What's a TPA (Third Party Administrator) In Health Insurance | Pazcare
TPA in health insurance, Advantages of TPA, Role of TPA, Top TPA companies
September 21, 2022
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Let us imagine Tarun and Shivani are working in the same organization. Tarun is hospitalized for dengue in a non-network hospital and Shivani decides to get a cosmetic procedure done. Tarun spends close to Rs.50,000 on his medical bills whereas, Shivani spends around Rs.75,000 on the procedure. After discharge, they decide to raise a group health insurance claim as they have an active group health insurance policy.
For Tarun, the TPA approves the claim and he gets the money spent on the medical bills reimbursed. On the other hand, Shivani’s claim gets rejected. The health insurance TPA informs Shivani that cosmetic procedures are not covered in her insurance plan. Cosmetic procedures are mentioned as exclusions in the insurance policy hence, the claim is rejected.
Now, why did this happen?
Shivani was unaware of the exclusions mentioned in her GHI policy. As a result of which she had to pay for it on her own.
So, this is why one has to read the exclusion in an insurance policy contract carefully before going for any treatments or procedures.
Always know that your health insurance plan will not cover every medical expense of yours and there are certain exclusions in the insurance policy. A health insurance plan, individual or group plan generally covers most diseases and treatments. However, there are certain treatments and medical conditions that are not covered by your plan.
The treatments and procedures that are not covered in your policy are called exclusions in a health insurance policy. You can’t claim for any expenses you make for a treatment that is mentioned as exclusion.
Exclusions are always clearly mentioned in your insurance contracts. So just like Shivani, you will have to pay the medical bills out of your pockets when you raise a claim for such exclusions.
However, in an individual health insurance plan, pre-existing diseases are covered after a certain waiting period. Hence, they are considered exclusions during the waiting period. But, your group plan is different. It covers your pre-existing diseases from day 1 with 0 waiting period.
So, as long your group plan is considered, pre-existing conditions and waiting periods are not exclusions in your health insurance plan.
Permanent exclusions in health insurance policies are those treatments and conditions which will be never covered in your plan at any point in time. They are permanently excluded from your health insurance. These include HIV, AIDS, congenital diseases, damages due to war or nuclear weapons, etc.
Cosmetic treatments or surgeries which enhance the appearance of people are generally not covered in your group insurance policy. However, plastic surgeries or reconstructive treatments due to accidents, burns or cancer may be covered in your policy depending on its terms and conditions.
Treatment expenses generated due to injuries caused by suicide attempts or any other self-harm are not included in your policy.
Expenses related to treatments or procedures on the account of substance abuse, alcoholism or any other addiction are excluded from coverage.
Your group health insurance policy do not cover expenses generated due to alternative treatments like naturopathy, acupuncture, magnetic therapies or any such treatments.
According to the IRDAI circular, there is a standard list of exclusions for your health insurance contracts. However, a few like pre-existing diseases and waiting periods do not apply to a group insurance policy.
Here are some things your health insurance policy does not cover!
Dental treatments are considered cosmetic procedures by the insurer. Hence, expenses due to dental treatments are not covered in your policy. But dental treatments due to accidents or injury may be covered by your insurer. However, while purchasing your group plan you can add a rider plan to cover dental treatments.
Just like dental insurance, maternity-related hospitalization and other expenses towards it are not covered by default in your group policy. However, you can purchase maternity insurance cover as an add-on cover to your group health insurance plan.
Expenses due to treatment or surgeries to change the gender of an individual are considered exclusions in your policy.
Most group health insurance policies provide you with provisions to cover room rent and ICU room rent expenses, doctor’s consultation, and diagnostic tests expenses. However, there is a limit on these expenses for most plans, unless you go for an add-on cover. Read your policy wording carefully to know the conditions attached to them.
Learn about room rent limit and sub-limits
Your group health insurance policy may not cover expenses that arise due to mental illness or disorders treatment.
Any hospitalization expense without a doctors’ recommendation will not be covered in your group insurance plan unless it's an emergency hospitalization.
Miscellaneous expenses include the cost of hearing aids, spectacles, health supplements or any other items included in the IRDAI’s list of expenses excluded category will not be covered by your insurer.
Inclusions are all medical treatments and hospitalizations that are covered in your policy. It basically states all the benefits you get from the group health insurance. Inclusions are also mentioned in your policy contract.