Key Definitions:
Third Party Administrator (TPA): A person registered with the Authority to provide health services, engaged by an insurer for a fee or remuneration, as specified in the regulations.
Eligible Entities
Registration Requirements:
Company: Incorporated under the Companies Act, 2013.
Other Legal Forms: As specified by the Authority.
Eligible Business Activities
TPAs may provide the following services under an agreement with an insurer:
Claims Servicing: Pre-authorization of cashless treatment, settlement of claims.
Hospitalization Cover: Servicing claims for hospitalization under personal accident and travel policies.
Medical Examinations: Facilitate pre-insurance medical exams for health insurance policies.
Non-Insurance Healthcare: Servicing non-insurance healthcare schemes.
Other Services: As specified by the Authority.
Naming and Display Requirements
The IIIO must include "Third Party Administrator" in its name to reflect its activities.
Foreign intermediaries can retain their approved names from their home countries.
Display certificates and registration details prominently in the office.
Commencement of Business
An IIIO must commence business within 180 days of receiving the certificate.
Extensions can be requested but not beyond 18 months from the date of the certificate.
Net Worth & Capital Requirements
Minimum Capital Requirements:
TPA: $550,000
TPA Branch in IFSC: $55,000
Minimum Net-Worth Requirements:
TPA: $150,000
Fee Structure
TPA Fees:
Application Fee: $500
Registration Fee: $500
Annual Fee: $200
Tax Benefits
100% Tax Exemption: Business profits are fully exempt for 10 years out of the first 15 years of operation.
Minimum Alternate Tax (MAT): Reduced rate of 9% for IFSC units.
Code of Conduct
TPAs must adhere to the following guidelines:
Professional Manner: Act professionally and ensure regulatory compliance.
Identity Establishment: Clearly establish identity to insured individuals, claimants, policyholders, and the public.
Disclosure of Registration: Present registration certificate on demand.
Service Details Disclosure: Provide details of authorized services upon request.
Grievance Management: Implement effective systems for resolving grievances and disputes.
Confidentiality: Maintain data confidentiality and refrain from trading information.
Advertising: Issue advertisements only with insurer approval and promote public awareness responsibly.
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Disclaimer: This post is for informational purposes only and does not constitute professional advice. While efforts are made to ensure accuracy, we do not guarantee the completeness or reliability of the information provided. Any reliance is at your own risk. Consult professionals for specific advice.
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