get access to quality healthcare but will also guarantee that you get it as quickly and stress-freely as possible. And worry not, if you have any queries regarding the TPA meaning, what a TPA in health insurance is or what the role of a TPA in health insurance is - we are here to answer any of those questions!