Third Party Administrator (TPA) and IRDA Norms
Insurance Regulatory and Development Authority of India (IRDA), which licenses and regulates the Third Party Administrator (TPA) has specified some entry norms:
1. The primary objective of the company shall be to carry on business in India in health service. The minimum capital of the company shall be in equity shares amounting to Rs.1 crore.
2. At no point of time of its functioning the TPA shall have a working capital of less than Rs.1 crore.
3. At least one of the directors of the TPA shall be a qualified medical doctor registered with the MCI.
4. The aggregate holdings of equity shares by a foreign company shall not at any time exceed twenty-six percent of the paid up equity capital of a third party administrator.
License is usually granted for a period of 3 years to a TPA. TPA ties-up with the hospitals and the hospitalization services are provided on cashless basis.
Procedures for Issue of License
- TPA shall obtain from the IRDA Authority a license prior to commission of functions.
- The application for license shall be accompanied by a non-refundable fee of Rs. 20,000/- payable to the IRDA Authority.
- Approved TPA shall pay a further sum of Rs.30,000/- as license fee by way of a crossed demand draft.
- A TPA whose application has been rejected by the Authority shall not apply once again for a period of two years from the date of such a rejection.
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I regret to inform that I have submitted my Domiciliary Treatment Claims from Nov.16 to February 16 along with necessary documents as prescribed by Bank/TPA to Vidal Health,Bangalore and there is no response from Vidal till date. My efforts to get the status of my claims proved futile. I am at a loss to understand the reasons for the inordinate delay on the part of Vidal to reimburse my claim amount . Pl help me to get my claims sanctioned at the earliest. As I am representing my difficulty to Insurance Ombudsman Hyderabad, kindly use your offices to get the problem solved. Thank you.
Kindly let me know if it is obligatory to have the services of TPA while purchasing the Mediclaim Policy?Kindly reply at the earliest as I am to renew my Mediclaim Policy next month,and I am not happy with the services of my existing TPA.Kindly also let me know,whom to complaint against the TPA for the unsatisfactory services of TPA. An early reply to my querry will be a big favour as I understand that the fee payable to TPA is by the Policy purchaser.
Health insurance consists of Pre Hospitalisation, Hospitalisation and Post Hospitalisation. But normally it is seen that Pre and post hospitalisation are not cared by TPAs. They pay only for hospitalisation in cashless claims to hospitals. If in a cashless claims, if an insured is late to intimate to TPA while still in Hospital, the tPA does not entertain cashless service. What are the reasons ?
Q. MY FATHER WAS ADMITED IN APOLLO HOSPITAL, KOLKATA ON 17.1.2013 AT 2.45PM, AND RELEASED ON 21.1.2013 AT 9.45AM. HOSPITAL AUTHORIYT SEND THE FINAL BILL AT 10.00AM ON 21.1.2013 FOR CASHLESS APPROVALTO TPA [Emeditek] FOR 5 (FIVE) DAYS. BUT TPA SEND THE APPROVAL AT 4.30PM FOR 4 (FOUR) DAYS, BECAUSE THR 5TH DAY NOT COVERING 24 HOURS. WHAT IS THE RULE OF IRDA and AM I CASH BACK FOR THE 5TH DAY'S AMOUNT ON REIMBURSEMENT BASIS?
You have stated in the third para related to TPA that TPA also collects premium.Is it permitted by IRDA regulations for TPAs?