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Third Party Administrators for Health Insurance

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Cashless Treatment

Customer Service

Medical Coverage

Claim Experience


What are TPAs or Third Party Administrators?

TPA or Third Party Administrator (TPA) is a company/agency/organisation holding license from Insurance Regulatory Development Authority (IRDA) to process claims - corporate and retail policies in addition to providing cashless facilities as an outsourcing entity of an insurance company.

TPAs function as an intermediary between the insurance provider and the insured. The stakeholders involved are as follows:

  • Insurance companies
  • Healthcare providers
  • Policyholders

Introduced by the IRDA in 2001, TPAs handle various pertinent aspects of insurance as listed below:

  • Processing of claims and settlement includes the following:
    • Accepting intimations
    • Approving cashless claims
    • Disbursing the claims
  • Utilization review
  • Provider network
  • Enrolment
  • Premium collection
  • Cashless processing (if and when a policyholder is admitted to a listed hospital of an insurance provider, the latter pays the bill)
  • Value added services such as the following:
    Third Party Administrator
    • Ambulance services
    • Specialised consultation
    • Availability of beds
    • 24-hour toll-free helplines
    • Lifestyle management
    • Wellbeing programmes
    • Medicine supplies
    • Health facilities
  • Database maintenance

According to experts, providing cashless hospitalization of the insured should be the primary service offered by TPAs. It is important to note that some insurance companies have a separate department which performs the functions of TPA instead of outsourcing it to another entity.

Need for Third Party Administrators:

According to industry observers, TPAs can bring in the following changes:

  • Greater efficiency/quality (delivery of services)
  • Improved standardisation (procedures and due diligence)
  • Increase knowledge base of healthcare services
  • New management system
  • Greater penetration of health insurance
  • Minimize costs/expenditure
  • Develop protocols to streamline investigation and avoid unnecessary delays
  • Pave way for lower insurance premiums

All the same, there is much discrepancy between the aims and the ground realities of functioning of TPAs. As a result, the jury is still out on the efficacy of TPAs in the growing and complex health insurance sector in the country. The institutionalisation of TPAs, therefore, leaves a lot to be desired.

Revenue model of Third Party Administrators:

There is a view that the organisation and revenue generation model of TPAs will determine the extent of their success. TPA’s major revenue comes in the form of fees or commission on premium, which is standardised by the IRDA. The other sources of revenue of TPAs include the following:

  • Benefit management
  • Provider network management
  • Data management
  • Medical management
  • Claim administration

Challenges galore:

According to experts, there are several impediments to the effective functioning of TPAs. Some of the problem areas in the health insurance sector in the country adversely affecting TPA-related services are listed below:

  • Information asymmetry
  • Weak networking
  • Inordinate delay in the issuance of identity cards to the insured
  • Lack of strong standardisation procedures in terms of billing
  • Under-reporting across hospitals
  • Nexus between corporate hospitals and insurance companies (i.e., low claim ratio for individual insurance and high claim ratio for corporate insurance)
  • IRDA has not put any strict regulations or mechanisms in place to effectively appraise the performance of TPAs. IRDA, therefore, assesses TPAs based on the latter’s financial performance in terms of policy premium rather than customer satisfaction. There is, therefore, a view that TPAs should be evaluated/accredited on the basis of quality of services provided
  • Low awareness about TPAs amongst general public/policyholders. According to reports, many policyholders are unaware of the extra premium charged by insurance companies for TPA services. Likewise, pertinent information related to cashless hospitalization and exclusions listed in insurance policies is not examined by many policyholders.
  • Policyholders’ dependence on insurance agents rather than TPAs. In many cases, policyholders do not see TPAs as distinct entities vis-a-vis their insurance agents and intriguingly place more faith in the latter.
  • Most hospitals have no substantial evidence to prove that TPAs increased their patient turnover
  • Experts point out that TPAs need to invest in developing human capital to improve their delivery of services and rein in costs.
  • Inadequate knowledge about the provisions and benefits of TPAs amongst policyholders
  • Healthcare providers look for well-trained TPAs to effectively deal with the operational inadequacies in the system. Poorly developed and half-baked protocols and systems instil little confidence amongst stakeholders. TPAs should have several in-house experts such as legal experts, IT professionals, doctors, management consultants and hospital managers among others given that claims management and settlement requires bargaining power and negotiation skills, i.e., combination of technical and management skills
  • Hospitals which already have robust delivery mechanisms in place are more likely to pave way for hassle-free claims settlement and other related services offered by TPAs.
  • While the primary purpose of outsourcing claims settlement is to minimise the claim period, claims processing, in several cases, is riddled with delays.
  • The insured do not have adequate knowledge about empanelled hospitals for cashless services
  • Many hospitals also report additional expenditure incurred by them in terms of smooth coordination with TPAs for efficient delivery of services to the policyholders

