TPA Vs In-House Claims Department: Which One is More Customer-friendly?

HEALTH INSURANCE


tpa vs in house claims department

Have you ever filed a health insurance claim request through a TPA desk?

Surprisingly, many policyholders are unaware that a TPA or Third Party Administration window differs from the insurer’s claims department. Unlike an in-house claims team, a TPA is an outsourced group handling claim processing communication on behalf of the insurer. No matter how similar they may sound, there’s a vast difference in how a TPA and an in-house claims team handle claim requests.

In this article, we’ll throw some light on the respective roles of both TPA and the claims department to ensure a hassle-free claim experience! 

What is a TPA Desk?

The Third-party Administration or TPA desk is a support team to take care of the health insurance claims at a hospital. Appointed by the insurance company, a TPA acts as a mediator between the hospital and the insured, helping both parties during the claim settlement.

That said, TPA is an outsourced entity that becomes the communication channel between the insurer and the insured. That’s why the TPA does not affect the acceptance or rejection of the claim; it is merely a medium to simplify the claim process for the policyholders. Here’s how a TPA desk functions:

  • Establishes tie-ups with one or more insurance companies to provide claim settlement services
  • Becomes the policyholder’s point of contact  as soon as the claim process begins
  • Assists and resolves query until the final claim settlement

The Insurance Regulatory Authority of India (IRDAI) is the supreme regulation body that has authorized 26 TPA companies across India. Each TPA has a code you would need during claim filing. 

What is an In-house Claim Settlement Team?

An in-house claims department is a dedicated health insurance claims team that operates within the company and manages the claim process. Usually, insurance companies set up an entire department to address the health insurance claims. This in-house team is directly in touch with the policyholders and handles the following responsibilities:

  • Addresses the claim requests from policyholders, first-hand
  • Communicates all the claim-related updates, requirements, and other information directly to the policyholder
  • Provides detailed explanation as to unfulfilled queries and following claim rejection, if any
  • Keeps the policyholders updated about changes in the claim process, list of network hospitals, and other important information

Now that you know the basic role of TPA and the in-house claims department, let us understand which one should be your go-to option.

The answer is – In-house Claim Settlement Team!

Here’s why and how an internal team eclipses the outsourced one.

Why is the In-house Claims Team Better than a TPA?

An in-house claim settlement team is always the first choice over a TPA for the following reasons:

1) Reduces TAT

When it comes to settling claims, an in-house team is better at responding to the claim queries within the Turn Around Time (TAT). By eliminating the middle man, the in-house team directly interacts with the policyholders, managing their queries first-hand while offering specialized services to their customers.

For instance, the internal claims department at Care Health Insurance reverts to requests within 2 hours (approx.) for cashless and 6 days for reimbursement claims. The in-house teams help us connect with the policyholders sooner than the standard TAT for quick and efficient processing.

2) Proves Cost-effective

From the insurer’s point of view, an in-house team is more budget-friendly than an outsourced TPA desk. This way, the insurer is able to allocate more resources to the internal team, thus improving their efficiency. With better resources, the in-house team works with advanced software tools, mobile applications, and digital portals to record and utilize customer data while offering effective services.

3) Improves Customer Service

The closer the insurance company is to the customer, the better assistance it offers. With an in-house team, customers can get first-hand information without any delays. The in-house team not only assists in claim processing but also conveys the latest updates concerning the claim process, network hospitals, documents required, etc., to ensure that policyholders are well-informed.

4) Easy Claim Settlement

Lesser middlemen mean lesser escalations of the claim request. On the part of the policyholder, it becomes easy to settle a claim when there are only one or two points of contact. On the other hand, a TPA can forward the request to multiple customer service executives – thereby increasing the chances of miscommunication, delays in claim processing, and confusion among policyholders. An in-house claims department provides a dedicated relationship manager to the customers, thus improving the customer service and final settlement.

Experience Hassle-free Claim Settlement with Care Health Insurance Claim Processing

Establishing its mark with the industry-leading claim settlement ratio of 95.2%, Care Health Insurance promises a seamless claim settlement process with an in-house department. With a record claims TAT of 2 hours, we ensure all customer queries are addressed with complete transparency and accuracy. That’s why we receive a significantly lower number of claim complaints – 5.5 per 10,000 claims – compared to other standalone health insurance companies. So, secure your health and finances with superior services of Care Health Insurance.

Disclaimer: The above information is updated for FY19-20 and FY20-21. Kindly connect with customer support for further information on claim settlement. 



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