TENDER DOCUMENTS. For Implementation of. Rashtriya Swasthya Bima Yojana, Senior Citizen Health Insurance Scheme and Megha Health Insurance Scheme

Transcription

1 TENDER DOCUMENTS For Implementation of Rashtriya Swasthya Bima Yojana, Senior Citizen Health Insurance Scheme and Megha Health Insurance Scheme Phase 3 In the State of Meghalaya VOLUME II Draft Insurance Contract Government of Meghalaya Department of Health & Family Welfare Dated 23 May 2016 Revised 8 September

2 TABLE OF CONTENTS 1. DEFINITIONS & INTERPRETATION Definitions Interpretation PART I TERMS AND CONDITIONS OF INSURANCE BENEFICIARIES SCOPE OF INSURANCE COVERS Benefits under Base Cover Replenishment Cover in Addition to Base Cover Benefits under Replenishment Cover First Loss to Base Cover and Replenishment Cover for Critical Illness Benefits under Critical Illness Cover Terms and Condditions for Additional benefits for Senior Citizen Health Insurance Scheme SUM INSURED Base Sum Insured Replenishment Sum Insured Critical Illness Sum Insured Reinstatement of Sum Insured Sum Insured on Family Floater Basis AVAILABILITY OF BENEFITS UNDER COVERS Benefits Available Only Through Network Hospitals Determination of Package Rates for Utilization of Covers Utilization of Base Cover and Replenishment Cover Benefits Utilization of Critical Illness Cover Benefits ISSUANCE OF POLICIES PERIOD OF INSURANCE Commencement of Policy Cover Period Policy Cover Period Renewal of Policy Cover Period Risk Cover Period for Each Beneficiary Family Unit in the First Policy Cover Period Risk Cover Period for Each Beneficiary Family Unit in the Renewal Policy Cover Periods Cancellation PREMIUM AND PREMIUM PAYMENT Premium for First Policy Cover Period Premium for Each Renewal Policy Cover Period Refund of Premium for a Policy Cover Period Payment of Premium for Each Policy Cover Period Conditions Precedent to Raising Invoices Compliance with Section 64VB of Insurance Act Taxes Premium All Inclusive No Separate Fees, Charges or Premium Approval of Premium and Terms and Conditions of Covers by IRDA CASHLESS ACCESS SERVICE CLAIMS MANAGEMENT Claim Payments and Turn-around Time Right of Appeal and Reopening of Claims No Contributions

3 11. INSURABLE INTEREST NO DUTY OF DISCLOSURE FRAUDULENT CLAIMS REPRESENTATIONS AND WARRANTIES OF THE INSURER Representations and Warranties Continuity and Repetition of Representations and Warranties Information regarding Breach of Representations and Warranties PART II PRE-ENROLMENT AND ENROLMENT PROJECT OFFICE AND DISTRICT OFFICES Project Office District Offices Organisational Set-Up and Functions EMPANELMENT OF HEALTH CARE PROVIDERS Empanelment Obligations Minimum Empanelment Criteria Process for Empanelment of Health Care Providers within Service Area Process for Empanelment of Health Care Providers outside Service Area Execution of Services Agreement Post-Empanelment Obligations of the Insurer Hospital IT Infrastructure to be Maintained by Empanelled Health Care Providers Post-Empanelment Obligations of Empanelled Health Care Providers Assistance from the State Nodal Agency for Empanelment De-empanelment of Empanelled Health Care Providers DISTRICT KIOSK AND DISTRICT SERVER District Kiosk District Server IEC AND BCC INTERVENTIONS Strategy for IEC and BCC Interventions IEC and BCC Activities CAPACITY BUILDING INTERVENTIONS Capacity Building Programme Minimum Training to be Provided by Insurer Implementation of the Capacity Building Programme OTHER PRE-ENROLMENT OBLIGATIONS Insurer s Pre-Enrolment Obligations State Nodal Agency s Obligations ENROLMENT OF BENEFICIARIES Enrolment Obligations Schedule for Enrolment Enrolment Procedure State Nodal Agency s Obligations in relation to Enrolment Hardship Allowance LIQUIDATED DAMAGES Enrolment Liquidated Damages Empanelment Liquidated Damages Cap on Aggregate Liquidated Damages Payment of Liquidated Damages Liquidated Damages Reasonable General Provisions Regarding Liquidated Damages

4 PART III OTHER OBLIGATIONS REGARDING IMPLEMENTATION OF THE MHIS PHASE SERVICES BEYOND SERVICE AREA BUSINESS CONTINUITY PLAN Acknowledgement by the Insurer Business Continuity Measures CALL CENTRE SERVICES Call Centre Services Insurer s Obligations in relation to Call Centre Services Toll Free Number Language Insurer to Inform Beneficiaries MANAGEMENT INFORMATION SYSTEMS (MIS) SERVICE REPORTING, MONITORING AND CONTROL Automated Reports and Automated Queries/Alerts Medical Audits Beneficiary Audit Audit Reports State Nodal Agency's Rights in Relation to Monitoring and Control State Nodal Agency s Obligations in Relation to Monitoring and Control PROVISION OF SERVICES BY INTERMEDIARIES Right to Appoint Intermediaries or Service Providers Appointment of Third Party Administrators Appointment of Smart Card Service Providers Non-Government Organisations (NGOs) or other Similar Agencies PART IV COORDINATION AND GRIEVANCE REDRESSAL COORDINATION COMMITTEE Constitution of Coordination Committee Role and Functions of the Coordination Committee GRIEVANCE REDRESSAL Constitution of Grievance Redressal Committees Lodging of Complaints Redressal of Complaints Grievance Redressal Mechanism Proceedings Initiated by the State Nodal Agency Compliance with Orders of Grievance Redressal Committees PART V OTHER TERMS AND CONDITIONS TERM & TERMINATION Term Termination by the State Nodal Agency State Nodal Agency Event of Default Termination Date Consequences of Termination Portability Hand-Over Obligations FORCE MAJEURE Definition of Force Majeure Event Limitation on the Definition of Force Majeure Event Claims for Relief Mitigation of Force Majeure Event

5 32.5 Resumption of Performance Termination upon Subsistence of Force Majeure Event ASSIGNMENT Assignment by Insurer Assignment by State Nodal Agency Effect of Assignment Assignment by Beneficiaries or Empanelled Health Care Providers ENTIRE AGREEMENT RELATIONSHIP VARIATION OR AMENDMENT SEVERABILITY NOTICES NO WAIVER GOVERNING LAW AND JURISDICTION SCHEDULE 1 Exclusions SCHEDULE 2 List Of Eligible Day Care Treatments SCHEDULE 3 Package Rates For Medical Treatments And Surgical Procedures SCHEDULE 4 Part 1 Critical Illnesses And Related Package Rates Part 2 Provisional List for Medical and Surgical Interventions /Procedures in General Ward for CHIS.245 SCHEDULE 5 Process For Cashless Access Services SCHEDULE 6 List Of Empanelled Health Care Providers Under The Scheme SCHEDULE 7 Minimum Empanelment Criteria SCHEDULE 8 Specifications For Hospital IT Infrastructure SCHEDULE 9 Process Note For De-Empanelment Of Empanelled Health Care Providers SCHEDULE 10 Guidelines For The District Kiosk And District Server SCHEDULE 11 Role And Functions Of DKMs and FKOs SCHEDULE 12 Smart Card Guidelines SCHEDULE 13 Enrolment Infrastructure And Manpower Requirements SCHEDULE 14 Indicative List Of Frauds And Fraud Control Measures SCHEDULE 15 Appointment Of Third Party Administrators SCHEDULE 16 Key Performance Indicators SCHEDULE 17 Classification Of Complaints And Grievances ANNEXURE 1 Format Of Empanelment Form ANNEXURE 2 Format Of Services Agreement ANNEXURE 3 Format For Submitting List Of Empanelled Health Care Providers ANNEXURE 4 Reporting Formats For Empanelled Health Care Providers ANNEXURE 5 Indicative Formats Of Management Information System (MIS) Dashboard And Reports On MIS Dashboard ANNEXURE 6 Insurer Reporting Formats ANNEXURE 7 Format Of Medical Audit ANNEXURE 8 Format Of Beneficiary Survey Questionnaire ANNEXURE 9 Format Of Actuarial Certificate For Determining Loading Of Premium ANNEXURE 10 Format Of Actuarial Certificate For Determining Refund Of Premium

6 INSURANCE CONTRACT FOR IMPLEMENTATION OF RASHTRIYA SWASTHYA BIMA YOJANA, SENIOR CITIZEN HEALTH INSURANCE SCHEME AND MEGHA HEALTH INSURANCE SCHEME (PHASE 3) [On appropriate stamp paper] This Agreement for the implementation of Phase 3 of the Rashtriya Swasthya Bima Yojana and the Megha Health Insurance Scheme for providing the Covers (the Insurance Contract) is made at Shillong on [ ] 2016: BETWEEN (1) THE GOVERNOR OF THE STATE OF MEGHALAYA, represented by the Secretary to the Department of Health & Family Welfare, Government of Meghalaya cum CEO, Megha Health Insurance Scheme, having his principal office at Room No. 414, Additional Secretariat Building, Shillong , Meghalaya (hereinafter referred to as the State Nodal Agency which expression shall, unless repugnant to the context or meaning thereof, be deemed to mean and include its successors and permitted assigns); [Note: The Government of Meghalaya is in the process of establishing a trust, that will be nominated as the State Nodal Agency. It is contemplated that a representative of the Board of Trustees will execute this Insurance Contract on behalf of the trust. This Parties clause will be amended accordingly at the time of execution.] AND (2) [ ], an insurance company registered with the Insurance Regulatory & Development Authority having registration number [ ] and having its registered office at [ ] (hereinafter referred to as the Insurer, which expression shall, unless repugnant to the context or meaning thereof, be deemed to mean and include its successors and permitted assigns). The State Nodal Agency and the Insurer shall collectively be referred to as the Parties and individually as the Party. WHEREAS A. The "Rashtriya Swasthya Bima Yojana" (the RSBY), a Government of India scheme which commenced in 2008, requires private insurers to provide social health insurance cover to the extent of 30,000 on a family floater and cashless basis through an established network of health care providers to the RSBY Beneficiary Family Units (defined below). 6

7 B. The Government of Meghalaya decided to implement the RSBY and the Megha Health Insurance Scheme in the State of Meghalaya in 2012, utilizing the existing RSBY framework to provide social health insurance to all the families that are resident in Meghalaya, including RSBY Beneficiary Family Units but excluding the families of central and state government employees. For this purpose, the GoM issued the Megha Health Insurance Scheme vide O.M. No. Health 34/2006/Pt/95 dated 10 October 2012 (which, along with the RSBY, is referred to as the Scheme), requiring the private insurer to provide social health insurance cover to the extent of 1,60,000 on a family floater and cashless basis through an established network of health care providers. C. Based on the lessons learned from the implementation of the Scheme in 2013, the GoM has now decided to implement Phase 2 of the Scheme in the State of Meghalaya. For this purpose, the GoM issued the Amended Megha Health Insurance Scheme vide O.M. No. Health.34/2006/Pt./293 dated 19 December 2013 (which, along with the RSBY, was referred to as the Amended Scheme). D. In continuity to the implementation of the Amended Scheme, the GoM has now decided to implement the Megha Health Insurance Scheme Phase 3 which along with RSBY and SCHIS shall be referred to as the Megha Health Insurance Scheme Phase 3. The objectives of the Megha Health Insurance Scheme Phase 3 are to: continue a sustainable and practical health insurance scheme for the residents of the State of Meghalaya; provide adequate cover after considering the incidence rate of regional diseases and diseases or illnesses requiring tertiary care procedures; improve the overall service quality, including patient care facilities and efficiency of the pre-enrolment, enrolment and post-enrolment activities and enhance the Hospital network under the Scheme. provide strong quality control, monitoring and fraud control mechanisms. D. On [ ], the State Nodal Agency commenced a competitive bidding process by issuing tender documents (the Tender Documents), inviting insurance companies empanelled by the MoLE (defined below) to submit their bids for the implementation of the Amended Scheme. Pursuant to the Tender Documents, the bidders submitted their bids on [ ] 2016 for the implementation of the Amended Scheme. The Insurer also submitted its bid to the State Nodal Agency on that date (the Bid). E. Following a process of evaluation of financial bids submitted by bidders, the State Nodal Agency accepted the Bid of the Insurer for the implementation of the MHIS Phase 3. The State Nodal Agency issued a notification of award dated [ ] 2016 (the NOA) and requested the Insurer to execute this Insurance Contract. The Insurer accepted the NOA on [ ] F. The Insurer is registered under Section 3 of the Insurance Act, 1938 (Act 4 of 1938) with Registration No. [ ] and has been engaged in the business of providing general insurance (including health insurance) in India for [ ] years. 7

8 G. The Insurer represents and warrants that it has the experience, capability and know-how required for carrying on general insurance (including health insurance) business and has agreed to provide health insurance services and provision of the Base Cover (defined below), the Replenishment Cover (defined below) and the Critical Illness Cover (defined below) to the Beneficiary Family Units (defined below) enrolled under the MHIS Phase 3 for the implementation of the MHIS Phase 3 in all the districts in the State of Meghalaya. H. Subject to the terms, conditions and exclusions set out in this Insurance Contract and each Policy (defined below), the Insurer undertakes that if during a Policy Cover Period (defined below) of such Policy any Beneficiary (defined below) covered by such Policy: (i) (ii) (iii) (iv) (v) (vi) undergoes a Medical Treatment (defined below) or Surgical Procedure (defined below) requiring Hospitalization (defined below) or a Day Care Treatment (defined below) or Follow-up Care (defined below) to be provided by an Empanelled Health Care Provider (defined below) or RSBY Network Hospital (defined below); or receives ante-natal or post-natal care provided by an Empanelled Health Care Provider; or receives child care provided by an Empanelled Health Care Provider; or receives cardiac or diabetes preventive OPD care provided by an Empanelled Health Care Provider; or receives OPD diagnostic care provided by an Empanelled Health Care Provider; or undergoes Tertiary Care requiring Hospitalization that is provided by a Specialty Hospital, then the Insurer shall pay the expenses incurred by a Beneficiary to the Empanelled Health Care Provider or RSBY Network Hospital in accordance with the terms of this Insurance Contract and such Policy, to the extent of the Sum Insured (defined below) under such Policy. NOW THEREFORE IT IS AGREED AS FOLLOWS: 1. DEFINITIONS & INTERPRETATION 1.1 Definitions Unless the context requires otherwise, the following capitalized terms and expressions shall have the following meanings for the purpose of this Insurance Contract: Additional Premium means the sum agreed by the Parties as the annual premium to be paid by the State Nodal Agency to the Insurer for each Beneficiary Family Unit that is enrolled by the Insurer, as consideration for providing the Replenishment Cover and the Critical Illness Cover to such Beneficiary Family Unit under this Insurance Contract and the relevant Policy. Affected Party shall have the meaning given to it in Clause Aggregate Liquidated Damages Cap in respect of each Policy Cover Period, means the amount that is equal to 10% of the total Premium paid by the State Nodal Agency to the 8

9 Insurer in such Policy Cover Period based on the Premium determined for such Policy Cover Period in accordance with Clause 8.1 or Clause 8.2, but without making any deductions for Liquidated Damages paid or payable under Clause 22 or the refund of the Premium payable under Clause 8.3 or any other deductions made or to be made in accordance with this Insurance Contract. Amended Scheme shall have the meaning given to it in Recital C. Annexure means an annexure to this Insurance Contract. Appointed Actuary means the actuary appointed by the Insurer in accordance with the Insurance Regulatory & Development Authority (Appointed Actuary) Regulations, 2000, as amended from time to time. Base Cover in respect of each Beneficiary Family Unit that is enrolled by the Insurer means the benefits that are set out at Clause 3.1. Base Premium means the sum agreed by the Parties as the annual premium to be paid by the State Nodal Agency to the Insurer for each Beneficiary Family Unit that is enrolled by the Insurer, as consideration for providing the Base Cover to such Beneficiary Family Unit under this Insurance Contract and the relevant Policy. Base Sum Insured in respect of each Beneficiary Family Unit enrolled under a Policy, means at any time, the Insurer s maximum liability for any and all Claims made on behalf of such Beneficiary Family Unit during the Policy Cover Period against the Base Cover. Beneficiary shall have the meaning given to it in Clause 2(d). Beneficiary Database in respect of each Policy Cover Period means the database providing details of households and their members that are resident in the State of Meghalaya, as evidenced by inclusion of the head of the household in the state electoral list. Such database will be prepared by or on behalf of the State Nodal Agency, validated by MoHFW and thereafter uploaded on the RSBY website: Beneficiary Family Unit shall have the meaning given to it in Clause 2(b). Bid shall have the meaning given to it in Recital D. Break-in Policy means that the Covers under a Policy shall cease to be effective upon the expiration of a Policy Cover Period, if the renewal Premium is not paid on or before the Renewal Premium Payment Due Date and failing that on or before the last day of the Grace Period. Business Day means a day on which commercial banks are open for business in Shillong, provided that for the purpose of the Call Centre Services it shall mean all the days of a Policy Cover Period. 9

10 Call Centre Services means the toll-free telephone services to be provided by the Insurer for the logging and redressal of beneficiary requests, complaints and grievances, in accordance with Clause 25. Capacity Building Programme shall have the meaning given to it in Clause 19.1(a). Cashless Access Service means a facility extended by the Insurer to the Beneficiaries where the payments of the expenses that are covered under each of the Covers are directly made by the Insurer to the Empanelled Health Care Providers in accordance with the terms and conditions of this Insurance Contract, such that none of the Beneficiaries are required to pay any amounts to the Empanelled Health Care Providers in respect of such expenses, either as deposits at the commencement or at the end of the care provided by the Empanelled Health Care Providers. CCGMS shall have the meaning given to it in Clause 30.3(a). CHC means a community health centre located at the block level in the State of Meghalaya. Claim means a claim that is received by the Insurer from an Empanelled Health Care Provider, either through a Smart Card transaction or manually, in accordance with Clause 9 and Clause 10. Claim Payment means the payment of a Claim received by an Empanelled Health Care Provider from the Insurer in respect of benefits under the Covers made available to a Beneficiary. Clause means a clause of this Insurance Contract. Congenital Anomaly means a condition(s) present since birth and which is/are abnormal with reference to form, structure or position, but only limited to such condition(s) which is/are present in the visible and accessible parts of the body. Coordination Committee shall have the meaning given to it in Clause 29.1(a). Cover means any of the following: (i) the Base Cover; (ii) the Replenishment Cover; (iii) the Critical Illness Cover; or (iv) the Senior Citizen Cover Critical Illness means any of the illnesses, diseases or pathological conditions for which a Beneficiary will be entitled to a Medical Treatment, Surgical Procedure, Day Care Treatment or a Follow-up Care listed in Schedule 4 to this Insurance Contract. Critical Illness Cover in respect of each Beneficiary Family Unit that is enrolled by the Insurer means the benefits that are set out at Clause 3.6. Critical Illness Sum Insured in respect of each Beneficiary Family Unit enrolled under a Policy, means at any time, the Insurer s maximum liability for any and all Claims made on 10

11 behalf of such Beneficiary Family Unit during the Policy Cover Period against the Critical Illness Cover. Day Care Centre means a stand-alone day care centre providing Day Care Treatments, whether public or private, satisfying the minimum criteria for empanelment and that is empanelled by the Insurer in accordance with Clause 16.3 or Clause Day Care Treatment means any Medical Treatment and/or Surgical Procedure which is undertaken under general anaesthesia or local anaesthesia at an Empanelled Health Care Provider or Day Care Centre in less than 24 hours due to technological advancements, which would otherwise have required Hospitalization. Deductible in relation to each instance of Hospitalization or Day Care Treatment for a Critical Illness in any Policy Cover Period, means an amount of 30,000 that must be met out of the benefits available under the Base Cover and/or the Replenishment Cover and/or by the Beneficiary, before the Insurer makes available any benefits under the Critical Illness Cover; provided that such Deductible shall not reduce the Critical Illness Sum Insured. MoHFW means the Ministry of Heath & Family Welfare Department. DGNO or District Grievance Nodal Officer for the purposes of Clause 30, means the District Key Manager for each district. Diagnostics Lab means a stand-alone diagnostics laboratory, whether public or private, that: (i) provides OPD diagnostics; (ii) satisfies the minimum criteria for empanelment for the OPD diagnostics that it provides; and (iii) is empanelled by the Insurer for provision of OPD diagnostics in accordance with Clause 16.3 or Clause District Coordinator shall have the meaning given to it in Clause 15.3(a)(ii). District Key Manager or DKM in relation to a district, means a government official or other person appointed by the State Nodal Agency to administer and monitor the implementation of the MHIS Phase 3 in that district and to carry out such functions and duties as are set out in Clause 20.2(d) and Schedule 11. District Kiosk in relation to a district means the office established by the Insurer at that district to provide post-issuance services to the Beneficiaries and to Empanelled Health Care Providers in that district in accordance with Clause 17.1 and Schedule 10. District Office shall have the meaning given to it in Clause District Server shall have the meaning given to it in Clause Domiciliary Care means treatment for any disease, illness or injury which in the normal course would require care and treatment at a hospital, but which is actually taken while confined at home. 11

12 Empanelled Health Care Provider means a hospital, a nursing home, a CHC, a PHC or any other health care provider, whether public or private, satisfying the minimum criteria for empanelment and that is empanelled by the Insurer or the TPA in accordance with Clause 16.3 or Clause 16.4 for the provision of health services to the Beneficiaries. For the avoidance of doubt, Empanelled Health Care Provider includes: (i) a Day Care Centre, but only for the purposes of Day Care Treatments that such Day Care Centre is empanelled for; and (ii) a Specialty Hospital, but only for the purposes of providing Tertiary Care that such Specialty Hospital is empanelled for. Empanelment Form shall have the meaning given to it in Clause 16.2(b). Empanelment Liquidated Damages shall have the meaning given to it in Clause Empanelment Team shall have the meaning given to it in Clause 16.3(e). Enrolment Kit means the equipment meeting the requirements of Clause 21.3(d) and Schedule 13 that must be carried by an enrolment team for carrying out enrolment of the Beneficiaries. Enrolment Liquidated Damages shall have the meaning given to it in Clause Enrolment Rate shall have the meaning given to it in Section 1.1 of Table 1 in Schedule 16. Enrolment Schedule shall have the meaning given to it in Clause 21.2(a). Exclusion means any of the exclusions that have been listed at Schedule 1. Field Key Officer or FKO means a field level Government officer or other person appointed by the State Nodal Agency to identify and verify the Beneficiary Family Units at the time of enrolment based on the Beneficiary Database and to carry out such other functions and duties set out in Schedule 11. File & Use Procedure means the procedure to be followed by the Insurer for the approval of the Covers under this Insurance Contract by the IRDA in accordance with the Health Insurance Regulations. Final Termination Notice shall have the meaning given to it in Clause 31.2(b). Follow-up Care means the follow-up care provided to a Beneficiary after a Medical Treatment or Surgical Procedure. Force Majeure Event shall have the meaning given to it in Clause Force Majeure Notice shall have the meaning given to it in Clause 32.3(a). Fraudulent Activity shall have the meaning given to it in Clause 13(b). GoI means the Government of India. 12