Some of the Third Party Administrators in India:

  • Medi Assist India TPA Pvt. Ltd
  • United Healthcare Parekh TPA Pvt. Ltd
  • E Meditek (TPA) Services Ltd
  • MD India Healthcare (TPA) Services (Pvt.) Ltd
  • Family Health Plan (TPA) Ltd
  • Focus Healthservices TPA Pvt. Ltd
  • Vidal Health TPA Private Limited
  • Heritage Health TPA Pvt. Ltd.
  • Vipul Med Corp TPA. Pvt. Ltd
  • Raksha TPA Pvt. Ltd
  • Rothshield Healthcare (TPA) Services Limited
  • Dedicated Healthcare Services TPA (India) Private Limited
  • Spurthi Meditech TPA Solutions Pvt. Ltd. No.
  • Ericson TPA Healthcare Pvt. Ltd
  • Sri Gokulam Health Services TPA (P) Ltd
  • Safeway TPA Services Pvt. Ltd

GST rate of 18% applicable for all financial services effective July 1, 2017.

Disclaimer: Premiums may vary depending upon factors like age, location and prevailing taxes/GST.

Third Party Administrators for Health Insurance Reviews

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  • National Insurance Health Insurance
    "Good insurance"
    0.5 5.0/5 "Blown Away!"
    My health insurance was taken with National Insurance. It is a third party insurance, it was taken through medi assist. I have used the service two times, first time they provided 100% cashless and the second time it was 80% overall it was good.
    Was this review helpful? 0
    , mumbai
    Reviewed on Jan 30, 2018
  • New India Health Insurance
    "Do not take any insurance form New india assurance"
    0.5 1.0/5 "Really Bad"
    Worst service of this New India Assurance company, my wife got admitted and the same day i informed TPA. After operation i had submitted all the documents to TPA. but never get my claim. Every time i called TPA he asked me more documents , i arranged the same but no result. I arrange all the documents as per the first mail i received, but every time i called them they put a new requirement. I ask them to arrange a physical verification for this claim but my TPA refuse the same and reject my claim. After getting fed-up with this process and attitude i put a mail after two moths to return my all documents. i will never recommend any one for the New India Assurance company. Yuddhveer Singh(9599667477)
    Was this review helpful? 2
    , gurgaon
    Reviewed on Apr 28, 2017
  • Universal Sompo Health Insurance
    "Better insurannce for health"
    0.5 4.0/5 "Great!"
    Have a health insurance with UNIVERSAL SOMPO GENERAL INSURANCE , it is also called third party HHPPL insurance. My company has offered me this insurance, which is very useful for my whole family. The cashless treatment and post cash treatment is available with this health insurance. Need to renew it yearly once by paying around Rs.23,000, which covers for about 6members in my family. I can say, it is good to have health insurance for a family. It is also helpful for IT exemption.
    Was this review helpful? 0
    , hyderabad
    Reviewed on Apr 13, 2017
  • Royal Sundaram Health Insurance
    "Very bad... Not covering acute diseases.... Disaster"
    0.5 0.5/5 "Unacceptable"
    Royal sundaram group.. This side Dr Amrish cardiac surgeon paras gurgaon Myself has acute chest pain wct angio revealed single vessel disease which neeeds angio with +_ ptca.. My policy number HCE0027323 I was told that this is emergency... Its not congenital.... It means i have to wait till 2 yrs with chest pain as said by tpa team As myself cardiac surgeon its very disapointed from royal sundaram that they denied.. As i was previously starhealth from 3 yrs but u guys agreed me to take ur insurance.. But from today onwards i will not going to renew it and not going to refer to any of my patients as im in this field 12 yrs Dr Amrish kumar Cosultant Ctvs surgeon Paras gurgaon
    Was this review helpful? 3
    , new delhi
    Reviewed on Dec 05, 2016
  • HDFC Ergo Health Insurance
    "The most pathetic customer service"
    0.5 0.5/5 "Unacceptable"
