How a Third-Party Administrator (TPA) Helps in Health Insurance


02 Oct 2022

Health insurance claim processing can be tough, as health adversities bring time turmoil & inconvenience. Hence, third-party administrator can be of huge assistance.

As a health insurance policyholder, you must feel a certain relief to know that your future is secure and you are financially protected in case any health issues occur. But on the other hand, there’s also a certain degree of concern with respect to the claim processing and settlement. At the time of filing a claim, you should use all the help you can get to ease the filing process. Fortunately, you have third-party administrators, or, in other words, TPAs assisting you throughout the claim filing process.

What is a third-party administrator in health insurance?

Third-party administrators act as intermediaries between the insurer and the policyholder, and they are appointed by every insurance company There are many aspects involved in filing a claim. You have to be accurate with your details and documents and follow due process. If you leave anything out, your claim may be rejected or will take longer to process and accept.

There are chances that at the time of filing a claim, you may face difficulties or find yourself in a state of confusion, this is where third party administrator in health insurance, plays an important role. They help you with every single detail that you need. They are the experts who aim to provide you with a seamless claim process.

The claim settlement process can be quite a handful. But it’s the third-party administrator's responsibility to educate you about the same and provide end-to-end assistance throughout the process.

Advantages of a Third-Party Administrator

Medical third party administrators facilitate mainly in efficient settlement of cashless claims. Find out the other adavantages below

Acts as a link between the insurer and the policyholder

A TPA is appointed by insurance companies to help you file your claim. The TPA in medical insurance acts as a link between you and your insurer. In case of any inquiries from you, they are your representatives who get those queries resolved by connecting with the insurer. To file a claim, you should inform your insurer as well as your TPA so you can utilize their services right from the beginning.

Efficiency in the process

Third-party administrators are highly efficient in conducting the entire claim settlement process. To put it simply, they know how things work in the insurance industry. With your health plan TPA by your side, you get access to many services. You can let your third-party administrator lead the process and expect complete accuracy throughout.

Available throughout the process

Since you informed your third-party insurer about your claim right at the beginning, you get to enjoy all the assistance offered by them throughout the process. A TPA helps you out in the following aspects of the claim settlement process:

  • Disbursing claims

  • Access to the cashless hospital network

  • Inquire with the hospital

  • Premium collection

  • Bill accumulation

  • Data maintenance

  • Consultation

  • Ambulance services

  • The ID number for claim settlement

and more. Before buying your health insurance, you can check with your insurance company regarding the services offered by the third-party administrator that they have a tie-up with.

They are highly reliable

Third-party administrators are highly reliable as they are authorised by the Insurance Regulatory Development Authority of India (IRDAI). Hence, they work along the laws and regulations to provide you with the right assistance in your claim settlement process.

Is TPA available in cashless claim settlement?

Yes! No matter if you opt for reimbursement or cashless claim settlement, you can utilize the services of a third-party administrator in either of those cases. Cashless claim settlement in itself is very helpful, and with the assistance of a third-party administrator, your entire process, including consulting with the hospitals, helping you with the hospital car, connecting with the insurers, etc., is taken care of.

Things to note about third-party administrators

The third-party administrator is only available to public-sector health insurance companies. If you have your policy with any private insurance company, you can rely on their in-house claim processing department.

TPA is only responsible for helping you in the process of claim settlement. They depend on the insurance company for the final settlement. Hence, they are not responsible for the acceptance or rejection of your claim. TPA does not charge you directly.

The insurance companies pay them a certain percentage of the claim amount. If you want to eliminate or change your TPA, you will have to inform your insurer and offer a valid reason for the same. Third-party administrators are available only in health insurance and not in any other kind, like life insurance or motor insurance.

Claim processing in health insurance can be arduous for some, as health adversities bring time turmoil and inconvenience. The last thing you want is to go through a complicated claim settlement process. Hence, a third-party administrator can be of huge assistance and be the pillar of support that you need.

Team Kotak GIC

The content of this blog has been created and carefully reviewed by the esteemed team at Kotak General Insurance, with the sole purpose of providing valuable guidance and sharing insights on the importance of general insurance. Our objective is to assist users in making informed decisions when purchasing or renewing insurance policies for their cars, bikes, and health. Our expertly curated information aims to empower our readers with the knowledge they need to protect their valuable assets and financial interests.