CHAPTER I

(1)        These regulations may be called the Insurance Regulatory and Development Authority (Third Party Administrators - Health Services) Regulations, 2001.

(2)        They shall come into force from the date of their publication in the Official Gazette.

In these regulations, under the context otherwise requires ,-

(a)        "Act" means the Insurance Act, 1938 (4 of 1938)

(b)        "agreement" means an agreement entered into between a TPA and an insurance company registered under section 3 of the Act, prescribing the terms and conditions of health services, which may be rendered to and/or received by each of the parties thereto;

(c)        "Authority" means the Insurance Regulatory and Development Authority established under sub-section (1) of section 3 of the Insurance Regulatory and Development Authority Act, 1999 (41 of 1999);

(d)        "Health Services" means all the services to be rendered by a TPA under an agreement with an insurance company in connection with "health insurance business" or ‘health cover’ as defined in regulation 2(f) of the IRDA (Registration of Indian Insurance Companies) Regulations, 2000, but does not include the business of an insurance company or the soliciting, directly or through an insurance intermediary including an insurance agent, of insurance business.

(e)        "TPA" means a Third Party Administrator who, for the time being, is licensed by the Authority, and is engaged, for a fee or remuneration, by whatever name called as may be specified in the agreement with an insurance company, for the provision of health services;

(f)         All words and expressions used herein but not defined in these regulations but defined in the Act, or the Insurance Regulatory and Development Authority Act, 1999 (41 of 1999), shall have the meanings respectively assigned to them in those Acts.

 

(1)        Only a company with a share capital and registered under the Companies Act, 1956 can function as a TPA.

(2)        The main or primary object of the company shall be to carry on business in India as a TPA in the health services, and on being licensed by the Authority, the company shall not engage itself in any other business.

           

4. (1) The TPA shall obtain from the Authority a licence to function as a TPA for rendering health services.

5.        A copy of the agreement entered into between the TPA and the insurance company or any modification thereof, shall be filed, within 15 days of its execution                         or modification, as the case may be, with the Authority.

 6.        More than one TPA may be engaged by an insurance company and, similarly, a TPA can serve more than one insurance company.

7.                  The parties to the agreement shall agree between themselves on the scope of the contract and the facilities that have to be provided. Such an agreement shall also prescribe the remuneration that may be payable to the TPA by the insurance company.

8.         (1)        Every TPA shall appoint, with due intimation to the Authority, from among its directors or senior employees, a Chief Administrative Officer (CAO) or Chief     Executive Officer (CEO) who shall be responsible for the proper day to day administration of the activities of the TPA.

(2) Such a CAO or CEO shall possess the educational qualifications mentioned in sub-regulation ( 4 ) of this regulation and also undergo a specified period of training with any institution recognised by the Authority.

(3)        He shall not be :

(4)        The qualifications referred to in sub-regulation(2) are -

9.         (1)        Every application received by the Authority pursuant to these Regulations shall be considered by it within a reasonable time and its decision thereon communicated to the applicant.

2.                  On an examination of the material placed before it and on the basis of enquiries made by it, where the Authority is of the opinion that the application does not deserve acceptance, it shall communicate its opinion to the applicant, who shall be given a reasonable opportunity to represent against the proposed rejection of the application.

3.                  Where on a complete examination of the materials, documents, information, etc., available to it, the Authority finally comes to the conclusion that an application be rejected, it shall do so by making an order in writing, which shall be communicated to the applicant at the earliest.

4.                  Where the Authority decides to issue a licence to the applicant to act as TPA, it shall issue the same in Form TPA-2.

10.       Every licence granted by the Authority to a TPA or any renewal thereof, in terms of these regulations, shall remain in force for three years, unless the Authority decides, either to revoke or cancel it earlier, as provided in these regulations.

11.       (1) A licence granted to a TPA may be renewed for a further period of three years on submission of the prescribed renewal application in Form TPA-3 alongwith a renewal fee of Rs. 30,000/-(Rupees Thirty Thousand only), atleast thirty days prior to the date of expiry of the licence.

2.                  Any failure on the part of the TPA to get its licence renewed before its expiry has to be explained to the Authority. A delayed application shall state the reasons for the delay and be accompanied by a late fee of Rs. 100/- (Rupees One Hundred only).

3.                  The Authority after examining the reasons given in the application by the TPA may renew the licence, if it is satisfied that the TPA was prevented by sufficient cause from applying for the renewal of its licence at least 30 days (Thirty days) before the date on which the licence ceased to remain in force.

4.                  The Authority may, if it is satisfied that undue hardship would be caused otherwise, accept any application after the licence ceased to remain in force, on payment by the applicant of a payment of Rs. 750/- (Rupees Seven Hundred Fifty only).

12. Where a licence granted by the Authority is lost or mutilated, the Authority may issue a duplicate licence on payment of a fee of Rs. 1,000/-(Rupees One Thousand only) accompanied by an application in writing made by the TPA.

13.       A licence granted to a TPA may after due notice be revoked or cancelled by the Authority for one or more of the reasons as provided in regulation 14.

14. The Authority may initiate action under regulation 13 for any of the following reasons:

1)      the Authority, on the basis of information received by it, or on the basis of its own enquiry or investigation, is of the opinion that the TPA is functioning improperly and/or against the interests of the insured/policyholder or insurance company;

2)      the Authority, on the basis of information in its possession, is of the opinion that the financial condition of the TPA has deteriorated and that the TPA cannot function effectively or that the TPA has committed a breach of regulations (3), (4), (5) and (8) of these regulations;

3)      the Authority, after enquiry or upon information, is of the opinion that the character and ownership of the TPA has changed significantly since the grant of licence;

4)      the Authority, finds that the licence or any renewal thereof granted to the TPA was on the basis of fraud or misrepresentation of facts;

5)      there is a breach on the part of the TPA in following the procedure or acquiring the qualifications laid down by regulation 8 of these regulations;

6)      the TPA is subject to winding up proceedings made under Companies Act, 1956 or any statutory modification thereof.

