Claim Stuck Between Hospital, TPA & Insurer: Who Should You Follow Up With?

You have called the hospital. They tell you the documents have been submitted to the TPA.

You call the TPA. They say the insurer has not approved the claim.

You contact the insurer. They ask you to coordinate with the hospital.

And just like that, you find yourself making the same three calls again, except now you are more exhausted and no closer to an answer.

If this sounds familiar, you are not alone in finding the process confusing. When a health insurance claim gets delayed or questioned, it is not always obvious which organisation needs to take the next step. The hospital, Third Party Administrator (TPA) and insurer may all be involved, but they do not perform the same functions.

So, what to do now?

1. First, Who Does What?

Let us first understand the three parties involved.

●     The hospital provides treatment and maintains the medical records, bills, discharge summaries and other clinical documents needed for the claim.

●     The TPA (Third Party Administrator) is an organisation engaged by an insurer to provide specified health insurance administration services. Depending on the arrangement, this can include processing claim settlement documents, coordinating with hospitals and communicating claim requirements.

●     The insurer provides the insurance cover and is responsible for the insurance decision, including CIS for a claim settlement or communicating the reasons for a claim's rejection.

The distinction matters because a TPA may coordinate the assessment, but it does not replace the insurer's responsibility for the claim decision. Similarly, an insurer cannot correct a hospital's billing error without the necessary information from the hospital.

Now, let's look at what these differences mean when something goes wrong.

2. Four Situations That May Feel Painfully Familiar

Case 1: "The hospital says it has sent everything."

●     What happened

An elderly parent is admitted to a network hospital for a planned procedure. The family submits the insurance card and other requested information at the admission desk. Later, the hospital says the cashless request has been sent, but authorisation is still pending.

The family calls the TPA, which requests an additional investigation report. The hospital says it has already uploaded the records.

Everyone may be acting in good faith, yet the claim remains unresolved.

●     What could be happening?

The report may not have reached the correct claim file, may be illegible, or may not contain the information requested. Alternatively, the insurer may need a clinical clarification before making a decision.

●     Who should you contact?

Ask the TPA or the insurer handling the authorisation to identify the precise document or clarification outstanding. Then ask the hospital's insurance desk to verify whether it has been submitted successfully.

Request a reference number or written confirmation wherever possible. "Everything has been sent" is reassuring, but knowing which document was sent, when, and to whom is much more useful.

Remember that a pending cashless authorisation is not automatically a claim rejection. If treatment is urgent, do not delay necessary medical care while waiting for an administrative decision; discuss the available arrangements with the hospital.

Case 2: "The insurer says the bill does not match the records."

● What happened

A patient undergoes surgery and submits a reimbursement claim after discharge. Weeks later, the insurer raises a query because a procedure listed on the bill is not sufficiently explained in the submitted medical records.

The family is understandably frustrated. The surgery happened. The bill was paid.

Why is there another question?

●     What could be happening?

The billing description may be unclear, a supporting procedure note may be missing, or the insurer may require additional information to assess the expense under the policy. A documentation query does not, by itself, establish that the treatment was improper or the claim invalid.

●     Who should you contact?

Start with the insurer or the claims administrator named in the query to understand exactly what clarification is required. If the missing information relates to the procedure, billing or treatment records, approach the hospital's medical records department or billing team for the relevant document or correction.

Do not ask the hospital to change a record merely to satisfy the insurer. Any correction must accurately reflect what happened.

Case 3: "The hospital says cashless was not approved, so I have to pay everything."

●     What happened

A family arrives at a network hospital expecting cashless treatment. The hospital informs them that authorisation has not been granted. They are asked to make payment arrangements, and nobody is able to explain clearly about why the rejection happened or if it can be reconsidered.

●     What could be happening?

Cashless authorisation may be awaiting information, may have been declined, or may be affected by policy conditions or the information supplied. 

●     Who should you contact?

Ask the hospital's insurance desk for the status and reference number of the authorisation request. Contact the TPA or insurer to obtain the specific reason for the pending decision or decline, along with any available next steps.

If cashless treatment is unavailable, ask the hospital and insurer whether you can proceed with payment and submit a reimbursement claim, subject to the policy terms and the applicable process. Keep the bills, receipts, medical records and all correspondence.

A cashless request being declined does not necessarily mean that a subsequent reimbursement claim will also be rejected. 

Case 4: "I have complained, but nobody has replied."

● What happened

A reimbursement claim has been pending for weeks. The policyholder has emailed customer service, spoken to the TPA and followed up with the hospital, but still has no clear explanation.

At this stage, making another routine inquiry may not be enough.

●     What could be happening?

The matter may require formal escalation, particularly if the insurer has not adequately addressed a complaint about the delay or the handling of the claim.

●     Who should you contact?

Submit a written grievance to the insurer's Grievance Redressal Officer (GRO). Include the policy number, claim reference, relevant dates, copies of earlier correspondence and a concise explanation of the unresolved issue. Keep the acknowledgement and grievance reference.

IRDAI states that insurers are required to resolve grievances within 15 days of receipt. If you remain dissatisfied or do not receive a response, you can explore the further escalation options described by IRDAI, including the Bima Bharosa system and, where the applicable eligibility requirements are met, the Insurance Ombudsman.

A formal grievance should identify the problem and the resolution sought. It is more effective than sending several disconnected messages that do not explain what remains unresolved.

A simple rule: follow the issue, not just the organisation

3.      When You Are Unsure Whom To Contact, Use This Quick Guide.

If the problem is…	Your first practical step
Missing medical records or a billing error	Contact the hospital's relevant department.
A pending authorisation or unclear document request	Ask the TPA or insurer managing the claim to specify what is outstanding.
A deduction or claim rejection you do not understand	Request the insurer's written explanation and the applicable policy clause.
A prolonged delay in claim process with no clear update	Follow up in writing with the insurer and retain the reference number.
An unresolved service complaint	Escalate through the insurer's formal grievance mechanism.

This is a starting point, not a rigid rule. A single problem may require coordination between two or more parties. The aim is to establish who needs to act next, rather than assuming that the first organisation you contacted is responsible for every part of the claim.

4.      Where Does Bima Seva Kendra Fit In?

Sometimes the difficulty is not making contact. It is understanding what the responses actually mean.

A policyholder may have a hospital bill, a TPA message, an insurer's email and a policy document, yet still be unable to identify the missing link. In such circumstances, an experienced subject matter expert can help review the available records, explain the relevant policy terms, organise the sequence of correspondence and identify a reasonable next step.

SMEs main motive is helping policyholders understand their situation before deciding how to proceed. Depending on the case, that may involve identifying a missing document, understanding the reason for a deduction, preparing a clearer follow-up or explaining the insurer's grievance process.

That kind of guidance should be accessible to people regardless of their education, occupation or financial circumstances. No one should need to understand insurance jargon before being able to ask a reasonable question about their own claim.

Conclusion 

If you are dealing with recurring insurance claim-related issues, a delay in claim process, or claim rejection-related issues, clarity about the next step is a practical place to begin. 

Keep your communications in writing wherever possible, and save reference numbers, emails and submitted documents.

You do not have to know every insurance rule to ask for a clear answer. You simply need to know what remains unresolved, what evidence supports your concern and who is responsible for addressing it.

And if those three things are still difficult to work out, getting help from an SME to make sense of the paperwork may be the most useful next call you make.