13 GoM means the Government of Meghalaya. Grace Period shall have the meaning given to it in Clause 8.3(c). Hardship Allowance shall have the meaning given to it in Clause 21.5(b). Health Insurance Regulations mean the Insurance Regulatory and Development Authority (Health Insurance) Regulations, 2013 read with the Guidelines on Standardization in Health Insurance, 2013, as both may be amended by the IRDA from time to time. Hospital IT Infrastructure means the hardware (including Smart Card related devices) and software to be installed at the premises of each Empanelled Health Care Provider for the provision of Cashless Access Services, the minimum specifications of which have been set out at Schedule 8. Hospitalization means any Medical Treatment or Surgical Procedure which requires the Beneficiary to stay at the premises of an Empanelled Health Care Provider for 24 hours or more. ICU or Intensive Care Unit means an identified section, ward or wing of an Empanelled Health Care Provider which is under the constant supervision of dedicated Medical Practitioners and which is specially equipped for the continuous monitoring and treatment of patients who are in critical condition, require life support facilities and where the level of care and supervision is considerably more sophisticated and intensive than in the general ward. Identified Blocks shall have the meaning given to it in Clause 21.5(a). IEC and BCC means Information, Education and Communication (IEC) and Behavioral Change Communication (BCC) which are activities required to be undertaken by the Insurer to make information relating to the MHIS phase 3 available to the Beneficiaries. IEC/BCC Plan shall have the meaning given to it in Clause 18.1(b). Incumbent Cover shall have the meaning given to it in Clause 7.1(a). Insurance Act means the Insurance Act, 1938, as amended from time to time. Insurance Contract means this contract between the State Nodal Agency and the Insurer for the provision of the benefits under the Base Cover, the Replenishment Cover and the Critical Illness Cover to the Beneficiaries and setting out the terms and conditions for the implementation of the MHIS Phase 3. Insurance Laws means the Insurance Act, the Insurance Regulatory and Development Authority Act, 1999, the Health Insurance Regulations and any other rules, regulations, notifications or other delegated legislation issued by the IRDA from time to time. 13

14 Insured means the State Nodal Agency, which will pay the Premium on behalf of the Beneficiary Family Units enrolled in each district for each Policy Cover Period and in whose name the Policies will be issued or renewed. Insurer Event of Default shall have the meaning given to it in Clause 31.2(a). IRDA means the Insurance Regulatory and Development Authority established under the Insurance Regulatory and Development Authority Act, IRDA Solvency Regulations means the IRDA (Assets, Liabilities and Solvency Margin of Insurers) Regulations, 2000, as amended from time to time. Law means all statutes, enactments, acts of legislature, laws, ordinances, rules, bye laws, regulations, notifications, guidelines, policies, and orders of any statutory authority or judgments of any court of India. Liquidated Damages means the Enrolment Liquidated Damages and the Empanelment Liquidated Damages. Listed Specialty means each specialty listed in Section 4 of Schedule 7, other than oncosurgery and cancer therapy. Management Information System or MIS shall have the meaning given to it in Clause 26. Master Hospital Card or MHC shall have the meaning given to it in Clause 16.6(d). Medical Practitioner means a person who holds a valid registration from the medical council of any state of India and is thereby entitled to practice medicine within its jurisdiction, acting within the scope and jurisdiction of his/her license. Medical Treatment means any medical treatment of an illness, disease or injury, including diagnosis and treatment of symptoms thereof, relief of suffering and prolongation of life, provided by a Medical Practitioner, but that is not a Surgical Procedure. Medical Treatments include: bacterial meningitis, bronchitis-bacterial/viral, chicken pox, dengue fever, diphtheria, dysentery, epilepsy, filariasis, food poisoning, hepatitis, malaria, measles, meningitis, plague, pneumonia, septicaemia, tuberculosis (extra pulmonary, pulmonary etc.), tetanus, typhoid, viral fever, urinary tract infection, lower respiratory tract infection and other such diseases requiring Hospitalization. Medically Necessary means any Medical Treatment, Surgical Procedure, Day Care Treatment, Follow-up Care or OPD Benefit, which: (i) (ii) is required for the medical management of the illness, disease or injury suffered by the Beneficiary; does not exceed the level of care necessary to provide safe, adequate and appropriate medical care in scope, duration or intensity; 14

15 (iii) (iv) has been prescribed by a Medical Practitioner; and conforms to the professional standards widely accepted in international medical practice or by the medical community in India. MHIS Guidelines mean the guidelines issued by MoHFW from time to time for the implementation of the RSBY, to the extent modified by the Tender Documents pursuant to which the Insurance Contract has been entered into; provided that MoHFW or the State Nodal Agency may, from time to time, amend or modify the MHIS Guidelines or issue new MHIS Guidelines, which shall then be applicable to the Insurer. MHIS Operational Manual means any operational manual issued by MoHFW from time to time for the implementation of the RSBY; provided that MoHFW or the State Nodal Agency may, from time to time, amend or modify the MHIS Operational Manual or issue a new MHIS Operational Manual, which shall then be applicable to the Insurer. MIC shall have the meaning given to it in Clause 21.4(b). Migration Request shall have the meaning given to it in Clause 31.6(a). Migration Termination Date shall have the meaning given to it in Clause 31.6(f). MoLE means the Ministry of Labour & Employment, Government of India. New Insurer shall have the meaning given to it in Clause 31.6(a). NOA shall have the meaning given to it in Recital E. Non-RSBY Beneficiary Family Units means those Beneficiary Family Units that are not eligible to receive benefits under the RSBY. OPD means out-patient department. OPD Benefits means: (i) the ante-natal and post-natal care benefit, the child care benefit, the cardiac and diabetes preventive care benefit and the OPD diagnostic care benefit available under the Base Cover and the Replenishment Cover. Package Rate means the fixed maximum charges for a Medical Treatment or Surgical Procedure or for any OPD Benefit or for any Follow-up Care that will be paid by the Insurer under each Cover, which shall be determined in accordance with Clause 5.2(a). Party means either the Insurer or the State Nodal Agency and Parties means both the Insurer and the State Nodal Agency. Performance KPI Evaluation shall have the meaning given to it in Clause 22. Performance KPIs shall have the meaning given to it in Section 2 of Schedule

16 PHC means a primary health centre in the state of Meghalaya. Policy in respect of each district in the Service Area, means the policy issued by the Insurer to the Insured describing the terms and conditions of providing the Base Cover, the Replenishment Cover and the Critical Illness Cover to all the Beneficiary Family Units and including the details of the scope and extent of cover available to the Beneficiaries, the Exclusions from the scope of the Covers available to the Beneficiaries, the Policy Cover Period and the terms and conditions of the issue of the Policy. Policy Cover Period in respect of each Policy, means the period for which risk cover shall be made available by the Insurer to all the enrolled Beneficiary Family Units in a district and which shall be determined in accordance with Clause 7.1 and Clause 7.2, unless cancelled earlier in accordance with this Insurance Contract. Preliminary Termination Notice shall have the meaning given to it in Clause 31.2(b). Premium means the aggregate sum agreed by the Parties as the annual premium to be paid by the State Nodal Agency to the Insurer for each Beneficiary Family Unit that is enrolled by the Insurer, as consideration for providing all the Covers relevant to such Beneficiary Family Unit under this Insurance Contract and the relevant Policy. Project Office means the office of the Insurer that shall be located at Shillong and which shall coordinate the provision of health insurance services by the Insurer under this Insurance Contract for the implementation of the MHIS Phase 3. Pure Claim Ratio shall have the meaning given to it in Clause 8.2(c) or Clause 8.3(b) as appropriate. Qualified Nurse means a person who holds a valid registration from the Nursing Council of India or the Nursing Council of any state in India. Renewal Premium Payment Due Date shall have the meaning given to it in Clause 8.3(b). Replenishment Cover in respect of each Beneficiary Family Unit that is enrolled by the Insurer means the benefits that are set out at Clause 3.4 and that will be available after the benefits under the Base Cover have been utilized in accordance with Clause 3.3. Replenishment Sum Insured in respect of each Beneficiary Family Unit enrolled under a Policy, means at any time, the Insurer s maximum liability for any and all Claims made on behalf of such Beneficiary Family Unit during the Policy Cover Period against the Replenishment Cover. RSBY shall have the meaning given to it in Recital A. RSBY Beneficiary Family Unit means a Beneficiary Family Unit that: (i) is eligible to receive the benefits under the RSBY, i.e. those Beneficiary Family Units that fall within any of the following categories: below poverty line (BPL) households listed in the BPL list published for 16

17 the State of Meghalaya, MGNREGA households, households of unorganized workers (i.e., domestic workers, beedi workers, building and construction workers, street vendors, licensed railway porters, cycle rickshaw pullers, rag pickers, sanitation workers, mine workers, autorickshaw/taxi drivers, handloom weavers and handicrafts artisans), IGNOAPS beneficiaries and any other category of households notified by MoHFW as being eligible for benefits under the RSBY; and (ii) has its head of household listed in the Beneficiary Database. RSBY Network Hospital means a hospital, nursing home, a CHC or any other health care provider that is empanelled by the Insurer or any other insurance company under the RSBY, but does not include an Empanelled Health Care Provider. Rupees or means Indian Rupees, the lawful currency of the Republic of India. Schedule means a schedule of this Insurance Contract. Scheme shall have the meaning given to it in Recital B. Screening shall mean any clinical, laboratory or diagnostic studies undertaken on a patient to detect the presence or absence of any disease or pathological condition. Senior Citizen means a person who is enrolled as the beneficiary of RSBY and is of aged 60 years and above. Senior Citizen Cover in respect of each RSBY Beneficiary Family Unit consisting of one or more Senior Citizen that is enrolled by the Insurer and has its meaning set out at clause 3.6. Senior Citizen Premium means the sum to be quoted by the Bidders as the annual premium to be paid by the State Nodal Agency for each enrolled Beneficiary Family Unit, as consideration for providing the Senior Citizen Cover. Service Area means all the districts in the State of Meghalaya. Services Agreement means an agreement to be executed between the Insurer, the Insurer's TPA and an Empanelled Health Care Provider, in the form set out at Annexure 2. SGNO or State Grievance Nodal Officer shall have the meaning given to it in Clause 30.1(b). Smart Card means the 64kB electronic identification card issued by the Insurer in accordance with the specifications set out in Schedule 12 to each Beneficiary Family Unit that is enrolled, for utilization of the Covers provided under the Policy on a cashless basis. Smart Card Service Provider means the intermediary that is accredited by the Quality Council of India in accordance with the MHIS Guidelines and that is appointed by the Insurer to provide the services mentioned at Clause Specialty Hospital means a hospital, whether public or private, that: (i) provides specialized Tertiary Care and/or OPD diagnostics; (ii) satisfies the minimum criteria for empanelment 17

18 for the specialty that it caters to and/or the OPD diagnostics that it provides; and (iii) is empanelled by the Insurer for provision of Tertiary Care and/or OPD diagnostics in accordance with Clause 16.3 or Clause State Coordinator shall have the meaning given to it in Clause 15.3(a)(i). State Nodal Agency Event of Default shall have the meaning given to it in Clause 31.3(a). Sum Insured in respect of each Beneficiary Family Unit enrolled under a Policy, means at any time, the Insurer s maximum liability for any and all Claims made on behalf of such Beneficiary Family Unit during the Policy Cover Period against each Cover. Surgical Procedure means any manual and/or operative procedure or intervention required for the treatment of an illness or injury, correction of deformities and defects, diagnosis and cure of diseases, relief of suffering or prolongation of life, performed at the premises of an Empanelled Health Care Provider by a Medical Practitioner. Tender Documents shall have the meaning given to it in Recital E. Term shall have the meaning given to it in Clause Termination Date shall have the meaning given to it in Clause Tertiary Care means the Medical Treatments or Surgical Procedures that have been identified as tertiary care in Schedule 3 and Schedule 4. Third Party Administrator or TPA means any organization that is licensed by the IRDA as a third party administrator, meets the criteria set out at Schedule 15 and that is engaged by the Insurer, for a fee or remuneration, for providing Policy and Claims facilitation services to the Beneficiaries as well as to the Insurer for an insurable event. Turn-around Time means the time taken by the Insurer or the TPA appointed by the Insurer in processing a Claim received from an Empanelled Health Care Provider and in making a Claim Payment or investigating such Claim. UCN shall have the meaning given to it in Clause 30.3(b). WPI means the Wholesale Price Index for all commodities as published by the Ministry of Industry, GOI at the web link and shall include any index which substitutes the WPI, and any reference to WPI shall, unless the context otherwise requires, be construed as a reference to the WPI published for the period ending with the preceding month. 18

19 1.2 Interpretation (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) (m) (n) Any grammatical form of a defined term herein shall have the same meaning as that of such term. Any reference to an agreement, contract, instrument or other document (including a reference to this Insurance Contract) herein shall be to such agreement, instrument or other document as amended, varied, supplemented, modified or suspended at the time of such reference. Any reference to an "agreement" includes any undertaking, deed, agreement and legally enforceable arrangement, whether or not in writing, and a reference to a document includes an agreement (so defined) in writing and any certificate, notice, instrument and document of any kind. Any reference to a statutory provision shall include such provision as modified or reenacted or consolidated from time to time. Terms and expressions denoting the singular shall include the plural and vice versa. Any reference to "persons" denotes natural persons, partnerships, firms, companies, corporations, joint ventures, trusts, associations, organizations or other entities (in each case, whether or not incorporated and whether or not having a separate legal entity). The term "including" shall always mean "including, without limitation", for the purposes of this Insurance Contract. The terms "herein", "hereof", "hereinafter", "hereto", "hereunder" and words of similar import refer to this Insurance Contract as a whole. Headings are used for convenience only and shall not affect the interpretation of this Insurance Contract. The Schedules and Annexures to this Insurance Contract form an integral part of this Insurance Contract and will be in full force and effect as though they were expressly set out in the body of this Insurance Contract. References to Recitals, Clauses, Schedules or Annexures in this Insurance Contract shall, except where the context otherwise requires, be deemed to be references to Recitals, Clauses, Schedules and Annexures of or to this Insurance Contract. References to any date or time of day are to Indian Standard Time. Any reference to day shall mean a reference to a calendar day. Any reference to a month shall mean a reference to a calendar month. 19

20 (o) Any reference to any period commencing from a specified day or date and till or until a specified day or date shall include both such days or dates. (p) Any agreement, consent, approval, authorization, notice, communication, information or report required under or pursuant to this Insurance Contract from or by any Party shall be valid and effectual only if it is in writing under the hands of a duly authorized representative of such Party. (q) (r) (s) The provisions of the Clauses, the Schedules and the Annexures of this Insurance Contract shall be interpreted in such a manner that will ensure that there is no inconsistency in interpretation between the intent expressed in the Clauses, the Schedules and the Annexures. In the event of any inconsistency between the Clauses, the Schedules and the Annexures, the Clauses shall prevail over the Schedules and the Annexures. The Parties agree that in the event of any ambiguity, discrepancy or contradiction between the terms of this Insurance Contract and the terms of any Policy issued by the Insurer, the terms of this Insurance Contract shall prevail, notwithstanding that such Policy is issued by the Insurer at a later point in time. The rule of construction, if any, that an agreement should be interpreted against the Party responsible for the drafting and preparation thereof shall not apply to this Insurance Contract. 20

21 PART I TERMS AND CONDITIONS OF INSURANCE 2. BENEFICIARIES (a) (b) The Parties agree that for the purpose of this Insurance Contract and any Policy issued pursuant to this Insurance Contract, all the persons that are resident in the Service Area shall be eligible to become Beneficiaries, other than Government employees and their families that are already covered by alternate government sponsored health benefits or health insurance schemes such as ESIS and CGHS. However, only those persons that are enrolled in accordance with Clause 21 shall be entitled to avail benefits under this Insurance Contract and a Policy as Beneficiaries. The unit of enrolment for the purpose of this Insurance Contract and any Policy shall be a family that is resident in the Service Area, whose head of family is listed in the Beneficiary Database and that has up to five members (a Beneficiary Family Unit). For the purpose of this Insurance Contract and any Policy: (i) (ii) (iii) A Beneficiary Family Unit shall comprise of the head of the family, spouse and up to three dependants. If the spouse of the head of the family is listed in the Beneficiary Database, the spouse shall mandatorily be a member of the Beneficiary Family Unit. If the head of the family is absent at the time of enrolment, then the spouse shall become the head of the family for the purpose of the MHIS Phase 3. (iv) The head of the family shall nominate up to, but not more than, 3 dependants as part of the Beneficiary Family Unit from those dependents that are listed as part of the family in the Beneficiary Database. (v) (vi) If the spouse is dead or is not listed in the Beneficiary Database, the head of the family may nominate a fourth member as part of the Beneficiary Family Unit. If both the head of the family and the spouse are absent at the time of enrolment, then the next oldest member of the family shall become the head of the family for the purpose of the MHIS Phase 3. Such head of the family may nominate up to, but not more than, 4 dependants as part of the Beneficiary Family Unit from those dependents that are listed as part of the family in the Beneficiary Database. If such a member is not listed in the Beneficiary Database, the FKO can add such a person if they have a certificate from Revenue or Panchayat authorities showing a relationship with the head of family listed in the Beneficiary Database. 21

22 The Insurer agrees that: (x) no entry or exit age restrictions will apply to the members of a Beneficiary Family Unit; and (y) no member of a Beneficiary Family Unit will be required to undergo a pre-insurance health check-up or medical examination before their enrolment as a Beneficiary. (c) (d) The issuance of a Smart Card to each Beneficiary Family Unit shall be the proof of eligibility of the Beneficiary Family Unit for the purpose of availing benefits under this Insurance Contract and a Policy issued pursuant to this Insurance Contract. For the purpose of this Insurance Contract and a Policy issued pursuant to this Insurance Contract, a Beneficiary shall mean each member of a Beneficiary Family Unit that has: (i) been enrolled in accordance with Clause 21; and (ii) paid its contribution towards the Premium, and whose details are encrypted on the Smart Card; and the term Beneficiaries shall be construed accordingly. Such Beneficiary shall be entitled to avail benefits under this Insurance Contract and a Policy issued pursuant to this Insurance Contract. (e) A child born into a Beneficiary Family Unit after the commencement of a Policy Cover Period under a Policy shall automatically be covered as a Beneficiary under this Insurance Contract and the relevant Policy from the time of its birth and for the remainder of such Policy Cover Period, whether its delivery is institutional or domiciliary. A new-born child will not be a Beneficiary for the subsequent Policy Cover Periods, unless the head of family has nominated such child as a Beneficiary for such subsequent Policy Cover Periods. (f) The State Nodal Agency may issue MHIS Guidelines and/or a MHIS Operational Manual from time to time for the creation of enrolment units for the following categories of residents in the Service Area: orphans, mentally ill, destitute, homeless, juveniles and similar categories of persons that are not otherwise covered within the definition of Beneficiary Family Unit in Clause 2(b). Thereafter, the Insurer shall use its best efforts to identify and enrol all such categories of persons in accordance with the MHIS Guidelines and/or the MHIS Operational Manual. 3. SCOPE OF INSURANCE COVERS 3.1 Benefits under Base Cover The Insurer hereby agrees, subject to the terms, conditions and Exclusions contained in this Insurance Contract and each Policy, to pay and/or reimburse the following benefits to each enrolled Beneficiary covered by such Policy in the manner set out in Clause 9, for the Policy Cover Period and to the extent of the Base Sum Insured: 22

23 (a) Hospitalization Expenses benefit: provides cover for payment of Hospitalization expenses that are incurred by the Beneficiary for a Medical Treatment or Surgical Procedure (including Tertiary Care) provided by an Empanelled Health Care Provider, subject only to the Exclusions; provided that: (x) any one instance of Hospitalization for a Medical Treatment for which ALOS is specified in Schedule 3 or Schedule 4 shall not exceed the number of days so specified; (y) any one instance of Hospitalization for a Medical Treatment for which ALOS is not specified in Schedule 3 or Schedule 4 shall not exceed 5 days; and (z) Tertiary Care shall only be provided by a Specialty Hospital. The benefit under this Clause 3.1(a) is limited to the available Base Sum Insured. For the purpose of this Clause 3.1(a), Hospitalization expenses shall include, amongst other things: (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) (ix) (x) (xi) Registration charges; Bed charges (General Ward or ICU, as the case may be); Nursing and boarding charges; Surgeons, anaesthetists, Medical Practitioners, consultants fees, etc.; Anaesthesia, blood transfusion, oxygen, operation theatre charges, cost of surgical appliances, etc.; Medicines and drugs; Cost of prosthetic devices, implants, organs, etc.; Screening, including X-Ray and other diagnostic tests, etc.; Food to the Beneficiary (optional); Cost of treating any complications arising during Hospitalization; and Any other expenses related to the Medical Treatment or Surgical Procedure provided to the Beneficiary by an Empanelled Health Care Provider. (b) Day Care Treatment benefit: provides cover for payment of expenses that are incurred by the Beneficiary for a Day Care Treatment (including Tertiary Care) that is listed at Schedule 2, Schedule 3 or Schedule 4 and that is provided by an Empanelled Health Care Provider or a Day Care Centre, subject only to the Exclusions; provided that a Day Care Treatment that qualifies as Tertiary Care shall only be provided by a Specialty Hospital. This benefit is limited to the available Base Sum Insured. For the purpose of this Clause 3.1(b), Day Care Treatment expenses shall include, amongst other things: (i) (ii) (iii) (iv) (v) Registration charges; Surgeons, anaesthetists, Medical Practitioners, consultants fees, etc.; Anaesthesia, blood transfusion, oxygen, operation theatre charges, cost of surgical appliances, etc.; Medicines and drugs; Cost of prosthetic devices, implants, organs, etc.; 23

24 (vi) (vii) Screening, including X-Ray and other diagnostic tests, etc.; and Any other expenses related to the Day Care Treatment provided to the Beneficiary by an Empanelled Health Care Provider. (c) Pre-hospitalization and Post-hospitalization Expenses benefit: provides cover for payment of expenses that are incurred by the Beneficiary one day prior to Hospitalization or Day Care Treatment and for continuous Follow-up Care for up to 5 days after discharge or Day Care Treatment. This benefit is a part of the benefit available under Clause 3.1(a) or Clause 3.1(b), as relevant, and is limited to the available Base Sum Insured. For the purpose of this Clause 3.1(c), pre-hospitalization and post-hospitalization expenses shall include, amongst other things: (i) Screening, medicines and consultations in the 1 day period prior to Hospitalization or Day Care Treatment; (ii) Screening and medicines in the 5 days after Hospitalization or Day Care Treatment; and (iii) any other expenses related to such pre-hospitalization or posthospitalization. (d) Follow-up Care benefit: provides cover for payment of expenses that are incurred by the Beneficiary for Follow-up Care provided by an Empanelled Health Care Provider, but not for any Follow-up Care provided in relation to a Critical Illness. The Follow-up Care benefit is in addition to the pre-hospitalization and posthospitalization expenses benefit set out in Clause 3.1(c), i.e., it will only be available in respect of expenses incurred by the Beneficiary once the 5 day posthospitalization period has been completed. Further, this benefit will only be available in relation to the Medical Treatment or Surgical Procedure for which the Beneficiary has been Hospitalized or for which the Beneficiary obtained Day Care Treatment, whether such Hospitalization or Day Care Treatment took place prior to or during the Policy Cover Period. This benefit is limited to the available Base Sum Insured. For the purpose of this Clause 3.1(d), Follow-up Care expenses shall include: (i) (ii) (iii) OPD consultation expenses; expenses of Screening; and expenses of medicines and drugs. The medicines will be handed over to the Beneficiary by the Empanelled Health Care Provider and the costs thereof will then be claimed from the Insurer as part of the prescribed Package Rate. 24

