Health Insurance Plans

Cashless Medical Treatment

In the sector of best health insurance in India, each insurer hospitals nationwide. So, if you find yourself admitted to any of these esteemed partnerships with a vast network of empanelled hospitals,you can bid farewell to worries about payment. Simply present your policy number, and your insurer and the hospital will shoulder all your expenses. Cashless claims reign supreme in health insurance policies, owing to their seamless process that eliminates hassles related to claim disbursement and tedious documentation.

Post and Pre-Hospitalisation Coverage

Best health insurance in India goes beyond merely covering hospitalisation expenses, providing clients with comprehensive coverage. Today, traditional health plans extend their reach to include pre and post-hospitalisation expenses, ensuring a holistic approach to healthcare. Moreover, these plans offer benefits like medication costs, doctor consultations, ambulance charges, and much more, ensuring that individuals are safeguarded against various healthcare expenses.

No Claim Bonus

Best health insurance in India gives policyholders an enticing perk known as a "no-claim bonus." This bonus rewards individuals who haven't made any claims during the previous year by offering them a discount on their premiums or an increase in their coverage. Upon renewing the policy, policyholders can take advantage of this appealing no-claim bonus, ensuring they are recognised and rewarded for their healthy track record.

Medical Checkup Facility

Choosing the best health insurance in India that aligns with your needs not only grants you coverage when required but also opens the door to regular medical check-ups. In addition, as a valuable inclusion within your health plan, insurers understand the significance of proactive healthcare and provide this facility to ensure your well-being remains a top priority.

Co-Payment

Co-payment is a valuable benefit offered by health insurance plans that helps individuals manage their medical expenses. With co-payment, policyholders must pay a fixed, predetermined amount out of pocket for specific healthcare services while the insurance company covers the remaining costs. This feature of the best health insurance plans in India ensures that individuals have affordable access to necessary medical treatments, consultations, or prescription drugs, promoting timely healthcare utilisation and reducing financial burden.

TPA

The third-party administrator, or the TPA, is not an employee of any health insurance company but an independent and separate entity that acts as the bridge between you and your insurance provider. The TPA is licensed by the IRDAI to execute this task for insurers across categories, and not just for players engaged in health insurance. It can be an individual, an agency or could be a company that is retained by the insurer to perform several administrative services such as managing customer services on its behalf. Typically, it receives a fee of 5.5% of the premium amount. However, for the customer, the services provided by the third-party administrator are for free – there is no hidden cost in the contract.

Scope Of Work for a TPA

The tasks that make TPA a key cog in your relationship with your health insurance provider is primarily customer service. This includes claims processing which makes it necessary for you to interact with a TPA. Insurers across verticals, including health insurance companies, outsource their claims process (a portion of it or entirely) to a TPA of their choice. In the case of health insurance-related claims though, the third-party administrator also coordinates with the network hospital or any other hospital where the policyholder has undergone treatment before filing their claim. In India, many health insurance companies have their own dedicated departments for claims processing. For instance, NivaBupa health insurance processes your claims without any TPA, which significantly reduces the time taken to process your claims.

Role/Importance Of TPA

While some of the functions of the third-party administrator have been touched upon earlier, let's get into further details for a better insight. Broadly, the TPA is supposed to- Promote cashless facilities Provide customer service Process claims

Customer Service

The work of the third-party administrator – vis-à-vis you – begins the day the policy is sold to you,i.e. when you enter your health insurance provider’s database. Any service of your’s which is due, is now the responsibility of the TPA. Some of these services include- delivery of the health/identity card, attending to your grievances if any and of course, settling claims. The TPA streamlines costs and services and keeps you posted on network hospitals and addresses any concern that you may have. The TPA also makes payments to the hospital (in the case of non-cashless cases) and aids the reimbursement process with the help of your provider.

Cashless Service

The TPA is also responsible for building the network of hospitals for the health insurance company. In the process, it brings the cashless facility to you as the insured. It takes the call on empanelling a hospital-based on its service track record, infrastructure and facilities, management background and IT infrastructure.

Claims Processing

This is the role that the TPA is most known for. It coordinates with the hospitals for claim settlements, verifies bills for treatments, checks for false claims and even settles payments with hospitals in case of cashless facilities.

IRDAI Amendments

Until recently, a policyholder had to accept any third-party administrator their health insurance provider chose. This changed on December 3, 2019, when the IRDAI announced amended regulations giving customers the right to choose a TPA from the list suggested by their health insurance provider. To be precise, “The policyholder can choose a TPA of their choice from amongst the TPAs engaged by the insurer” as stated in the notification on the website. Keep in mind though that as a policyholder, you can only choose the TPA from the list suggested at the time of buying or renewing the policy. If you do not choose any of the suggested TPAs, then the health insurance company can allot you a TPA of its own choice. IRDAI also allows the health insurance company to limit the TPA list based on the health insurance product and geographical location of the policyholder. Hence, if the insurer engages the services of only one TPA because of those factors, you will have no option but to go along with that particular TPA. The regulator also says that it is the insurer’s “prerogative” to engage or discontinue the services of a TPA for a particular health insurance product. Also, the only time you can choose (an alternate) TPA is if the services of the original TPA are terminated during the period of your health insurance coverage.