Section 16 in Insurance Regulatory and Development Authority of India (Third Party Administrators - Health Services) Regulations, 2016
16. Revocation, Suspension, Cancellation or denial of renewal of Certificate of Registration granted to a TPA.
(1)The Authority may by order, revoke, suspend or cancel the Certificate of Registration granted to a TPA or deny renewal to an applicant if it is satisfied, that:a. The TPA is functioning in a manner detrimental to the interests of the insured, policyholder or insurer;b. The financial condition of the TPA has deteriorated because of which the TPA cannot function effectively;c. The character, constitution and ownership of the TPA has changed significantly since the grant of Certificate of Registration;d. The TPA furnished wrong or false information or undertaking or willfully concealed or failed to disclose material facts in the application for obtaining a Certificate of Registration or renewal of Certificate of Registration and such Certificate of Registration or renewal was granted to the TPA on the basis of non-disclosure, misrepresentation of facts or fraud;e. The TPA is under liquidation or is adjudged as being insolvent;f. The TPA has violated or failed to comply with these regulations or any other provisions of the Insurance Act,1938, Insurance Regulatory and Development Authority Act, 1999 or rules, regulations, guidelines or circulars issued by the Authority;g. The TPA failed to furnish information relating to its business as a TPA or failed to submit periodical returns as required by the Authority;h. The TPA did not co-operate with any inspection, audit or enquiry conducted by the Authority or caused by the Authority;i. The TPA failed to resolve the complaints of the policyholders or network providers or failed to give a satisfactory reply to the Authority in this behalf;j. The TPA is found guilty of misconduct or its conduct is not in accordance with the Code of Conduct mentioned in these regulations.[k. The TPA failed to maintain the minimum capital or net worth requirement in accordance with the provisions of regulation 6 of these regulations.] [Substituted by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).]l. The TPA failed to pay to the Authority the fees, penalties imposed or the reimbursement of expenses under these regulations;m. The TPA violated the conditions, if any, imposed at the time of issuance of Certificate of Registration or renewal of Registration;n. The TPA did not carry out its obligations as mentioned in the regulations;o. The Chief Executive Officer or Chief Administrative Officer or Chief Medical Officer does not fulfill the norms mentioned in Regulation 11 of these regulations though the TPA is otherwise compliant;p. The TPA has been set up only to divert or siphon off the funds within a group of companies or their associates.q. The TPA has failed to furnish additional information or clarifications called for by the Authority within the time laid down, in connection with the application for renewal of TPA registration.(2)Before taking action under regulation 16(1) of these regulations, the Authority shall grant a reasonable opportunity of being heard, to the TPA.(3)However, the Authority may issue an order revoking or suspending the Certificate of Registration without notice if the TPA;a. violates any one or more of the requirements under the Code of Conduct mentioned in Regulation 23 of these regulations;b. is found to be guilty of fraud or is convicted of a criminal offence;c. commits such defaults which require immediate action in the opinion of the Authority;[***] [[Omitted 'd. has not commenced business within twelve months from the date of Certificate of Registration :Provided that the Certificate of Registration so revoked or suspended shall not be cancelled by the Authority unless an enquiry is conducted and the TPA has been given a reasonable opportunity of being heard.' by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).]](4)Every order made by the Authority under Regulation 16 (1) of these regulations shall be in writing stating clearly the reasons for revocation, suspension or cancellation or denial of renewal of the Certificate of Registration and shall be served on the TPA.(5)Every order of revocation, suspension or cancellation of Certificate of Registration or denial of renewal of the Certificate of Registration, shall be displayed on the website of the Authority for information of general public and the insurance companies for necessary action.(6)[ A TPA against whom an order of revocation or cancellation or denial of the renewal has been passed by the Authority shall not, for a period of two year from the date of such revocation or cancellation or denial, submit a fresh application to the Authority for grant of certificate of registration as a TPA.] [Inserted by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).]
