IRDA Third Party Administrators Health Services Regulations

[भाग II—खण्ड 3(ii)] भारत का राजपत्र : असाधारण 17

INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY

NOTIFICATION

New Delhi, 17th September, 2001

The IRDA (Third Party Administrators—Health Services) Regulations, 2001

2001

S.O. 891(E).— In exercise of the powers conferred by sections 14 and 26 of the Insurance Regulatory and Development Authority Act, 1999 (41 of 1999) read with section 114A of the Insurance Act, 1938 (4 of 1938), the Authority, in consultation with the Insurance Advisory Committee hereby makes the following regulations, namely :-

CHAPTER I

1. Short title and commencement

(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.

2. Definitions

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.

CHAPTER II

Third Party Administrator

3. Conditions of and Procedure for Licensing of TPA

(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.

(3) The minimum paid up capital of the company shall be in equity shares amounting to Rs. 1 crore(Rupees One crore only);

(4) At no point of time of its functioning the TPA shall have a working capital of less than Rs. 1 crore;

(5) At least one of the directors of the TPA shall be a qualified medical doctor registered with the Medical Council of India;

(6) The aggregate holdings of equity shares by a foreign company shall not at any time exceed twenty-six percent of the paid up equity capital of a third party administrator.

(7) Any transfer of shares exceeding 5% of the paid up share capital shall be intimated by the TPA to the Authority within 15 days of the transfer indicating the names and particulars of the transferor and transferee.

Explanation : For the purpose of this sub-regulation “working capital” means the difference between the aggregate of the current assets and current liabilities as on the date of reckoning

4.

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

(2) The application for licence shall be made in writing to the Authority in Form TPA-1 appended to these regulations and shall be accompanied by a non-refundable processing fee of Rs. 20,000 (Rupees Twenty Thousand only) to the Authority by way of a crossed demand draft in favour of the Authority payable in Delhi.

(3) The Authority may, in the course of examination of the application, call for such information or ask for production of such documents, as it may deem fit, and it shall be incumbent upon the applicant to furnish the same within the specified time.

(4) The Authority, on examination of the application and details furnished by the applicant, may issue a licence, if it is satisfied that the applicant TPA is eligible to function as a TPA.

(5) Every TPA approved by the Authority shall pay a further sum of Rs. 30,000 (Rupees Thirty Thousand only) to the Authority as licence fee before the licence is granted to it and the same shall be paid to the Authority in the manner as stated in sub-regulation (2) of this regulation.

(6) A TPA whose application has been rejected by the Authority shall not, for a period of two years from the date of such a rejection, apply once again to the Authority for a licence.

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 :

• (i) a person of unsound mind;
• (ii) an undischarged insolvent;
• (iii) a person who had been subjected to a term of imprisonment for a period of three months by a court of competent jurisdiction on grounds of misconduct, misfeasance, forgery etc.

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

• (1) a degree in arts, science or commerce or management or health or hospital administration or medicine; and
• (2) a pass in the Associateship examination conducted by the Insurance Institute of India or such equivalent examination as may be recognised by the Authority and notified from time to time;
• (3) completion of practical training, as may be specified by the Authority, not exceeding one hundred hours with an institution recognised by the Authority, for these purposes, from time to time.
• (4) The Authority may grant, on an application made to it, by the CAO or CEO through the TPA, time not exceeding twenty four months from the date of the coming into force of these regulations for fulfilling the qualification, requirements as stated in sub-clauses (2) and (3) of this sub-regulation.