Section 21(3) in Insurance Regulatory and Development Authority of India (Third Party Administrators - Health Services) Regulations, 2016
(3)Scrutiny and handling of claims:a. TPA may admit claims, authorize cashless facility and recommend to the insurer for the payment of the claim which shall be in line with the detailed claims guidelines issued to TPA by the insurers for the particular product:Provided that the detailed guidelines as given by the insurer to the TPA for claims assessments and admissions shall be within the terms and conditions of the policy contract, the capacity requirements envisaged and the internal control norms put in place.b. TPAs shall endeavour to collect all documents pertaining to the claims reported in electronic mode for seamless processing and for recommending to the insurer for payment or rejection as the case may be.c. A TPA shall adopt the following procedure with respect to settlement of the claims:i. In case of admissible claim, full or partial: In the communication addressed to the policyholder or claimant, the TPA shall state clearly the following:(a)"Your claim bearing No (Claim No) against policy issued by (name of the insurer) has been settled for Rs (Amount Paid) against the Amount Claimed for Rs (Claimed Amount) towards Medical Expenses incurred for treatment of (name of the Ailment) at (Name and City of the Hospital) for the period from (Date of Admission) to (Date of Discharge)":(b)The granular details of the payments made, amounts disallowed and the reasons there for.(c)The details of (i) Grievance Redressal Procedure in place with the insurer (ii) Contact details of concerned Grievance Redressal Office and officer (iii) Procedure to be followed for approaching Insurance Ombudsman in case the policyholder or claimant is not satisfied with the resolution provided by the insurer (iv) Contact details of office of Insurance Ombudsman:Provided that the above details shall be mandatorily included in the communication to the policyholder or claimant in every case where the TPA has disallowed any part of the claim.ii. In case of inadmissibility of the entire claim(a)The TPA on its own shall not reject or repudiate the claim;(b)The decision and the communication with respect to rejection or repudiation of claim shall be sent only by the concerned insurer directly to the Policy holder or the claimant as the case may be.