7)      there is a breach of code of conduct prescribed by regulation 21 of these regulations;

8) there is violation of any directions issued by the Authority under the Act or these regulations.

15. Before proceeding under regulation 13 to revoke or cancel a licence granted to a TPA, the Authority shall grant a reasonable opportunity of being heard to    the TPA.

16. (1) Every order made by the Authority under regulation 13 shall be in writing, stating clearly the reasons for the revocation or cancellation of the licence and the order shall be served on the TPA as soon as same is made.

(2) The Authority shall also send copies thereof to the insurance company with whom the TPA has subsisting agreement(s).

17.       The TPA on receipt of an order under regulation 13 shall forthwith cease to carry on its functions as TPA in relation to the insurance company and the insurance company shall immediately take such alternative steps including appointment of another TPA, as may be necessary to continue to cater to the insured/policyholders served by the TPA whose licence has been revoked or cancelled.

18.       A TPA whose licence has been revoked or cancelled in terms of these regulations may file a review application with the Authority within 30 days of the receipt of the order cancelling or revoking the licence.

19.       Within reasonable period of the receipt of the application for review but not later than 90 days thereof, the Authority shall dispose of the application after affording the applicant a reasonable opportunity of being heard.

20.       Nothing contained in these regulations may be deemed to prevent or prohibit an insurance company in cancelling or modifying for good and sufficient reasons an agreement that has been entered into by it with a TPA.

(a)    establish its or his or their identity to the public and the insured/policyholder and that of the insurance company with which it has entered into an agreement.

(b)   disclose its licence to the insured/policyholder/prospect.

(c)    disclose the details of the services it is authorised to render in respect of health insurance products under an agreement with an insurance company;

(d)   bring to the notice of the insurance company with whom it has an agreement, any adverse report or inconsistencies or any material fact that is relevant for the insurance company’s business;

(e)    obtain all the requisite documents pertaining to the examination of an insurance claim arising out of insurance contract concluded by the insurance company with the insured/policyholder;

(f)     render necessary assistance specified under the agreement and advice to policyholders or claimants or beneficiaries in complying with the requirements for settlement of claims with the insurance company;

(g)    conduct itself /himself in a courteous and professional manner;

(h)    refrain from acting in a manner, which may influence directly or indirectly insured/policyholder of a particular insurance company to shift the insurance portfolio from the existing insurance company to another insurance company;

(i)      refrain from trading on information and the records of its business;

(j)     maintain the confidentiality of the data collected by it in the course of its agreement;

(k)   refrain from resorting to advertisements of its business or the services carried out by it on behalf of a particular insurance company, without the prior written approval by the insurance company;

(l)      refrain from inducing an insured/policyholder to omit any material information, or submit wrong information;

(m) refrain from demanding or receiving a share of the proceeds or indemnity from the claimant under an insurance contract;

(n)    follow the guidelines/directions that may be issued down by the Authority from time to time.

 

(1)        A TPA shall maintain proper records, documents, evidence and books of all transactions carried out by it on behalf of an insurance company in terms of its agreement. These books and records shall be maintained by it in accordance with accepted professional standards of record keeping and for a period of not less than three years. Such records, documents, evidence, books, etc., and the information contained therein shall be available to the insurance company and the Authority and access to them shall not be denied by the TPA on any ground.

(2)        Every TPA shall, in maintaining the records in terms of sub-regulation (1), follow strictly the professional confidentiality between the parties as required, but this does not prevent the TPA from parting with the relevant information to any Court of Law/Tribunal, the Government, or the Authority in the case of any investigation carried out or proposed to be carried out by the Authority against the insurance company, TPA or any other person or for any other reason.

(3)        If the licence granted to the TPA is either revoked or cancelled in terms of these regulations, the data collected by the TPA and all the books, records or documents, etc., relating to the business carried on by it with regard to an insurance company, shall be handed over to that insurance company by the TPA forthwith, complete in all respects.

                                                           

23.              The Authority may, from time to time, constitute Committees consisting of members drawn from various sources including the TPAs, insurance companies, Authority, or any other persons as may be decided by the Authority to look into the proper and efficient performance of the TPAs.

 

24.              (1) Every TPA shall furnish to the insurance company and the Authority an annual report and any other return, as may be, required by the Authority on its activities.

(2)               The Annual Report, duly verified by a director of TPA and the Chief Administrative Officer or the Chief Executive Officer shall be submitted in Form TPA-4 (No. 1 to 7) within a period of sixty days of the end of its financial year or within such extended time as the Authority may grant.

(3)               The TPA shall also make available to the Authority for inspection, copies of all contracts with insurance company.

  

(1)   Any changes made from time to time in the agreement entered into by an insurer and a TPA shall be filed with the Authority;

(2)   A TPA shall not charge any separate fees from the policyholders which it serves under the terms of the agreement with the insurance company.

(3)   If any person fails to furnish any document, statement, return, etc., to the Authority, the same shall be construed as a non-compliance of the Act.

  

 INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY (Third Party Administrators-Health Services) Regulations, 2001

APPLICATION FOR GRANT OF LICENCE

 

 

 

 

INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY (Third Party Administrators-Health Services) Regulations, 2001

APPLICATION FOR RENEWAL OF LICENCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 (F.No. IRDA/Reg/9/2001)