Section 20 in Insurance Regulatory and Development Authority of India (Third Party Administrators - Health Services) Regulations, 2016
20. [Health Service Agreements] [Substituted 'Agreements between (i) a TPA and an Insurer and (ii) a TPA and a Network Provider and (iii) a TPA, an insurer and a Network Provider' by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).].
(1)A TPA shall enter into an agreement for providing the defined Health Services with an insurer and network provider, in respect of Health Insurance Policies covering hospitalization benefits within India, issued by an Indian insurer. A TPA shall ensure that the agreement is enforceable at all times.(2)The insurer and the TPA shall define the scope of the Agreement, the health and related services that may be provided by the TPA and the [fees] [Substituted 'remuneration' by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).] therefor, subject to such stipulations as may be laid down by the Authority, wherever applicable.(3)Nothing contained in these regulations shall be deemed to prevent or prohibit an insurer from cancelling or modifying an agreement that has been entered into by it with a TPA.(4)A TPA shall file details of the agreement entered into between the TPA, insurer, Network Provider as the case may be or any modification thereof, in such form as may be specified by the Authority from time to time.Provided that the Authority, at any point of time, may call for a certified copy of the agreement.(5)The agreement shall contain following clauses;a. its termination by either party on mutual consent or on grounds of any fraud, misrepresentation, deficiency of services or other non-compliance or default. However, there shall be no clause in the Agreement which shall dilute, restrict or otherwise modify the regulatory stipulations mentioned by the Authority in respect of policyholders' interests, protection, service standards and turn-around-time parameters.b. prescribing the minimum Turn Around Time envisaged for rendering various policy services stipulated in the terms and conditions of the policy contract:Provided that the Turn Around Times stipulated shall at no point of time exceed the minimum norms prescribed in any of the regulatory requirements.c. the [fees] [Substituted 'remuneration' by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).] payable to the TPA by an Insurer.Provided that, the Authority may specify additional minimum standard clauses to be included in the agreement that may be entered into between insurer, network provider and TPA, as the case may be.(6)The [fees] [Substituted 'remuneration' by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).] agreed to be payable to the TPA and agreed to be receivable by the TPA shall be based on the health services rendered to the insurer. Insurers are prohibited to pay any remuneration related to the product, linking to the claims experience or the reduction of claim costs or loss ratios.(7)TPA are prohibited to charge any fees in any form or in any manner from the policyholders or network providers for the health services rendered under these Regulations and in terms of the agreement.(8)Any change in a TPA by the insurer shall be communicated to all the policyholders thirty days before giving effect to the change.a. The contact details like helpline numbers, addresses etc. of a new TPA shall be immediately made available to all the policyholders in case of change of TPA.b. The insurer shall take over all the data in respect of the policies serviced by the earlier TPA and make sure that the same is transferred seamlessly to the newly assigned TPA, if any. It shall be ensured that no inconvenience or hardship is caused to the policyholder as a result of the change. In this regard, inter alia the following aspects shall be taken into consideration;i. Status of cases where pre-authorization has already been issued by existing TPA.ii. Status of cases where claim documents have been submitted to the existing TPA for processing.iii. Status of claims where processing has been completed by the existing TPA and payment is pending with the insurer.(9)Discounts on Bills offered by Network Providers. - The insurers and the TPAs shall ensure that discounts, if any, received or agreed to be received from the hospital towards health services are passed on to the policyholder or the claimant. Subject to this,a. Where discounts are obtained from any of the Network Providers or from any other Hospitals outside the network, either by TPAs or by the Insurers, it shall be ensured that the discounts, if any, so obtained from the network providers / hospitals, are passed on to the policyholders or the claimants of the concerned health insurance policy.b. Where, by virtue of any agreement, discounts are agreed to be received on the aggregated bills raised by the hospitals, every insurer or TPA shall appropriately identify and apportion the eligible amount of the discount to the underlying health insurance policy in respect of which the claim is settled so as to pass on the benefit of the discount to the concerned policyholder or the claimant, as the case may be.c. In order to implement the above Regulations, every Insurer and the TPA shall put in place the following procedures:i. The insurers and TPAs shall mandate the hospitals to reflect such agreed discounts in the final hospitalization bill of each claim, by which the policyholder or the claimant can also be aware of the actual bill raised by the hospital.ii. Where the admissible claim amount is more than the Sum Insured, the agreed discount shall be effected on the Gross amount raised in the bill, before letting the policyholder or the claimant bear the costs over and above the eligible claim amounts.iii. Where the underlying health insurance policies have co-payment or the deductible conditions, the insurer or TPA shall ensure that the said co-payment or deductible is effected only after netting off the discounts offered by the hospital, if any.d. Every Insurer shall make these procedures as part of the detailed guidelines on claim settlement to be provided to the TPAs, in accordance with the provisions of [sub-regulation (b) of regulation 33 of Insurance Regulatory and Development Authority of India (Health Insurance) Regulations, 2016] [Substituted 'Reg. 12 (b) (i) of IRDA (Health Insurance) Regulations, 2013' by Notification F. No. IRDAI/Reg/15/166/2019, dated 3.12.2019 (w.e.f. 14.3.2016).] as amended from time to time.e. The above procedures shall be applicable to both cashless services and reimbursements of all the claims of health insurance policies.
