A TPA cannot finally reject your health insurance claim, only the insurer can. If the TPA has denied your cashless or queried the claim, write to BOTH the TPA and the insurer together, demand a written reason that cites a policy clause, and escalate to IRDAI Bima Bharosa if you do not get a reasoned reply within 15 working days.
Part of the Health Insurance Claim Recovery Series by RightToInformation.Wiki.
A TPA window at a hospital can feel like a wall. Staff say “TPA refused, please pay”. The TPA helpline says “ask insurer”. The insurer call centre says “TPA decides”. In that loop, families pay lakhs out of pocket while a valid claim sits unattended. This guide breaks the loop. It explains who actually decides, what you must put in writing in the first 30 minutes, and the exact IRDAI grievance ladder that forces a written reply.
The TPA is not your insurer. Under the IRDAI (Third Party Administrators - Health Services) Regulations 2016 and the IRDAI Master Circular on Health Insurance Business dated 29 May 2024, the insurer is the principal who carries financial and regulatory liability. The TPA is an agent that processes documents and recommends decisions. Final repudiation power sits with the insurer, not the TPA. Once you understand that single sentence, every escalation step below becomes simple.
TPA stands for Third Party Administrator. It is a licensed intermediary that processes health insurance claims on behalf of the insurer. The TPA issues the health card, runs the helpline, talks to the hospital insurance desk, and recommends approval or denial. It is a service facilitator, not a risk carrier.
The insurer is the company you bought the policy from. The insurer carries the money, the underwriting decision, and the regulatory accountability. Common TPAs in India include Family Health Plan TPA, Medi Assist, MD India Health Insurance TPA, Vidal Health, Paramount Health Services, Heritage Health, Health India TPA, and Raksha TPA. You will find the TPA name printed on your health card and in your policy schedule.
What a TPA can do:
What a TPA cannot do:
The IRDAI (Third Party Administrators - Health Services) Regulations 2016 govern TPAs in India. Read the regulations on the IRDAI portal at irdai.gov.in grievance redressal mechanism and the master circular on health insurance dated 29 May 2024 for cashless timelines.
Most families confuse a TPA query with an insurer rejection. The two are very different in law and in escalation.
| TPA query | Insurer rejection |
|---|---|
| TPA wants more documents or clarification | Insurer formally repudiates with a policy clause |
| Open claim, still being processed | Closed claim, needs grievance escalation |
| 1 to 3 hours typical resolution | 15 working day grievance officer window |
| Reply to TPA and insurer with documents | File grievance under the IRDAI ladder |
| TPA reference number stays “pending” | Insurer issues a claim ID with status “repudiated” |
| No appeal needed yet | Appeal route opens up |
If you cannot tell which one you are facing, ASK in writing. Send the dual-email format below and demand a written confirmation. Verbal answers from the hospital insurance desk or the TPA helpline do not count.
A query is not a denial. Many families pay out of pocket because a hospital insurance desk reads out a TPA query message and says “TPA refused”. That is wrong. Pause, photograph the screen, and write the dual-email below before you sign any hospital “no-claim” undertaking.
These eight steps protect your evidence trail. Skipping any one of them weakens your IRDAI grievance later.
Documents checklist
Policy copy and KFD, health card front and back, hospital pre-auth form, all hospital bills, discharge summary, ICP (In-patient Case Paper), prescriptions, lab and investigation reports, TPA query or denial letter, all TPA emails, all insurer emails, payment receipts marked “paid under protest”, acknowledged claim form, Aadhaar and PAN, doctor medical-necessity certificate, hospital seal on each page, attending doctor signature on the discharge summary.
Make two photocopy sets. One stays with you. One goes to your reimbursement claim file. The originals stay safe in a folder you can carry to the Insurance Ombudsman office if needed.
Ask these five points in every email so the reply is on record:
Each bullet forces a paper trail. If the insurer ducks any of them, that gap itself becomes a ground for the IRDAI complaint.
Subject: TPA query or denial. Cashless claim. Policy [POLICY NUMBER], Patient [PATIENT NAME]. Clarify status. To: [Insurer Grievance Officer email] Cc: [TPA grievance email], [Hospital insurance desk email], [Your own email] Dear Sir or Madam, This concerns the cashless approval for [PATIENT NAME] admitted at [HOSPITAL NAME] on [DATE] for [DIAGNOSIS]. The TPA [TPA NAME] has communicated a denial or query under ticket number [TPA TICKET NUMBER]. I request clarification in writing within 24 hours on the following points. 1. Is this communication a query asking for more documents, or is it a final denial of cashless? 2. Which entity has issued the decision, the TPA or the insurer underwriting team? 3. The exact reason for the decision quoting the relevant policy clause number and clause text. 4. Whether reimbursement will be admissible for this admission if cashless is finally denied. 5. The insurer claim ID for tracking under the IRDAI grievance system. Reference details Policy number: [POLICY NUMBER] Insurer: [INSURER NAME] TPA: [TPA NAME] TPA card number: [HEALTH CARD NUMBER] Patient name: [PATIENT NAME] Hospital: [HOSPITAL NAME] Date of admission: [DATE] Diagnosis: [BRIEF DIAGNOSIS] TPA ticket reference: [NUMBER] Please respond by email within 24 hours. If cashless is finally denied, I shall convert this to a reimbursement claim and escalate the matter under the IRDAI grievance redressal mechanism and to the Insurance Ombudsman if needed. Regards, [Your Name] [Phone] [Email]
This single email puts everyone on notice. The insurer can no longer hide behind the TPA. The TPA can no longer say “ask insurer”. The hospital insurance desk has a copy of the chain, so the bill is contested in writing.
