Let’s Connect

IRDAI Order in the matter of Heritage Health Insurance TPA Pvt. Ltd.

The IRDAI (“Authority”) issued an order in the matter of Heritage Health Insurance TPA Pvt. Ltd. (“TPA”) vide order bearing reference number IRDAI/E&C/ORD/MISC/54/04/2025 dated April 09, 2025 (“Order”), with respect to the Show Cause Notice dated September 05, 2024, issued by the Authority in connection with the remote inspection conducted by the Authority from November 08, 2021 to November 11, 2021.

The observations raised by the Authority and decisions on these observations are summarized hereunder for reference:

ChargeViolationObservation of the AuthorityDecision of the Authority
1.

Violation of:

  • Regulation 3 (1) (a) of IRDAI Third Party Administrators-Health Services, Regulations, 2016.
  • Regulation 27 (V) of IRDAI (Health Insurance) Regulations, 2016.

Regulation 3 (1) (a):

‘A TPA may render the following services to an insurer under an agreement in connection with health insurance business: servicing of claims under health insurance policies by way of preauthorization of cashless treatment or settlement of claims other than cashless claims or both, as per the underlying terms and conditions of the respective policy and within the framework of the guidelines issued by the insurers for settlement of claims.’

Regulation 27 (V):

‘Every Insurance Claim shall be disposed of in accordance with the Terms and Conditions of the policy contract and the extant Regulations governing the settlement of Claims. No Claim shall be closed in the books of the Insurers.’

The Authority observed:

  • TPA has closed the health claims for need of documents/further information from the claimants, and a copy of the said communication is marked to insurer.
  • There is no evidence that the TPA has forwarded the query letter or any reminders to policyholders.

Warning and Advisory

Warning:

The Authority warned TPA for closing the health claims on its own and issuing the communication regarding denial/repudiation of the claim directly to the policyholders.

Advisory:

The Authority advised TPA:

  • to ensure that the decisions on claims are not taken or influenced by them;
  • to ensure that the communication with respect to repudiation of claim shall only be issued by the insurer and not the TPA.

The Authority has directed the TPA to:

  • TPA shall place the Order before its Board in the upcoming Board Meeting and shall provide a copy of the minutes of the discussion.
  • TPA shall submit an Action Taken Report to the Authority on direction given within 90 days from the date of this Order.
  • If TPA feels aggrieved by any of the decisions in this order, an appeal may be preferred to the Securities Appellate Tribunal as per Section 110 of the Insurance Act, 1938.

A copy of the Order is attached for your ready reference.

Source category: IRDAI

Attachments

Comments are closed