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| ROLE OF TPA (Third Party Administrator) |
Hospital where hospitalization is planned.
Reason why hospitalization is required.
Copy of the prescription from the doctor specifying the treatment/surgery.
TPA may ask you to send this on fax also.
If the Hospital where Hospitalization is planned is on approved list then they will give the authorization,
which means that Hospital is getting the instructions to provide treatment and send the bills for payment to TPA.
It means that this is a case of cashless settlement.
If the Hospital where Hospitalization is planned is not on approved list then they will give the authorization to
go ahead with treatment at that hospital. In this case insured makes the payment and then submits the bills to TPA
for payment. It means that treatment is approved but it is not a case of cashless settlement.
List of TPA's is attached at the end of this for reference purpose. List is continuosly being enlarged.
Sometimes existing hospitals are being deleted from the list. It is suggested that you verify with the hospital
that it is on the approved list of specific TPA.
5% Concept :
Recently in 2006 some TPA's have introduced 5% concept under which insured pays 5% of the hospital bill and 95%
of the bill is to be paid by the TPA. This has been done as hospital bill may be having some expenses which
are ultimately not payable by the insurance company. If during finalisation of the claim it is found that 100%
of hospital bill is payable then this amount of 5% which is being paid by insured will be paid by TPA to him.
Who pays for TPA
The insured pays for services of TPA and it is included in the premium charged by the Insurance Co. Oriental
Insurance offers discount of 5% if you do not opt for cashless settlement option and agree to submit claim bills
directly to the Insurance Company
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