Irdai allows TPAs to process foreigners' health claims

Decision pertains to foreign travel policies and health policies issued by Indian insurers covering medical treatment or hospitalisation outside India

The Insurance Regulatory and Development Authority of India (Irdai) has allowed third party administrators (TPAs) to process health claims of foreigners who have taken policies from Indian life insurance companies. The regulator also said a TPA can provide health services to multiple insurers. Similarly, an insurer can engage multiple TPAs for providing health services to its policyholders.

The regulator said a TPA can extend its services for foreign travel policies and health policies issued by Indian insurers covering medical treatment or hospitalisation outside India. This includes health services under travel insurance issued by foreign insurers to those visiting India. However, such services shall be restricted to the treatment required during the India stay of an international policyholder.

Irdai said insurers and TPAs should ensure that discounts, if any, from hospitals are passed on to policyholders or claimants. For this, insurers and TPAs would have to ask hospitals to reflect such discounts in the final bill of each claim.

In cases where the claim is more than the sum insured, the regulator said, the agreed discount would have to be effected on the gross amount of the bill, before letting the policyholder or the claimant bear the extra cost.

Similarly, in cases where underlying health insurance policies have co-payment or deductible conditions, insurer or TPA must ensure that the co-payment or deductible is effected only after netting off the discounts offered by a hospital.

On complaints saying that TPAs forced some customers to go to specific hospitals, Irdai said TPAs should refrain from acting in a manner which may influence a policyholder to migrate from one insurer to another. It said TPAs should also refrain from discouraging policyholders from approaching a hospital of their choice.

A TPA is required to maintain minimum paid-up equity share capital of Rs 4 crore. Further, at least one director of a TPA must hold an MBBS degree.