TPA Vs In-House Health Insurance

TPA vs in-house health insurance claim settlement process: Differences to know

  • TPA Vs In-House Health Insurance you should also consider other factors such as coverage benefits offer under the policy.
  • Exclusions, claim settlement ratio of the insurers, waiting period, etc.

TPA Vs In-House Health Insurance

The health insurance claim settlement process is one of the most important aspects of a policy.

You can get your health insurance claim settle by the insurer in two ways.

In-house claim processing department and a TPA Vs In-House Health Insurance.

While buying a policy, a buyer should understand that TPAs associate with the insurers are available for processing the health insurance claims only.

They cannot accept or reject the claims, the authority for acceptance or rejection lies with insurers only.

Besides, there are no TPAs for other kinds of insurance such as life insurance or motor insurance.

A TPA acts as an intermediary between the insurer & the claimant

Who facilitates the settlement/processing of health insurance claims.

A TPA Vs In-House Health Insurance is appoint by the insurance company.

The in-house claim processing department, which is also known as Health Administration Team (HAT), is set up by insurers within their own company.

Both methods help in the claim settlement process and have some pros and cons.

In this piece, we take a look at five major differences between them.

Better services than TPAs

To stand in the competition, the insurance companies provide unique facilities to the policyholders.

Building an in-house claim process allows the insurance company to provide special offerings including ease on the claims handling front.

Lower Turnaround Time (TAT), etc. to policyholders from time to time.

TPA Vs In-House Health Insurance

The process is smooth & faster than TPA

Since the policyholder can directly deal with the insurer via the in-house claims settlement.

It takes less time to process the claim compare to a TPA that acts as the middleman between the insurer and the policyholder.

Sometimes, a TPA can be incompetent in handling a cluster of cases and rely on the insurer for decision.

TPAs are reliant on insurers

TPAs are dependent on the insurers for settling health claims.

Which is not the case in the in-house claim settlement process as ultimately.

The insurers are the ones to take care of health claims directly.

This can be another benefit of choosing an in-house claim settlement process.

TPAs have a greater hospital network

TPAs have their list of network hospitals, which is mostly longer than that of the in-house claim settlement department of any insurer.

It can be said that the extent of coverage for cashless treatment in-network hospitals of TPAs is greater than most of the insurance companies in India.

What is an in-house claims processing department?

In the in-house claim settlement process, instead of taking the services of a TPA company.

Insurers set up an entire department within their own company to act as in-house claims processing department.

The in-house claims processing department is also known as HAT (Health Administration team).

One of the major advantages of having an in-house claim settlement process is that the turnaround time (TAT) for resolving a query or claim is faster.

Hassle-free as the decisions are directly take between insurers and policyholders since there is no TPA in between.

If you are getting your health insurance claim processes through a TPA you need to submit all the details.

The TPA and then they will get your claims settle by the health insurer.

However, in case of the in-house claim settlement process, the health insurer will directly deal with you.

The concerned hospital and settle the claim probably within a few hours or a day itself.

TPAs provide better claim settlement facilities

TPAs can provide better facilities to the policyholders to make claims under their health insurance policies by making the process easily understandable.

While, in the case of the in-house claim settlement department, you have to go through the customer care route, which may take more time.

Advantages of in-house claims processing department over TPAs

  • The insurer builds a key differentiator on the claims handling front, around TAT.
  • Other facilities. Building an in-house claims process allows the insurer to provide special offerings to their policyholder from time to time.
  • TPAs cannot take any judgement on claims and are only allow to process them.
  • So, if there are a large number of cases requiring a formal judgement.

A TPA may be inefficient and will end up escalating most cases to the insurer only.

In case of in-house claims processing department where the entire process is done within the insurance company itself.

Claim process is more hassle-free and takes less time as compared to TPAs.

  • TPAs are dependent on the insurer for getting the health insurance claim settle for the policyholders.

Thus, the efficiency of a TPA depends on how tight its terms of operations are.

How clearly the processes are define for them by the health insurer to process the claims they receive.

Third Party Administrator TPA Role in Health Insurance India - PolicyX

Advantages of TPAs over in-house claims processing department

  • According to Ramani, TPAs have their own hospital networks which is mostly larger than an in-house claim settlement department of an insurance company.
  • The extent of coverage provided by some of the largest TPAs for cashless is higher than most insurance companies in India.

Mint takeaway

Both in-house claim department and TPA provide effective processes for health insurance claim settlement.

While the mentioned differences can help you decide to choose rightly between health insurance companies offering TPA.

An in-house claim settlement department, you must not take policy buying decisions solely based on these factors.

Instead, you should consider other factors as well, such as coverage benefits offer under the health policy, exclusions, claim settlement ratio of the insurers, waiting period, etc.

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