25 (e) Ante-natal and Post-natal care benefit: provides cover for expenses incurred by a Beneficiary who is a pregnant woman in respect of ante-natal and post-natal care provided by an Empanelled Health Care Provider, subject only to the Exclusions. This ante-natal and post-natal care benefit shall only be available to a Beneficiary who is: (i) (ii) a pregnant woman aged18 years and above; and giving birth to her first or second child, unless she: (x) delivered twins during the first birth, or (y) she has only one living child. This ante-natal and post-natal care benefit shall be available from the date of commencement of each Policy Cover Period. This benefit is limited to the available Base Sum Insured and further limited to the number of OPD consultations set out below: Period During ante-natal period During post-natal period Number of Eligible OPD Consultations 3 OPD consultations, 1 in every trimester of the pregnancy 3 OPD consultations within 30 days of delivery For the purpose of this Clause 3.1(e), ante-natal and post-natal care expenses mean and include: (1) Ante-natal expenses mean and include: (A) (B) (C) OPD consultation expenses; expenses of medicines and drugs as follows: folic acid in the first trimester of the pregnancy; and iron and calcium tablets in the second and third trimesters of the pregnancy; expenses of Screening as follows: Hb, Urine Routine, HIV, RFT (Urea & Creatinine), VDRL, Hbs Ag and Blood Group tests in the first trimester of the pregnancy; Fasting blood sugar & PP in each trimester of the pregnancy; and two ultrasounds in the course of the three trimesters. (2) Post-natal expenses mean and include: (A) (B) (C) OPD consultation expenses; expenses of Screening; and expenses of medicines and drugs. The medicines will be handed over to the Beneficiary by the Empanelled Health Care Provider and the costs thereof will then be claimed from the Insurer as part of the 25

26 prescribed Package Rate. (f) Maternity benefit: provides cover for maternity Hospitalization expenses arising out of child-birth, including normal delivery, Caesarean section, miscarriage or abortion induced by an accident or other medical emergency that is undertaken at the premises of an Empanelled Health Care Provider, subject only to the Exclusions. This maternity benefit shall be available from the date of commencement of the Policy Cover Period, provided that the Hospitalization period for both mother and child is not less than 24 hours post-delivery. This maternity benefit is limited to the available Base Sum Insured. (g) New-born Child benefit: provides cover for Hospitalization expenses and child care expenses incurred in respect of a new-born child, subject only to the Exclusions. This new-born child benefit shall be available from the birth until the expiry of the Policy Cover Period during which the child is born. The new-born child will be deemed a member of the Beneficiary Family Unit for such period, even if the Beneficiary Family Unit has 5 members enrolled. To avail of this new-born child benefit, any member of the Beneficiary Family Unit enrolled on the Smart Card will need to verify to the Empanelled Health Care Provider where Hospitalization of the new-born child is sought that the mother's name is included on the Smart Card. The new-born child benefit is limited to the available Base Sum Insured. For the purpose of this Clause 3.1(g), all Hospitalization expenses, Day Care Treatment expenses, pre- and post-hospitalization expenses and child care expenses described in this Clause 3.1 are included. (h) Child Care benefit: provides cover for payment of child care expenses incurred by a Beneficiary for OPD consultations provided by an Empanelled Health Care Provider, subject only to the Exclusions. This child care benefit shall only be available to a Beneficiary who is a child aged between 0 and 5 years. If the child is an infant between 0 and 12 months, this benefit can be availed either by identification of the child as a new-born by an enrolled Beneficiary or by enrolment of the child as a Beneficiary. If the child is between 1 and 5 years old, then the child must be enrolled as one of the Beneficiaries to avail this benefit. This benefit will be limited to the available Base Sum Insured and will be further limited to the number of OPD consultations listed below: 26

27 Age Group of Child Beneficiary Number of Eligible OPD Consultations in each Policy Cover Period 0-6 months months years 1 For the purpose of this Clause 3.1(h), child care expenses mean and include: (i) (ii) (iii) Expenses in relation to routine check-up or OPD consultation; Expenses of Screening as follows: basic diagnostic tests for CBC, urine routine and microscopy; and expenses of medicines and drugs as follows: antipyretics, anti-diarrhoeal agents, ORS, de-worming tablets, antibiotics, iron supplements, antimalarial, antispasmodic, anti-allergic and anti-motility agents. The medicines will be handed over by the Empanelled Health Care Provider to an enrolled Beneficiary accompanying the child Beneficiary and the costs thereof will then be claimed from the Insurer as part of the prescribed Package Rate. (i) Cardiac and Diabetes Preventive OPD Care: provides cover for payment of expenses incurred by a Beneficiary for cardiac and diabetes preventive care provided by an Empanelled Health Care Provider, subject only to the Exclusions. This benefit is limited to the available Base Sum Insured and further limited to three OPD consultations in each Policy Cover Period. For the purposes of this Clause 3.1(i), expenses of cardiac and diabetic preventive care mean and include: (i) (ii) (iii) expenses in relation to routine check-up or OPD consultation; expenses of Screening as follows: (A) cardiac and diabetic profile tests as follows: AOE, DOE, past history of IHD, smokers, diabetics and dyslipidaemia; (B) diagnostics for: lipid profile (once in each Policy Cover Period); CBC (every OPD consultation), meth-haemoglobin, fasting blood sugar & PP (every OPD consultation), serum creatinine (every OPD consultation) and ECG (once in each Policy Cover Period) and any other investigations that may be required; and expenses of medicines and drugs for the period of treatment, being: antiplatelet agents, statins, anti-hypertensive, OHAs, anti-diabetic drugs and injectibles, insulin and anti-anginals. The medicines will be handed over by the Empanelled Health Care Provider to the Beneficiary and the costs thereof will then be claimed from the Insurer as part of the prescribed Package Rate. 27

28 (j) OPD Diagnostic benefit: provides cover for payment of expenses incurred by a Beneficiary for diagnostic care provided by a Specialty Hospital or Diagnostics Lab on an out-patient basis, subject only to the Exclusions. This OPD diagnostic benefit only covers OPD diagnostic care that is provided by a Specialty Hospital or Diagnostics Lab pursuant to a referral from a government doctor.the MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or a MHIS Operational Manual from time to time to govern such referral. Thereafter, the Insurer shall only be required to honour Claims made under this benefit in compliance with such MHIS Guidelines and/or MHIS Operational Manual. This benefit will only be available only in relation to OPD diagnostic care that is listed in Section 2 of Schedule 3. The OPD diagnostic benefit does not extend to any diagnostic care provided by an Empanelled Health Care Provider that would otherwise be covered by any of the other benefits under the Base Cover. Further, the OPD diagnostic benefit can be availed of only by any one Beneficiary of a Beneficiary Family Unit for one instance of OPD diagnostic care in any consecutive 7 day period, i.e., the Insurer shall not be required to pay for more than one instances of OPD diagnostic care provided by any Specialty Hospital or Diagnostics Lab to one or more Beneficiaries belonging to the same Beneficiary Family Unit in any consecutive 7 day period. This benefit is limited to: (1) the available Base Sum Insured; and (2) a maximum of 6,000 for all instances of OPD diagnostic care, in each Policy Cover Period. (k) Transportation benefit: provides cover for cost of transportation incurred by the Beneficiary in travelling to and from the premises of the Empanelled Health Care Provider for availing of Hospitalization or Day Care Treatment or for Follow-up Care. This benefit is limited to 100 per occurrence of Hospitalization or Day Care Treatment or visit to an Empanelled Health Care Provider for Follow-up Care. The transportation benefit will be paid to the Beneficiary by the Empanelled Health Care Provider and will then be claimed from the Insurer as part of the Package Rate. Further, this benefit is limited to a maximum of 10 instances of Hospitalization or Day Care Treatment or Follow-up Care during each Policy Cover Period. (l) Economic Loss Compensation benefit: provides cover for economic loss suffered by the Beneficiary while availing of a Medical Treatment or Surgical Procedure requiring Hospitalization or Day Care Treatment or in visiting an Empanelled Health Care Provider for Follow-up Care. This benefit is limited to 100 per occurrence of Hospitalization or Day Care Treatment or visit to an Empanelled Health Care Provider for Follow-up Care; 28

29 provided that this benefit shall be limited to 900 per occurrence of Hospitalization or Day Care Treatment or visit to an Empanelled Health Care Provider for an oncology or radiotherapy package. The economic loss compensation benefit will be paid to the Beneficiary by the Empanelled Health Care Provider and will then be claimed from the Insurer as part of the Package Rate. Further, this benefit is limited to a maximum of 10 instances of Hospitalization or Day Care Treatment or Follow-up Care during each Policy Cover Period. (m) Domiciliary Care expenses: no benefits shall be available for Domiciliary Care. Each of the benefits specified above shall be available for all pre-existing conditions, diseases, illnesses or injuries affecting the Beneficiaries on the date of commencement of each Policy Cover Period, subject only to the Exclusions. 3.2 Replenishment Cover in Addition to Base Cover (a) (b) The Replenishment Cover is in addition to the Base Cover. The benefits under the Replenishment Cover shall only be available after the benefits under the Base Cover have been fully utilized. Without prejudice to Clause 3.3(a) above, if the available Base Sum Insured is insufficient to meet the expenses of Hospitalization or Day Care Treatment or visit to an Empanelled Health Care Provider for utilization of the OPD Benefits or for Followup Care that are covered by the Base Cover, then such expenses shall: (i) (ii) first be met out of the benefits under the Base Cover to the extent of the available Base Sum Insured; and then be met out of the benefits under the Replenishment Cover to the extent of the available Replenishment Sum Insured, provided that: (x) the maximum expenses that the Insurer shall be required to pay under the Base Cover and the Replenishment Cover for any one instance of Hospitalization or Day Care Treatment or visit to an Empanelled Health Care Provider for utilization of OPD Benefits or for Follow-up Care shall not exceed 30,000; and (y) the maximum expenses that the Insurer shall be required to pay under the Base Cover and the Replenishment Cover for any one instance of OPD diagnostic care shall not exceed 6,

30 3.3 Benefits under Replenishment Cover The Insurer hereby agrees, subject to the terms and conditions contained in this Insurance Contract, the Exclusions and each Policy, to pay and/or reimburse the benefits listed at Clause 3.1 to each enrolled Beneficiary covered by such Policy and in the manner set out in Clause 9, for the Policy Cover Period and to the extent of the Replenishment Sum Insured. For the avoidance of doubt, the Parties agree that the benefits under the Replenishment Cover are the same as the benefits under the Base Cover, with the following exceptions: (a) (b) The benefits under the Replenishment Cover can only be utilized in accordance with Clause 3.3. Each of the Hospitalization expense benefit, the Day Care Treatment benefit, the pre-hospitalization and post-hospitalization expense benefit, the Follow-up Care benefit, the ante-natal and post-natal care benefit, the maternity benefit, the newborn child benefit, the child care benefit, the cardiac and diabetes preventive OPD care benefit and the OPD diagnostic benefit shall be subject to the available Replenishment Sum Insured. (c) The utilization of the OPD diagnostic benefit is limited to a maximum of 6,000 in each Policy Cover Period, whether such OPD diagnostic benefit is claimed under the Base Cover and/or the Replenishment Cover. (d) (e) The transportation benefit is limited to a maximum of 10 instances of Hospitalization or Day Care Treatment or visit to an Empanelled Health Care Provider for Follow-up Care in each Policy Cover Period, whether such transportation benefit is claimed under the Base Cover and/or the Replenishment Cover. The economic loss compensation benefit is limited to a maximum of 10 instances of Hospitalization or Day Care Treatment or visit to an Empanelled Health Care Provider for Follow-up Care in each Policy Cover Period, whether such economic loss compensation benefit is claimed under the Base Cover and/or the Replenishment Cover. Each of the benefits under the Replenishment Cover shall be available for all pre-existing conditions, diseases, diseases or injuries affecting the Beneficiaries on the date of commencement of each Policy Cover Period, subject only to the Exclusions. 3.4 First Loss to Base Cover and Replenishment Cover for Critical Illness The benefits under the Critical Illness Cover, other than the Follow-up Care benefit, shall be available subject to the Deductible. The Insurer agrees that to the extent of the Deductible under the Critical Illness Cover, the Hospitalization and other expenses (other than Followup Care expenses) for treatment of a Critical Illness shall be met as follows: 30

31 (a) (b) (c) first, out of the benefits under the Base Cover, subject to the available Base Sum Insured; second, out of the benefits under the Replenishment Cover, subject to the available Replenishment Sum Insured; and third, if the available Base Sum Insured and/or the available Replenishment Sum Insured is insufficient to meet the Deductible, then the difference between: (i) the Deductible; and (ii) the available Base Sum Insured and/or the available Replenishment Sum Insured, shall be borne by the Beneficiary. 3.5 Benefits under Critical Illness Cover The Insurer hereby agrees, subject to the terms, conditions and Exclusions contained in this Insurance Contract and each Policy, to pay and/or reimburse the following benefits to each enrolled Beneficiary covered by such Policy in the manner set out in Clause 9, for the Policy Cover Period and to the extent of the Critical Illness Sum Insured: (a) Hospitalization Expenses benefit: provides cover for payment of Hospitalization expenses that are incurred by the Beneficiary for a Medical Treatment or Surgical Procedure for a Critical Illness that is provided by an Empanelled Health Care Provider, subject only to the Exclusions; provided that a Medical Treatment or Surgical Procedure that qualifies as Tertiary Care shall only be provided by a Specialty Hospital. The benefit under this Clause 3.6(a) is limited to: (x) the available Critical Illness Sum Insured, which shall be in excess of the Deductible; and (y) the eligible Medical Treatments or Surgical Procedures that are listed at Section 1 of Schedule 4. For the purpose of this Clause 3.6(a), Hospitalization expenses shall have the meaning given to it in Clause 3.1(a). (b) Day Care Treatment benefit: provides cover for payment of expenses that are incurred by the Beneficiary for a Day Care Treatment that is listed at Schedule 4 and that is provided by an Empanelled Health Care Provider, subject only to the Exclusions; provided that a Day Care Treatment that qualifies as Tertiary Care shall only be provided by a Specialty Hospital. The benefit under this Clause 3.6(b) is limited to: (x) the available Critical Illness Sum Insured, which shall be in excess of the Deductible; and (y) the eligible Day Care Treatments that are listed at Section 1 of Schedule 4. For the purpose of this Clause 3.6(b), Day Care Treatment expenses shall have the meaning given to it in Clause 3.1(b). (c) Pre-hospitalization and Post-hospitalization Expenses benefit: provides cover for payment of expenses that are incurred by the Beneficiary 15 days prior to 31

32 Hospitalization or Day Care Treatment for a Critical Illness and for continuous and follow-up treatment for up to 30 days after discharge. This benefit is a part of the benefit available under Clause 3.6(a) or Clause 3.6(b) and is limited to the available Critical Illness Sum Insured. For the purpose of this Clause 3.6(c), pre-hospitalization and post-hospitalization expenses shall have the meaning given to it in Clause 3.1(c). (d) Follow-up Care benefit: provides cover for payment of expenses that are incurred by the Beneficiary for Follow-up Care provided by an Empanelled Health Care Provider consequent to Hospitalization or Day Care Treatment of the Beneficiary for a Critical Illness. The Follow-up Care benefit is in addition to the post-hospitalization expenses benefit set out in Clause 3.6(c), i.e., it will only be available in respect of expenses incurred by the Beneficiary once the 30 day period post-discharge has been completed. This benefit will only be available in relation to Follow-up Care provided consequent to a Medical Treatment or Surgical Procedure for a Critical Illness for which: (x) the Beneficiary has been Hospitalized or obtained Day Care Treatment, whether such Hospitalization or Day Care Treatment took place prior to or during the Policy Cover Period; and (y) a Package Rate is prescribed in Section 2 of Schedule 4. This benefit is limited to: (1) the available Critical Illness Sum Insured; (2) a maximum of 40,000 for all instances of Follow-up Care; and (3) up to four instances of Follow-up Care, in each Policy Cover Period. For the purpose of this Clause 3.6(c), Follow-up Care expenses shall include: (i) (ii) (iii) OPD consultation expenses; expenses of Screening, including diagnostics and tests; and expenses of medicines and drugs for the period of treatment. The medicines will be handed over by the Empanelled Health Care Provider to the Beneficiary and the costs thereof will then be claimed from the Insurer as part of the prescribed Package Rate. (e) Transportation benefit: provides cover for cost of transportation incurred by the Beneficiary in travelling to and from the premises of the Specialty Hospital for availing of Medical Treatment or Surgical Procedure from the Specialty Hospital. This benefit is limited to 100 per occurrence of Hospitalization or Day Care Treatment or visit to an Empanelled Health Care Provider for Follow-up Care required for treatment of a Critical Illness. The transportation benefit will be paid to the Beneficiary by the Empanelled Health Care Provider and will then be Claimed 32

33 from the Insurer as part of the Package Rate. Further, this benefit is limited to a maximum of 10 instances of Hospitalization or Day Care Treatment or Follow-up Care required for treatment of a Critical Illness. (f) Economic Loss Compensation benefit: provides cover for economic loss suffered by the Beneficiary while availing of a Medical Treatment or Surgical Procedure requiring Hospitalization or Day Care Treatment or in visit for Follow-up Care provided by a Specialty Hospital. This benefit is limited to: (i) 900 per occurrence of Hospitalization or Day Care Treatment; and (ii) 100 per visit for Follow-up Care, for treatment of a Critical Illness. The economic loss compensation benefit will be paid to the Beneficiary by the Empanelled Health Care Provider and will then be claimed from the Insurer as part of the Package Rate. Further, this benefit is limited to a maximum of 10 instances of Hospitalization or Day Care Treatment or Follow-up Care required for treatment of a Critical Illness. (g) Domiciliary Care expenses: no benefits shall be available for Domiciliary Care. Each of the benefits specified above shall be available for all pre-existing diseases, illnesses or conditions for which Medical Treatments, Surgical Procedures or Day Care Treatments are listed in Section 1 of Schedule 4 and that affect the Beneficiaries on the date of commencement of each Policy Cover Period, subject only to the Exclusions Terms and Conditions for Additional Benefits for Senior Citizens Health Insurance Scheme To provide additional top up benefits to senior citizens and take care of additional geriatric diseases, it has been decided by Government of India that an enhanced coverage will be provided exclusively for senior citizens over and above the benefits being provided under RSBY. These additional benefits will be called Senior Citizens Health Insurance Scheme in this document. The terms and conditions for SCHIS are as follows: a. Benefits An enhanced coverage of Rs. 30,000 per senior citizen in the eligible RSBY family will be provided over and above the benefits provided to entire family under RSBY and subject to other terms and conditions outlined herein, are the following: (i) Health Insurance Coverage: The scheme shall provide an additional coverage of Rs, 30,000 per senior citizen in the eligible family. This package will be over and above the package of Rs. 30,000 provided under RSBY. (ii) This additional benefit can only be used exclusively by senior citizens of the family who are enrolled in RSBY. (iii) The hospital will provide services included in benefit package for Senior Citizens only after due pre-authorisation procedures. 33

34 (iv) A senior citizen seeking treatment under the scheme would have to first exhaust this additional top up cover of Rs. 30,000 (or more if there are more than one senior citizens) before utilizing the existing basic cover of Rs. 30,000 of RSBY. (v) If in any RSBY enrolled family there would be more than one senior citizen, then the additional cover will be in multiple of Rs. 30,000 per senior citizen and it will be provided on a floater basis among the senior citizens of the RSBY enrolled family. (vi) This means that if in a family if there are 2 senior citizens then an additional cover of Rs. 60,000 would be available on a floater basis to both the senior citizens and they would need to exhaust first this top up cover before they can utilize the basic family cover of Rs. 30,000 of RSBY. b. Target Beneficiaries The target beneficiaries of this schemes are such MHIS 3 enrolled beneficiaries that are 60 years and above in age. Such senior citizens who are BPL or belong to other designated categories of RSBY but not enrolled in MHIS 3 will not be eligible to get benefit of this scheme. c. Premium Payment and Refund The premium for this additional top up cover will be paid by the State Government to the insurance companies on a per family floater basis. A flat premium as determined through this tender; will be paid to the insurance company irrespective of the number of senior citizens enrolled in a family for RSBY. However, the benefit package per family may differ depending on the number of senior citizens enrolled in RSBY from the family The premium will be paid to the insurance company in the same way as it is done for RSBY and MHIS 3. The State share of 40% (20% for North Eastern and three Himalayan States) will need to be paid first to the insurance company based on the number of families that have at least one senior citizen enrolled in RSBY before raising the request for Central share of premium of 60% (80% for North Eastern and three Himalayan States). The same premium refund formula as applicable for RSBY of this tender document will also be applicable for premium related to SCHIS. The refund clause for SCHIS shall be computed separately and will be independent of the refund clause applicable for RSBY premium amount. d. Eligible Health Services Providers and their Empanelment All the providers already empaneled for providing inpatient services under RSBY will be automatically empaneled for providing benefits under senior citizen health insurance scheme. In addition, Insurance Company can empanel additional hospitals that have facilities to provide defined tertiary care packages. The proposed criteria for hospitals providing tertiary care is as under: EMPANELMENT OF HEALTH CARE PROVIDERS All the health care providers already empanelled for providing inpatient services under MHIS 3 will 34

