Page 264 - IC38 GENERAL INSURANCE

d) The membership with the TPA is used for availing cashless facility as well
as processing of claims when the member requires the support of the
policy for a hospitalization or treatment that is covered.

e) TPA processes the claim or cashless request and provides the services
within the time agreed with the insurer.

The cut-off point from which the role of a TPA begins is the moment of
allocation of the policy in the name of the TPA as the servicing entity. The
servicing requirement continues through the policy period and through any
further period that is allowed under the policy for reporting a claim.

When thousands of policies are serviced, this activity is continuous, especially
when the same policy is renewed and the same TPA is servicing the policy.

3. Objectives of third party administration (TPA)

The concept of Third Party Administration in health insurance can be said to
have been created with the following objectives:

a) To facilitate service to a customer of health insurance in all possible
manners at the time of need.

b) To organise cashless treatment for the insured patient at network
hospitals.

c) To provide fair and fast settlement of claims to the customers based on
the claim documents submitted and as per procedure and guidelines of
the insurance company.

d) To create functional expertise in handling health insurance claims and
related services.

e) To respond to customers in a timely and proper manner.

f) To create an environment where the market objective of an insured
person being able to access quality healthcare at a reasonable cost is
achieved and

g) To help generate/collate relevant data pertaining to morbidity, costs,
procedures, length of stay etc.,

4. Relationship between insurer and TPA

Many insurers utilize the services of the TPA for post-sale service of health
insurance policies while few insurers, especially from the life insurance sector
also seek assistance of a TPA for arranging pre-policy medical check-up service.

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