IRDA

&
TPA
PRESENTED BY:
ARSHPREET 15177
SONAL 15178
Insurance Regulatory & Development
Authority is the controlling and
regulatory apex body in the country for
insurance sector and its chairman and
members are appointed by Government
of India.
IRDAs HQ is located at Hyderabad.
IRDA
Mission
a) To protect the interests of
the policyholders

b) To promote, regulate and ensure orderly
growth of the insurance industry and for
matters connected therewith or incidental
thereto
c) Conduction of insurance
businesses across India in an
ethical manner.
10/14/2014 3 IRDA Group 1
Composition of Authority
As per the section 4 of IRDA Act' 1999, Insurance Regulatory
and Development Authority (IRDA, which was constituted by
an act of parliament) specify the composition of Authority

The Authority is a ten member team consisting of

(a) a Chairman;
(b) five whole-time members;
(c) four part-time members,

(all appointed by the Government of India)
4
Guidelines on Standardization in
Health Insurance 2013

Standard Definition for 46 commonly used term s
in health insurance policies:
accident, co-payment, day care treatment,
deductible, dependent child, domiciliary
hospitalization, emergency care etc
Standard Nomenclature and Procedures for
Critical Illnesses:
Standard Pre-authorization and Claim form
Standard List o f Excluded Expenses in
Hospitalization Indemnity policies:

Standard agreement between TPA & Insurer
and Provider (Hospital) & Insurer
Standard File and Use Application Form ,
Database Sheet and Customer Information
Sheet


TPA was introduced by IRDA in 2001 through
notification on TPA-Health Service
Regulations.
Basic role is to function as an intermediary
between insurer and insured.
Facilitates the cash-less service of insurance
ELIGIBILITY
Company with share capital and register under
Companies Act 1956.
Object of the company: Only TPA service,no other
activity.
Minimum paid up capital Rs1 crore
At no point of time its functioning the TPA shall
have a working capital of less than Rs.1 crore
At least one of the directors of the TPA shall be
qualified medical doctor registered with the
medical council of India.
Foreign equity if any not exceeding 26%.

Any transfer of shares exceeding 5% of the
paid up share capital shall be intimated by the
TPA to the authority within 15 days of the
transfer indicating the names and particulars
of the transferor and transferee



Prescribed form
Fees of Rs 20000/-
Any additional information during examination
is to be provided
Before granting license fees of Rs 30000/- to
be paid
If an application is rejected for two years can
not apply
CAO or CEO to be appointed immediately or
with in 24 months
Qualification: Graduate or AIII, training of 100
hrs in approved Institute
If license is granted -valid for three years
Tie up insurance companies
TPA can enter in to an agreement with any no.
Of insurance companies
Copy of agreement to IRDA with in 15 days

Benefits of TPA
Introduction of TPA benefits both the insured and
the insurer in the healthcare industry. While the
insured benefits from the 24 x 7 service, the
insurer is benefited by reduction in
administration cost.
Policy holders welcome introduction of TPA since
they receive enhanced facilities at same cost.




Benefit to insurance
Faster and focused claims management
Lower overhead cost and reduced cost of claim
management
Immediate access to highly trained claim administrators
Improved control over claims outcomes
Provision of cashless services at much ease
Safeguarding of customer relationships
Protection of brand reputation.
Control of possible frauds by the private healthcare
providers