35 be automatically empanelled for providing benefits under senior citizen health insurance scheme. In addition, Insurance Company can empanel additional hospitals that have facilities to provide defined tertiary care packages for senior citizens. The hospital will need to install machines and the equipment, conforming to the guidelines issued by the Central Government, for providing benefits under this scheme. The software to be used thereon shall be the one approved by the Central Government. The criteria for empanelment of hospitals empanelled for providing treatment to senior citizens only including tertiary care are as follows: i. Minimum 50 inpatient medical beds with adequate spacing of 60Sq.feet for each bed and supporting staff as per norms. ii. At least one in-house surgeon and or in-house physician (MD) shall be available for empanelment of Surgical and Medical packages respectively. iii. The hospital should have at least minimum of 3 MBBS doctors as duty doctors, for bed strength of 50 and above. The doctors mentioned at (b) above may also act as duty doctors. Round- the-clock, availability of Duty Doctors & Paramedic staff iv. Round- the-clock, availability of Duty Doctors & Paramedic staff v. In-house round-the-clock basic diagnostic facilities for biochemical, pathological and radiology tests such as Calorimeter, Auto analyzer, Microscope, X-ray, E.C.G, USG. etc., round-the-clock lab and imageology support. vi. Casualty should be equipped with Monitors, Defibrillator, Crash Cart, Resuscitation equipment, Oxygen and Suction facility and with attached toilet facility. vii. Fully equipped Operation Theatre along with required equipments as mentioned in the specific requirements for each Specialty. viii. Post-op ward with adequate number of Monitors, Ventilators and other required facilities. ix. ICU facility with Monitors, Ventilators, Oxygen facility, Suction facility, Defibrillator, and required other facilities & requisite staff. x. Round-the-clock availability of specialists in the concerned specialties having sufficient experience and availability of specialists in support fields with short notice. xi. Round-the-clock advanced diagnostic facilities either In-House or with Tie -up with a nearby Diagnostic Centre. xii. Round-the-clock Blood Bank facilities either In-House or with Tie-up with a nearby Blood Bank. xiii. Round-the-clock Physiotherapy centre facilities either In-House or with Tie -up with a nearby Physiotherapy Centre, wherever it is applicable. xiv. xv. xvi. xvii. xviii. xix. xx. xxi. xxii. xxiii. Round-the-clock own Ambulance facilities. Records Maintenance: Maintain complete records as required on day-to-day basis and is able to provide necessary records of hospital / patients to the Society/Insurer or his representative as and when required. 24 Hrs In-house pharmacy Registration with the Income Tax Department. NEFT enabled bank account Telephone/Fax and Internet Facility Safe drinking water facilities. Generator facility with required capacity suitable to the bed strength of the hospital should be installed. Bio Medical waste management facility available Fire Fighting system available. 35

36 e. Period of Insurance: The period of insurance will be same as provided in Clause 7 of this document. f. Enrolment of Beneficiaries: Any beneficiary who is enrolled in MHIS (RSBY Category) and is of age 60 years and above is eligible for these additional benefits. There will be no separate process for enrolment for providing benefits under SCHIS. g. Specific Tasks of Insurance Company for Additional top up benefits The Insurance Company will be required to do following functions for the purpose of providing the SCHIS benefits: i. May empanel additional eligible health care providers to provide these additional benefits. ii. Provide a separate leaflet to the beneficiary detailing the additional benefits. iii. Carry out additional IEC activities to inform the target beneficiaries about these additional benefits h. Apart from other terms and conditions of claim raising and settlement, the claims under SCHIS shall be processed only on pre-authorisation basis. i. All other terms and conditions as applicable for RSBY Beneficiaries will also be applicable for SCHIS Beneficiaries. 4. SUM INSURED 4.1 Base Sum Insured For each Policy Cover Period, the Sum Insured in respect of the Base Cover for each Beneficiary Family Unit: (a) (b) as on the date of commencement of risk cover for such Beneficiary Family Unit under Clause 7.4 or Clause 7.5, as applicable, shall be 30,000; and as on the date of a Claim Payment by the Insurer, shall stand reduced by all Claim Payments made as on that date in respect of the Base Cover, for the remainder of such Policy Cover Period. 4.2 Replenishment Sum Insured For each Policy Cover Period, the Replenishment Sum Insured in respect of the Replenishment Cover for each Beneficiary Family Unit: (a) as on the date of commencement of risk cover for such Beneficiary Family Unit under Clause 7.4 or Clause 7.5, as applicable, shall be 30,000; and 36

37 (b) as on the date of a Claim Payment by the Insurer, shall stand reduced by all Claim Payments made as on that date in respect of the Replenishment Cover, for the remainder of such Policy Cover Period. 4.3 Critical Illness Sum Insured For each Policy Cover Period, the Critical Illness Sum Insured in respect of the Critical Illness Cover for each Beneficiary Family Unit: (a) (b) as on the date of commencement of risk cover for such Beneficiary Family Unit under Clause 7.4 or Clause 7.5, as applicable, shall be 2,20,000; and as on the date of a Claim Payment by the Insurer, shall stand reduced by all Claim Payments made as on that date, for the remainder of such Policy Cover Period. 4.4 Reinstatement of Sum Insured On the date of commencement of each renewal Policy Cover Period, the Sum Insured in respect of each Cover for each Beneficiary Family Unit shall be reinstated to the maximum amounts set out in this Clause 4, notwithstanding that the Insurer has made any Claim Payments in respect of that Cover in the immediately preceding Policy Cover Period. 4.5 Sum Insured on Family Floater Basis (a) (b) The Covers shall be provided to each Beneficiary Family Unit on a family floater basis covering the members of the Beneficiary Family Unit, i.e., the Sum Insured will be available to any or all members of such Beneficiary Family Unit for one or more Claims during each Policy Cover Period. The maximum liability of the Insurer on a family floater basis for one or more Claims during any Policy Cover Period shall not exceed: (i) 2,80,000 in respect of a Beneficiary Family Unit. 5. AVAILABILITY OF BENEFITS UNDER COVERS 5.1 Benefits Available Only Through Network Hospitals (a) The Base Cover and Replenishment Cover benefits shall only be available to a Beneficiary through an Empanelled Health Care Provider or through an RSBY Network Hospital, against presentation of the Smart Card and verification of the Beneficiary's details on the Smart Card. Provided however that the OPD diagnostic benefit under the Base Cover and the Replenishment Cover shall only be available to a Beneficiary through a Specialty Hospital or a Diagnostics Lab that is empanelled for providing such OPD diagnostic 37

38 care, whether within or outside the Service Area, against presentation of the Smart Card and verification of the Beneficiary's details on the Smart Card. Provided further that the Tertiary Care expenses that are covered by the Base Cover and the Replenishment Cover benefits shall only be available to a Beneficiary through a Specialty Hospital that is empanelled for such Tertiary Care, whether within or outside the Service Area, against presentation of the Smart Card and verification of the Beneficiary's details on the Smart Card. (b) The Critical Illness Cover benefits shall only be available to a Beneficiary through an Empanelled Health Care Provider, against presentation of the Smart Card and verification of the Beneficiary's details on the Smart Card. Provided however that the Tertiary Care expenses that are covered by the Critical Illness Cover benefits shall only be available to a Beneficiary through a Specialty Hospital that is empanelled for such Tertiary Care, whether within or outside the Service Area, against presentation of the Smart Card and verification of the Beneficiary's details on the Smart Card. (c) Upon presentation of the Smart Card the benefits under each Cover shall, subject to the available Sum Insured, be available to the Beneficiary on a cashless basis in accordance with Clause Determination of Package Rates for Utilization of Covers (a) In respect of the first Policy Cover Period, the Insurer shall empanel public and private health care providers based on Package Rates determined as follows: (i) (ii) If the Package Rate for a Medical Treatment, Surgical Procedure, Day Care Treatment, OPD Benefit or Follow-up Care listed in Schedule 3 or Schedule 4 is fixed, then the fixed Package Rate shall apply for the first Policy Cover Period. If the Package Rate for a Medical Treatment, Surgical Procedure, Day Care Treatment, OPD Benefit or Follow-up Care listed in Schedule 3 or Schedule 4: (1) is indicative or not fixed; or (2) there is a duplication of Package Rates for such Medical Treatment, Surgical Procedure, Day Care Treatment, OPD Benefit or Follow-up Care, then the Insurer shall propose the Package Rate for such Medical Treatment, Surgical Procedure, Day Care Treatment, OPD Benefit or Follow-up Care within 30 days of the date of signing of this Insurance Contract and in any event, prior to the commencement of the first Policy Cover Period. Provided 38

39 that the Package Rate proposed by the Insurer for the OPD diagnostic care procedures listed in Section 2 of Schedule 3 shall be no lesser than the rates for such OPD diagnostic care procedures prevailing as indicative in Section 2 of Schedule 3. If the Insurer fails to propose the Package Rate for such Medical Treatment, Surgical Procedure, Day Care Treatment, OPD Benefit or Follow-up Care on the date of commencement of the first Policy Cover Period, then the rates for such Medical Treatment, Surgical Procedure, Day Care Treatment, OPD Benefit or Follow-up Care prevailing as indicative in Schedule 3 and Schedule 4 shall be deemed to be the Package Rates. Each Package Rate determined in accordance with this Clause 5.2(a)(ii) shall then apply for the first Policy Cover Period subject to the State Nodal Agency's approval. (iii) (iv) If the Package Rate for a Medical Treatment that is listed in Section 2 of Schedule 3 has not been provided, then the Insurer is not required to determine the Package Rate for such Medical Treatment in accordance with Clause 5.2(a)(ii) above. If the Package Rate for a Medical Treatment is not listed in Section 2 of Schedule 3, the flat daily Package Rates specified in Section 1 of Schedule 3 shall apply. (v) (vii) The Package Rates for Medical Treatments, Surgical Procedures or Day Care Treatments set out in Schedule 3 do not include the expenses of Follow-up Care for the Medical Treatments, Surgical Procedures and Day Care Treatments that are listed in Schedule 3. No separate Package Rates have been specified for such Follow-up Care. The Package Rates for the Critical Illnesses that are listed in Section 1 of Schedule 4 do not include the expenses of Follow-up Care. However, separate Package Rates have been specified for such Follow-up Care for certain Critical Illnesses at Section 2 of Schedule 4. (b) Empanelled Health Care Providers that have a valid NABH accreditation or similar accreditation from an equivalent national or international body shall be entitled to Package Rates that are higher than the Package Rates determined in accordance with Clause 5.2(a) for the first Policy Cover Period. The Package Rates for Medical Treatments, Surgical Procedures, Day Care Treatments, OPD Benefits or Follow-up Care provided by such NABH or equivalent accredited Empanelled Health Care Providers will be increased as follows: (i) If an Empanelled Health Care Provider has obtained the highest level of accreditation from NABH or a similar accreditation by an equivalent national 39

40 or international body, then the Package Rates for such Empanelled Health Care Provider shall be fixed at 120% of the Package Rates determined in accordance with Clause 5.2(a). (ii) If an Empanelled Health Care Provider has obtained an intermediate grade of accreditation from NABH or a similar accreditation by an equivalent national or international body, then the Package Rates for such Empanelled Health Care Provider shall be fixed by the Insurer within a range of 105% and 115% of the Package Rates determined in accordance with Clause 5.2(a). Provided that the increased Package Rates offered to Empanelled Health Care Providers having a valid NABH accreditation or similar accreditation from an equivalent national or international body shall not provide for an increase in the price of implants or other consumables that are included within the Package Rates determined in accordance with Clause 5.2(a). Notwithstanding anything contained in this Clause 5.2(b), the State Nodal Agency may, from time to time, issue MHIS Guidelines and prescribe the manner in which Package Rates for Empanelled Health Care Providers validly accredited by NABH or other equivalent national or international bodies are to be determined. (c) Without prejudice to Clause 5.2(e), the Insurer may change the Package Rates determined in accordance with Clause 5.2(a) for each renewal Policy Cover Period, based on discussions with the Empanelled Health Care Providers and subject to obtaining prior written approval from the State Nodal Agency for such changes in Package Rates and with prior intimation to MoHFW. Any changes in the Package Rates should be finalized and approved by the State Nodal Agency at least 30 days prior to the date of commencement of a renewal Policy Cover Period. Provided that, if the Package Rate being changed is listed in the RSBY contract published by MoHFW, then the revised Package Rate shall not be lower than the lowest prevailing rate in similar states under RSBY. Provided further that, if the Package Rate being changed is not listed in the RSBY contract published by MoHFW, then the revised Package Rate shall not be lower than the lowest prevailing rate in similar schemes. For the purpose of these provisos, the State Nodal Agency shall issue MHIS Guidelines from time to time for the determination of prevailing rates in similar states and/or under similar schemes. Notwithstanding the foregoing provisos, the State Nodal Agency may on merit and based on market conditions require the Insurer to reduce the Package Rate for any Medical Treatment, Surgical Procedure, Day Care Treatment, Follow-up Care or OPD Benefit below the benchmark rate determined by reference to similar states or similar schemes by a further 20%. 40

41 The Insurer may make such change for a renewal Policy Cover Period only prior to the commencement of such renewal Policy Cover Period, unless the State Nodal Agency requests such a change during any Policy Cover Period. The Insurer shall, upon a request being made by the State Nodal Agency, consult with the Empanelled Health Care Providers and revise the Package Rates after obtaining prior written approval of the State Nodal Agency and with prior intimation to MoHFW. (d) (e) (f) The Insurer shall be responsible for publishing the Package Rates determined in accordance with this Clause 5.2 on its website in advance of each Policy Cover Period. The Insurer shall ensure that the Beneficiaries are advised that such information regarding the Package Rates are available on its website. During each Policy Cover Period, the Insurer shall not: (i) seek or permit any change to the Package Rates; and (ii) revise the Package Rates determined in accordance with Clause 5.2(a) or Clause 5.2(c) through bilateral arrangements with any Empanelled Health Care Provider. As part of the regular review process, the Parties shall review information on incidence of common Medical Treatments or Surgical Procedures that are not listed in Schedule 3 or Schedule 4 and that require Hospitalization or Day Care Treatments. Either Party may suggest the inclusion of additional Package Rates, based on the incidence of diseases or medical conditions and other relevant data. The Parties shall then mutually agree on the Package Rates for such Medical Treatments or Surgical Procedures, as the case may be. The agreed Package Rates shall be deemed to have been included in Schedule 3 or Schedule 4 based on the value of such Package Rate (i.e., Rs. 30,000 or more) with effect from the date on which the Parties have mutually agreed the new Package Rates in writing. (g) Notwithstanding anything to the contrary contained in this Clause 5.2: (i) (ii) (iii) If any Package Rate that is determined for any Policy Cover Period in accordance with this Clause 5.2 exceeds 30,000, then such Medical Treatment, Surgical Procedure or Day Care Treatment shall be deemed to be a Critical Illness and shall be deemed to be included in Schedule 4 from the date of such determination. If any Package Rate that is determined for any Policy Cover Period in accordance with this Clause 5.2 falls below 30,000, then such Medical Treatment, Surgical Procedure or Day Care Treatment shall be deemed to be a Tertiary Care and shall be deemed to be included in Schedule 3 from the date of such determination. No Package Rate for a Critical Illness that is determined in accordance with Clause 5.2(a) or Clause 5.2(b) or revised in accordance with Clause 5.2(c) shall exceed 2,50,000 (h) The Insurer agrees that the Package Rates for: 41

42 (i) Medical Treatments, Surgical Procedures or Day Care Treatments listed in Schedule 3 and determined in accordance with this Clause 5.2 shall cover the entire cost of treatment of the disease, illness or injury suffered by a Beneficiary from the date that the Beneficiary reports to the Empanelled Health Care Provider (i.e., 1 day prior to hospitalization) and until 5 days after the date of discharge of the Beneficiary; (ii) (iii) (iv) Critical Illnesses that are determined in accordance with this Clause 5.2 shall cover the entire cost of treatment of the disease, illness or injury suffered by a Beneficiary from the date that the Beneficiary reports to the Empanelled Health Care Provider (i.e., 15 days prior to hospitalization) and until 30 days after the date of discharge of the Beneficiary; OPD Benefits that are determined in accordance with this Clause 5.2 shall cover the entire cost of such OPD Benefits; and Follow-up Care for Critical Illnesses that are determined in accordance with this Clause 5.2 shall cover the entire cost of such Follow-up Care, making the transaction truly cashless for the Beneficiary. 5.3 Utilization of Base Cover and Replenishment Cover Benefits (a) Utilization of Base Cover and Replenishment Cover Benefits limited to Package Rates (i) A Claim by an Empanelled Health Care Provider for the utilization of the Base Cover benefits or the Replenishment Cover benefits, as the case may be, for a given instance of: (A) (B) (C) Hospitalization of a Beneficiary for a Medical Treatment or Surgical Procedure provided by an Empanelled Health Care Provider; Day Care Treatment provided by an Empanelled Health Care Provider; or visit to an Empanelled Health Care Provider for Follow-up Care or OPD Benefit, shall be limited to the Package Rate that is determined in accordance with Clause 5.2 for the Empanelled Health Care Provider providing such health care services. (ii) If: (A) a Medical Treatment, Surgical Procedure, Day Care Treatment, Follow-up Care or OPD Benefit is not listed in Schedule 3 or in Schedule 4; or 42

43 (B) no Package Rate is determined for a Medical Treatment, Surgical Procedure, Day Care Treatment, Follow-up Care or OPD Benefit that is listed in Schedule 3 in accordance with Clause 5.2, then a Claim by an Empanelled Health Care Provider for the cost of such Medical Treatment, Surgical Procedure, Day Care Treatment, Follow-up Care or OPD Benefit under the Base Cover or Replenishment Cover shall be subject to the category 3 pre-authorization and Claim procedure specified in Schedule 5. (b) Pre-authorization for Utilization of Base Cover and Replenishment Cover benefits For each Medical Treatment, Surgical Procedure, Day Care Treatment, Follow-up Care or OPD Benefit that is listed in Schedule 3, the relevant category of preauthorization and Claim procedure is identified with reference to Schedule 5. A Claim by an Empanelled Health Care Provider under the Base Cover or Replenishment Cover shall be subject to the category of pre-authorization and Claim procedure identified in Schedule 3 and set out in Schedule 5. (c) Cap on Utilization of Base Cover and Replenishment Cover benefits A Claim made by an Empanelled Health Care Provider for utilization of Base Cover and Replenishment Cover benefits for a Medical Treatment, Surgical Procedure, Day Care Treatment, Follow-up Care or OPD Benefit shall be subject to the following limits: (i) (ii) (iii) the available Base Sum Insured or the available Replenishment Sum Insured; the applicable sub-limits or conditions specified in Clause 3.1, Clause 3.2 or Clause 3.4 in relation to the utilization of such benefits; the Package Rate determined in accordance with Clause 5.2 or the Preauthorized Amount; and (iv) a maximum of: (aa) 30,000 per Claim made under the Base Cover and/or the Replenishment Cover. Illustrative Examples: (1) At the beginning of a Policy Cover Period, the Base Sum Insured for a Beneficiary Family Unit under the Base Cover is 30,000 and the Replenishment Sum Insured under the Replenishment Cover is 30,000. If the Beneficiary requires a Medical Treatment for which the Package Rate is 10,000 then subject to the Category 2 pre-authorization procedure specified in Schedule 5, the entire cost of such procedure will be met out of 43

44 the Base Cover. (2) Following this, the available Base Sum Insured is 20,000 Following this, the available Base Sum Insured continues to be 20,000. (3) Following this, the available Base Sum Insured is 20,000 and the available Replenishment Sum Insured is 30,000. Now, if the Beneficiary requires a Medical Treatment for which no Package Rate is determined, then the Claim of the Empanelled Health Care Provider is subject to Category 3 preauthorization in Schedule 5. If the Insurer accepts the RAL and specifies that the Pre-authorized Amount for such Medical Treatment is 30,000, then: the first 20,000 will be met out of the Base Cover; and 10,000 will be met out of the Replenishment Cover. (4) Following this, the available Base Sum Insured is 0 and the Replenishment Sum Insured is 20,000. Now, if the Beneficiary requires a Surgical Procedure which is identified as Tertiary Care, for which the Package Rate is 30,000 and Schedule 3 specifies that Category 2 preauthorization procedure must be followed, then subject to the Claim being pre-authorized, the first 20,000 will be met out of the Replenishment Cover and the Beneficiary will have to bear the cost of the remaining 10, Utilization of Critical Illness Cover Benefits (a) Utilization of Critical Illness Cover Benefits limited to Package Rates (i) A Claim by an Empanelled Health Care Provider for the utilization of the Critical Illness Cover benefits, for a given instance of Hospitalization or Day Care Treatment of a Beneficiary for a Critical Illness, shall be limited to the Package Rate that is determined in accordance with Clause 5.2 for the Empanelled Health Care Provider providing such health care services. Provided however that such Claim shall be subject to the Deductible, i.e., the first 30,000 of the Claim shall be met in accordance with Clause 3.5 and the balance of the Claim to the extent of the Package Rate will be met out of the Critical Illness Cover. (ii) (iii) A Claim by an Empanelled Health Care Provider for the utilization of the Follow-up Care benefit under the Critical Illness Cover shall be limited to the Package Rate that is determined in accordance with Clause 5.2 for the Empanelled Health Care Provider providing such health care services. If a Medical Treatment, Surgical Procedure, Day Care Treatment or Followup Care is not listed or deemed to be listed in Schedule 4 and the cost 44

45 thereof exceeds 30,000, then a Claim by an Empanelled Health Care Provider for the utilization of the Critical Illness Cover benefits shall be rejected by the Insurer. (b) Pre-authorization for Utilization of Critical Illness Cover benefits (i) (ii) A Claim by an Empanelled Health Care Provider under the Critical Illness Cover for a Critical Illness requiring Hospitalization or Day Care Treatment shall be subject to the Category 5 pre-authorization and Claim procedure set out in Schedule 5. A Claim by an Empanelled Health Care Provider under the Critical Illness Cover for Follow-up Care shall be subject to the Category 1 preauthorization and Claim procedure set out in Schedule 5. (c) Cap on Utilization of Critical Illness Cover benefits A Claim made by an Empanelled Health Care Provider for utilization of the Critical Illness Cover benefits for Hospitalization or Day Care Treatment of a Critical Illness shall be subject to the following limits: (i) (ii) the available Critical Illness Sum Insured, which shall be in excess of the Deductible of 30,000 (which Deductible shall be met out of the available Base Cover Sum Insured or the available Replenishment Sum Insured or be paid by the Beneficiary); the Package Rate determined in accordance with Clause 5.2; and (iii) a maximum of: (A) 250,000 per Claim in the case of a Hospitalization or Day Care Treatment; and (B) 40,000 per Claim in the case of Follow-up Care. Illustrative Examples: (1) Assume that the Base Sum Insured available is 30,000 and the available Critical Illness Sum Insured is 2,20,000, which is in excess of the Deductible of 30,000. If the Beneficiary requires Hospitalization for a Critical Illness for which the Package Rate is 260,000 then subject to the Category 5 pre-authorization procedure specified in Schedule 5, the cost of such Critical Illness treatment will be met as follows: the first 30,000 will be met out of the Base Cover; and the remaining 2,20,000 will be met out of the Critical Illness Cover. 10,000 will have to be paid by the Beneficiary. (2) Following utilization in Illustrative Example 1, the available Base Sum Insured is 0, the Replenishment Sum Insured is 30,000 and the available Critical Illness Sum Insured is 0. Now, if the Beneficiary requires Follow-up Care for which the agreed Package Rate is 15,000, then subject to the Category 1 pre-authorization 45

