TPA Grievance Unresolved: What to Do Next

Reviewed on: 2026-05-30.

If tpa grievance unresolved, collect the account, application, transaction, policy, property, employee, pension, scholarship or bill reference and send one precise written complaint to the office that can correct the record or release the money. Ask for a written reason if the request is refused or kept pending. Escalate with the same evidence bundle to insurer branch, grievance officer, Bima Bharosa and Insurance Ombudsman. Use RTI only for records held by a public authority: file movement, deficiency notes, dispatch records, sanction details, payment advice, inspection reports or reasons recorded on file.

Use the correct external forum. Use Bima Bharosa or the other official source linked below where it fits the subject. For consumer-service disputes, consider National Consumer Helpline and e-Daakhil. For public departments, CPGRAMS, state grievance portals and RTI may help. For high-value or time-sensitive cases, take professional advice before limitation expires.

• Bima Bharosa
• Insurance Ombudsman
• IRDAI

• /practical-guides/
• /practical-guides/category/insurance-money/
• /practical-guides/fixed-deposit-lien-not-removed-after-settlement/
• /practical-guides/hospital-refuses-medical-records-reasonable-time/
• /practical-guides/life-insurance-maturity-payment-delayed/
• /practical-guides/employer-not-giving-salary-slip/

1. Step 1: What to do when TPA grievance is unresolved? (a) TPA: (i) Third Party Administrator — processes health insurance claims on behalf of insurer, (ii) TPA handles pre-auth, claim documents, hospital coordination, (iii) common TPAs: Medi Assist, Star Health TPA, Vidal Health, Raksha TPA, (b) common issues: (i) pre-auth denied — TPA rejects without reason, (ii) claim documents demanded repeatedly — harassment, (iii) TPA unresponsive — no response to queries, (iv) claim settlement delayed — TPA not processing, (v) TPA-insurer passing buck — neither takes responsibility, © rights: (i) policyholder has right to timely claim — IRDAI guidelines, (ii) right to escalation — insurer + IRDAI, (iii) right to Insurance Ombudsman — if claim denied, (d) authority: Insurer Grievance + Insurance Ombudsman + IRDAI Grievance Cell, (e) law: IRDAI Act 1999 + IRDAI (Health Insurance) Regulations 2016 + Insurance Ombudsman Rules 2017.

1. Step 2: Comparison table — TPA grievance scenarios. (a) Pre-auth denied: (i) issue: TPA denies pre-auth without reason, (ii) remedy: escalate to insurer grievance, (iii) timeline: 7-15 days, (iv) example: denied; escalated; approved, (b) Documents demanded repeatedly: (i) issue: TPA asks for same documents again, (ii) remedy: submit all + complain to insurer, (iii) timeline: 7-15 days, (iv) example: repeated; complained; processed, © TPA unresponsive: (i) issue: no response to calls/emails, (ii) remedy: escalate to insurer + IRDAI, (iii) timeline: 15-30 days, (iv) example: silent; escalated; responded, (d) Claim delayed: (i) issue: TPA not processing claim, (ii) remedy: complain to insurer + Ombudsman, (iii) timeline: 30-90 days, (iv) example: delayed; complained; settled, (e) Passing buck: (i) issue: TPA says insurer, insurer says TPA, (ii) remedy: complain to insurer head + Ombudsman, (iii) timeline: 30-90 days, (iv) example: buck-passing; Ombudsman; settled. (Note: TPA acts for insurer. Insurer is responsible. Escalate to insurer first, then Ombudsman.)

1. Step 3: How to escalate TPA grievance. (a) Step 1: Complain to TPA — written + keep reference, (b) Step 2: If unresolved in 7 days — escalate to insurer grievance, © Step 3: If insurer doesn't resolve in 30 days — Insurance Ombudsman, (d) Step 4: If Ombudsman doesn't resolve — IRDAI grievance cell, (e) Step 5: Consumer Forum for compensation, (f) Step 6: File RTI if government scheme (CGHS, ECHS).

1. Step 5: Practical tips. (a) always complain in writing — keep proof, (b) insurer is ultimately responsible — not TPA, © IRDAI timeline: 30 days for claim, (d) Insurance Ombudsman is free, (e) Example: A policyholder's cashless claim was denied by TPA; escalated to insurer; approved in 7 days.

1. Step 6: Key provisions. (a) IRDAI Act 1999, (b) IRDAI Health Insurance Regulations 2016, © Insurance Ombudsman Rules 2017, (d) TPA Regulations, (e) IRDAI grievance: 30 days.

See TPA Grievance and Insurance Ombudsman and How to File RTI.