Reference is invited to the provisions of IRDAI (Third Party Administrators – Health Services) Regulations, 2016. Under the powers vested with Regulation (27) of these Regulations, the following clarifications are issued.
1. Regulation (2) (1) (k) the definition of Network Providers stands replaced with the following and shall be read as under;
“Network Provider” means hospital enlisted by an insurer, TPA or jointly by an insurer and TPA to provide medical services to an insured by a cashless facility.
2. Provisions of Regulations (5) (1) shall be replaced with the following and shall be read as under;
“No person or an entity can commence or carry out the business of TPA and render health services mentioned at Regulation (3) (1) (a) and regulation (3) (1) (b) of these regulations without a valid certificate of registration from the Authority.”
3. Provisions of regulation (5) (4) shall be replaced with the following and shall be read as under;
“No insurer shall engage any person or entity to carry out the business of TPA and render health services mentioned at Regulation (3) (1) (a) and Regulation (3) (1) (b) of these Regulations unless he is holding a valid certificate of registration from the Authority as TPA.”
4. Heading of Regulation (20) shall be replaced with the following and shall be read as under;
“Health Service Agreements”
5. The following clauses specified under Schedule – I of the Regulations shall be replaced as specified hereunder:
Clauses Wordings are replaced as under
| Clause Number | Description |
|---|
| 10 | Return for Status of Shareholding Pattern of a TPA Company |
| 19 | Format for claims data for TPAs |
| 22 | Form for service level agreement details |
| 24 | Periodical returns – information on non-insurance health schemes |
| 26 | Format for periodical information on services rendered in foreign jurisdictions for policies issued by Indian insurers |
| 27 | Format for periodical information on health services rendered to foreign travel policies issued by foreign insurers |
Insurers and Third Party Administrators are advised to make a note of the above clarifications and ensure compliance.