46 procedure specified in Schedule 5, the entire cost of such Follow-up Care will be met out of the Replenishment Cover. The Follow-up Care Benefit under the Critical Illness Cover is not subject to the Deductible and therefore, the available Replenishment Sum Insured cannot be utilized. Following such utilization, the available Base Sum Insured is 0, the available Replenishment Sum Insured is 30,000 and the available Critical Illness Sum Insured is 5,000. (3) Assume that the available Base Sum Insured is 0, the available Replenishment Sum Insured is 10,000 and the available Critical Illness Sum Insured is 2,20,000. If the Beneficiary requires Hospitalization for treatment of a Critical Illness for which the Package Rate is 250,000 then subject to the Category 5 preauthorization procedure specified in Schedule 5, the cost of such Critical Illness treatment will be met as follows: 6. ISSUANCE OF POLICIES (1) the first 10,000 will be met out of the Replenishment Cover; (2) the second 20,000 (i.e., the amount of the Deductible not covered by the available Base Sum Insured and the available Replenishment Sum Insured) must be paid for by the Beneficiary to the Empanelled Health Care Provider; and (3) the remaining 2,20,000 will be met out of the Critical Illness Cover. Following such utilization, the available Base Sum Insured is 0, the available Replenishment Sum Insured is 0 and the available Critical Illness Sum Insured is 0. (a) (b) In respect of each district, the Insurer shall issue a Policy before the commencement of the Policy Cover Period for such district. The terms and conditions set out in each Policy issued by the Insurer to the State Nodal Agency shall at a minimum include: (i) (ii) (iii) the Policy number (which shall be included as a field on the Smart Card issued to or renewed for each Beneficiary Family Unit enrolled in that district); the Policy Cover Period under such Policy, determined in accordance with Clause 7.1 and Clause 7.2; and the terms and conditions for providing the Covers, which shall not deviate from or dilute in any manner the terms and conditions of insurance set out in this Insurance Contract. 46

47 (c) (d) Notwithstanding any delay by the Insurer in issuing or failure by the Insurer to issue a Policy for a district in accordance with Clause 6(a), the Insurer agrees that the Policy Cover Period for such district shall commence on the date determined in accordance with Clause 7.1 and that it shall provide the Beneficiaries enrolled in that district with the Covers from that date onwards. In the event of any discrepancy, ambiguity or contradiction between the terms and conditions set out in this Insurance Contract and a Policy issued for a district, the terms of this Insurance Contract shall prevail for the purpose of determining the Insurer's obligations and liabilities to the State Nodal Agency and the Beneficiaries. 7. PERIOD OF INSURANCE 7.1 Commencement of Policy Cover Period (a) The first Policy Cover Period under the Policy for a district shall commence from 0000 hours of the first day of the month succeeding the month in which the first Smart Card is issued in that district. The Insurer shall use its best efforts to commence enrolment in all districts in the same month of each year. Notwithstanding the foregoing, the Insurer shall ensure that it commences enrolment in at least six districts across the Service Area in the same month in each year. While determining the Enrolment Schedule for each district and the Service Area, Parties shall keep in mind this requirement. If, however, the policy cover extended by the incumbent insurer under the insurance contract awarded by the State Nodal Agency under the Scheme (the Incumbent Cover) has commenced prior to the date of signing of this Insurance Contract but continues on the date mentioned above or is renewed on or before the date mentioned above, then the first Policy Cover Period under the Policy for a district shall commence from 0000 hours of the day following the day on which the Incumbent Cover expires. (b) Upon renewal of the Policy for a district in accordance with Clause 7.3, the renewal Policy Cover Period for such district shall commence from 0000 hours of the day following the day on which the immediately preceding Policy Cover Period expires. 7.2 Policy Cover Period In respect of each district, each Policy Cover Period shall be a period of 12 months from the date of commencement of such Policy Cover Period, i.e., until 2359 hours on the date of expiration of the twelfth month from the date of commencement determined in accordance with Clause 7.1. Provided that upon early termination of this Insurance Contract, the Policy Cover Period for each district shall terminate on the earlier to occur of the Termination Date and the Migration Termination Date. 47

48 For the avoidance of doubt, the expiration of the risk cover for any Beneficiary Family Unit in the district during the Policy Cover Period shall not result in the termination of the Policy Cover Period for such district. 7.3 Renewal of Policy Cover Period (a) (b) In respect of each district, a Policy may be renewed by the State Nodal Agency for a maximum of 2 renewal Policy Cover Periods in accordance with this Clause 7.3. The Insurer shall renew the Policies for all districts in the Service Area subject to the following conditions being satisfied: (i) (ii) (iii) (iv) The Insurer demonstrating to the reasonable satisfaction of the State Nodal Agency that the Insurer is not suffering from any Insurer Event of Default or if it has occurred, such Insurer Event of Default is not continuing. The Insurer demonstrating to the reasonable satisfaction of the State Nodal Agency that the Insurer has met or exceeded the Renewal KPIs set out at Schedule 16 for the entire Service Area during the on-going Policy Cover Period; or the State Nodal Agency not having exercised its right to refuse renewal in accordance with Section 3.2 of Schedule 16. This determination shall occur at the time and in accordance with the procedure set out in Section 3 of Schedule 16. The renewal Premium for the renewal Policy Cover Period being determined in accordance with Clause 8.2 and the renewal of the Policies not being denied or refused in accordance with Clause 8.2(d) or Clause 8.2(f). The Insurer receiving the renewal Premium for the renewal Policy Cover Period on or before the Renewal Premium Payment Due Date, and failing that on or before the date of expiration of the Grace Period, in accordance with Clause 8.4(b). If any of the conditions for renewal in this Clause 7.3(b) are not satisfied, then the State Nodal Agency may refuse or the Insurer may deny renewal of a Policy for a district, provided that it gives written reasons for its refusal or denial, as the case may be. In no other circumstances (including the circumstances set out in Clause 12 or in Clause 13) shall the State Nodal Agency refuse or the Insurer deny renewal of a Policy for a district. (c) Without prejudice to the provisions of Clause 12, Clause 13 and Clause 14, the Insurer shall not deny renewal of a Policy for a district: (i) for fraud, moral hazard, misrepresentation or non-cooperation of the Beneficiaries or of the Insured; or 48

49 (ii) (iii) on the ground that the Beneficiaries have received Claim Payments from the Insurer or that any of the Beneficiary Family Units have exhausted the Sum Insured under the Covers in previous Policy Cover Periods; or on the ground that the State Nodal Agency and/or the Beneficiaries have not made any representation, statement or warranty regarding the risks or responsibilities to be borne by the Insurer during the renewal Policy Cover Period. (d) Upon renewal of each Policy for a district, the Insurer shall inform all of the Beneficiary Family Units in that district of the renewal of the Policy for that district, along with the commencement and expiry dates of the renewal Policy Cover Period and the risk cover period for all the Beneficiary Family Units in that district. Such information shall be widely publicised. 7.4 Risk Cover Period for Each Beneficiary Family Unit in the First Policy Cover Period During the first Policy Cover Period for a district: (a) (b) (c) The risk cover for the first Beneficiary Family Unit to be issued a Smart Card in such district shall commence from 0000 hours of the date of commencement of the first Policy Cover Period. The risk cover for each Beneficiary Family Unit issued a Smart Card in a district after the issuance of the first Smart Card in that district will commence from 0000 hours on the later to occur of: (i) the date of issuance of the Smart Card to such Beneficiary Family Unit; and (ii) the date of commencement of the first Policy Cover Period for such district. The end date of the risk cover for each Beneficiary Family Unit in that district in respect of each Cover provided to it shall be the earlier to occur of: (i) the date on which the available Sum Insured in respect of that Cover becomes zero; and (ii) the date of expiration of the first Policy Cover Period for such district. (d) The Insurer shall ensure that each Beneficiary Family Unit shall have a minimum of 9 months of risk cover in respect of each Cover in the first Policy Cover Period, unless the available Sum Insured in respect of such Cover becomes zero earlier. Illustrative Example 1: If: (i) the first Smart Card in a district is issued anytime during the month of November 2014; and (ii) the Incumbent Cover expires on 30 November 2014, the Policy Cover Period for that district shall commence from the midnight of 1 December The Policy Cover Period shall continue for a period of 12 months, i.e., until the midnight of 30 November However, in the same example, if a Smart Card is subsequently issued in the month of December 2014 in the same district, then the risk cover for such Beneficiary Family Unit will 49

50 commence on the date of issuance of the Smart Card, but will terminate on 30 November Thus, all Beneficiary Family Units issued Smart Cards in the district will be entitled to a risk cover under the Policy for that district. The risk cover available to a Beneficiary Family Unit enrolled in that district shall be determined based on the date of enrolment of such Beneficiary Family Unit, as follows: Sl. No. Smart Card issued to Beneficiary Family Unit on Commencement of Risk Risk Cover End Date* Cover for Beneficiary Family Unit enrolled 1 December November November 2014 (First Smart Card) 2. 1 December December November December December November January January November February February November 2015 * Assuming that the available Sum Insured in respect of each Cover does not become zero before such date. Illustrative Example 2: If: (i) the first Smart Card in a district is issued anytime during the month of January 2015; and (ii) the Incumbent Cover expires on 30 April 2015, the Policy Cover Period for that district shall commence from the midnight of 1 May The Policy Cover Period shall continue for a period of 12 months, i.e., until the midnight of 30 April However, in the same example, if a Smart Card is subsequently issued in the month of February 2015 in the same district, then the risk cover for such Beneficiary Family Unit will commence on the date of commencement of the Policy Cover Period (as this occurs after the date of issuance of the Smart Card), but will terminate on 30 April Thus, all Beneficiary Family Units issued Smart Cards in the district will be entitled to a risk cover under the Policy for that district. The risk cover available to each Beneficiary Family Unit enrolled in that district will be for the full 12 months of the Policy Cover Period, as follows: Sl. No. Smart Card issued to Beneficiary Family Unit on Commencement of Risk Risk Cover End Date* Cover for Beneficiary Family Unit enrolled 1 May April January 2015 (First Smart Card) 2. 1 February May April February May April March May April April May April

51 * Assuming that the available Sum Insured in respect of each Cover does not become zero before such date. The insurer will have a maximum of four months to complete the entire enrolment process. Full premium for the four months will be paid to the insurer 7.5 Risk Cover Period for Each Beneficiary Family Unit in the Renewal Policy Cover Periods During each renewal Policy Cover Period following the first Policy Cover Period for a district: (a) (b) (c) The risk cover for each Beneficiary Family Unit to whom a Smart Card is issued or whose Smart Card is renewed, shall commence from the later to occur of: (i) 0000 hours of the day following the day on which the immediately preceding Policy Cover Period has expired; and (ii) the date on which the State Nodal Agency has paid the renewal Premium for such Beneficiary Family Unit in accordance with Clause 8.3(b). The end date of the risk cover for each Beneficiary Family Unit in respect of each Cover provided to it shall be the earlier to occur of: (i) the date on which the available Sum Insured in respect of that Cover becomes zero; and (ii) the date of expiration of such renewal Policy Cover Period for such district. The Insurer shall ensure that each Beneficiary Family Unit shall have a minimum of 12 months of risk cover in respect of each Cover in each renewal Policy Cover Period, unless: (i) (ii) the renewal Premium for such Beneficiary Family Unit has not been paid in accordance with Clause 8.3(b); and/or the available Sum Insured in respect of such Cover becomes zero earlier. Illustrative Example: If the Policy in a district is expiring on 30 November 2015 then the renewal Policy Cover Period shall commence on the midnight of 1 December 2015 and the Smart Card renewal/issuance in that district shall commence no later than 1 July 2015, assuming that the Insurer has not denied or the State Nodal Agency has not refused renewal for any of the grounds set out in Clause 7.3. The renewal Policy Cover Period for that district shall continue for a period of 12 months, i.e., until 30 November In this example, the risk cover for each Beneficiary Family Unit that is issued a Smart Card or whose Smart Card is renewed will commence on 1 December 2015 and will terminate on 30 November Sl. No. Smart Card issued to Beneficiary Family Unit in Commencement of Risk Cover for Beneficiary Family Unit enrolled Risk Cover End Date 1. July December November

52 Sl. No. Smart Card issued to Beneficiary Family Unit in Commencement of Risk Cover for Beneficiary Family Unit enrolled Risk Cover End Date 2. August December November September December November October December November Cancellation Upon early termination of the Insurance Contract by the State Nodal Agency in accordance with Clause 31.2, all Policies issued by the Insurer under this Insurance Contract shall, subject to Clause 31.5 and Clause 31.6, be deemed cancelled with effect from the Termination Date or the Migration Termination Date, whichever occurs earlier. 8. PREMIUM AND PREMIUM PAYMENT 8.1 Premium for First Policy Cover Period The Premium payable by the State Nodal Agency to the Insurer for providing the Covers is [ ] per Beneficiary Family Unit for the first Policy Cover Period, which is split as follows: (a) The Base Premium for providing the Base Cover is [ ] per Beneficiary Family Unit for the first Policy Cover Period. (b) The Additional Premium for providing the Replenishment Cover and the Critical Illness Cover is [ ] per Beneficiary Family Unit for the first Policy Cover Period. (c) The Senior Citizen Premium for providing the Senior Citizen Cover is [ ] per Beneficiary Family Unit for the first Policy Cover Period. 8.2 Premium for Each Renewal Policy Cover Period (a) (b) The Insurer shall cause its Appointed Actuary to submit to the State Nodal Agency an actuarial certificate (in the format prescribed at Annexure 10) stating the Insurer's Pure Claim Ratio for the first six months of each Policy Cover Period for all the districts within the Service Area, based on such Appointed Actuary's fair and reasonable view. The Insurer shall ensure that such actuarial certificate is submitted no later than 190 days from the date of commencement of each Policy Cover Period. The State Nodal Agency shall, in good faith, review and consider the actuarial certificate issued by the Appointed Actuary. The State Nodal Agency may seek additional information from or consultations with the Insurer and/or its Appointed Actuary. 52

53 The Insurer shall consult with the State Nodal Agency and cause its Appointed Actuary to provide the State Nodal Agency with such additional information as may be requested, within 5 days of receiving such request. (c) If the Insurer's Pure Claim Ratio for the first six months of any Policy Cover Period triggers any of the thresholds set out in the table below, then the renewal Premium for the next renewal Policy Cover Period shall be loaded in the manner set out in the table below. Pure Claim Ratio Premium Adjustment PCR 90% The renewal Premium for the next Policy Cover Period shall be loaded in the manner set out in Clause 8.2(e), unless the Insurer has exercised its right to refuse renewal of the Policies in accordance with Clause 8.2(d). 70% PCR < 90% The renewal Premium for the next Policy Cover Period shall be loaded in the manner set out in Clause 8.2(e). 30% < PCR < 70% The renewal Premium for the next Policy Cover Period shall be the same as the Premium for the ongoing Policy Cover Period. PCR 30% The renewal Premium for the next Policy Cover Period shall be the same as the Premium for the ongoing Policy Cover Period; unless the State Nodal Agency has exercised its right to refuse renewal of the Policies in accordance with Clause 8.2(f). For the purpose of this Clause 8.2, the Pure Claim Ratio shall be determined as follows: PCR = C x x [P T {N E x (C SM + C AC )}] provided that (C SM + C AC ) per Beneficiary Family Unit shall not be greater than the amount determined as the lesser of: (x) 120; and (y) the actual cost per Beneficiary Family Unit stated in the actuarial certificate issued by the Insurer's Appointed Actuary in accordance with Clause 8.2(a). where: PCR is the Pure Claim Ratio for the first six months of the on-going Policy Cover Period; C is the total Claims paid by the Insurer to the Empanelled Health Care Providers in the first six months of the on-going Policy Cover Period; 53

54 P T is the total Premium earned by the Insurer in the on-going Policy Cover Period; C SM is the cost incurred by the Insurer in issuing a Smart Card to a Beneficiary Family Unit enrolled by it in the on-going Policy Cover Period; C AC is the administrative cost incurred by the Insurer in providing the Covers for each Beneficiary Family Unit enrolled by it in such Policy Cover Period (other than the cost of the Smart Cards); and N E shall have the meaning given to it in Section 1.1 of Table 1 set out in Schedule 16. (d) If the Pure Claim Ratio in the first six months of any Policy Cover Period is greater than or equal to 90%, then the Insurer shall have the right to refuse to renew the Policies for all the districts for the next Policy Cover Period, by giving the State Nodal Agency a notice within 10 days of submission of the actuarial certificate and in any event prior to the date on which the Insurer is required to commence enrolment for the next Policy Cover Period. If the Insurer has not issued such a notice to the State Nodal Agency within the prescribed period, it shall be deemed that the Insurer is satisfied with the renewal Premium determined in accordance with Clause 8.2(e) and the Policies for all the districts shall be renewed, subject to compliance with Clause 7.3. (e) If the Pure Claim ratio in the first six months of any Policy Cover Period is greater than or equal to 70%, then the Premium per Beneficiary Family Unit for the renewal Policy Cover Period shall be determined in accordance with the formula set out below: P n = P n-1 x [1+WPI av /100] where: n is the renewal Policy Cover Period; n 1 is the on-going Policy Cover Period; P n is the renewal Premium for the renewal Policy Cover Period; P n - 1 is the Premium for the on-going Policy Cover Period; and WPI av is the average WPI over the 5 year period immediately preceding the date on which the renewal Premium is being determined. For this purpose, the WPI values will be taken by reference to the last day of the month occurring immediately prior to the month in which the renewal Premium is being determined. Illustrative Example: 54

55 The WPI is published at the web link If the renewal Premium determination is being made on 15 June 2015, then the WPI for the year ending on 31 May 2015 will be determined by reference to the published WPI on 31 May The WPI for the preceding year will be determined as follows: [(WPI on 31 May 2015)/(WPI on 1 June 2014) - 1] X 100. Similarly, the average WPI over the 5 year period immediately preceding the date on which the renewal Premium is being determined will be determined as follows: [{(WPI on 31 May 2015)/(WPI on 1 June 2014)}^(1/5) - 1] x 100 (f) If the Pure Claim Ratio in the first six months of any Policy Cover Period is lesser than 30%, then the State Nodal Agency shall have the right to refuse to renew the Policies for all the districts for the next Policy Cover Period, by giving the Insurer a notice within 10 days of submission of the actuarial certificate and in any event prior to the date on which the Insurer is required to commence enrolment for the next Policy Cover Period in accordance with Clause 21.1(c). If the State Nodal Agency has not issued such a notice to the Insurer within the prescribed period, the Policies for all the districts shall be renewed, subject to compliance with Clause Refund of Premium for a Policy Cover Period (a) (b) The Insurer shall cause its Appointed Actuary to submit to the State Nodal Agency an actuarial certificate (in the format prescribed at Annexure 10) stating the Insurer's Pure Claim Ratio for all twelve months of each Policy Cover Period for all the districts within the Service Area, based on such Appointed Actuary's fair and reasonable view. The Insurer shall ensure that such actuarial certificate is submitted no later than 10 days following the date of expiration of each Policy Cover Period. The State Nodal Agency shall, in good faith, review and consider the actuarial certificate issued by the Appointed Actuary. The State Nodal Agency may seek additional information from or consultations with the Insurer and/or its Appointed Actuary. The Insurer shall consult with the State Nodal Agency and cause its Appointed Actuary to provide the State Nodal Agency with such additional information as may be requested, within 5 days of receiving such request. (c) If the Insurer's Pure Claim Ratio for the full twelve months of any Policy Cover Period is below 70%, then the Insurer shall be liable to refund to the State Nodal Agency such part of the Premium for the immediately prior Policy Cover Period determined in the manner set out below. 55

56 (i) For the purpose of this Clause 8.3, the Pure Claim Ratio shall be determined as follows: PCR = C x 100 P T - [N E x (C SM + C AC )] provided that (C SM + C AC ) per Beneficiary Family Unit shall not be greater than the amount determined as the lesser of: (x) 120; and (y) the actual cost per Beneficiary Family Unit stated in the actuarial certificate issued by the Insurer's Appointed Actuary in accordance with Clause 8.3(a). where: PCR is the Pure Claim Ratio for the full twelve months of the immediately prior Policy Cover Period; C is the total Claims paid by the Insurer to the Empanelled Health Care Providers in the full twelve months of the immediately prior Policy Cover Period; P T is the total Premium earned by the Insurer in the immediately prior Policy Cover Period; C SM is the cost incurred by the Insurer in issuing a Smart Card to a Beneficiary Family Unit enrolled by it in the on-going Policy Cover Period; C AC is the administrative cost incurred by the Insurer in providing the Covers for each Beneficiary Family Unit enrolled by it in such Policy Cover Period (other than the cost of the Smart Cards); and N E shall have the meaning given to it in Section 1.1 of Table 1 set out in Schedule 16. (ii) The Insurer s liability for refund shall be calculated as follows: R = 0.7 x [P T - [N E x (C SM + C AC )]] - C provided that (C SM + C AC ) per Beneficiary Family Unit shall not be greater than the amount determined as the lesser of: (x) 120; and (y) the actual cost per Beneficiary Family Unit stated in the actuarial certificate issued by the Insurer's Appointed Actuary in accordance with Clause 8.3(a). where: R is the Insurer s liability for refund of the Premium for the immediately prior Policy Cover Period; 56

57 C is the total Claims paid by the Insurer to the Empanelled Health Care Providers in the full twelve months of the immediately prior Policy Cover Period; P T is the total Premium earned by the Insurer in the immediately prior Policy Cover Period; C SM is the cost incurred by the Insurer in issuing a Smart Card to a Beneficiary Family Unit enrolled by it in the on-going Policy Cover Period; C AC is the administrative cost incurred by the Insurer in providing the Covers for each Beneficiary Family Unit enrolled by it in such Policy Cover Period (other than the cost of the Smart Cards); and N E shall have the meaning given to it in Section 1.1 of Table 1 set out in Schedule 16. (iii) The refund of the Premium for the immediately prior Policy Cover Period determined in accordance with this Clause 8.3 shall be payable by the Insurer within 90 days of the date of expiration of the immediately prior Policy Cover Period. (iv) If the Insurer delays payment of or fails to pay the refund amount within 90 days of the date of expiration of the immediately prior Policy Cover Period, then the Insurer shall be liable to pay interest at the rate of 0.5% of the refund amount due and payable to the State Nodal Agency for every 15 days of delay beyond such 90 day period. (v) If the Insurer fails to refund the Premium within such 90 day period and/or the default interest thereon, the State Nodal Agency shall be entitled to deduct such amount from the renewal Premium payable by the State Nodal Agency or to recover such amount as a debt due from the Insurer. Provided that no such deduction made by the State Nodal Agency from the renewal Premium shall be deemed as a failure to pay the renewal Premium for the renewal Policy Cover Period on or before the Renewal Premium Payment Date or the expiration of the Grace Period. (d) If the Insurer's Pure Claim Ratio for the full twelve months of any Policy Cover Period calculated in accordance with Clause 8.3(c) is in excess of 100%, then the State Nodal Agency shall not be liable to refund to the Insurer the Claims made on it in excess of the total Premium earned by it in the immediately prior Policy Cover Period. 8.4 Payment of Premium for Each Policy Cover Period (a) Payment of Premium for First Policy Cover Period 57

