Role of TPA in claims


Who decides on my health insurance claim? Is it the insurance company or its TPA?


For any claims you will need to inform your TPA about any hospitalization as soon as possible. While the final responsibility of claim settlement is that of the insurer and not the TPA, you need to file your claim with the TPA who in turn will forward your request to the insurance company.


Hi Sohini,

Usually, the insured has to inform the insurance provider or the TPA of the hospitalization or treatment requirement ahead of time in order to avail cashless treatment. They should be informed at least 4 days before the treatment date. A cashless claim request form should be submitted at the relevant address of the insurance provider – mostly via post, e-mail, or fax. For more information you can contact the customer care of your Health Insurance provider. Once these steps are completed, the insurance provider will notify the insured as well as the concerned hospital regarding the policy cover and eligibility. On the day of admission in the hospital, the policyholder has to display their Health Insurance card and the confirmation letter. The medical bills will be paid by the insurance provider, directly to the hospital.

In case of reimbursement claims for Health Insurance, they can be made if the policyholder opts to go to a hospital of their choice, which is a non-empanelled hospital. In this case, the cashless claim facility cannot be used. Therefore, the insured has to pay all their medical bills and other costs involved in hospitalisation and treatment and then claim reimbursement. In order to avail reimbursement claim you have to provide the necessary documents including original bills to the insurance provider. The company will then evaluate the claim to see if it comes under the policy cover and then will make a payment to the insured. In case the treatment is not covered under the policy, the claim will be rejected. The insurance provider generally provides reasons for the rejection.

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BB Expert