Subject: Re: Cashless decision. Insurer accountability requested. Policy [POLICY NUMBER]. Dear Sir or Madam, Thank you for your email dated [DATE]. The TPA reply states that the insurer instructed the denial. Under the IRDAI (Third Party Administrators - Health Services) Regulations 2016, the TPA acts as an agent. The insurer is the principal and is answerable for any cashless decision. I therefore request the insurer to confirm the following on the record. 1. Confirm whether the TPA recommendation was approved by the insurer underwriting team. 2. Provide the underwriting reason for denial quoting the relevant policy clause number and clause text. 3. Process my reimbursement claim within the IRDAI timeline if cashless is finally denied. If a written reply from the insurer does not reach me within 7 working days from this email, I shall escalate to IRDAI Bima Bharosa at bimabharosa.irdai.gov.in and to the Insurance Ombudsman. Regards, [Your Name] Policy number: [POLICY NUMBER] Phone: [PHONE]
This second email locks the principal-agent point in writing. Insurance Ombudsman benches and IRDAI grievance officers read it well. It also clears the legal fiction that the TPA is a separate, untouchable body.
Escalate the moment you see any of these signs:
Each of these is a separate ground in your IRDAI complaint. Document each one with a screenshot, a timestamped email, or a written note signed by the hospital insurance desk officer.
Complaint route:
Hospital insurance desk → TPA grievance + Insurer grievance officer (15 working days) → IRDAI Bima Bharosa portal at bimabharosa.irdai.gov.in (15 working days) → Insurance Ombudsman at cioins.co.in (30 day SLA, free, claims up to ₹50 lakh, binding on insurer) → Consumer court via edaakhil or a regular consumer court complaint.
Always file the grievance with the insurer grievance officer, NOT only with the TPA. The TPA is the agent. The insurer is the principal. The IRDAI grievance machinery routes through the insurer. A complaint filed only against the TPA can be closed as “not maintainable” by IRDAI because the policy contract is between you and the insurer.
Key portals and helplines for India 2026:
No. A TPA cannot finally reject your claim. Only the insurer can issue a written repudiation under the policy contract. The TPA can only recommend. If a TPA tells you the claim is rejected, demand a written denial letter from the insurer naming the policy clause. If the insurer letter does not arrive in 15 working days, escalate to IRDAI Bima Bharosa.
The Insurance Regulatory and Development Authority of India (IRDAI) governs TPAs through the IRDAI (Third Party Administrators - Health Services) Regulations 2016 and the IRDAI Master Circular on Health Insurance Business dated 29 May 2024. TPAs must hold a valid IRDAI licence to operate. Complaints against a TPA can be filed on the IRDAI Bima Bharosa portal once you have given the insurer 15 working days to respond.
A TPA query is a request for more documents or clarification. The claim is still open and the TPA expects a reply within a few hours. An insurer denial is a formal repudiation under the policy contract. The claim is closed. A denial needs a grievance escalation, a query needs a quick reply with documents. If the message you received is unclear, ask in writing whether it is a query or a final denial.
You escalate to the insurer first. Under IRDAI rules, the insurer is the principal and the TPA is the agent. The insurer carries the contractual and regulatory liability. Write a single email to the insurer grievance officer with the TPA in copy and demand a written reason citing the policy clause. If no reply arrives in 15 working days, file at IRDAI Bima Bharosa naming both the insurer and the TPA.
You can name the TPA in your IRDAI complaint, but you must also name the insurer. IRDAI grievance handling routes through the insurer because the policy contract is between you and the insurer. A complaint filed only against the TPA can be closed as not maintainable. The right format is to file against the insurer and add the TPA as a related party in the complaint body.
Under the IRDAI Master Circular on Health Insurance Business dated 29 May 2024, the insurer or its TPA must convey the cashless authorisation decision within 1 hour of receiving the pre-authorisation request at admission and within 3 hours of receiving the final bill at discharge. Any breach of this timeline is a clear ground to escalate to the insurer grievance officer and then to IRDAI Bima Bharosa.
The insurer holds the policy contract and the underwriting file. The TPA holds the claim processing file, which includes the pre-authorisation form, hospital bills, and medical records you submit during the claim. When you escalate, ask both the TPA and the insurer to share the file under your right to records. The insurer cannot deny access to the policy contract or the claim file.
No. The TPA is paid by the insurer under the IRDAI (Third Party Administrators - Health Services) Regulations 2016. The TPA cannot demand cash from a policyholder for claim processing, card issue, or grievance handling. If a TPA representative or a hospital insurance desk asks you to pay a service fee outside the policy terms, raise a written grievance at the insurer and at IRDAI Bima Bharosa.
Yes. If the TPA denies cashless at one network hospital, you can shift to another network hospital that may agree to cashless. You can also stay in the current hospital, pay under protest, and file a reimbursement claim. Either way, get the original denial in writing first. A written denial protects your reimbursement and Insurance Ombudsman options.
Yes. The Insurance Ombudsman is free for the complainant. There is no court fee or filing fee. The Ombudsman handles complaints up to ₹50 lakh and the decision is binding on the insurer. The 12 regional Ombudsman offices are listed at cioins.co.in complaint. File only after the insurer has had 30 days to respond and has either refused, partially settled, or stayed silent.
Many cashless delays start at the hospital insurance desk. The desk may submit the pre-authorisation late or with wrong documents. If the TPA shows you a portal screen with no submission timestamp from your hospital, the bottleneck is the hospital, not the TPA. Email the hospital medical superintendent and the TPA together with the timestamped pre-authorisation copy and demand a written explanation.
Part of the Health Insurance Claim Recovery Series by RightToInformation.Wiki.
Last reviewed by RTI Wiki editorial team on 2026-05-16.