58 The State Nodal Agency will, on behalf of the Beneficiary Family Units that are enrolled by the Insurer and issued Smart Cards for the first Policy Cover Period, pay or cause to be paid the Premium for the Covers to the Insurer in accordance with the following schedule: (i) (ii) First instalment: The Insurer or its representative shall collect a registration fee of 50 from each Beneficiary Family Unit, at the time of enrolment and on issuance and delivery or on renewal of the Smart Card. Such registration fee will be deemed as the first instalment of the Premium for providing the Covers. Second instalment: The Insurer shall raise an invoice for the second instalment of the Premium payable for Beneficiary Family Units that are enrolled in a month on the last day of such month. Along with its invoice, the Insurer shall provide the complete enrolment data (including personal data i.e., photograph, biometric print images). For this purpose, the Insurer shall rely on the enrolment data compiled by it or on its behalf by the TPA or the Smart Card Service Provider in the field at the time of enrolment; the Insurer shall not seek or rely on the enrolment data maintained on the DKM Server. The State Nodal Agency shall pay the second instalment within 21 Business Days of receipt of the invoice from the Insurer, after verifying the enrolment data submitted by the Insurer against the data downloaded from the FKO cards on the DKM server. If the enrolment data is not available from the DKM Server, the Insurer shall submit signed data of the enrolment and such signed data shall be used to determine number of families enrolled under the MHIS phase 3. If there is a mismatch between the enrolment data submitted by the Insurer along with its invoice and the enrolment data available on the DKM server, then the State Nodal Agency shall rely on the enrolment data available on the DKM server for paying the Premium. The second instalment of the Premium for the Beneficiary Family Units that have been enrolled in that month and that have been provided Smart Cards shall be calculated as follows: 1 NBFU1 x [[0.1 x (B - 60) - 30] + [A - 20] 2. NBFU2 x [(B + A) 50] 3. NBFU2 x{ [(B + A) 50] 60} (For Renewal of Non RSBY Category Only) 4. NBFU3 x [S x 0.2] Where: NBFU1 is the number of Beneficiary Family Units belonging to the RSBY category enrolled in that month, based on the verification conducted by the 58

59 State Nodal Agency from the data downloaded from the DKM Server; NBFU2 is the number of Beneficiary Family Units belonging to the APL, BoCW, etc. category enrolled in that month, based on the verification conducted by the State Nodal Agency from the data downloaded from the DKM Server; NBFU3 is the number of Beneficiary Family Units consisting of one or more Senior Citizen category under NBFU1 enrolled in that month, based on the verification conducted by the State Nodal Agency from the data downloaded from the DKM Server; B is the Base Premium per Beneficiary Family Unit for the first Policy Cover Period; A is the Additional Premium per Beneficiary Family Unit for the first Policy Cover Period; S is the Senior Citizen Premium per Beneficiary Family Unit for the first Policy Cover Period; (iii) Third instalment: The Insurer shall raise an invoice for the third instalment of the Premium along with the invoice raised for the second instalment. The third instalment of the Premium for the Beneficiary Family Units that have been enrolled in that month and that have been provided Smart Cards shall be calculated as follows: 1 N BFU1 x [0.9 x (B 60) + 60] 2 N BFU1 x [0.9 x (B 60)] {For Renewal of RSBY Category Only) 3 N BFU3 x [S x 0.8] [Note. For this formula as well, N BFU and B will be determined in the same manner as it is determined for the purpose of Clause 8.4(a)(ii) above.] (A) In relation to the RSBY Beneficiary Family Units, the State Nodal Agency shall use its best efforts to pay the third instalment within 30 Business Days of receipt of the invoice from the Insurer, subject to verification of the enrolment data in accordance with Clause 8.4(a)(ii) above. The State Nodal Agency shall request payment of the GoI s contribution towards the invoiced amount within 7 days of receipt of the Insurer s invoice, after verifying the enrolment data submitted by the Insurer against the data downloaded from the FKO cards on the DKM server. 59

60 The total amount that is to be contributed by the GoI towards the Premium payable on behalf of such RSBY Beneficiary Family Unit shall not exceed the amount that is calculated as [= 0.9 x (X 60) + 60] subject to a maximum of Rs. 675/- + Rs. 60/- provided by the Central Government (not applicable for the GoI share for the Senior Citizen Premium). Any portion of the Premium in excess of such amount shall be borne by the State Nodal Agency. The State Nodal Agency shall use its best efforts to cause the GoI to release this amount to the State Nodal Agency within 21 days of receiving a request being made by the State Nodal Agency in the prescribed format. The State Nodal Agency shall then release this payment to the Insurer within 7 days of receipt from the GoI. (B) In relation to the Non-RSBY Beneficiary Family Units, the State Nodal Agency shall pay the invoiced amount within 30 Business Days of receipt of the invoice from the Insurer, subject to verification of the enrolment data submitted by the Insurer against the data downloaded from the FKO cards on the DKM server. (b) Payment of Premium for Each Renewal Policy Cover Period In respect of each renewal Policy Cover Period for a district, the Renewal Premium Payment Due Date shall be the last day of the immediately preceding Policy Cover Period for that district. The State Nodal Agency will, on behalf of the Beneficiary Family Units that are enrolled by the Insurer and issued Smart Cards for each renewal Policy Cover Period, pay or cause to be paid the Premium for the Covers to the Insurer in accordance with the following schedule: (i) (ii) First instalment: The Insurer or its representative shall collect a registration fee of 50 (or such other amount as may be prescribed in the MHIS Guidelines) from each Beneficiary Family Unit, at the time of enrolment and on issuance and delivery or on renewal of the Smart Card. Such registration fee will be deemed as the first instalment of the Premium for providing the Covers. Second instalment: The Insurer shall raise an invoice for the second instalment of the Premium payable for all the Beneficiary Family Units that are enrolled for the renewal Policy Cover Period no later than 30 Business Days prior to the Renewal Premium Payment Due Date. Along with its invoice, the Insurer shall provide the complete enrolment data (including personal data i.e., photograph, biometric print images). For this purpose, the Insurer shall rely on the enrolment data compiled by it or on its behalf by the TPA or the Smart Card Service Provider in the field at the time of enrolment; the Insurer shall not seek or rely on the enrolment data 60

61 maintained on the DKM Server. The State Nodal Agency shall pay the second instalment within 21 Business Days of receipt of the invoice from the Insurer, after verifying the enrolment data submitted by the Insurer against the data downloaded from the FKO cards on the DKM server. If the enrolment data is not available from the DKM Server, the Insurer shall submit signed data of the enrolment and such signed data shall be used to determine number of families enrolled in RSBY. If there is a mismatch between the enrolment data submitted by the Insurer along with its invoice and the enrolment data available on the DKM server, then the State Nodal Agency shall rely on the enrolment data available on the DKM server for paying the Premium. The second instalment of the Premium for all the Beneficiary Family Units that are enrolled for the renewal Policy Cover Period and who have been provided with new Smart Cards or whose existing Smart Cards have been revalidated shall be calculated as follows: 1 NBFU1 x [[0.1 x (B - 60) - 30] + [A - 20] 2. NBFU2 x [(B + A) 50] 3. NBFU2 x{ [(B + A) 50] 60} (For Renewal of Non RSBY Category Only) 4. NBFU3 x [S x 0.2] [Note. If the MHIS Guidelines or the MHIS Operational Manual prescribe that the registration fee should be an amount other than 50 or that the registration fee should not be collected on renewal, then in the above formula 50 will be replaced with the amount prescribed by the MHIS Guidelines or the MHIS Operational Manual.] [Note. For this formula as well, N BFU, A, S and B will be determined in the same manner as it is determined for the purpose of Clause 8.4(a)(ii) above.] (iii) Third instalment: The Insurer shall raise an invoice for the third instalment of the renewal Premium along with the invoice raised for the second instalment. The third instalment of the renewal Premium for the total number of Beneficiary Family Units that have been enrolled for the renewal Policy Cover Period and whose Smart Cards have been revalidated or that have been issued new Smart Cards shall be calculated as follows: 1 N BFU1 x [0.9 x (B 60) + 60] 2 N BFU1 x [0.9 x (B 60)] {For Renewal of RSBY Category Only) 3 N BFU3 x [S x 0.8] 61

62 [Note. For this formula as well, N BFU and B will be determined in the same manner as it is determined for the purpose of Clause 8.4(b)(ii) above.] (A) In relation to the RSBY Beneficiary Family Units, the State Nodal Agency shall use its best efforts to cause the GoI to pay the third instalment within 30 Business Days of receipt of the invoice for the third instalment from the Insurer, subject to verification of the enrolment data in accordance with Clause 8.4(b)(ii) above. The State Nodal Agency shall request payment of the GoI s contribution towards the invoiced amount within 7 days of receipt of the Insurer s invoice, after verifying the enrolment data submitted by the Insurer against the data downloaded from the FKO cards on the DKM server. The total amount that is to be contributed by the GoI towards the Premium payable on behalf of such RSBY Beneficiary Family Unit shall not exceed the amount that is calculated as [= 0.9 x (X 60) + 60] subject to a maximum of Rs. 675/- + Rs. 60/- or such other amount that is stipulated by MoHFW from time to time. Any portion of the Premium in excess of such amount shall be borne by the State Nodal Agency. The State Nodal Agency shall use its best efforts to cause the GoI to release this amount to the State Nodal Agency within 21 days of receiving a request being made by the State Nodal Agency in the prescribed format. The State Nodal Agency shall then release this payment to the Insurer within 7 days of receipt from the GoI. (B) In relation to the Non-RSBY Beneficiary Family Units, the State Nodal Agency shall pay the invoiced amount within 30 Business Days of receipt of the invoice from the Insurer, subject to verification of the enrolment data submitted by the Insurer against the data downloaded from the FKO cards on the DKM server. (c) The State Nodal Agency shall pay the entire renewal Premium for all the months of enrolment for each such renewal Policy Cover Period for a district, on or before the Renewal Premium Payment Due Date. Without prejudice to the foregoing, the State Nodal Agency shall have a grace period of 60 Business Days' from the Renewal Premium Payment Due Date (the Grace Period) in which to pay the entire renewal Premium for all the months of enrolment in respect of each renewal Policy Cover Period for such district. 62

63 If the State Nodal Agency or the GoI: (i) delays payment of the entire renewal Premium for all the months of enrolment beyond the Renewal Premium Payment Due Date for a district but makes full payment within the Grace Period, then: (A) (B) the date of commencement of the renewal Policy Cover Period for such district shall continue to be determined in accordance with Clause 7.1(b) and there shall be no Break-in Policy in respect of such renewal Policy Cover Period; but the risk cover for each Beneficiary Family Unit enrolled in that district shall not commence until the full payment of the entire renewal Premium and the date for commencement of risk cover for each Beneficiary Family Unit that is set out at Clause 7.5 shall be extended on a day-for-day basis for the period of delay. (ii) fails to pay the entire renewal Premium for all the months of enrolment for such renewal Policy Cover Period for a district on or before the last day of the Grace Period, then the Insurer shall have the right not to renew the Policy for that district. (d) (e) (f) For each Policy Cover Period, the State Nodal Agency shall be responsible for collecting the enrolment data from the FKO cards at the district level DKM server. The State Nodal Agency and the GoI shall be responsible for paying the second and third instalments of the Premium to the Insurer based on the reconciliation of the enrolment related information provided by the Insurer in its invoice(s) and the enrolment data downloaded from the FKO cards at the district level DKM server. The State Nodal Agency undertakes that all Premium payments to the Insurer shall be made through electronic bank transfers to the bank account nominated by the Insurer. The Insurer shall provide full details of its bank account in its invoices. If the State Nodal Agency delays payment of or fails to pay the Premium for: (i) (ii) the first Policy Cover Period and such delay exceeds 8 months beyond the date of commencement of the first Policy Cover Period; or any renewal Policy Cover Period and such delay exceeds 3 months beyond the date of expiration of the Grace Period for such renewal Policy Cover Period, then the State Nodal Agency shall be liable to pay interest at the rate of 0.5% of the amount of Premium due and payable to the Insurer for such Policy Cover Period for every 15 days of delay beyond the period stipulated above. 63

64 8.5 Conditions Precedent to Raising Invoices In respect of each Policy Cover Period, the Insurer shall satisfy each of the following conditions before raising an invoice on the State Nodal Agency for the second and third instalments of the Premium in accordance with Clause 8.4(b) above: (a) The Insurer shall submit digitally signed enrolment data generated by the enrolment software at the DKMA software to the State Nodal Agency on a weekly basis. This data shall be matched by the State Nodal Agency with the FKO data to determine the total number of Beneficiary Family Units enrolled in a month. (b) The Insurer shall enter the details of the Premium payable to it in respect of the RSBY Beneficiary Family Units on the following web portal: As soon as the Insurer makes an entry regarding the Premium payable to it, a Premium Claim Reference (PCR) Number will be generated by the system, which should be mentioned on the invoice submitted by the Insurer to the State Nodal Agency. (c) The Insurer shall not contact the DKM or the ADKM or in any way induce the DKM to change the data downloaded from the DKM Server or seek any certificate from the DKM regarding the enrolments completed by the Insurer or its intermediaries. 8.6 Compliance with Section 64VB of Insurance Act (a) (b) 8.7 Taxes (a) (b) The State Nodal Agency undertakes to release the payments within 30 Business Days of receipt of invoices intimating the instalments of the Premium payable by the State Nodal Agency and the GoI. Without prejudice to the State Nodal Agency's undertaking at Clause 8.6(a) above, it shall be the responsibility of the Insurer to comply with the provisions of Section 64VB of the Insurance Act. The Premium payable by the State Nodal Agency to the Insurer for each Beneficiary Family Unit that is enrolled and that has been provided with a Smart Card, shall be inclusive of all costs, expenses, service charges, taxes, overheads and profits payable in respect of such Premium excluding Service Tax. The Ministry of Finance (Department of Revenue) vide notification no: 25/2012- Service Tax, dated New Delhi the 20th June 2012 have notified that Services of General Insurance which include Rashtriya Swasthiya Bima Yojana and Universal health Insurance Schemes are exempted from Service Tax. Furthermore the Megha Health Insurance Scheme is classified as a Universal Health Insurance Scheme functioning in the state of Meghalaya as per Department of Health & Family Welfare vide Office Memorandum No. Health.34/2006/Pt/95 dated 10th October The Insurer shall protect, indemnify and hold harmless the State Nodal Agency, from any and all claims or liability to: (i) pay any service tax assessed or levied by any competent tax authority on the Insurer or on the State Nodal Agency for or on account of any act or omission on the part of Insurer; or 64

65 (ii) (iii) on account of the Insurer s failure to file tax returns as required by applicable Laws or comply with reporting or filing requirements under applicable Laws relating to service tax; or arising directly or indirectly from or incurred by reason of any misrepresentation by or on behalf of the Insurer to any competent tax authority in respect of the service tax. (c) The State Nodal Agency may deduct taxes as required by applicable Law. The Insurer shall have no recourse against the State Nodal Agency in respect of such tax deduction at source. 8.8 Premium All Inclusive Except as expressly permitted under Clause 8.2, Clause 8.7 and Clause 21.5, the Insurer shall have no right to claim any additional amount from the State Nodal Agency in respect of: (a) (b) (c) the risk cover provided to each Beneficiary Family Unit that is enrolled and that has been provided with a Smart Card; or the performance of any of its obligations under this Insurance Contract; or any costs or expenses that it incurs in respect thereof. 8.9 No Separate Fees, Charges or Premium Except for the first instalment of the Premium collected by the Insurer from each Beneficiary Family Unit in accordance with Clause 8.4(a)(i) and Clause 8.4(b)(i), the Insurer shall not charge any Beneficiary Family Unit or any of the Beneficiaries with any separate fees, charges, commission or premium, by whatever name called, for providing the benefits under this Insurance Contract and a Policy Approval of Premium and Terms and Conditions of Covers by IRDA (a) (b) The Insurer shall, if required by the Health Insurance Regulations, obtain IRDA's approval for the Premium (including the loading or discounting of Premium for renewal Policy Cover Periods) and the terms and conditions of the Covers provided under this Insurance Contract under the File & Use Procedure prescribed in the Health Insurance Regulations, within 75 days of the date of execution of this Insurance Contract. The Insurer undertakes and agrees that it shall not: (i) file an application with the IRDA for approval of the revision, modification or amendment of the Premium for or the terms and conditions of or for the withdrawal of any or all of the Covers; or 65

66 (ii) revise, modify, amend or withdraw any or all of the Covers, whether with or without the IRDA's approval under the Health Insurance Regulations, at any time during the Term of this Insurance Contract. The Insurer hereby irrevocably waives its right to seek the IRDA's approval for the revision, modification, amendment or withdrawal of any or all of the Covers under this Insurance Contract by filing an application under the File & Use Procedure. 9. CASHLESS ACCESS SERVICE (a) (b) (c) (d) The Insurer shall ensure that each Empanelled Health Care Provider shall at a minimum possess the Hospital IT Infrastructure required to read the Smart Card to ascertain the balance available under the Base Cover, the Replenishment Cover and the Critical Illness Cover provided by the Insurer. Each Empanelled Health Care Provider shall undertake the Medical Treatment, Surgical Procedure or Day Care Treatment or provide OPD Benefits or Follow-up Care; and each Specialty Hospital shall provide the Tertiary Care or Follow-up Care or OPD diagnostic care, based on Smart Card and fingerprint authentication only, with a minimum of delay for pre-authorization (if necessary). The Insurer shall ensure that the Smart Card issued to each Beneficiary Family Unit in accordance with Clause 21, shall contain one field for 60,000, of which the first 30,000 shall represent the Base Sum Insured and the next 30,000 shall represent the Replenishment Sum Insured. The Insurer shall require the Empanelled Health Care Providers to utilize the Hospital IT Infrastructure for making electronic transactions through the Smart Card issued to the Beneficiaries for utilization of the Base Cover and Replenishment Cover benefits. The Insurer shall use its best efforts to obtain necessary modifications to the enrolment software from MoHFW or modify the enrolment software as necessary with the prior written consent of MoHFW, as soon as possible and in any event prior to the commencement of the first Policy Cover Period for a district, to permit the use of the second field on the Smart Card to represent the Critical Illness Sum Insured of 2,20,000. The State Nodal Agency shall provide the Insurer with reasonable assistance for obtaining such modifications to the enrolment software from MoHFW or in obtaining MoHFW s consent. Until such time that the Insurer obtains or makes such modifications to the enrolment software with consent from MoHFW, the Insurer shall require the Empanelled Health Care Providers to undertake manual transactions after verification of the Beneficiary using the Smart Card, for utilization of the Critical Illness Cover benefits. The detailed procedure has been set out in the Category 5 pre-authorization procedure described in Schedule 5. The Insurer shall record all manual Claims received from the Empanelled Health Care Providers on the District Server at the back-end. The Insurer may develop an online system for the collection of Claims for utilization of the Critical Illness Cover benefits, at its own cost. 66

67 Upon obtaining the enrolment software modifications or consent from MoHFW, the Insurer shall: (i) (ii) (iii) ensure that the Smart Card issued to or renewed for each Beneficiary Family Unit in the next Policy Cover Period, shall contain: (A) one field for 60,000, of which the first 30,000 shall represent the Base Sum Insured and the next 30,000 shall represent the Replenishment Sum Insured; and (B) a second field for 2,20,000 which shall represent the Critical Illness Sum Insured; require the Empanelled Health Care Providers to use the Hospital IT Infrastructure for making electronic transactions through the Smart Card for utilization of the Critical Illness Cover benefits. The detailed procedure for such utilization shall be prepared by the Insurer in consultation with the State Nodal Agency; and provide the Empanelled Health Care Providers with training in the use of the Smart Card for making electronic transactions through the Smart Card for utilization of the Critical Illness Cover benefits. (f) (g) (h) (i) Subject to Clause 9(d) and Clause 9(e) above, the Insurer shall require each Empanelled Health Care Provider (including each Specialty Hospital) to raise Claims electronically in accordance with Clause 10.1(a). The Insurer shall make Claims Payments to the Empanelled Health Care Providers and Specialty Hospitals based on such electronic Claims made by the Empanelled Health Care Providers (including the Specialty Hospitals), provided that the Insurer shall permit the Empanelled Health Care Providers to make manual Claims for the utilization the Critical Illness Cover benefits until such time that the Smart Cards issued to the Beneficiary Family Units are enabled for electronic transactions in accordance with Clause 9(d). The detailed process and steps to be followed by the Insurer (or the TPA appointed by it) and the Empanelled Health Care Providers for providing Cashless Access Service to the Beneficiaries has been set out in Schedule 5. The Insurer shall comply with and ensure that the TPA and the Empanelled Health Care Providers (including the Specialty Hospitals) comply with this process. The Insurer shall: (i) (ii) provide each Empanelled Health Care Provider (including a Specialty Hospital) with an operating manual describing in detail the verification, preauthorization and Claims procedures, that shall be in compliance with the terms of this Insurance Contract; and train those representatives of the Empanelled Health Care Providers (including the Specialty Hospitals) that will be responsible for the 67

68 administration of the MHIS phase 3. on the use of the Smart Cards and Hospital IT infrastructure for making Claims electronically (or manually in case of Claims for utilization of the Critical Illness Cover benefits and providing Cashless Access Services. (j) If the Insurer appoints a TPA to undertake Claims processing, the Insurer shall ensure that the TPA appointed by it shall at all times have: (i) (ii) adequate infrastructure and trained personnel for undertaking Policy and Claims facilitation services in accordance with the terms of this Insurance Contract; and an updated electronic copy of the information regarding the enrolled Beneficiary Family Units, for verification of Claims received from the Empanelled Health Care Providers. 10. CLAIMS MANAGEMENT 10.1 Claim Payments and Turn-around Time The Insurer shall comply with the following procedure regarding the processing of Claims received from the Empanelled Health Care Providers: (a) The Insurer shall require the Empanelled Health Care Providers to submit their Claims electronically within 48 hours of discharge or provision of OPD Benefits or Follow-up Care to the Beneficiary in a format to be prescribed by the Insurer. However, if the Empanelled Health Care Provider is: (i) unable to do so due to a lack of internet connectivity; or (ii) making a Claim for utilization of the Critical Illness Cover benefits, then such Empanelled Health Care Provider shall be required to submit its Claims electronically or manually within a maximum of 30 days. The Empanelled Health Care Provider shall provide its reasons for delay in raising Claims. The Insurer shall not reject a Claim if received within the 30 day period only on the grounds that it has been received after 48 hours or is not in the prescribed format. However, the Insurer may reject any Claim that is received after 30 days of discharge or visit of the Beneficiary. (b) (c) The Insurer shall decide on the acceptance or rejection of any Claim received from an Empanelled Health Care Provider. Any rejection notice issued by the Insurer to the Empanelled Health Care Provider shall state clearly that such rejection is subject to the Empanelled Health Care Provider s right to file a complaint with the relevant Grievance Redressal Committee against such decision to reject such Claim. If the Insurer rejects a Claim, the Insurer shall issue a written letter of rejection to the Empanelled Health Care Provider stating: details of the Claim summary; reasons for rejection; and details of the District Grievance Nodal Officer. The letter of rejection shall be issued to the State Nodal Agency and the Empanelled Health Care 68

