What Is TPA In Health Insurance?

What is a TPA?

A third-party administrator (TPA) is a company responsible for handling insurance health cover claims covered by the mediclaim policy. These administrators are often independent, but they can behave as if they were a part of the insurer or insurers.

The number of insurers, the types of health insurance available, and the number of customers all increased significantly over time. Eventually, it became challenging to maintain track of work that did not produce quality services. As a result, the Third Party Administrators were developed by IRDA. A TPA is now expected to provide:

  • Consistently high-quality services.
  • Processing several insurance claims for health. #

What Function Does a TPA Serve in Health Insurance?

The complete handling of health insurance claims involves a TPA. Some of a TPA’s jobs in the real world of insurance might be of the following kind:

  • Give the insured people their health cards:

Every policy given to the policyholder is subject to a validation process. A valid health card is issued to achieve this. This card contains information on the policy number and the  TPA in health insurance in charge of handling claims.

The insured can provide this card at the time of hospital admission and notify the insurer or TPA of the claim’s occurrence. It is one of the crucial records required for processing claims.


  • Effortless claim processing and resolution:

As soon as the insured informs a TPA of a claim, the TPA must expedite the claim. Their responsibility is to examine all the supporting documentation provided. It may request as much data as necessary to cross-check the details. Either a cashless settlement or reimbursement will be used to resolve the claim.

Whatever the situation, a TPA will be responsible for checking all paperwork. When using Cashless, the TPA can obtain the necessary paperwork from the hospital. In other situations, the TPA may require the policyholder to provide supporting documentation and invoices.


  • Set up Value-Added Services:

A TPA in health insurance often makes arrangements for other services like ambulance, wellness programmes, and others in addition to claim processing and card issuing.


  • Helpline Service:

All policyholders can contact their TPA for information and other claim help. Customers can call this facility, which offers customer care around the clock, anywhere in India. The policyholders can call the toll-free number 1800-258-5956 to find out the status of their claims.

How does TPA benefit Policyholders?

A TPA serves as a go-between for the insurance provider and the policyholder. Their responsibility is to streamline the health insurance claim process. As far as we know, claims can be classified as either reimbursement or cashless.

The policyholder goes to the hospital when they require medical or emergency treatment. A claim becomes valid if the person is asked to stay in the hospital for at least 24 hours (for an illness that isn’t specifically stated, like cataracts).

In this situation, the policyholder will inform the TPA or insurer about the admission and the requirement for the treatment.

# Visit the official website of IRDAI for further details.

Insurance is the subject matter of solicitation. For more details on benefits, exclusions, limitations, terms, and conditions, please read the sales brochure/policy wording carefully before concluding a sale.


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