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Agreement between TPA and insurance company must be disclosed

Last Updated: Oct 24, 2011 | 1970 Views

The Central Information Commission (CIC) has asked public sector health insuranceAgreement between TPAs and Hospitals companies to disclose their agreement with third party administrators (TPAs) and hospitals, in order to ensure transparency in delivery of medical services.

There are four public sector insurance companies - Oriental Insurance, National Insurance, United India Insurance and New India Assurance. These insurers appoint TPAs, who act as an intermediary between them and health insurance policyholders. TPAs were introduced in the year 2000 by the Insurance Regulatory and Development Authority (IRDA), and carry out most of the back office work for which they get around 5% of the premium as fees.

The settlement of the claim is done by the TPA either to the network hospital or to the insured. A network hospital has an agreement with the TPA to participate for providing cashless health services to the insured persons and the list is maintained by and available with the TPA.

An RTI applicant had sought certain information related to health insurance from Oriental Insurance Company.

The CIC rejected Oriental Insurance Company’s arguments that the agreement is between the TPAs and the hospitals, and since a TPA is not a public authority, it has no obligation to disclose the same.

Deepak Sandhu, Information Commissioner, said that funds for implementation of health insurance policies are paid by the respondent (Oriental Insurance) after it is collected as premium from its customers. “Therefore this argument is without merit”, Sandhu said and ordered the insurer to disclose the information as well as to provide the names of hospitals that offer cashless treatment on the company website.

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