CIRCULAR NO.
IRDA/TPA/GDL/CIR/008/01/2011, DATED 12-1-2011
1. It has come to the notice of
the Authority that in some instances policyholders could not get cashless
facility at the hospital approached, due to change in the network hospitals
and/ or the servicing TPA by the insurers, about which the policyholder was not
properly informed.
2. Where the policyholder had
renewed the policy well before the expiry of earlier policy, the IT system of
the insurer could not update the details of the new TPA in the policy since it
was renewed before the date of change of TPA. The inception of the renewed
policy was to take effect after the date when the TPA servicing the particular
office of the insurer was to change.
3. Since both the network
hospitals, as well as the servicing TPA, were changed and the system could not
update the details of the same in the policy, the policyholders were put to
great inconvenience.
4. All insurers are hereby
advised that they should ensure that their systems update the details with
respect to network hospitals and the servicing TPAs at the time of issue of
policy or any time thereafter during the period the policy is in force.
Alternatively, the decisions on change of list of PPN hospitals and/ or TPAs
shall be with prospective effect giving adequate time for the IT systems to
have the necessary modifications in software in place. All the policyholders
must be informed appropriately about the service providers at all times.