Question 1

What is a TPA (Third Party Administrator) in health insurance?

Accepted Answer

A Third Party Administrator (TPA) is an IRDAI-licensed intermediary that handles cashless pre-authorisation, claim processing, and network hospital management on behalf of a health insurer. TPAs like Medi Assist, FHPL, and Vidal process claims for insurers who choose not to manage claims in-house.

Question 2

What is the difference between TPA settlement and in-house settlement?

Accepted Answer

With in-house settlement, the insurer (e.g. HDFC ERGO, Niva Bupa, Star Health) processes claims directly through their own team - usually faster (1–3 hours pre-auth) and more accountable. With TPA settlement, a third-party administrator handles the process - response times are typically 2–8 hours for planned admissions.

Question 3

How long does TPA take to approve a cashless pre-authorisation?

Accepted Answer

For planned hospitalisations, most TPAs respond within 2–6 hours of receiving a complete pre-auth request. For emergency admissions, IRDAI mandates a response within 1 hour. Medi Assist typically responds within 2–4 hours; FHPL within 4–6 hours for planned cases.

Question 4

What should I do if the TPA rejects my pre-authorisation?

Accepted Answer

If your TPA rejects pre-authorisation, ask for the written rejection with specific reason. You can: (1) get the treating doctor to provide additional medical justification; (2) escalate directly to the insurer's grievance team; (3) opt for reimbursement and claim after discharge; or (4) file a complaint with the IRDAI Ombudsman if rejection is unjustified.

Question 5

Can I submit a claim directly to the insurer instead of the TPA?

Accepted Answer

For reimbursement claims, you can submit documents directly to the insurer's claims department even if a TPA manages your policy. For cashless claims, the pre-auth must go through the designated TPA. Contact your HR or broker to confirm the correct submission address for your policy.

Question 6

How do I find out which TPA manages my group health policy?

Accepted Answer

Your TPA name and contact details are printed on your e-health card issued at policy inception. It is also mentioned in the policy schedule document and the welcome kit sent by the insurer. If unclear, your HR or insurance broker can confirm within minutes.

Question 7

Is TPA required for all group health insurance policies in India?

Accepted Answer

No. Many private insurers - including HDFC ERGO, ICICI Lombard, Star Health, Niva Bupa, and Aditya Birla Health - process claims in-house without a TPA. PSU insurers (New India Assurance, Oriental Insurance) typically assign a TPA for group policies.

Insurer	Settlement Model	TPA / Claims Team	Pre-auth Speed
HDFC ERGO	In-house	Own claims team	1–2 hours
ICICI Lombard	In-house	Own claims team	1–2 hours
Star Health	In-house	Own claims team	2–3 hours
Niva Bupa	In-house	Own claims team	1–2 hours
Aditya Birla Health	In-house	Own claims team	2–3 hours
Bajaj Allianz	TPA	Medi Assist / FHPL	2–4 hours
Tata AIG	TPA / In-house	Medi Assist (plan-dependent)	2–4 hours
New India Assurance	TPA	Medi Assist, FHPL, Vidal	4–6 hours
Oriental Insurance	TPA	FHPL, Vidal, Medi Assist	4–8 hours
SBI General	TPA	Medi Assist	3–5 hours
Reliance General	TPA	Medi Assist / FHPL	3–6 hours

Factor	TPA Settlement	In-House Settlement
Pre-auth speed	2–8 hours typical	1–3 hours typical
Accountability	TPA is intermediary; insurer is at one remove	Insurer is fully responsible end-to-end
Escalation path	TPA → Insurer → IRDAI Ombudsman	Insurer → IRDAI Ombudsman
Claim tracking	Via TPA portal (Medi Assist, FHPL, Vidal)	Via insurer's own app or portal
Network hospitals	TPA's empanelled hospitals only	Insurer's own empanelled hospitals
Best suited for	PSU insurers (New India, Oriental)	Private insurers (HDFC ERGO, Niva Bupa, Star Health)

Third Party Administrators (TPA)

What is a Third Party Administrator?

Key TPA Services

Leading TPA Providers

Medi Assist India TPA Services

Family Health Plan Limited (FHPL)

Vidal Health TPA Services

Government Health Insurance Company (GHICO)

Good Health TPA Services

Heritage Health TPA Private Limited

Paramount Health Services

Raksha TPA Private Limited

Genins India TPA Services

MD India TPA Services

Benefits of TPA Services

Quick Processing

Extensive Network

Customer Support

Which Insurer Uses Which TPA?

TPA vs In-House Settlement

Frequently Asked Questions

Need Health Insurance with TPA Services?