TPAs are licensed by the Insurance Regulatory and Development Authority to provide health services. The services of a TPA would usually include:

• Member enrolment and issuance of health card
• Pre-authorization for cashless treatment
• Reimbursement Claim Processing.
• Call center service.
• Customer service support

The role of TPA begins after policy issuance by insurance company.

Yes. The TPA service can be availed anywhere in India.In the event of a hospitalization, you can use the services of any network hospital spread across the country and contact us through toll free, email, web etc.

It is a medical condition/disease that existed before you obtained  health insurance policy, and it is significant, because the  insurance companies do not cover such pre-existing conditions, within 48 months of prior to the 1st policy. It means, pre-existing conditions can be considered for payment after completion of 48 months of  continuous insurance cover.

Pre-Existing diseases are generally excluded in retail health Policies (Exclusion No 4.1) for a period up to 4 years from first policy inception date. Pre-existing diseases will be covered after expiry of defined waiting periods provided that the pre-existing disease was disclosed in the proposal form filled at the time of obtaining policy application.

Health Insurance policy does not cover few diseases in first, second and third year of policy commencement

The list varies from insurer to insurer for different policies. Kindly refer to your policy document or log on to our website for details.

Insurance would usually pay for claims requiring a continuous hospital stay of at least 24 hours . However, for certain Day care procedures (defined in the policy) example dialysis, chemotherapy, eye surgery, etc., the stay could be less than 24 hours. Kindly refer to the policy document or log on to our website for complete list of Day care procedures.

Any one illness' would mean the continuous period of illness,including relapse within a certain number of days as specified in the policy. Usually this is 45 days.

If there is any mistake in the policy you need to contact the insurance company for correction in the same.

There could be a chance that the Insurance Company has still not forwarded your details to us. Also there is a possibility that your card has been dispatched and you have not received the same. You can call our call center and they will guide you accordingly. Alternatively, you can log on to our website (www.hitpa.co.in) and enter your policy number to get your card status.

You may please send your ID card back to us, mentioning the mistakes example: name, age, gender, and photo etc. along with the rectification required. The corrected card will be dispatched to you within 7 days without any additional cost. You can also report the mistakes in the card to our call center and they will guide you.

Yes, you may send a request letter along with the duplicate card issuance charges, the duplicate ID card will be dispatched to you within 7 working days on your registered address.

• Login to www.hitpa.co.in and click "user login"
• Select card menu option
• Put your User Name and Password in the given option
• If you are a new user create login ID and password
• Click Proceed to enter in user domain

Click on member card option to download your HI TPA E Card

Insurance companies have tie-up arrangements with several hospitals which are called network hospitals. Under a health insurance policy, a policyholder can take treatment in any of the network hospitals without having to pay the hospital bills as the payment is made to the hospital directly by the insurance company. TPA helps in organizing cashless treatment to the member. However, expenses beyond the limits or sub-limits as per terms and conditions of the insurance policy or expenses not covered under the policy have to be paid by customer directly to the hospital. Preauthorization, however, is not available if treatment is taken in a non-network hospital.

Preauthorization is facilitated by TPA at network Hospitals. Patient should contact an Empanelled Hospital for treatment. Hospital would then send the duly filled preauthorization request to HI TPA prior to planned hospitalizations. For emergency cases preauthorization process can be initiated within 24 hours of hospitalization.

HI TPA would then process the pre-authorization based on policy terms and convey its decision on admissibility to the Hospital. If the cashless is extended, patient is required to pay only for the Non Payable Expenses.

If the Preauthorization is denied, patient pays the hospital bill, collects original receipts and other documents at the time of discharge from the Hospital and files for reimbursement claim later on.

Cashless facility can be availed at any of the network hospitals listed on HI TPA or insurance company website. The insured has a choice to go to any of the hospitals/nursing homes which are part of the Insurer/TPA network it can also be confirmed through call center toll free numbers ……… and ………. It is useful to confirm before seeking admission because network of hospitals is continuously updated with new additions and deletions.

In the absence of network hospital of choice or due to any other reason, insured can get treated at the hospital of choice which means the entire bill is paid by the policy holder and claim for reimbursement of expenses. The claim shall then be processed as per policy terms and conditions.

Claimant is required to intimate about a planned hospitalization in advance by 72 hours calling at the Toll Free number or logging on to the web portal www.hitpa.co.in. For Emergency Hospitalizations intimation should be sent within 24 hours of hospitalization.

Following documents are required for processing your claims on reimbursement basis:

Address for claim documents submission:-

Health Insurance TPA of India Ltd.

2nd Floor, Majestic Omnia Building,

A-110, Sector 4

Noida, Uttar Pradesh - 201301

Claimant is required to submit reimbursement claim documents within 7 to 15 days from the date of discharge. (However it varies from insurer to insurer).

Medical expenses can be claimed for a period ranging from 30 days prior to date of admission   up to 60 days to 90 days (as specified in the policy) from the date of discharge , provided they are related to the ailment/accident for which you were hospitalized. Such expenses are termed as pre and post hospitalization expenses.

Usually there is a waiting period of 30 days during which claims are not payable. This waiting period may vary from insurance company to insurance company. This clause is not applicable for Accident related Claims.

Yes. Claimant can opt for Cashless facility or file for reimbursement claim. We would advise that in case you are taking treatment from a network hospital, then you should avail cashless facility.

The IRDA list of Non- payable items is shared in the policy document. It is also available on our website. Some of the items are mentioned below:-

• Admission charges
• Extra bed charges for attendant
• Telephone expenses
• Food and beverage charges for attendant
• Vaccination & Dietician charges etc.
• Cotton and bandage charges etc.

The claim documents can be submitted to the Health insurance TPA of India office at Health Insurance TPA of India 2nd floor, Majestic Omnia Building, A-110, Sector 4, Noida Uttar Pradesh - 201301.

Only insured member is eligible to receive the claim payment

As per "AML (Anti-Money Laundering) guidelines for General insurance companies "issued by IRDA, beneficiary need to submit KYC documents where the amount payable is equal to or above Rs.1 lakh. If it is cashless hospitalization, the documents need to be submitted to our network hospital at the time of sending cashless request to us, which in turn will submit those documents to us along with other claim documents. In case of reimbursement claim, KYC documents need to be submitted to us directly along with other claim documents you will be submitting to us for reimbursement.

Individual claims where cashless request approved is more than 1 lakh, hospital needs to collect any one of the KYC documents mentioned below.

You can approach the customer services department of HI TPA. If not satisfied with the resolution you may contact the respective insurance  company.

Along with your member ID card, you will get a kit comprising of a Guide Book and List of Network Hospitals.

You can also download the list from our website www.hitpa.co.in from the "Hospital Network" section.

You may immediately call our call center, giving details of such hospitals/medical providers. Our hospital network department will immediately contact the concerned medical provider and address the issue. However the treatment should not be denied in any circumstances by the hospital.

We regret that our services have not been to your satisfaction. You may write/email to us giving details of your grievance. We assure you that our grievance department will address the issue within 72 hours.

Customer can also lodge a grievance at IRDA Integrated Grievance Management System or insurance company’s website/call centre.

Policy holders can approach Ombudsman or Consumer Courts for unresolved disputes which are not addressed through grievance resolution channels.