Section 33 in Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016
33. Engagement of Services of TPAs by Insurers in relation to Health Insurance Policies.
- a. Every Insurer shall provide detailed product wise guidelines to TPAs for handling of claims i.e. claim admissions and assessments. The guidelines shall articulate the payments / benefits allowed or disallowed under various products that are being serviced by the TPAs. While prescribing such guidelines the Insurers shall also prescribe the capacity requirements, internal control procedures to be put in place by the TPA under the agreement for rendering the services under such product.b. Detailed Claim Guidelines: Every Insurer shall issue detailed product specific claim guidelines to TPAsc. Insurers shall ensure that the TPAs are not carrying out the following activities as part of the agreementi. Claim rejections/repudiations with respect to the health insurance policies;ii. Payments to the policyholders, claimants or the network providers;iii. Any services directly to the policyholder or insured or to any other person unless such service is in accordance with the terms and conditions of the Agreement entered into with the insurer and complies with the IRDAI (TPA-Health Services) Regulations, 2016.d. Settlement and Denial of Claims:i. Insurers and/or TPAs, as may be applicable, shall endeavour to collect documents for processing claims for disposal electronically. Claims that are being settled shall be done through e-payments by the insurers.ii. Where claims are directly handled by the Insurers, the provisions of Regulation (21) (3) (c) (i) of IRDAI (TPA-Health Services) Regulations, 2016 shall be complied in the correspondence to the policyholder with respect to settlement of the claimsiii. The insurer shall be responsible for proper and prompt service to the policyholders at all times.iv. Where a claim is denied or repudiated, the communication about the denial or the repudiation shall be made only by the Insurer by specifically stating the reasons for the denial or repudiation, while necessarily referring to the corresponding policy conditions. The insurer shall also furnish the grievance redressal procedures available with the Insurance Company and with the Insurance Ombudsman along with the detailed addresses of the respective offices.e. More than one TPA may be engaged by an insurance company.
