“Insurance Regulatory and Development Authority of India (Third Party Administrators-Health Services) Regulations, 2016” provides comprehensive guidelines and requirements for the operation of Third-Party Administrators (TPAs) in the health services sector. Here’s a detailed summary of the regulations:
Title and Commencement:
These regulations are titled as IRDAI (Third Party Administrators-Health Services) Regulations, 2016, effective from the date of their publication in the Official Gazette.
Definitions:
Definitions are provided for terms such as “Act,” “Authority,” “TPA,” “Health Services by TPA,” “Health Insurance Business,” and other relevant terms to ensure clarity in the interpretation and application of these regulations.
Health Services by TPA:
TPAs may render services like claims servicing (both cashless and non-cashless), pre-insurance health check-ups, and other health-related services under specified agreements.
Prohibited Activities for TPAs:
TPAs are restricted from directly making payments concerning claims, rejecting or repudiating claims, and from soliciting insurance business.
Registration Requirements:
No entity can operate as a TPA without a valid certificate of registration from the Authority. The main business of a registered TPA should be to provide health services.
Capital and Net Worth Requirements:
TPAs must maintain a minimum paid-up equity capital and net worth as specified, ensuring financial stability.
Application for Registration:
Detailed procedures and requirements for applying for a TPA registration are stipulated, including the necessary documentation and fees.
Grant of Certificate of Registration:
Criteria for the grant of a certificate include financial stability, adequate infrastructure, and necessary medical and managerial expertise among TPAs.
Renewal and Surrender:
Procedures for the renewal and voluntary surrender of registration are outlined, ensuring continuous compliance with regulatory standards.
Revocation and Suspension:
Conditions under which a TPA’s registration may be revoked or suspended are detailed, including non-compliance and operational misconduct.
Code of Conduct:
TPAs must adhere to a strict code of conduct, ensuring ethical handling of all health services and claims.
Inspection and Information Requirements:
The Authority retains the right to inspect TPAs and requires them to maintain detailed records and submit periodic reports.
Health Service Agreements:
Requirements for agreements between TPAs, insurers, and health service providers are specified, including standards for service levels and data security.
General Guidelines and Operational Requirements:
Guidelines cover operational aspects such as infrastructure, claims processing, and adherence to policyholder rights and interests.
This regulation is comprehensive in scope, covering every aspect of TPA operations from registration to compliance, ensuring that TPAs function in a manner that protects the interests of policyholders and aligns with the regulatory framework established by IRDAI.
