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9 reasons why individual health insurance is a must over group policy (Pixabay)

Health insurance plans help you plan during medical emergencies. But if your Third Party Administrator or TPA is not proactive in dealing with the claim process, it can unnecessarily delay the whole process. This is because in the event of hospitalisation, your hospital first reaches out to TPA, as they play a crucial role from checking documents, cross verifying details to the pre-authorisation for cashless facility.

Here is a lowdown on what all services are offered by a TPA:

What is TPA?

Over the years because the number of health policies has increased considerably due to which many insurers prefer to outsource their work to TPAs. These administrators are independent bodies and only provide claim processing services to insurers. Their role is limited to processing insurance claims received by insurance companies.

“The role of a TPA significantly reduces if you opt for a cashless claim, as the TPA desk of the hospital liaisons with the TPA or the insurer on your behalf. So, it hardly matters which TPA you are dealing with. Their role is prominent only in the case of reimbursement claims. But if you keep your paperwork ready and follow the specified process, your claim experience would significantly improve, irrespective of the TPA,” said Dhirendra Mahyavanshi, Co-Founder, Turtlemint, an InsurTech company.

“TPA plays a major role in the administration of Health Insurance policy thus selecting the right TPA is important. A good TPA helps you in getting your claim ratio down and helps you identify any abuse in the policy,” said Amit Sharma, Founder, and CEO at eExpedise Healthcare.

Having said that not all insurers outsource their claim processing department. Many companies have an in-house claim settlement team. “Bajaj Allianz General Insurance has an internal claim settlement team. However, some insurers utilize the services of TPAs to service claims of their customers, and accordingly, the servicing TPA as mentioned in the policy of the customer, will support and process their claims, said Gurdeep Singh Batra, Head – Retail Underwriting, Bajaj Allianz General Insurance.

Can you choose a TPA?

Choosing a TPA is not usually in the customer’s hands. The insurance company ties up with a TPA and you will have to comply with it if you choose to buy a health insurance plan from that company. Mahyavanshi said, “In some cases, if the insurance company is tied up with more than one TPA, then you can choose a preferred TPA for handling your health insurance claims.”

Points to consider while choosing a TPA

Active case management: TPA should have a good record of handling cases. “TPA should have a team who is working with the hospital on regular basis, getting a special discount and scrutinizing any abuse and work as a gatekeeper for policy members and help them save on their sum Insured,” said Sharma

Wide provider network: TPAs role is to engage with hospitals and empanel them for offering cashless benefits to policyholders. Choose a TPA which has good liaising with the hospitals. In addition to empanelling such hospitals, TPAs also enter into contracts with them for availing preferential rates of various healthcare treatments for its members. If possible enquire about preferential rates offered.

Adoption of digital technology: Go with the one who offers you digital platform to track your claims. ICICI Securities report states“Recently, TPAs have started providing digital tools such as client portals, mobile apps and claims download tools that facilitate automation. The technology-driven infrastructure and services of TPAs are integral to Insurance, the operations of insurance companies, healthcare providers, insurance brokers, and insurance agents. All these are also expected to drive efficiency both internally and externally.”

Customer support: There should be ease of reaching out to the TPA in the case of claims and their turn-around time should be quick. The TPA should have good customer support with an efficient 24×7 customer call centre to address such queries.