Page 33 - Insurance Times May 2019

THIRD PARTY

ADMINISTRATOR:

INTEGRAL PART FOR

SUSTAINABLE

GROWTH OF RETAIL

HEALTH INSURANCE

IN INDIA

T he advent of Third Party Administrator (TPA) to be improved. The following problems were given due

begins in India with the development of
consideration for improving the quality of service provided.
Mediclaim, which was introduced in 1986 by the
Public Sector Insurers. Since Mediclaim was an
indemnity policy, insured person could select a (a) Paying entire hospitalization expenses first, then to
submit a claim to obtain reimbursement and then
hospital, avail treatment at the hospital, including any waiting for the insurer to process and reimburse the
surgical treatment (in-patient only, with a minimum 24 hour claim.
stay). Once the insured patient was discharged from the
(b) Lacking of knowledge as to how much of the overall
hospital, the policy holder would have to submit claim to
expenses would be reimbursed even if the claim would
the Insurance Company, with discharge summary and all be admissible.
medical bills along with supporting documents for
diagnostics, prescription for medicines, etc.
To bridge the gap of service, a novel concept of Third Party
Administrator (TPA) was introduced in India through the
The Insurer would process the claim and arrange notification on TPA-Health Services Regulations, 2001 by the
reimbursement as per limits and sub-limits of the policy. Insurance Regulatory and Development Authority of India
Slowly, it was recognized that there was a gap in the offering (IRDAI) and it has been updated in 2016.
for medical insurance and that some areas of policy needed
Their basic role is to function as an intermediary between
About the author the Insurer and the Insured. The core product of service of
a TPA is ensuring CASHLESS Hospitalization to policy holders.
Paresh Nath Karmakar
F.I.I.I., Ex- Faculty Member of There is Service Level Agreement between
National Insurance Academy and
Retired Chief Manager of United India Insurance Co. Ltd. (i) A TPA and an Insurer

The Insurance Times, May 2019 33