INTRODUCTION:

Health insurance in India has been limited to the persons who can afford it and second was the workers of formal group. The health insurance infrastructure is facing many problems and challenges to meet the health goals and complexities. In Indian scenario, the problems and challenges of health insurance industry has been much talked about but less understood.

There was a substantial growth of health insurance in India between 2000-2010. A new act IRDA, 1999 was enacted which allowed private players to enter the insurance sector. With the IRDA act, Third Party Administrators-Health insurance was notified on 17^th September 2001 according to the IRDA Regulations 2001. Health insurance sector assumed a new dimension with the advent of TPAs.

TPAs aims at increasing the efficiency ,standardisation and improvement in the health sector of the country. TPAs provide cashless treatment to beneficiaries and helps to maintain customer relationship and contact manager.

As per The IRDA Regulations, 2001, “TPA or Third Party Administrators means any person who is licensed under the IRDA (Third Party Administrators-Health services) Regulations,2001 by the Authority, and is engaged, for a fee or remuneration by an insurance company ,for the purposes of providing health services”.

One TPA can work with more than one insurance companies and insurers when attached with the TPA, provides information about the customers and the policy to the TPA.

OBJECTIVES:

The main object of the research paper is to know about the role of TPAs in health insurance and their advantages to the insurer.

1. Understand the cashless facility provided by TPA.

2. To know about the proper working of TPA at different stages.

3. Understand the awareness among the policyholders of health insurance about the TPAs.

4. To understand the cashless access service provided by the TPAs.

5. Efficient intermediary between insurer and policyholder.

Moreover the research paper aims to study the importance of TPA regarding cashless facilities and quick and easy settlement of claims and providing the services within the time agreed with the insurer. How working with TPA has smoothened the work of the insurers in case of health insurance. Vital role played by the TPA in expansion and promotion of health insurance in the country.

RESEARCH METHODOLOGY AND LIMITATIONS:

Research methodology is mainly dependant on the secondary data.All the information is collected from magazines, books and internet site.

Research is limited with the study of claim settlement process and cashless services provided by the TPA.

ANALYSIS OF THE SUBJECT:

TPAs basically function as an intermediary between the insurance company and the insured. By working as an agency they provide facilities such as cashless treatment to the insured. Ensuring cashless hospitalisation to policyholders is the core service of TPA provided to the insurance sector. TPAs working as an intermediary gets fixed rate of commission on premium amount. The rate of commission is 5.6% at present.

Concept of TPA:-

1. Giving response to customers in proper manner and time.

2. Providing services relating health insurance to insured at time of need.

3. Organising cashless treatment for the insured in network hospital.

4. Quick and fair settlement of claims to the customers.

5. Proper handling of health insurance claim and other services.

6. Creation of environment to access quality healthcare reasonably.

Cashless access services:-

Cashless services means where payments of cost of treatment are directly made to network hospital by insurer. Cost of treatment undergone by insured should be according to terms and conditions of the policy.

Conditions regarding cashless treatment

1. Insurer should provide all the information regarding the insured to the TPA.

2. TPA should provide the Identity Card to the insured carrying general information about insured .This card which relates to insured person is valid through out the year.

3. Proper data regarding members in accordance to policy should be available.

4. TPA can reject cashless treatment request incase of unclarity and unavailability of information.

5. Letter of guarantee must be issued to the network hospital based on information providing for request of cashless treatment.

Thus cashless treatment is the core object of the TPA and before providing these information all the conditions should be fulfilled properly.

Claim settlement and payment services:

After the cashless treatment provided by the nework hospital the TPA should settle the claims admitted. TPA plays important role in tracking the case of insured at the hospital and streamline the claim process.

Claims processing is the most critical service of the TPA. This process is the end to end process right from registering intimation to processing to recommend approval and payment.

TPAs get the funds in advance from insurer to make the payment of claims and some times it is settled through bank to the hospital and customers. TPA keeps all the records about money received from the insurance company and this money is to be used for payment of claim and not in any other purpose.

Introduction of TPAs was done as a intermediary to settle claim between the insurer and the insured. Collection of information is done regarding bills of the treatment. Re-imbursement is done after the proper examination and is processed to the insurer . TPA introduction expects for the simplified claim settlement. IRDA had suggested that all claims should be settled in seven days.

CONCLUSIONS:

Thus,TPA was introduced as a intermediary and is also playing a important role as of intermediary between the insurer and insured. Mainly TPA services are to provide easy and quick claim settlement. Which is one of the critical function of insurance industry. And this functions is also properly managed by TPA according to the guidelines of the IRDA.

And the other function is to provide cashless treatment to the insured at the network hospital. TPA has proved to be a boon in health insurance. And by proper facilities and services it is also helpful in expansion of health insurance sector in India. Which is one of the untapped and misunderstood topic in India.

SUGGESTIONS:

For better services from TPAs insurer should provide all information regarding policy and policyholders to TPA. So, that they can process all these functions properly.

Whereas TPA should also make aware the policyholders about role and working of the TPAs to insured.Most of the time policyholders are unaware about the TPA services.They should provide 24 hour helpline for customer services,inform customers about network hospital and specialised consultation at time of admissibility of claim process. Claims should be settled quickly after examining of documents and managing claims properly.

REFERENCES:

http://www.irda.gov.in

http://www.healthindiatpa.com

www.medindia.net/.../insurance/tpa

www.sashipublications.com/health-insurane-in

www,iimahd.ernet.in/publications/data/2005.01-02.pdf

Insurance Times

Express Health care magazines

Received on 15.09.2015 Modified on 18.10.2015

Int. J. Rev. & Res. Social Sci. 3(4): Oct. - Dec., 2015; Page 156-158