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No TPA? Soon, you may be following up on a health insurance claim directly with the insurer

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Insurance regulator IRDA has directed third-party administrators (TPA) not to take health claims payment decisions on behalf of insurance companies. This means that a TPA, which is essentially an intermediary between a health insurance policyholder and a general insurer, will merely be involved with the processing of claims.

Whenever a policyholder files a health insurance claim, a TPA has to be contacted. The TPA is an external entity that works with multiple general insurers to help process customer claims. However, the rise in health insurance claims, which has been accelerated by the Covid-19 pandemic, and complaints over payment delays, has pushed general insurance companies to set up internal teams to ensure payments are quicker.

HDFC ERGO General Insurance, Bajaj Allianz General Insurance, ICICI Lombard, Max Bupa and Liberty General Insurance are among insurers that have in-house claims processing teams.

The idea of having a TPA was to ensure that when there is a spike in the volume of claims, the processing can be managed by an external party that could guide the customer on the claims process. However, industry sources said that the rise in claims settlement timelines has led to greater reliance on the in-house team. The idea here is to slowly reduce the reliance on TPAs and build in-house teams to help settle health claims.

Moneycontrol looks at how an in-house claims processing team works and how different it is from a TPA:

Claims intimation to the TPA

A policyholder has to contact a TPA to submit a health insurance claim. The details of the TPA are mentioned in the policy documents given to the customer. In the case of hospitalisation or diagnosis of a health ailment, the TPA has to be informed first.

The TPA then passes on the claim information to the insurance company. This process could take time since this is an external company handling thousands of claims on behalf of multiple insurers.

In comparison, an in-house team is able to pass on the claim information immediately and expedite the claims settlement process.

Submission of documents

Once a claim is submitted to a TPA, the policyholder is required to submit a slew of documents, including the medical bills, hospital discharge certificate and bill, pharmacy receipts, X-Ray reports (if any) as well as doctor prescriptions.

Sometimes, if one or two documents are missing the external TPA has to first contact the insurance company to check whether the claim is payable without the said document. In comparison, an in-house team’s turnaround time is quicker and ensures that documents are submitted on time for claims settlement.

Approval of claim

There is a misconception among customers that the TPA can accept or reject a claim. However, the insurance regulator’s rules state that a TPA is only involved in processing a claim and is not allowed to make any approval-related judgement.

So, once a policyholder has submitted all the claims to an external TPA, this entity has to contact the claims department of the concerned insurer to verify if approval has been granted. This could take about 7-10 days depending on the type of claim and claim size. In comparison, an in-house team would be able to make an approval decision within a week.

Settlement of claims

Whatever be the size of the health insurance claim, only the insurance company can decide what part of the claim is payable and what isn’t. For instance, consumables such as gloves, PPE kits, masks, sanitisers and cotton, which are provided for one-time use, are not typically covered by health insurance policies.

Similarly, any personal expenses incurred in the hospital, including telephone/internet charges or special food and supplements, are also not payable under standard health insurance products. This means that even if these items are filed under claims, the amount will be excluded from payment.

An in-house processing team is able to clearly explain which expenses under health insurance are payable and which ones are not. This is because they are internal company experts. Sometimes an expense covered under a policy’s terms may be inadvertently excluded. In such instances, an in-house team would be able to resolve the discrepancy quickly.

In comparison, a TPA has to first check with the insurance company as to why a particular claim component has been excluded from the final settlement. Customer complaints with respect to exclusions in the settlement amount also take time to be resolved.

At a time when there have been 2.2 million confirmed Covid-19 cases in India, with over 6,00,000 active cases currently, settling health insurance claims through an in-house claims-processing team could prove beneficial for customers.

But it may not be feasible for the industry to take out TPAs immediately. Industry sources are of the view that a phased exit of the model, wherein internal teams will be strengthened to handle claim volumes, is the way forward.