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Mediclaim & TPA — Senior Reference Card
Third Party Administrator · India · IRDAI Norms 2024–2026 · For Adults 60+
✅ IRDAI 2026 Updated
📋 Printable Guide
🧓 Senior Friendly
🏢 What is a TPA — In Plain Words
Simple Definition
TPA stands for Third Party Administrator. It is a company licensed by IRDAI that sits between you (patient) and your insurance company.
Think of TPA as the "middleman office" that actually processes your claim paperwork, approves cashless treatment at hospitals, issues your health card, and answers your queries — so the insurer does not have to handle every claim directly.
TPA does not own your policy. It does not pay the money. The insurance company pays — but TPA does all the paperwork and approval work on the insurer's behalf.
Think of TPA as the "middleman office" that actually processes your claim paperwork, approves cashless treatment at hospitals, issues your health card, and answers your queries — so the insurer does not have to handle every claim directly.
TPA does not own your policy. It does not pay the money. The insurance company pays — but TPA does all the paperwork and approval work on the insurer's behalf.
69% of all health insurance claims in India are processed by TPAs.
Only 31% handled directly by insurers (in-house).
Source: IRDAI Annual Report 2024–25
Only 31% handled directly by insurers (in-house).
Source: IRDAI Annual Report 2024–25
Who Are the Key Players
You (Senior)
Policyholder. Pays premium. Has right to claim.
Insurer
Star, United India, New India, HDFC Ergo etc. Holds your money.
TPA
Licensed processor. Manages claims, approves cashless, issues e-card.
Hospital
Empanelled network. Contacts TPA for your cashless authorisation.
GST Removed — Sept 22, 2025: Individual and family health insurance premiums are now 18% cheaper — GST fully waived by 56th GST Council. A major saving for seniors.
🔄 Step-by-Step — How TPA Works During Your Hospitalisation
1
👤 You — Before Admission
Call TPA Helpline — FIRST, Before Entering Hospital
The moment hospitalisation is planned or emergency arises — call the TPA helpline number on your health card. Inform them: policy number, hospital name, diagnosis, and estimated admission date.
🧓 Senior Tip: Save TPA number in mobile as "TPA HELPLINE". Also save on a paper card in wallet. Your family member should have this number too.
2
🏥 Hospital TPA Desk — At Admission
Present E-Card / Health Card at Hospital TPA Desk
Every network hospital has a TPA Desk (Insurance Help Desk) near admission. Show your TPA e-card, policy number, and Aadhaar. The hospital sends a Pre-Authorisation Request to TPA on your behalf.
🧓 Senior Tip: Do not go to billing counter first. Go directly to TPA Desk. Ask: "Where is the insurance help desk?" if not visible.
3
🗂️ TPA — IRDAI Time Limit Applies Here
Pre-Authorisation: TPA Must Respond Within 1 Hour ⏱ 1 HR LIMIT
IRDAI 2024 rule: TPA / insurer must give cashless pre-authorisation within 1 hour of receiving complete documents from hospital. If they delay beyond 1 hour without reason — this is a violation. Note the time of hospital's request.
⚠️ If TPA does not respond in 1 hour — call TPA helpline, then call insurer directly. Write time and name of person spoken to.
4
📋 During Hospitalisation
TPA May Send Queries — Respond Quickly
During treatment, TPA may ask for additional documents — doctor's notes, test reports, clarification on diagnosis. Hospital will pass these to you. Respond same day. Delayed response = delayed or denied claim.
🧓 Senior Tip: Keep a family member as "Claims Contact Person" — ask TPA and hospital to call them if you are in ICU or unable to respond.
5
🗂️ TPA — Discharge Approval
Final Discharge: TPA Must Approve Within 3 Hours ⏱ 3 HR LIMIT
At discharge, hospital sends final bill to TPA. IRDAI 2024 rule: TPA must give final cashless approval within 3 hours of receiving all bills at discharge. If TPA delays beyond 3 hours causing extra room charges — insurer must pay those extra costs, not you.
⚠️ Do not sign any "balance payment" receipt at discharge without first checking if TPA delay caused the extra charge.
6
✅ Cashless — Ideal Outcome
TPA Approves — Hospital Settles Bill Directly with Insurer
If all goes well — you pay only your share (co-pay, exclusions, non-covered items). TPA coordinates payment directly to hospital. You receive a settlement statement. Keep this document safely.
🧓 Senior Tip: Read the settlement statement carefully. Check if any amount was deducted incorrectly. You can raise a query within 30 days.
7
⚠️ If Cashless is Denied — Do Not Panic
Pay First, Claim Reimbursement — Rights Still Apply
If TPA denies cashless — ask for written reason immediately (IRDAI mandates this). Pay hospital bill yourself. Keep all original bills, discharge summary, prescriptions. File reimbursement claim within 15–30 days of discharge as per your policy terms.
⚠️ Never accept verbal denial. Always demand written denial with specific reason. This is your right under IRDAI rules — insurer must provide it.
8
📁 After Discharge — Reimbursement Track
Submit Documents to TPA Within Deadline
For reimbursement: submit original hospital bills, discharge summary, all lab reports, prescriptions, and claim form to TPA office or upload on insurer portal. TPA reviews → passes to insurer → payment within 30 days (IRDAI norm).
🧓 Senior Tip: Ask a family member to help upload/courier documents. Keep photocopies of everything submitted. Note submission date and TPA acknowledgement number.
