Third Party Administrator (TPA) for Health Insurance

Health Services by TPA” means the services specified in Regulation (3) of IRDAI (Third Party Administrators-Health Services) Regulations, 2016. “Third Party Administrators or TPA’’ means any person who is registered under the IRDAI (Third Party Administrators – Health Services) Regulations, 2016 notified by the Authority, and is engaged, for a fee or remuneration by an insurance company, for the purposes of providing health services as defined in those Regulations. 3 which provide Servicing of claims under health insurance policies by way of pre-authorization of cashless treatment or settlement of claims other than cashless claims or both, as per the underlying terms and conditions of the respective policy and within the framework of the guidelines issued by the insurers for settlement of claims.Servicing of claims for Hospitalization cover, if any, under Personal Accident Policy and domestic travel policy.Facilitating carrying out of pre-insurance medical examinations in connection with underwriting of health insurance policies: Provided that a TPA can extend this service for life insurance policies also.Health services matters of foreign travel policies and health policies issued by Indian insurers covering medical treatment or hospitalization outside IndiaServicing of health services matters of foreign travel policies issued by foreign insurers for policyholders who are travelling to India: Provided that such services shall be restricted to the health services required to be attended to during the course of the visit or the stay of the policyholders in India.Servicing of non-insurance healthcare schemes as mentioned in Regulation 22 (3) of these Regulations g. any other services as may be mentioned by the Authority.While performing the services as indicated at Regulation 3 (1) of these regulations, a TPA shall not Directly make payment in respect of claims Reject or repudiate any of the claims directlyHandle or service claims other than hospitalization cover under a personal accident policyProcure or solicit insurance business directly or indirectlyOffer any service directly to the policyholder or insured or to any other person unless such service is in accordance with the terms and conditions of the policy contract and the agreement entered into in terms of these regulations.A TPA can provide health services to more than one insurer. Similarly an insurer may engage more than one TPA for providing health services to its policyholders or claimants.

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