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Process To Choose the Best TPA for Health Claim

Published On Mar 30, 2023 10:15 AM By InsuranceDekho

Ever since the pandemic crept into our lives, the demand for health insurance plans has become extremely high. A health insurance plan provides protection against health uncertainties which means that in case of a medical emergency, health insurance plans will offer financial compensation for the same. However, in order to get this benefit, policyholders need to raise a health insurance claim. It is while raising health insurance claims that the role of a TPA or third-party administrator becomes important. So, let us understand the process to choose the best TPA for a health claim. 

Process to choose the best tpa for health claim

What is TPA in Health Insurance Claims?

A TPA or third-party administrator is an individual entity or organisation that acts as a mediator between the insurance company and the policyholder. The Insurance Regulatory and Development Authority of India or IRDA provides the license to the TPA to carry out the necessary function. The TPA coordinates between the policyholder and the organisation so that the health insurance claims are settled in an effortless manner. A TPA is responsible for settling both cashless and reimbursement health insurance claims. The TPAs work with the hospitals so that policyholders can easily raise claims as well as receive quality treatment.

How to Choose the Best TPA in Health Insurance?

The third-party administrator or TPA is either assigned by the insurance company or chosen by the policyholder themselves. The IRDA since 2019, has permitted health insurance companies to give liberty to policyholders in choosing a desired TPA. A list of third-party administrators is given to the policyholders while renewing or buying the health insurance policy, during which policyholders can choose the TPA. 

Listed below are the factors that will help you in choosing the best TPA in health insurance:

  • Policyholders must check the reputation of a chosen TPA. For the same, you can research online or speak to customers and enquire about the reputation of the TPA.
  • It is very important that you check the services offered by the TPA. You must check whether your chosen TPA is providing services related to cashless hospitalisation, pre-authorisation form submission, and others. You should also check whether the claim settlement process of the TPA is convenient and hassle-free or not.
  • Another factor that you need to consider while choosing the best TPA in health insurance is to check the cost of the services offered by the TPA. You must always choose the TPA whose services you can easily afford.
  • You must also check the number of hospitals, clinics, etc, that will help you in getting quality treatment as a policyholder. 

Benefits of TPA in Health Insurance

Listed below are some of the benefits of TPA in health insurance that you should know about:

    • Claim settlement: The third-party administrator in health insurance has a greater knowledge of claim settlement and thus settling claims with TPA is easier. The TPAs help in handling everything related to the claim settlement, from paperwork to submitting relevant documents. Thus, with TPA involved in health insurance claims, the claims can be settled in a fast manner.
  • Cost-effective: The involvement of TPAs in a health insurance claim is not just cost-effective for health insurance companies but also more convenient.
  • Better customer service: With TPA in health insurance, you can get tailor-made solutions to your queries related to claim services. Thus, with TPAs involved, you can enjoy better customer service and customer satisfaction. 
  • Onboarding Hospitals: Another benefit of TPA in health insurance is to onboard hospitals based on different criteria. The TPA checks whether the hospital fulfills all the requirements and then accordingly onboards the hospital to a health insurance company. 
  • 24*7 service: The TPA provides 24*7 service which means customers can easily reach out to TPAs in case of queries. Be it settlement queries or details about network hospitals, TPA helps in settling all of these on time.
  • Reducing the chance of fraud claims: The TPAs in health insurance is also helpful in reducing the chances of fraud claims. As TPAs have expertise in settling claims, so if any fraud claim is raised, then the TPA easily identifies it.

Key Facts to Know About TPA in Health Insurance

Here are some of the key facts that you should know about TPA:

  • TPAs are separate from insurance companies and work independently
  • TPAs are regulated by the IRDA
  • TPAs are not at all responsible for selling insurance policies

How Does TPA Work?

A TPA or third-party administrator in health insurance helps in both cashless and reimbursement claims. Read on to learn more about the same:

  • Cashless Claims: In cashless claims, the health insurance company is directly allowed to settle the claims. Thus, in this case, the policyholder contacts the TPA for initiating and settlement of claims. The TPA will help in choosing the best network hospital as well as with the paperwork.
  • Reimbursement Claim: In a reimbursement claim, the policyholder first settles the hospital expenses from their pocket and later gets it reimbursed by the insurance company. So, once the policyholder submits the bills, then the TPA will intervene to check the bill and get the claim approved by the insurance company. 

Take Away

Thus, a TPA in health insurance is beneficial for both the policyholder and the insurance company. Moreover, with the above-listed factors, you can easily check the best TPA in your health insurance plan.

Also Read: 

Reliance Health Insurance Policy Benefits


This article is issued in the general public interest and meant for general information purposes only. Readers are advised not to rely on the contents of the article as conclusive in nature and should research further or consult an expert in this regard.

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