    I had bought a health insurance a year ago. unfortunately I met with an accident and also fell from the stairs and tore the ligaments on my knees and ankle. Since HDFCergo support ayush treatment, I decided to go for it. Since two weeks I have been calling and writing to their customer service dept to check which all treatments are covered for ligament tear under ayush. with the all the pain in my leg I am struggling to get a confirmation mail from the concern dept and all I get is will get back to you withing two business days. I don't understand why it is taking so long just to look into this matter. The worst experience ever. Very angry and disappointed with the response we are getting. I would never ever recommend them to any one. Before treatment this is the response. I wonder if I would ever be able to claim back if I go for a TPA hospital.
    Was this review helpful? 1
    , bangalore
    Reviewed on Oct 07, 2016
  • Apollo Munich Health Insurance
    "Excellent Response Time and Easy Process"
    0.5 5.0/5 "Blown Away!"
    After about 7 claim free years, I used my health insurance for the 1st time with Apollo Munich and my experience was very pleasant. The customer service staff were responsive and the process of claims approval was handled seamlessly. The policy has no room sublimits or copay. We used the Apollo Hospital and the entire process went very smooth. The claim was approved without much hassles. I am thankful for opting Apollo Munich. I had different TPA when I was working and my experience with Apollo Munich was the best.
    Was this review helpful? 1
    , chennai
    Reviewed on Jul 13, 2016
  • review Health Insurance
    "Good Services by TPA and Insurance company"
    0.5 4.5/5 "Excellent!"
    I have a group insuarnce from bharti AXA and United Health Parekh is TPA. Unfortunetly I have some health issue and has to go for Cashless hospitalization. and It was really hassle free. Also I filed for Pre and post hospitalization, It was also quite easy. I have applied for Non cashless tratment for my mother also which was also very smooth.
    Was this review helpful? 0
    , ghaziabad
    Reviewed on Jul 08, 2016
  • United India Health Insurance
    "100% is always very good coverage"
    0.5 5.0/5 "Blown Away!"
    I have my two wheeler insurance with United Insurance for the past 7-8 years which I renew every year through payment of Rs.1600 to my agent. The insurance has a 100% coverage and covers accidental damages, theft, third party cover etc. The agents are quite helpful and approachable and handle everything and there is no need to run from pillar to post.
    Was this review helpful? 1
    , chennai
    Reviewed on May 21, 2016
  • Royal Sundaram Health Insurance
    "Good coverage "
    0.5 5.0/5 "Blown Away!"
    I have taken medical coverage for whole family from Royal Sundaram. The TPA is bad with the hospital because they do not make the settlement on time by which customers are not getting the cashless treatment facility it was my personal experience. They should improve the TPA services. But the medical coverage is very good because in other companies which coverage is not given in the second year is covered in royal sundaram.
    Was this review helpful? 0
    , ghaziabad
    Reviewed on Feb 02, 2016
  • New India Health Insurance
    0.5 4.0/5 "Great!"
    My health insurance is with New India Assurance. I had taken it before 5 months through my company. My policy is Raksha TPA. This policy is enrolled for my entire family for almost 10 lakhs. Tenured duration is 2 years. I need to pay 22,000 for 3 months. I am pretty happy with this policy.
    Was this review helpful? 0
    , varanasi
    Reviewed on Feb 02, 2016
  • Oriental Insurance Health Insurance
    "Got hundred percent from Oriental Insurance..."
    0.5 5.0/5 "Blown Away!"
    Indeed this is a group health insurance offered by my company so interacting via third party agency. Last year I made one claim with Oriental Insurance where got hundred percent of reimbursement. In a week time I got the settlement amount. I submitted all the papers via online and got the amount.
    Was this review helpful? 1