📊 What TPA Does vs What It Cannot Do — Know the Boundary
| Area | ✅ TPA CAN Do | ❌ TPA CANNOT Do |
|---|---|---|
| Cashless | Approve or deny cashless request on insurer's behalf | Change the terms of your policy or coverage amount |
| Health Card | Issue your TPA e-card / health card with policy details | Refuse to issue health card once policy is active |
| Documents | Ask for additional documents to process claim | Ask for documents not relevant to the claim |
| Queries | Raise queries and ask for clarification | Reject claim on basis of non-fraud after 5 years of policy |
| Settlement | Process and coordinate final payment to hospital | Deduct amounts not mentioned in policy exclusion list |
| Denial | Deny claim with written reason — mandatory per IRDAI | Deny claim verbally or without specific written reason |
| Network | Maintain and update list of empanelled hospitals | Force you to go to a specific hospital without valid reason |
| Grievance | Help you escalate complaint to insurer / IRDAI | Dismiss your complaint without providing a response |
⚖️ TPA — Pros & Cons for Indian Seniors
✅ PRO — Where TPA Helps Seniors
- Issues health card — one card for cashless at all network hospitals
- Dedicated phone helpline — available 24×7 for queries
- Hospital does all cashless paperwork — patient does not chase insurer
- Specialist in claims — faster processing than insurer direct in large volumes
- Serves multiple insurers — experienced in variety of policy types
- NHCX platform (2024) — digital paperless claim submission at 300+ hospitals
- You can change TPA if unhappy — IRDAI now allows this
- Pre-authorisation time bound — 1 hour norm protects patient
- Fake claim detection — audit reduces fraud, protects premium pool
⚠️ CON — Where TPA Hurts Seniors
- TPA staff at hospitals often unhelpful — untrained for senior needs
- Queries sent by email only — seniors miss them, claim lapses
- TPA changes — insurer may change your TPA without clear notice
- TPA desk closed evenings / weekends in some hospitals
- Accountability gap — "TPA says insurer, insurer says TPA" — blame game
- Unnecessary queries to delay payment — common complaint
- Poor coordination between TPA and hospital billing — discharge delays
- Online portal mandatory for reimbursement — hard for seniors without help
- Small town hospitals may not have dedicated TPA desk staff
🆕 Latest 2025–2026 Updates That Affect TPA & Claims
🌐 NHCX — July 2024
National Health Claims Exchange
IRDAI's new digital platform connecting 34 insurers + TPAs with 300+ hospitals. Paperless, standardised claim submission. Reduces errors and delays at source. Expanding to more hospitals in 2026.
⚖️ SBSR Act 2025
Sabka Bima Sabki Raksha Act
New insurance law 2025. TPA registration now perpetual (earlier 3-year term). Better accountability. TPAs allowed to list on stock exchange under conditions. Stronger policyholder rights.
🔒 Bima-ASBA — 2025
Funds Blocked — Not Debited at Purchase
Like an IPO ASBA system. When buying new policy, your premium is blocked in bank account, not debited. If policy rejected — auto-refund. Removes the old problem of money deducted but policy not issued.
💰 GST Removed — Sept 2025
Health Insurance 18% Cheaper
56th GST Council removed GST on individual and family floater health policies. Effective 22 September 2025. Senior citizen policies now 18% cheaper at renewal — significant saving on ₹30,000–₹60,000 annual premiums.
🔄 TPA Change — New Right
You Can Now Change Your TPA
IRDAI 2024–25 guidelines now allow policyholders to request TPA change where feasible. If your TPA service is poor — write to insurer requesting a switch. Keep record of communication.
📱 ABHA Integration
Link ABHA ID for Faster Claims
ABDM's Ayushman Bharat Health Account (ABHA ID) now links your health records and policy. TPA can pull records digitally — reduces paper query rounds. Senior citizens should create and link ABHA ID free.
🧓 7 Things Every Senior Must Do — TPA & Mediclaim
01
Know Your TPA Name & Number
Find TPA name on your policy schedule (first page). Save helpline in mobile as "TPA HELPLINE". Also write on paper and keep in wallet. Do not rely on finding it during emergency.
02
Register Family Member as Claims Contact
Register a son / daughter / trusted person's mobile number with your TPA for all communications. Queries will come to them. Prevents missed deadline when you are in ICU.
03
Get TPA E-Card — Print It
Your TPA issues a digital health card. Download it, print one copy, laminate and keep in wallet. Hospital TPA desk needs this for cashless admission — without it, process is delayed.
04
Always Ask for Written Denial
If TPA or insurer denies any request — demand a written letter stating the exact reason. This is your legal right under IRDAI. Without written denial, you cannot appeal. Never accept "we cannot help" on phone alone.
05
Note Every Date & Time
Write: date of hospital's pre-auth request, time TPA responded, name of TPA officer spoken to. If 1-hour cashless rule is violated, this record is your evidence for complaint to IRDAI Ombudsman.
06
Create ABHA Health ID
Go to healthid.ndhm.gov.in — create free Ayushman Bharat Health Account ID. Link to your mediclaim policy. Digital records speed up TPA query resolution. Reduces rounds of paper submission.
07
Escalate If TPA Delays — Use Ombudsman
If TPA / insurer delays beyond 30 days or rejects unfairly — file online at ecoi.co.in (Insurance Ombudsman). Free service. No lawyer needed. Resolution within 3 months. Most disputes resolve at this stage.
📞 Emergency Helplines — Save All Numbers Now
IRDAI Bima Bharosa
155255
National helpline · Any insurer
IRDAI Grievance Portal
igms.irda.gov.in
Online complaint filing
Insurance Ombudsman
ecoi.co.in
Free · No advocate needed
PMJAY Helpline
14555
Ayushman Bharat
ABHA Health ID
healthid.ndhm.gov.in
Create free health account
Ambulance
108
Free · Pan India
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