The TPA rejected my claim — is it the TPA's decision or the insurer's?

The insurer is responsible for the decision, even when the letter comes from the TPA. IRDAI requires every health claim repudiation to be approved by the insurer's own committee, and one insurer's policy wording says claim settlement and rejection are not among a TPA's services. Complain in writing to the insurer's grievance officer, quote the TPA's claim reference as well as your policy number, and copy the TPA.

If your health policy is serviced by a third party administrator (TPA), the TPA handles cashless requests and claim processing for the insurer. When the rejection letter carries the TPA's name, it is easy to assume the TPA made the decision and that the insurer is out of reach. Neither is right.

What a TPA does

IRDAI's policyholder-protection master circular describes TPAs as registered with IRDAI and engaged by insurers to provide services on the insurer's behalf, especially at the time of a claim. One insurer's policy wording describes those services as claim admissions and assessments, cashless pre-authorisation and processing of reimbursement claims, and says they do not include claim settlement and claim rejection.^{[1, 2]}

Who actually decides

Under IRDAI's health master circular, no claim can be repudiated without the approval of the insurer's Product Management Committee or its three-member Claims Review Committee, which takes the final decision on every repudiation independently. The rejection must also give full details with reference to the specific policy terms.^[3]

So a rejection sent by a TPA communicates a decision the insurer has to stand behind, and your complaint goes to the insurer.

Where to complain

1. 1

   The insurer's grievance officer

   Write to the Grievance Redressal Officer, give the complaint in writing with supporting documents, and take a dated acknowledgement. The master circular also lets you complain directly to the insurer, to its distribution channel including the TPA, or to both.^{[4, 1]}

2. 2

   Bima Bharosa, if needed

   IRDAI's Bima Bharosa portal accepts complaints against insurers and against intermediaries, and its user manual lists TPAs among those intermediaries.^{[5, 6]}

3. 3

   The Insurance Ombudsman

   The Ombudsman Rules apply to insurers and their agents and intermediaries. You must first have complained to the insurer in writing.^[7]

What to put in the letter

• Both references: Your policy number and the TPA's claim number, so that nothing is lost between the two offices.
• The decision you dispute: Quote the TPA's letter and ask the insurer to confirm the decision as its own, naming the clause it relies on.
• What it relied on: Ask for any report or document the decision was based on; see asking for documents the insurer relied on.
• A timeline: The insurer should resolve a complaint within 14 days and, if it rejects it, give reasons that refer to the policy terms.^[1]

ClaimAssure is an independent private platform. It is not an insurer, IRDAI, Bima Bharosa or the Insurance Ombudsman, it never files anything on your behalf, and it cannot promise any outcome. What it does is read your documents and show you what they say.

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