IRDAI Warns Heritage TPA Over Claim Norm Breach
Why in the news
IRDAI warned Heritage TPA for closing health claims on its own and telling policyholders about denials, which breaks claim-handling norms.
Key facts
- Regulator: IRDAI; entity warned: Heritage TPA (third-party administrator).
- Only insurers may communicate approvals or rejections; TPAs must not sway outcomes or send repudiation letters.
- Heritage TPA closed claims without passing on insurers’ query letters or sending reminders, per a November 2021 remote inspection.
Required TPA process
- Issue deficiency letters when papers are incomplete.
- Send up to three reminders, seven days apart, if documents stay pending.
Breach of claim norms
- IRDAI counts exceeding claim consultancy limits, fees as a claim percentage, settlement delays and unexplained deductions as breaches.
Implication
- Claim communication is solely the insurer’s job; TPAs overstepping face regulatory action.
Exam angle
- Remember: three reminders, seven days apart.