69 Provider within 15 days of receipt of the electronic Claim. The Insurer should inform the Empanelled Health Care Provider of its right to seek redressal for any Claim related grievance before the District Grievance Redressal Committee in its letter of rejection. If a Claim is rejected because the Empanelled Health Care Provider making the Claim is not empanelled for providing the health care services in respect of which the Claim is made, then the Insurer shall while rejecting the Claim inform the Beneficiary of an alternate Empanelled Health Care Provider where the benefit can be availed. (d) (e) (f) (g) (h) (i) If a Claim is not rejected within 15 days, the Insurer shall either make the Claim Payment (based on the Package Rate or the Pre-Authorized Amount) or conduct further investigation into the Claim received from the Empanelled Health Care Provider. The Insurer shall make the full Claim Payment without deduction of tax, for all PHCs, CHCs, District Hospitals and other government sponsored hospitals, for private healthcare providers the Insurer shall make the full Claim Payment without deduction of tax, if the Empanelled Health Care Provider submits a tax exemption certificate to the Insurer within 7 days after signing the agreement with the Insurer making a Claim. If the Empanelled Health Care Provider fails to submit a tax exemption certificate to the Insurer, then the Insurer shall make the Claim Payment after deducting tax at the applicable rate. If the Beneficiary is admitted by an Empanelled Health Care Provider during a Policy Cover Period, but is discharged after the end of such Policy Cover Period and the Policy is not renewed, then the arising Claim shall be paid in full by the Insurer subject to the available Sum Insured. Subject to Clause 10.1(f) and Clause 10.1(h), if a Claim event falls within two Policy Cover Periods, the Claim shall be paid taking into consideration the available Sum Insured in the two Policy Cover Periods. The eligible Claim Payment shall be made by the Insurer in full, whether or not the renewal Premium for the subsequent Policy Cover Period has been received by the Insurer. If a Claim is made during a Policy Cover Period and the Policy is not subsequently renewed, then the Insurer shall make the Claim Payment in full subject to the available Sum Insured. The process specified in paragraphs (b) to (e) above in relation to Claim Payment or investigation of the Claim shall be completed such that the Turn-around Time shall be no longer than 30 days. Without prejudice to the foregoing, during the subsistence of any delay by the State Nodal Agency in making payment of the Premium for a Policy Cover Period, the Insurer shall have the right to delay making Claim Payments to the Empanelled 69

70 Health Care Providers until the Premium is received, provided that the Insurer completes the processing of the Claims in accordance with paragraphs (b) to (e) above within te Turn-Around Time of 30 days. If the Insurer fails to make the Claim Payment within a Turn-around Time of 30 days for a reason other than a delay by the State Nodal Agency in making payment of the Premium that is due and payable, then the Insurer shall be liable to pay a penal interest to the Empanelled Health Care Provider at the rate of 1% of the Claim amount for every 15 days of delay beyond the 30 day period. (j) (k) (l) (m) The counting of days for the purpose of this Clause 10.1 shall start from the date of receipt of the Claim. The Insurer shall make Claim Payments to each Empanelled Health Care Provider against Claims received on a weekly basis and as far as possible through electronic transfer to such Empanelled Health Care Provider s designated bank account. All Claims investigations shall be undertaken by qualified and experienced Medical Practitioners appointed by the Insurer or its TPA, to ascertain the nature of the disease, illness or accident and to verify the eligibility thereof for availing the benefits under this Insurance Contract and relevant Policy. The Insurer s or the TPA's medical staff shall not impart or advise on any Medical Treatment, Surgical Procedure or Follow-up Care or provide any OPD Benefits or provide any guidance related to cure or other care aspects. The Insurer shall submit details of: (i) (ii) (iii) all Claims that are under investigation to the district-level administration of the State Nodal Agency on a monthly basis for its review; every Claim that is pending beyond 30 days to the State Nodal Agency, along with its reasons for delay in processing such Claim; and details of interest paid to the Empanelled Health Care Providers for every Claim that was pending beyond 30 days to the State Nodal Agency. (n) (o) (p) The Insurer may collect at its own cost, complete Claim papers from the Empanelled Health Care Provider, if required for audit purposes. This shall not have any bearing on the Claim Payments to the Empanelled Health Care Provider. The Insurer shall, at all times, comply with and ensure that its appointed TPA is in compliance with the Health Insurance Regulations and any other Law issued or notified by the IRDA in relation to the provision of Cashless Access Services and Claims processing. The Insurer shall ensure that the TPA does not approve or reject any Claims on its behalf and that the TPA is only engaged in the processing of Claims. The TPA may 70

71 however recommend to the Insurer on the action to be taken in relation to a Claim. However, the final decision on approval and rejection of Claims shall be made by the Insurer Right of Appeal and Reopening of Claims (a) (b) The Empanelled Health Care Provider shall have a right of appeal against a rejection of a Claim by the Insurer, if the Empanelled Health Care Provider feels that the Claim is payable. Such decision of the Insurer may be appealed by filing a complaint with the DGNO in accordance with Clause 30 of this Insurance Contract. The Insurer and/or the DGNO or the DGRC, as the case maybe, may re-open the Claim, if the Empanelled Health Care Provider submits the proper and relevant Claim documents that are required by the Insurer No Contributions (a) (b) The Insurer agrees that any Beneficiary Family Unit or any of the Beneficiaries or any other third party shall be entitled to obtain additional health insurance or any other insurance cover of any nature whatsoever, including in relation to the benefits provided under this Insurance Contract and a Policy, either individually or on a family floater cover basis. Notwithstanding that such Beneficiary Family Unit or any of the Beneficiaries or any third party acting on their behalf effect additional health insurance or any other insurance cover of any nature whatsoever, the Insurer agrees that: (i) (ii) (iii) its liability to make a Claim Payment shall not be waived or discharged in part or in full based on a rateable or any other proportion of the expenses incurred and that are covered by the benefits under the Covers; it shall be required to make the full Claim Payment in respect of the benefits provided under this Insurance Contract and the relevant Policy; and if the total expenses incurred by the Beneficiary exceeds the available Sum Insured under the Covers (after taking into account the deductibles and copayment obligations), then the Insurer shall make payment to the extent of the available Sum Insured in respect of the benefits provided under this Insurance Contract and the relevant Policy and the other insurers shall pay for any excess expenses not covered. 71

72 11. INSURABLE INTEREST (a) Under the Directive Principles of State Policy that are set out in the Constitution of India, the Government of Meghalaya is required to: (i) (ii) improve public health as among its primary duties; and within the limits of its economic capacity and development, make effective provision for securing public assistance in cases of sickness and disablement of citizens. (b) Accordingly, the Insurer acknowledges, confirms and undertakes that: (i) (ii) the State Nodal Agency, as the Insured, has sufficient and adequate insurable interest in the Covers to be provided by the Insurer under the Insurance Contract; and the Insurer hereby waives and releases its right to claim that the Insurance Contract is void on the ground that the State Nodal Agency does not have sufficient or adequate insurable interest in the Covers to be provided under the Insurance Contract. 12. NO DUTY OF DISCLOSURE (a) (b) Notwithstanding the issue of the Tender Documents and any other information provided by the State Nodal Agency prior to the date of this Insurance Contract, the Insurer hereby acknowledges that it does not rely on and has not been induced to enter into this Insurance Contract or to provide the Covers or to assess the Premium for providing the Covers on the basis of any statements, warranties, representations, covenants, undertakings, indemnities or other statements whatsoever and acknowledges that none of the State Nodal Agency or any of its agents, officers, employees or advisors or any of the enrolled Beneficiary Family Units have given or will give any such warranties, representations, covenants, undertakings, indemnities or other statements. Prior to commencement of each Policy Cover Period for any district, the State Nodal Agency undertakes to prepare or cause a third party to prepare the Beneficiary Database as correctly as possible. The Insurer acknowledges that, notwithstanding such efforts being made by the State Nodal Agency, the information in the Beneficiary Database may not be accurate or correct and that the Beneficiary Database may contain errors or mistakes. Accordingly, the Insurer acknowledges that the State Nodal Agency makes no warranties, representations, covenants, undertakings, indemnities or other statements regarding the accuracy or correctness of the Beneficiary Database that will be provided by it to the Insurer in accordance with Clause 20.2(d). 72

73 (c) (d) The Insurer represents, warrants and undertakes that it has completed its own due diligence and is relying on its own judgment in assessing the risks and responsibilities that it will be undertaking by entering into this Insurance Contract and in providing the Covers to the enrolled Beneficiary Family Units and in assessing the adequacy of the Premium for providing the Covers for the Beneficiary Family Units that are enrolled by it. Based on the acknowledgements of the Insurer in this Clause 12, the Insurer: (i) (ii) (iii) acknowledges and confirms that the State Nodal Agency has made no and will make no material disclosures to the Insurer; acknowledges and confirms that the State Nodal Agency shall not be liable to the Insurer for any misrepresentation or untrue, misleading, incomplete or inaccurate statements made by the State Nodal Agency or any of its agents, officers, employees or advisors at any time, whether made wilfully, negligently, fraudulently or in good faith; and hereby releases and waives all rights or entitlements that it has or may have to: (A) (B) make any claim for damages and/or declare this Insurance Contract or any Policy issued under this Insurance Contract declared null and void; or not renew any Policy, 13. FRAUDULENT CLAIMS as a result of any untrue or incorrect statements, misrepresentation, misdescription or non-disclosure of any material particulars that affect the Insurer s ability to provide the Covers. (a) (b) The Insurer shall be responsible for monitoring and controlling the implementation of the MHIS phase 3in the State of Meghalaya in accordance with Clause 27. In the event of a fraudulent Claim being made or a false statement or declaration being made or used in support of a fraudulent Claim or any fraudulent means or device being used by any Empanelled Health Care Provider or the TPA or other intermediary hired by the Insurer or any of the enrolled Beneficiaries to obtain any benefits under this Insurance Contract or any Policy issued by the Insurer (each a Fraudulent Activity), then the Insurer s sole remedies shall be to: (i) refuse to honour a fraudulent Claim or Claim arising out of Fraudulent Activity or reclaim all benefits paid in respect of a fraudulent Claim or any Fraudulent Activity relating to a Claim from the Empanelled Health Care Provider and/or the Beneficiary that has undertaken or participated in a 73

74 Fraudulent Activity; and/or (ii) (iii) (iv) de-empanel the Empanelled Health Care Provider that has made a fraudulent Claim or undertaken or participated in a Fraudulent Activity, in accordance with Clause and the procedure specified in Schedule 9; terminate the services agreement with the TPA or other intermediary appointed by the Insurer; and/or revoke the benefits available under this Insurance Contract and the relevant Policy that would otherwise be available to the Beneficiary Family Unit that has undertaken or participated in a Fraudulent Activity, provided that the Insurer has: issued a notice to the State Nodal Agency of its proposed exercise of any of these remedies before exercising such remedies; and such notice is accompanied by reasonable documentary evidence of such fraudulent Claim or Fraudulent Activity. An indicative list of fraudulent Claims and Fraudulent Activities has been set out in Schedule 14. The State Nodal Agency shall have the right to conduct a random audit of any or all cases in which the Insurer has exercised such remedies against an Empanelled Health Care Provider and/or any Beneficiary. If the State Nodal Agency finds that the Insurer has wrongfully de-empanelled an Empanelled Health Care Provider and/or wrongfully revoked the benefits available to any Beneficiary Family Unit, then the Insurer shall be required to reinstate such benefits to such Empanelled Health Care Provider and/or Beneficiary Family Unit. (c) The Insurer hereby releases and waives all rights or entitlements to: (i) (ii) make any claim for damages and/or have this Insurance Contract or any Policy issued under this Insurance Contract declared null and void; or to refuse to renew any Policy, as a result of any fraudulent Claim by or any Fraudulent Activity of any Empanelled Health Care Provider or any Beneficiary. 14. REPRESENTATIONS AND WARRANTIES OF THE INSURER 14.1 Representations and Warranties The Insurer represents, warrants and undertakes that: (a) The Insurer has the full power, capacity and authority to execute, deliver and perform this Insurance Contract and it has taken all necessary actions (corporate, statutory or otherwise), to execute, deliver and perform its obligations under this Insurance Contract and that it is fully empowered to enter into and execute this 74

75 Insurance Contract, as well as perform all its obligations hereunder. (b) Neither the execution of this Insurance Contract nor compliance with its terms will be in conflict with or result in the breach of or constitute a default or require any consent under: (i) (ii) (iii) any provision of any agreement or other instrument to which the Insurer is a party or by which it is bound; any judgment, injunction, order, decree or award which is binding upon the Insurer; and/or the Insurer s Memorandum and Articles of Association or its other constituent documents. (c) (d) (e) (f) (g) (h) The Insurer is duly registered with the IRDA, has duly obtained renewal of its registration from the IRDA and to the best of its knowledge, will not have its registration revoked or suspended for any reason whatsoever during the Term of this Insurance Contract. The Insurer undertakes that it shall continue to keep its registration with the IRDA valid and effective throughout the Term of this Insurance Contract. The Insurer has conducted the general insurance (including health insurance) business in India for at least 2 financial years prior to the submission of its Bid and shall continue to be an insurance company that is permitted under Law to carry on the general insurance (including health insurance) business throughout the Term of this Insurance Contract. In the financial year prior to the submission of its Bid, the Insurer has maintained its solvency ratio in full compliance with the requirements of the IRDA Solvency Regulations and the Insurer undertakes that it shall continue to maintain its solvency ratio in full compliance with the IRDA Solvency Regulations throughout the Term of this Insurance Contract. The Insurer has been empanelled by MoHFW for the award of this Insurance Contract and continues to be empanelled as on the date of this Insurance Contract. The Insurer has complied with and shall continue to comply with all Laws, including but not limited to the rules or regulations issued by the IRDA in connection with the conduct of its business and the MHIS Guidelines issued by MoHFW and/or the State Nodal Agency from time to time. The Insurer has quoted the Premium and accepted the terms and conditions of this Insurance Contract: (i) after the Insurer and its Appointed Actuary have duly satisfied themselves regarding the financial viability of the Premium; and 75

76 (ii) in accordance with the Insurer's underwriting policy approved its Board of Directors. The Insurer shall not later deny issuance or renewal of a Policy or payment of a Claim on the grounds that: (x) the Premium is found financially unviable; or (y) the assumptions taken by the Insurer and/or its Appointed Actuary in the actuarial certificate submitted with its Bid have been breached; or (z) the Insurer's underwriting policy has been breached, other than in accordance with Clause 8.2(d) or Clause 8.2(f). (i) (j) (k) (l) Without prejudice to Clause 14(e) above, the Insurer is and shall continue to be capable of meeting its liabilities to make Claim Payments, servicing the Covers being provided by it under this Insurance Contract and has and shall continue to have sufficient infrastructure, trained manpower and resources to perform its obligations under this Insurance Contract. The Insurer has at no time, whether prior to or at the time of submission of its Bid and at the time of execution of this Contract, been black-listed or been declared as ineligible from participating in government sponsored schemes (including the MHIS phase 3) by the IRDA. After the issuance of each Policy, the Insurer shall not withdraw or modify the Premium or the terms and conditions of the Covers provided to the Beneficiaries during the Term of this Insurance Contract, except in accordance with Clause 8.8(b). The Insurer abides and shall continue to abide by the Health Insurance Regulations and the code of conduct prescribed by the IRDA or any other governmental or regulatory body with jurisdiction over it, from time to time Continuity and Repetition of Representations and Warranties The Insurer agrees that each of the representations and warranties set out in Clause 14.1 are continuing and shall be deemed to repeat for each day of the Term Information regarding Breach of Representations and Warranties The Insurer represents, warrants and undertakes that it shall promptly, and in any event within 15 days, inform the State Nodal Agency in writing of the occurrence of a breach or of obtaining knowledge of a potential breach of any of the representations and warranties made by it in Clause 14.1 at any time during the continuance of the Term. 76

77 PART II PRE-ENROLMENT AND ENROLMENT 15. PROJECT OFFICE AND DISTRICT OFFICES 15.1 Project Office The Insurer shall establish a Project Office at a convenient place at Shillong for coordination with the State Nodal Agency on a regular basis District Offices The Insurer shall set up an office in each of the districts of the State of Meghalaya at the district headquarters of such district (each a District Office). Each District Office shall be responsible for coordinating the Insurer s activities at the district level with the State Nodal Agency s district level administration. The District Offices shall perform the functions set out at Clause 15.3(c) at the district level Organisational Set-Up and Functions (a) The Insurer shall recruit or employ experienced and qualified personnel for each of the following roles within its organisation, exclusively for the purpose of implementation of MHIS phase 3 and for the performance of its obligations and discharge of its liabilities under this Insurance Contract and the Policies issued hereunder: (i) (ii) One State Coordinator who shall be responsible for implementation of the MHIS phase 3 and performance of this Insurance Contract in the State of Meghalaya. One full time District Coordinator for each of the districts who shall be responsible for implementation of the Amended MHIS phase 3 in the district for which such person is recruited. The State Coordinator shall be located in the Project Office and each District Coordinator shall be located in the relevant District Office. (b) In addition to the personnel mentioned in Clause 15.3(a), the Insurer shall recruit or employ experienced and qualified personnel for each of the following roles within its organisation exclusively for the purpose of implementation of the MHIS phase 3: (i) To operate a 24 x 7 call centre with a toll free help line in the local language and English for purposes of handling queries related to benefits and operations of the MHIS Phase 3, including information on Empanelled Health Care Providers and on individual account balances. 77

78 (ii) (iii) (iv) (v) To undertake Information Technology related functions which will include, among other things, collating and sharing enrolment and Claims related data with the State Nodal Agency and running the website at the State level and updating data on a regular interval on the website. The website shall have information on the MHIS phase 3in the local language and English with functionality for Claims settlement and account information access for Beneficiaries and Empanelled Health Care Providers. To undertake publicity and IEC/BCC activities for the MHIS Phase 3 so that all the relevant information related to MHIS Phase 3 reaches the Beneficiary Family Units, Empanelled Health Care Providers and other stakeholders. To implement the grievance redressal mechanism and to participate in the DGRCs and the SGRC in accordance with Clause 30 of this Insurance Contract, provided that such persons shall not carry out any other function simultaneously if such functioning will affect their independence as members of the DGRCs and the SGRC. To coordinate the Insurer s State level obligations with the State level administration of the State Nodal Agency. (c) In addition to the personnel mentioned in Clause 15.3(a) and Clause 15.3(b), the Insurer shall recruit or employ experienced and qualified personnel for each of the following roles within its organisation at the district level, exclusively for the purpose of implementation of the MHIS Phase 3: (i) (ii) (iii) To manage the District Kiosk and to carry on the duties and functions set out in Schedule 10. To undertake the Management Information System functions, which include creating the MIS dashboard and collecting, collating and reporting data. To generate reports in formats prescribed by the State Nodal Agency from time to time or as specified in the MHIS Guidelines, at monthly intervals. (iv) To undertake the Pre-authorization function in accordance with Clause 5 and Clause 9 read with Schedule 5. (v) (vi) To undertake paperless Claims settlement for the Empanelled Health Care Providers with electronic clearing facility, including the provision of necessary Medical Practitioners to undertake investigation of Claims made. To undertake empanelment of both public and private health care providers and specialty hospitals in accordance with Clause

79 (vii) (viii) (ix) To undertake monitoring and control functions in accordance with Clause 27. To undertake Feedback Functions which include designing feedback formats, collecting data based on those formats from different stakeholders like beneficiaries, hospitals etc., analyzing feedback data and suggest appropriate actions. To coordinate the Insurer s district level obligations with the district level administration of the State Nodal Agency. (d) The Insurer shall not be required to appoint the personnel listed at Clause 15.3(b) and Clause 15.3(c), if the Insurer has outsourced any of the roles and functions listed in those Clauses to third parties in accordance with Clause 28. Provided however that the Insurer shall not outsource any roles or functions that are its core functions as a health insurer or that relate to its assumption of risk under the Covers or that the insurer is prohibited from outsourcing under the Insurance Laws, including but not limited to: implementation of the grievance redressal mechanism, managing the District Kiosks, undertaking pre-authorization (other than in accordance with the Health Insurance Regulations), undertaking Claims Payments (other than in accordance with the Health Insurance Regulations) and undertaking empanelment of Empanelled Health Care Providers. (e) (f) The Insurer shall provide a list of all such appointments and replacement of such personnel to the State Nodal Agency in a timely manner. The Insurer shall ensure that its employees coordinate and consult with the State Nodal Agency s corresponding personnel for the successful implementation of the MHIS phase 3 and the due performance of the Insurer's obligations and discharge of the Insurer's liabilities under this Insurance Contract and the Policies issued hereunder. The Insurer shall complete the recruitment of such employees within 30 days of the signing of the Insurance Contract and in any event, prior to commencement of enrolment of Beneficiaries. 16. EMPANELMENT OF HEALTH CARE PROVIDERS 16.1 Empanelment Obligations (a) (b) The Insurer shall ensure that an adequate number of both public and private health care providers are empanelled in each district within 30 days of the signing of this Insurance Contract. The Insurer shall also make efforts to ensure that the Empanelled Health Care Providers are spread across different blocks of the district so that the Beneficiaries have greater coverage of health care services. Without prejudice to the Insurer s empanelment obligations under Clause 16.1(a), the Insurer shall use its best endeavours to empanel the following health care 79

80 providers within 30 days of the signing of this Insurance Contract and on a best efforts basis all the private hospitals or other private health care providers that have already been empanelled under the Scheme. A list of all the private health care providers that have previously been empanelled under the Scheme has been set out at Schedule 6. (i) (ii) (iii) (iv) (v) (vi) All public hospitals, CHCs, PHCs or other public health care providers that have already been empanelled under the Scheme in the Service Area. A list of the public hospitals, CHCs, PHCs and other public health care providers in the Service Area that have previously been empanelled for the Scheme has been set out at Schedule 6. At least one health care provider for every 8,000 Beneficiary Family Units enrolled under the MHIS phase 3. At least two health care providers in each block of each district. At least six private health care providers within the Service Area. At least two public or private specialty hospitals in Guwahati for each Listed Specialty, for provision of Tertiary Care to the Beneficiaries under any of the Covers and at least three hospitals should be empanelled in Guwahati for Secondary care. At least two specialty hospitals for each Listed Specialty in each of the following cities: Delhi; Kolkata; and at least three of the following cities - Mumbai, Bengaluru, Hyderabad and Chennai, for provision of Tertiary Care to the Beneficiaries under any of the Covers. Provided that all such Specialty Hospitals that are empanelled shall, on a cumulative basis, provide all of the Medical Treatments, Surgical Procedures and Day Care Treatments that qualify as Tertiary Care. (vii) (viii) At least two hospitals anywhere in India that are NABH accredited. At least two specialty hospitals anywhere in India that have facilities and expertise in oncosurgery and cancer therapy, for providing oncosurgery and cancer related Medical Treatments and Surgical Procedures. Provided that the Insurer shall only empanel those hospitals, CHCs, PHCs, standalone day care centres, specialty hospitals or other health care providers that meet the minimum empanelment criteria set out in Section 1, Section 2 or Section 3 of Schedule 7. In addition, the health care providers that are located within the Service Area should at a minimum cater to the following specialties: (1) general medicine; (2) general surgery; (3) Obstetrics & Gynaecology; (4) paediatrics; (5) ophthalmology; 80

