Section 3 in Insurance Regulatory and Development Authority of India (Third Party Administrators - Health Services) Regulations, 2016
3. Health services by TPA.
(1)A TPA may render the following services to an insurer under an agreement in connection with health insurance business:a. servicing of claims under health insurance policies by way of pre-authorization of cashless treatment or settlement of claims other than cashless claims or both, as per the underlying terms and conditions of the respective policy and within the framework of the guidelines issued by the insurers for settlement of claims.b. servicing of claims for Hospitalization cover, if any, under Personal Accident Policy and domestic travel policy.c. facilitating carrying out of pre-insurance medical examinations in connection with underwriting of health insurance policies:Provided that a TPA can extend this service for life insurance policies alsod. health services matters of foreign travel policies and health policies issued by Indian insurers covering medical treatment or hospitalization outside Indiae. servicing of health services matters of [travel or health or medical insurance] [Substituted 'foreign travel' by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).] policies issued by foreign insurers for policyholders who are travelling to India:Provided 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.f. servicing of non-insurance healthcare schemes as mentioned in Regulation 22 (3) of these Regulations.g. any other services as may be mentioned by the Authority.(2)While performing the services as indicated at Regulation 3 (1) of these regulations, a TPA shall nota. Directly make payment in respect of claimsb. Reject or repudiate any of the claims directlyc. Handle or service claims other than hospitalization cover under a personal accident policyd. Procure or solicit insurance business directly or indirectlye. Offer any service directly to the policyholder or insured or to any other person unless such service is in accordance with the terms and conditions of the policy contract and the agreement entered into in terms of these regulations.(3)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 claimants.(4)[ The policyholder can choose a TPA of their choice from amongst the TPAs engaged by the insurer, where services of TPAs are engaged by the insurer for a given insurance product.(a)Where the services of the TPA are terminated during the course of health services rendered by the said TPA, every insurer shall allow the policyholder to choose an alternate TPA from amongst the TPAs engaged by it.(b)The insurer shall explicitly provide the names of the TPAs amongst whom the policyholder may choose the TPA of their choice at the point of sale. The Policyholder may be allowed to change the TPA of their choice only at the point of renewal.Provided that the policyholder shall have no right to seek dispensing the services of the TPA and request the insurer to undertake rendering the health service directly.Provided further that the insurer shall have the prerogative of whether or not to engage any TPA or to terminate the services of the TPA or not to engage the services of the TPA for a particular health insurance product or discontinue the services of the TPA to service a particular health insurance product.Provided further that the insurer shall have the prerogative of changing the TPA in accordance to the provisions of sub-regulation (8) of regulation 20 of these regulations.(c)Where the Policyholder did not choose any of the TPAs, the insurer may allot the policy servicing to a TPA of its choice.(d)Where the insurer engages the services of only one TPA, no option need be provided to the policyholder.Explanation. - For the purposes of this sub-regulation, the choice of the policyholder to choose a TPA for rendering health services is limited to the TPAs with whom the insurer is having Service Level Agreements in place. Based on the health insurance product and geographical location of the policyholders, the insurer may also limit the number of TPAs amongst whom the policyholder may choose a TPA of their choice. The insurer explicitly shall provide the list of the TPAs engaged, from amongst whom the policyholder may choose a TPA of their choice, at the time of proposal or the renewal as the case may be.(5)The Authority may specify guidelines for disclosure of qualitative and quantitative parameters by all insurers and TPAs with respect to the health services rendered.] [Inserted by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).]
