TPA and insurer in health insurance, who decides your claim

What a TPA is

A TPA, or third party administrator, is a company that services health insurance claims for an insurer. IRDAI's TPA Regulations 2016 define it as a company registered with IRDAI and engaged by an insurer, for a fee, to provide health services under those regulations.

Not every policy uses one. The 2016 regulations say an insurer may engage a TPA, and the September 2024 policyholder master circular uses the same "may". So an insurer can also service claims itself. IRDAI's list of TPAs showed 17 registered TPAs, dated 18 February 2026, when we checked.

What a TPA does

Under Regulation 3 of the 2016 regulations, a TPA can:

• Service cashless claims by handling pre-authorisation at network hospitals.
• Process reimbursement claims under the policy terms and the insurer's claim guidelines.
• Arrange pre-insurance health check-ups for underwriting.
• Service hospitalisation claims under personal accident and domestic travel policies.

The regulations also require a TPA to keep its phone and toll-free numbers working, to publish its network hospitals, and to help policyholders with cashless procedures during a stay.

What a TPA cannot do

The same regulation says a TPA shall not:

• Pay any claim directly.
• Reject or repudiate any claim directly.
• Sell or solicit insurance.
• Offer services to you outside the policy terms and its agreement with the insurer.

Who decides your claim

1. 🏥Hospital desksends the request and the bills
2. 🤝TPAprocesses it; cannot pay or reject a claim itself
3. 🏢Insurerdecides, and pays or rejects

Your insurer decides. The TPA can admit a claim, authorise cashless and pass its view to the insurer, all within the insurer's claim guidelines. For a full rejection, the 2016 regulations say the decision and the letter must come from the insurer, sent directly to you.

IRDAI's 2024 master circulars add another check. No claim can be rejected without approval of the insurer's Product Management Committee, or a three-member sub-group of it called the Claims Review Committee. Any rejection or partial cut must be explained with reference to the specific policy terms.

When a TPA settles a claim in part, its letter must show the amount paid against the amount claimed, the amounts disallowed with reasons, and how to reach the insurer's grievance officer and the Insurance Ombudsman.

How the insurer oversees the TPA

The May 2024 master circular requires insurers to monitor TPA performance and turnaround times. A TPA's pay cannot depend on the claims ratio of the policies it services. Insurers must collect feedback from customers, and money clawed back from a TPA on that feedback must be passed to the customer.

How to find your TPA

• Look in your policy wording. The standard wording IRDAI published in 2020 has a clause on services offered by the TPA, to be filled in where a TPA is involved.
• Check your Customer Information Sheet. Row 9 gives the helpline number and claim procedure.
• Call your insurer and ask which TPA services your policy, if any.
• Find the TPA's toll-free and senior citizen helpline numbers on IRDAI's list of TPAs.

If you have a complaint about a TPA

The September 2024 policyholder master circular lets you complain to the insurer, to the TPA, or to both. You can also register it on IRDAI's Bima Bharosa portal. If the insurer does not resolve it, the Insurance Ombudsman hears complaints against insurers and their intermediaries.

A recent change

On 30 July 2026, IRDAI amended the TPA regulations to align them with the Sabka Bima Sabki Raksha (Amendment of Insurance Laws) Act, 2025. The changes cover registration, fees and related-party disclosures. The rules on who pays and who rejects claims did not change.

Have a hospital stay coming up? Send your policy on WhatsApp and a person checks it for you.