TPAs to also service foreigners' health plans from life insurers: IRDAI

Their services will also extend to foreigners travelling to India on a travel policy issued by a foreign insurers

Insurance Regulatory and Development Authority of India (IRDAI) has allowed third party administrators (TPAs) to also service health claims of foreigners who have taken such policies from life insurers. In its regulations on TPA-Health Services, the regulator said that a TPA can provide health services to more than one insurer. Similarly an insurer may engage more than one TPA for providing health services to its policyholders or claimant.

The regulator said that a TPA can extend their services for life insurance policies with respect to health services matters of foreign travel policies and health policies issued by Indian insurers covering medical treatment or hospitalisation outside India. It also includes servicing of health service matters of foreign travel policies issued by foreign insurers for policyholders who are travelling to India. However, IRDAI said that such services shall be restricted to the health services required to be attended to during the course of the visit or the stay of the policyholders in India.

In the regulations, IRDAI said that the insurers and the TPAs should ensure that discounts, if any, received or agreed to be received from the hospital towards health services are passed on to the policyholder or the claimant. For this, the insurers and TPAs would be required to mandate the hospitals to reflect such agreed discounts in the final hospitalization bill of each claim, by which the policyholder or the claimant can also be aware of the actual bill raised by the hospital.

There have been also been cases where the claim is more than the sum insured. Here, the regulator said that the agreed discount would have to be effected on the gross amount raised in the bill, before letting the policyholder or the claimant bear the costs over and above the eligible claim amounts. Where the underlying health insurance policies have co-payment or the deductible conditions, the insurer or TPA have to ensure that the said co-payment or deductible is effected only after netting off the discounts offered by the hospital.

Some complaints have been raised in the past of TPAs forcing customers to go to specific hospitals. IRDAI has said that TPAs should refrain from acting in a manner which may influence, either directly or indirectly, the insured or policyholder of a particular insurer to migrate from one insurer to another. It added that they should refrain from dissuading or discouraging policyholder from approaching specific hospital of his / her choice or persuade or encourage the policy holder to approach any specific hospitals which are in their network.

A TPA is required to maintain minimum paid up equity share capital of Rs four crore. Further, atleast one director of TPA should hold MBBS qualification with a valid registration from the Medical Council of India or Medical Council of any state of India and is entitled to practice medicine within its jurisdiction.