VADODARA: Did a third-party administrator (TPA) reject your insurance claim or deduct money from your claim amount under some or the other clause? Well, you may now hold the TPA responsible for going beyond its role and taking arbitrary action by rejecting your claim.
Recently, in at least half-a-dozen cases, the
consumer court
ruled in favour of the insured person just because the TPA had rejected their claim, citing the regulations of Insurance Regulatory and
Development Authority
of India (Third Party Administrators - Health Services) Regulations, 2016
The Vadodara district consumer disputes redressal forum (additional) referred to regulation 3(2) of the rules which stated that ‘TPA shall not reject or repudiate any of the claims directly’ and ‘shall not directly make payments in respect of the claims.’
In at least six instances, the court has stated that the TPA has no authority to reject the claims yet they went against the regulations and acted.
“According to us, the rejection of claims by TPA is illegal and against the provisions of the regulations, so their stand is inadmissible,” the court has stated in the judgements.
“The TPA’s role is to conduct an internal investigation of a claim and propose its findings whether to pay the amount and if it is to be paid then how much amount is to be paid to the insurance company. The final decision must be from the insurance company on the claims,” said Akhil Dave, a practicing consumer lawyer.
He added that whatever the court has pointed out is correct. “Even if TPA is rejecting the claim or deducting the amount it has to communicate on the letterhead of the insurance company which is not happening,” he said.
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