    , bangalore
    Reviewed on Jan 13, 2016
  • United India Health Insurance
    "Delay in getting settlement..."
    0.5 3.0/5 "Satisfactory"
    I am dealing with United India Insurance via third party as this is a corporate offer. Last year the value is of 1lakh but now the medical coverage is just 50 thousand as they reduced that. Te settlement is not that smooth. For my spouse maternity I claimed where they took a long time to give settlement and after three months they asked for few papers.
    Was this review helpful? 0
    , chennai
    Reviewed on Jan 09, 2016
  • United India Health Insurance
    0.5 4.0/5 "Great!"
    United India Insurance has third party involvement to get the reimbursement. In terms of response they are good. Recently I claimed for my mother and on the same day they approved for cashless. They just took my company id card for proof. Overall coverage for health insurance is good and they has wide range of hospitals. And hospitals are well organized.
    Was this review helpful? 0
    , bangalore
    Reviewed on Dec 07, 2015
  • Star Health Health Insurance
    0.5 5.0/5 "Blown Away!"
    My health insurance is from Star health. The services are very good from them. I have taken the two plus one policy. They do not have a tpa. The premium is on a yearly basis. The coverage is very good too. I have not had a claim yet.
    Was this review helpful? 0
    , thane
    Reviewed on Nov 28, 2015
  • HDFC Ergo Health Insurance
    "Not satisfied"
    0.5 1.0/5 "Really Bad"
    HDFC ergo is using third party service. But the medical coverage offer was good like 2 lakhs for every years Most of the listed hospital are covered. Cancer and HIV are not covered. They charge around rs.8000 yearly in case we do not use policy it is reimbursement every year but if we call them they use to change the policy .
    Was this review helpful? 0
    , chennai
    Reviewed on Nov 26, 2015
  • Oriental Insurance Health Insurance
    "Excellent Services"
    0.5 5.0/5 "Blown Away!"
    It is a corporate health insurance with Oriental Insurance. I have had a claim experience. The process was good. The TPA is medi assist. It was a cashless facility. It was hassle free. The premium is renewed by the company.
    Was this review helpful? 0
    , pune
    Reviewed on Nov 20, 2015
  • ICICI Lombard Health Insurance
    "Good services"
    0.5 4.0/5 "Great!"
    ICICI Lombard has been good in their services to me. They have good benefits. They also have good policy coverage. The insurance has a third party insured too. The premium is on a half yearly basis. The coverage is of 70%
    Was this review helpful? 1
    , hyderabad
    Reviewed on Nov 19, 2015
  • United India Health Insurance
    "Floater value is good..."
    0.5 4.5/5 "Excellent!"
    They are excellent in health insurance. I had all the claims like domiciliary claims where that is periodic claim and these are only reimbursement type. One to two times I got cashless treatment from United India Insurance. Employer have tied up with third party and the claim is always smooth. Medical coverage and floater value is good.
    Was this review helpful? 0
    , kochi
    Reviewed on Nov 09, 2015
  • Max Bupa Health Insurance
    0.5 4.0/5 "Great!"
    Max Bupa covers all the diseases where they just have exceptions on plastic surgeries, cosmetic surgeries and dental.There is no third party involved and we can directly get in touch with the Max Bupa for claim process. So far I am happy with the health insurance.
    Was this review helpful? 0
    , bangalore
    Reviewed on Nov 04, 2015
  • Max Bupa Health Insurance
    "Very useful on for my future"
    0.5 2.5/5 "Just OK"
    MAX BUPA is an third party where our company taken health insurance policies from them. The health card was given to me. Through my friend I heard about this policy benefits. There is an medical reimbursement plan under this policy.
    Was this review helpful? 0
    , new delhi
    Reviewed on Oct 23, 2015
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