Page 265 - IC38 GENERAL INSURANCE

The relationship between an insurer and the TPA is contractual with a host of
requirements and process steps built into the contract. IRDAI Health Insurance
Standardization guidelines now lay down guidelines and provide a set of
suggested standard clauses for contract between TPA and insurance company,

The services that an insurer expects out of the TPA are as follows:

A. Provider networking services

The TPA is expected to build a relationship with a network of hospitals across
the country, with the objective of providing cashless claim payments for health
claims to the insured persons. The recent guidelines by IRDAI require the
relationship to be tri-partite including the insurer and not just between the
TPA and the provider.

They also negotiate good scheduled rates for various hospitalization procedures
and packages from such network hospitals reducing costs to insureds and also
insurers.

B. Call centre services

The TPA is usually expected to maintain a call centre with toll-free numbers
reachable at all times including nights, weekends and holidays i.e. 24*7*365.
The call centre of the TPA will provide information relating to:

a) Coverage and benefits available under the policy.

b) Processes and procedures relating to health claims.

c) Guidance relating to the services and cashless hospitalization.

d) Information on network hospitals.

e) Information on balance sum insured available under the policy.

f) Information on claim status.

g) Advice on missing documents in case of claims.

The call centre should be accessible through a national toll free number and
the customer service staff should be able to communicate in the major
languages normally spoken by the customers. These details are of course
governed by the contract between the insurers and their TPAs.

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