Significance of TPA to insurance and policyholders

Significance of TPA to insurance and policyholders

In 2001, IRDAI created the TPA agency to assist insurance firms with claims. These administrators manage policies, keep track of claims and handle other tasks that help the insurance companies stay profitable and continue operating. They also ensure hassle-free claim disbursement for the policyholders. This article will tell you about the significance of TPA in detail.

TPA full form – Third Party Administrator is the backbone of health insurance firms. The relentless work of this team is the story behind every hassle-free claim. When we know that we have health insurance, we feel less frantic about the future. This agency assists healthy insurance firms and the hospital in association in making your claim easy.

TPA in the Health Insurance sector:

A third-party administrator, TPA in health insurance, is an entity that plays the managerial role according to the third party in a health insurance agreement and soothes the claim settlement process between a policyholder and the insurer. Here are some things that can help you better comprehend TPA.

In the event of a hospitalization claim, a TPA serves as a liaison between the insurer and the insured.

  • The health insurance company selects the TPA.
  • The Insurance Regulatory and Development Authority of India licenses TPAs (IRDAI).
  • TPAs handle the administrative chores of dealing with documentation and paying hospital costs.
  • TPAs work with insurers to ensure a seamless claim settlement process.
  • A single TPA can have an affiliation with many insurers.

Work of TPA:

TPA is the third-party administrator in health insurance that does intermediary services between the insurance provider and the insured to ensure that claims for cashless transactions and reimbursements are handled seamlessly. By doing so, they help the health insurance companies with their management needs. When an insured person needs medical care, that person contacts the insurance firm’s TPA. The TPA will provide the information to the client on which tie-up hospital is closest and help them with the claim procedure. TPA will receive the medical bills for settlement at the time of discharge. TPA will review the insurance firm’s terms and conditions to verify the bill’s adherence. Once all the paperwork and payments are approved, the firm will pay for the costs either to the hospital or compensate the insured if paid already.

Significance of TPA in health insurance:

1) Intermediary:

In case of medical assistance is required for any health insurance policy holder, they meet the TPA. TPA issues a claim ID and a Unique Identification Number for the policyholder. TPA handles hospitalization claims for policyholders and mediates them to the Insurance firm.TPA may investigate hospital records for dubious claims in case of suspicion. Once TPAs evaluate the paper works and validates the claim, the medical bill is either settled to the hospital or reimbursed to the patient on prepayment.

2) Database Maintenance:

Policy paperwork is handed to TPA after the policy issue, and the policyholder communicates exclusively with TPA rather than the insurance provider in the future. TPA issues and keep track of the policyholders’ unique identification numbers (UINs) and their hospitalization records.

3) Cashless Claim Process:

In the Cashless Claims settlement procedure, TPAs play an irreplaceable role in mediating the insurance company and the hospital to ensure no issue in the claim’s settlement. In these cases, the TPA provides back-end assistance by checking all the documents related to the settlement process.

4) 24×7 Assistance:

It is common for good health insurance TPAs to provide policyholders with an around-the-clock help desk where they may voice their concerns and get timely responses. Policyholders may use toll-free lines to check the progress of their claims.

5) Onboarding Hospitals:

TPAs are also responsible for ensuring that patients are enrolled in the network hospitals. They handle the process of examining the onboarding of hospitals and ensuring they comply with the Network Hospitals’ terms and conditions for a problem-free claim settlement.

6) Extra Services:

Apart from processing the hospital claims of policyholders and issuing UID cards, a TPA provides other services, such as an ambulance, availability of beds, health and wellness programs, and drug supplies.

Benefits of TPA to the insurance company:

  • TPA works with a 24×7 helpline number accessible throughout India, thus reducing the administrative workload of an insurance company.
  • Apart from looking after the claims, the Insurance company outsources many of its functions like premium billing, customer registration, and other regular work.
  • The insurance company hands over all the records of the policyholders to the TPA, and further communication during claims is also looked after by TPA.
  • TPA checks every claim and verifies it thoroughly, so there is no false claim. The medical professionals working under them help immensely in deciding whether any disease is covered under the concerned policy or not.
  • As all the required data remains with TPA, insurance claims processing becomes faster.
  • With TPA, the customer relationship enhances, thus giving trust to the policyholder. It makes sure the insurance company’s reputation is safe.

Benefits of TPA to Policyholders:

  • The 24×7 helpline helps the policyholder in getting immediate support.
  • Helps in hospitalization procedures and clearing the claims.
  • Claims are processed faster with TPA, and the settlement process is handled without glitches.
  • TPA also provides wellness programs and medical advice, which helps the individual to a great extent.
  • The document process is handled smoothly, along with the issuance of health cards.
  • TPA also provides ambulance service, extra beds, and supplies essential medicines.


TPAs are the mediating managers of the claim process and the maintenance head of the policy details. Their engagement in insurance enables the different processes of Health Insurance, like settlement of claims, cashless healthcare, customer support, etc., to be simple and fast. However, many individuals still approach their broker for these needs since they are ignorant, which might postpone their request and escalate issues. It is best if people start learning the simple fact that once the insurance is bought, they have to contact the TPA for all their issues, they can get the benefits without any delays or difficulties.