Health Insurance (5)
TPA is an abbreviation for Third Party Administrator. These companies assist the health insurance companies with their back end processing of claims and are responsible for coordinating all aspects of claims arising due to health insurance policies.
These companies are licensed by IRDA (Insurance Regulatory & Development Authority) and enter into agreements with health insurance companies to provide them with support on claims administration and management. When you purchase a health insurance policy, the insurance company will inform you of it TPA and provide you with its contact details. In the case of hospitalization and associated claims, you will need to contact the TPA who in turn will assist you with the settlement of your claims.
TPAs will be your point of contact in case of both emergency as well as planned medical procedures and will provide necessary authorization to hospitals for ‘cashless’ treatments or in other cases coordinate with you for the settlement of claims for expenses incurred by you.
The insurance company ties up with a group of hospitals for cashless claim process, and these hospitals then become a part of its “network”. When you avail of a cashless treatment in any of these network hospitals, the company would settle the claim with the hospital directly. A complete list of network hospitals is generally made available on the insurance company website or as part of the insurance documentation received at the time of purchasing a health insurance policy.
A typical health insurance policy will cover expenses related to:
• Room and boarding expenses in case of hospitalisation
• Diagnostic expenses
• Surgeon, Anesthetist, medical practitioner, Consultant and specialist fees
• Anesthesia, blood transfusion, Oxygen, Operation Theatre expense, cost of surgical appliances, medicine and drug related expenses
• Pre and post hospitalisation expenses subject to terms and conditions as applicable to the product
Please read the products terms and conditions including coverage and exclusions as these can vary from product to product
Health insurance policies do not cover hospital expenses incurred overseas. To cover yourself for any expenses that you may incur related to medical treatments or hospitalisation on account of an illness or accident while on a trip abroad, you need to have a Travel Insurance policy.
There is no limit on number of claims allowed during the year. The limit is on the overall Sum Assured or the insurance cover purchased with your health insurance policy. However, the coverage is reduced by the sum claimed by you with each claim. For e.g. if you have a health insurance policy with Rs. 5,00,000 as Sum Assured and you claim for expenses of Rs. 2,00,000, then the available cover for the remaining part of the year will be Rs. 3,00,000.