81 (6) ENT; and (7) orthopaedics. Further, each Specialty Hospital that is empanelled for a Tertiary Care specialty shall meet the minimum empanelment criteria for such Tertiary Care specialty that is set out in Section 4 of Schedule 7. For the avoidance of doubt, a Specialty Hospital may be empanelled for more than one Tertiary Care specialty; but shall not be bound to be empanelled for providing any Medical Treatment or Surgical Procedure that does not qualify as Tertiary Care. (c) (d) (e) (f) The empanelment of each Empanelled Health Care Provider shall continue from the date of its empanelment and until the expiration or early termination of the Term, unless such Empanelled Health Care Provider is de-empanelled earlier. The Insurer and the State Nodal Agency shall review the empanelment of each hospital on an annual basis to determine compliance of the Empanelled Health Care Providers with the minimum empanelment criteria specified in Schedule 7 and the objectives of MHIS Phase 3. Without prejudice to the other provisions of this Clause 16.1, the Insurer shall use its best efforts to increase health service coverage for the Beneficiaries within and outside the Service Area by continuing to empanel public or private health care providers that meet the minimum empanelment criteria set out at Schedule 7 by following the procedure set out in Clause 16.3 or in Clause 16.4, as relevant. If the Insurer is unable to comply with the requirements of Clause 16.1(b) or Clause 16.2 due to the unavailability of health care facilities within the Service Area or adjoining the Service Area, then the Insurer shall obtain a certificate to that effect from the relevant district administration authorities. The Insurer shall then have the right to empanel public and private health care providers that do not meet these requirements with the prior written consent of the State Nodal Agency Minimum Empanelment Criteria (a) (b) The Insurer shall be responsible for empanelling public and private health care providers, day care centres and specialty hospitals that meet, at a minimum, the empanelment criteria that have been set out in Schedule 7. The Insurer shall prepare the format of an empanelment form taking into account the minimum empanelment criteria that have been set out in Schedule 7 (the Empanelment Form) in consultation with the State Nodal Agency. An indicative format of the Empanelment Form is set out in Annexure 1. The Insurer shall ensure that each public or private health care provider, standalone day care centre or specialty hospital that it seeks to empanel fills the Empanelment Form. 81

82 16.3 Process for Empanelment of Health Care Providers within Service Area (a) (b) (c) Within 5 days of the date of execution of this Insurance Contract, the State Nodal Agency shall prepare an indicative list of public and private health care providers in each district of the Service Area which can be considered for empanelment under MHIS Phase 3 and provide this to the Insurer, after seeking assistance and facilitation from the district level administration. The State Nodal Agency may consider health care providers other than those applying through the online RSBY portal or through the post. Once the list of public and private health care providers has been populated by the State Nodal Agency and provided to the Insurer, the Insurer shall organise a districtlevel workshop in each district for sensitization of public and private health care providers in accordance with the MHIS Guidelines. The Insurer shall invite all the listed public and private health care providers in a district to attend the district-level workshop on a specified date. At the end of the district-level workshop, the Insurer shall require each public or private health care provider attending the district workshop to: (i) (ii) provide a written consent if it wishes to be empanelled under the MHIS phase 3 ; and if it consents to empanelment, complete the Empanelment Form and return such Empanelment Form to the Insurer within a reasonable time period specified by the Insurer. (d) (e) (f) Based on the consent received from the public and private health care providers within the Service Area, the Insurer shall then compile a final list of public and private health care providers that are willing to be empanelled under the MHIS phase 3. The Insurer shall constitute a qualified technical team (the Empanelment Team) that will be responsible for: (i) reviewing the Empanelment Form submitted; and (ii) inspecting the facilities and services provided by willing health care providers before empanelment. The Empanelment Team shall conduct inspection of the facilities and services provided by a willing health care provider to determine whether: (i) (ii) the minimum empanelment criteria set out in Schedule 7 are met by such health care provider; such health care provider meets the infrastructure and personnel requirements for the Medical Treatments, Surgical Procedures, Day Care Treatments, Follow-up Care or OPD Benefits that it is being empanelled for; and 82

83 (iii) such health care provider meets the additional compliance requirements set out in Schedule 7. Such inspection of the facilities and services shall be completed by the Empanelment Team in consultation with the district level administration of the State Nodal Agency for public and private health care providers within a district. (g) A health care provider that has indicated its willingness to be empanelled under the MHIS phase 3 shall be eligible for empanelment only if: (i) (ii) the Empanelment Team is satisfied after inspection that such health care provider meets the minimum empanelment criteria set out in Schedule 7 and the district or state level administration of the State Nodal Agency has approved the inspection report submitted by the Empanelment Team; and such health care provider has not been de-empanelled under the RSBY or under the Scheme in the 1 year period immediately preceding the date of the Bid and thereafter until the date of execution of the Insurance Contract. (h) Once the Empanelment Team has satisfactorily conducted inspections of the public and private health care providers that have consented to empanelment, the Insurer shall enter the details of these health care providers on the online RSBY portal. This will generate a hospital code and a request for the issuance of a MHC for for each health care provider Process for Empanelment of Health Care Providers outside Service Area (a) (b) (c) Within 5 days of the date of execution of this Insurance Contract, the Insurer shall prepare an indicative list of hospitals, stand-alone day care centres and specialty hospitals meeting the requirements of Clause 16.2 outside the Service Area. The Insurer shall set up individual meetings with each hospital, stand-alone day care centre, specialty hospital or other health care provider situated outside the Service Area and identified by it. The purpose of these meetings will be to sensitize such health care providers in accordance with the MHIS Guidelines. At the end of each meeting, the Insurer shall require such health care provider to: (i) provide a written consent if it wishes to be empanelled under MHIS Phase 3; and (ii) if it consents to empanelment, complete the Empanelment Form and return such Empanelment Form to the Insurer within a reasonable time period specified by the Insurer. 83

84 (d) (e) The Insurer shall cause its Empanelment Team to review the Empanelment Form submitted by the willing private health care provider and conduct an inspection of the facilities and services provided by such health care provider in accordance with Clause 16.3(f). A health care provider that is outside the Service Area and that has indicated its willingness to be empanelled under MHIS Phase 3 shall be eligible for empanelment only if: (i) (ii) the Empanelment Team is satisfied after inspection that such health care provider meets the minimum empanelment criteria set out in Schedule 7 and the state level administration of the State Nodal Agency has approved the inspection report submitted by the Empanelment Team; and such health care provider has not been de-empanelled under the RSBY or under the Scheme in the 1 year period immediately preceding the date of the Bid and thereafter until the date of execution of the Insurance Contract. (f) (g) If a specialty hospital that is located outside the Service Area is empanelled for any Listed Specialties, then such Specialty Hospital shall only provide health care services under MHIS Phase 3 to Beneficiaries that are resident in Meghalaya and not any other persons that are eligible for benefits under the RSBY outside the Service Area. Once the Empanelment Team has satisfactorily conducted inspections of the public and private health care providers that have consented to empanelment, the Insurer shall enter the details of these health care providers on the online RSBY portal. This will generate a hospital code and a request for the issuance of a MHC for for each health care provider Execution of Services Agreement (a) Once a willing health care provider is found to be eligible for empanelment, the Insurer along with its TPA shall enter into a Services Agreement with such health care provider substantially in the form set out in Annexure 2 for the Medical Treatments, Surgical Procedures, Day Care Treatments, OPD Benefits and Follow-up Care for which such health care provider meets the infrastructure and personnel requirements. Such health care provider will then be an Empanelled Health Care Provider for the purpose of MHIS Phase 3, this Insurance Contract and the Policies issued under this Insurance Contract. (b) The empanelment of an Empanelled Health Care Provider shall continue for a period of at least 3 years from the date of the execution of the Services Agreement, unless the Empanelled Health Care Provider is de-empanelled in accordance with Clause or the Services Agreement is terminated in accordance with its terms. 84

85 (c) (d) (e) The Insurer shall submit a copy of the Services Agreement entered into by it, the TPA and the Empanelled Health Care Provider to the State Nodal Agency within 30 days of the execution of such Services Agreement. The Insurer agrees that neither it nor its TPA will permit the Services Agreement with any Empanelled Health Care Provider to contain any provisions that are in contradiction to or that deviate from or breach the terms of this Insurance Contract. If the State Nodal Agency finds that any Services Agreement executed by the Insurer and/or its TPA is in breach of the terms of this Insurance Contract, the State Nodal Agency shall have the right to require the Insurer to de-empanel such Empanelled Health Care Provider in accordance with Clause 16.10(b). The Insurer agrees that neither it nor its TPA shall substantially modify the form of the Services Agreement or amend the Services Agreement once executed with an Empanelled Health Care Provider, without the prior written approval of the State Nodal Agency Post-Empanelment Obligations of the Insurer (a) (b) The Insurer shall submit a list of Empanelled Health Care Providers both within and outside the Service Area before the commencement of enrolment in each district of the Service Area, in the appropriate format set out in Annexure 3. If the Insurer empanels any health care providers after the commencement of enrolment in that district, then the Insurer shall submit empanelment related information at the end of every month to the State Nodal Agency. Such submissions shall also be in the formats set out in Annexure 3. The Insurer shall ensure that details of all Empanelled Health Care Providers, both within and outside the Service Area, are conveyed to the Beneficiaries of MHIS Phase 3 at least once every quarter during the Term and an updated copy of such list is kept at the District Kiosks and panchayat offices at all times. In addition, the Insurer shall regularly publish on its website an up-to-date list of the Empanelled Health Care Providers and in the case of each Empanelled Health Care Provider, the Medical Treatments, Surgical Procedures, Day Care Treatments, Follow-up Care and OPD Benefits for which such Empanelled Health Care Provider has been empanelled. (c) In addition to the empanelment information submitted by the Insurer in accordance with Clause 16.6(a), the Insurer shall submit monthly reports to the State Nodal Agency containing the following empanelment related information: (i) (ii) the number of health care providers selected by the Insurer for empanelment under Clause 16.3(a) or Clause 16.4(a); the target number of health care providers to be empanelled in that month; 85

86 (iii) (iv) (v) (vi) (vii) (viii) (ix) (x) the number of health care providers empanelled by the Insurer in that month; the number of health care providers that refused empanelment in that month, with reasons; the profile of Empanelled Health Care Providers within the Service Area by district, specialty and ownership; the profile of Empanelled Health Care Providers outside the Service Area by city/state, specialty and ownership; the number of health care provider premises visited by the Empanelment Team for verification of the empanelment information; the Insurer's plans for undertaking medical audits in accordance with Clause 27.2 for the next month; the status of installation and operationalization of the Hospital IT Infrastructure at the premises of each Empanelled Health Care Provider; and the details of health care providers that have been de-empanelled by the Insurer in that month, along with reasons for such de-empanelment. The report shall be in the format specified in Annexure 6 and shall include the completed Empanelment Forms for the health care providers empanelled in that month. (d) (e) (f) (g) (h) The Insurer shall apply for the Master Hospital Card (MHC) for each Empanelled Health Care Provider, by filling in all the details of such Empanelled Health Care Provider on the relevant link of the RSBY website: The Insurer shall follow-up with each Empanelled Health Care Provider to ensure that it has received the MHC before the date of commencement of the first Policy Cover Period. The State Nodal Agency shall use its best efforts to ensure that the DKM carries out the requisite MHC modification and hands it only to the concerned authority of the Empanelled Health Care Provider. In each case where the Empanelled Health Care Provider has been empanelled prior to the commencement of a Policy Cover Period, the Insurer shall use its best efforts to see that such Empanelled Health Care Provider receives the MHC prior to the commencement of such Policy Cover Period. The Insurer shall ensure that at least 2 of the personnel of each Empanelled Health Care Provider are trained in accordance with Clause The Insurer shall establish a mechanism for collecting the hospital utilization data, top 25 procedures and health quality indicators reports submitted by the Empanelled Health Care Providers in accordance with Clause 16.8(i) at the end of each month. The Insurer shall then aggregate and the send the data summary to the State Nodal Agency within 15 days. The Insurer shall meet with the representatives of the Empanelled Health Care Providers at least once every quarter during each Policy Cover Period to amicably 86

87 discuss and resolve any issues that the Empanelled Health Care Providers may be facing in relating to making Claims, pre-authorisation, Claim payments or any other matter that is of concern to the Empanelled Health Care Providers Hospital IT Infrastructure to be Maintained by Empanelled Health Care Providers (a) At least 30 days prior to the commencement of each Policy Cover Period: (i) (ii) (iii) The Insurer shall be responsible for reviewing whether each public Empanelled Health Care Provider within the Service Area has the requisite Hospital IT Infrastructure. If a public Empanelled Health Care Provider has been empanelled under RSBY or the Scheme and has the requisite Hospital IT Infrastructure, the Insurer shall be responsible for ensuring that the new or modified transaction software is installed (at no additional cost to the public Empanelled Health Care Provider) and that the installed hardware is compatible with the new/modified transaction software issued by MoHFW or any other third party from time to time. If a public Empanelled Health Care Provider does not have the requisite Hospital IT Infrastructure, the Insurer shall procure and install such Hospital IT Infrastructure in the premises of such public Empanelled Health Care Provider, whether within or outside the Service Area. The Insurer shall complete such procurement and installation at its own cost. For the avoidance of doubt, the Insurer shall be required to install such Hospital IT Infrastructure in the premises of the public Empanelled Health Care Providers that were previously or that are currently empanelled under the RSBY and/or the Scheme, if they do not have the requisite Hospital IT Infrastructure. (iv) For the avoidance of doubt, the Insurer will need to bear all costs of procuring and installing or upgrading the Hospital IT Infrastructuer in the premises of public Empanelled Health Care Providers in accordance with this Clause 16.7(a). (b) The Insurer shall ensure that each private Empanelled Health Care Provider shall (at its own cost) procure and install the Hospital IT Infrastructure at its premises. The Insurer shall be responsible for providing each private Empanelled Health Care Provider with assistance in such installation in a timely manner. Provided that: (i) The Insurer shall review whether each private Empanelled Health Care Provider has the requisite Hospital IT Infrastructure. The objective of such review shall be to determine whether the private Empanelled Health Care 87

88 Provider has installed the new/modified transaction software and has installed compatible hardware. (ii) If pursuant to such review, the Insurer finds that a private Empanelled Health Care Provider has been previously empanelled under the RSBY and/or the Scheme, then the private Empanelled Health Care Provider shall be required to procure and install the Hospital IT Infrastructure only if the existing hardware is not in working condition or is lost. In such cases, the Insurer shall ensure that such private Empanelled Health Care Provider is not required to incur any additional expenditure for installation of new/amended transaction software. (c) The minimum specifications for the Hospital IT Infrastructure that needs to be installed at the premises of an Empanelled Health Care Provider have been set out in Schedule 8. The MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or MHIS Operational Manuals from time to time amending the minimum specifications for the Hospital IT Infrastructure. It shall be the responsibility of the Insurer to ensure that the Hospital IT Infrastructure installed and operated at the premises of each Empanelled Health Care Provider is at all times compliant with the latest MHIS Guidelines and/or the MHIS Operational Manual that are in force. (d) (e) (f) (g) Such review and installation (if required) shall be completed promptly after the execution of the Services Agreement with each Empanelled Health Care Provider and in any event within 30 days of the date of empanelment of each Empanelled Health Care Provider. If an Empanelled Health Care Provider is empanelled prior to commencement of a Policy Cover Period, then the Insurer shall ensure that the installation of the Hospital IT Infrastructure is completed before commencement of the Policy Cover Period for that district. On completion of the procurement and installation of the Hospital IT Infrastructure at the premises of each Empanelled Health Care Provider and thereafter at least once every quarter during each Policy Cover Period, the Insurer shall ensure that the Hospital IT Infrastructure is properly activated and operational. Notwithstanding that the Insurer or the private Empanelled Health Care Providers incur expenses in the procurement and installation of the Hospital IT infrastructure, the ownership of the Hospital IT infrastructure at the premises of each Empanelled Health Care Provider shall at all times remain with the State Nodal Agency. The Insurer shall provide annual maintenance or enter into annual maintenance contracts for the maintenance of the Hospital IT Infrastructure procured and installed by it at the premises of the public Empanelled Health Care Providers. If any of the Hospital IT Infrastructure (whether hardware devices or software) fails at the premises of a public Empanelled Health Care Provider, the Insurer shall be responsible for either repairing or replacing such part of the Hospital IT 88

89 Infrastructure within 72 hours and in an expeditious manner. For the duration of such failure, the public Empanelled Health Care Provider shall send Smart Cards to the District Kiosk for uploading transactions. (h) (i) Each private Empanelled Health Care Provider shall enter into an annual maintenance contract for the maintenance of the Hospital IT Infrastructure installed at its premises. If any of the Hospital IT Infrastructure installed at its premises fails, then it shall be responsible for either repairing or replacing such part of the Hospital IT Infrastructure within 72 hours and in an expeditious manner after becoming aware of such failure or malfunctioning. The private Empanelled Health Care Provider shall bear all costs for the maintenance, repair or replacement of the Hospital IT infrastructure installed in its premises. For the duration of such failure, the private Empanelled Health Care Provider shall send Smart Cards to the District Kiosk for uploading transactions. In each renewal Policy Cover Period, the Insurer shall be responsible for ensuring that: (i) (ii) the health care providers already empanelled under the Scheme are not required to incur any additional expenditure for the transaction software; and the hardware already installed in the premises of such health care providers are compatible with the new/modified transaction software, if any Post-Empanelment Obligations of Empanelled Health Care Providers The Insurer shall ensure that each Empanelled Health Care Provider complies with the following requirements: (a) The Empanelled Health Care Provider shall provide Cashless Access Services to the Beneficiaries availing of its services. For this purpose, the Empanelled Health Care Provider shall not charge more than the Package Rates or the Pre-Authorized Amounts and shall comply with the procedure set out in Clause 5.3 or Clause 5.4 read with Clause 9, Clause 10 and Schedule 5 for making electronic or manual Claims directly against the Insurer. The Insurer shall ensure that the Package Rates determined in accordance with Clause 5.2(a) or Clause 5.2(b) or revised in accordance with Clause 5.2(c) shall be included in the Services Agreement with each Empanelled Health Care Provider, to the extent that such Empanelled Health Care Provider is required to provide health care services (i.e., the Services Agreement with an Empanelled Health Care Provider will only set out the Package Rates for the Medical Treatments, Surgical Procedures, Day Care Treatments, Follow-up Care or OPD Benefits that such Empanelled Health Care Provider is empanelled for). 89

90 (b) Subject to the available Sum Insured and sub-limits or other conditions for provision of benefits, the Empanelled Health Care Provider shall not require the Beneficiary availing of its services to incur any expenses or costs towards the cost of a Medical Treatment, Surgical Procedure, Day Care Treatment, Follow-up Care or OPD Benefit. If the Sum Insured has been fully utilized, then the Empanelled Health Care Provider may charge the Beneficiary for a Medical Treatment, Surgical Procedure, Day Care Treatment, Follow-up Care or OPD Benefit, but only to the extent that costs and expenses thereof cannot be Claimed. However, the Empanelled Health Care Provider shall not charge the Beneficiary at a rate that exceeds: (i) the Package Rate determined in accordance with Clause 5.2(a) or Clause 5.2(b) or revised in accordance with Clause 5.2(c) and set out in the Services Agreement; or (ii) the Preauthorized Amount. (c) (d) (e) (f) (g) (h) (i) The Empanelled Health Care Provider shall clearly display its status of being an Empanelled Health Care Provider under the Rashtriya Swasthya Bima Yojana and Megha Health Insurance Scheme Phase 2 in the format provided by the State Nodal Agency, outside or at its main gate. The Empanelled Health Care Provider shall set up a functional help desk for providing necessary assistance to the Beneficiaries. At least two persons at the Empanelled Health Care Provider will be nominated, who will then be trained in different aspects of the MHIS Phase 3 and the Hospital IT Infrastructure by the Insurer. The Empanelled Health Care Provider shall display a poster near the reception or admission desks along with other materials supplied by the Insurer for the information of the Beneficiaries, the State Nodal Agency and the Insurer. The template of empanelled status and poster for reception area will be provided by the State Nodal Agency. The Empanelled Health Care Provider shall make Claims on the Insurer electronically, by swiping the Smart Cards issued to the Beneficiaries. The Empanelled Health Care Provider shall not make manual Claims on the Insurer, except in the circumstances specified in this Insurance Contract. The Empanelled Health Care Provider shall submit the hospitalization data of the Beneficiaries that have received treatment from the Empanelled Health Care Provider, electronically on a weekly basis to the District Server. The Empanelled Health Care Provider shall maintain such records and documentation as will be required for the Insurer to pre-authorise utilization of the Covers in accordance with this Insurance Contract and for processing of Claims. The Empanelled Health Care Provider shall also submit the monthly hospital utilization data in the formats prescribed in Annexure 4. 90

91 The Empanelled Health Care Provider shall also submit to the Insurer on a monthly basis: (i) (ii) the list of top 25 surgeries with average length of stay; and information regarding the following public health and other quality indicators: neonatal mortality rate, maternal mortality rate, average length of stay based on all Hospitalizations, number of hospital acquired infections and number of readmissions. Such reports shall be in the formats prescribed in Annexure 4. In addition, the Insurer shall be responsible for requiring the Empanelled Health Care Provider to submit any other information or data in such formats as may be required by MoHFW or the State Nodal Agency. The Insurer shall be responsible for collating such reports received from the Empanelled Health Care Providers and submitting a health quality report to the State Nodal Agency in respect of each district at least once every month, commencing from the date of commencement of the Policy Cover Period for each district. The Empanelled Health Care Providers shall also maintain records of needle stick injuries, Beneficiary falls and net death rate, which it shall provide to the Insurer if requested for. (j) (k) (l) (m) (n) The Empanelled Health Care Provider shall co-operate with the Insurer and the State Nodal Agency by ensuring that its doctors, nurses and other medical/administrative staff attend district level workshops and other training programmes conducted by the Insurer and/or the State Nodal Agency. The Empanelled Health Care Provider shall co-operate with the Insurer and the State Nodal Agency and provide the Insurer and State Nodal Agency with access to all facilities, records and information for the conduct of audits or any other evaluation of the performance by the Empanelled Health Care Provider. The Empanelled Health Care Provider shall comply with all applicable Laws, statutes, rules and regulations, as amended from time to time. The Empanelled Health Care Provider shall at all times comply with the minimum empanelment criteria set out in Schedule 7, unless the Insurer has sought specific permission from the State Nodal Agency for the dilution of the minimum empanelment criteria in specific cases. The Empanelled Health Care Provider shall comply with the standard treatment guidelines that may be issued by competent government agencies from time to time. 91

92 16.9 Assistance from the State Nodal Agency for Empanelment The State Nodal Agency shall make reasonable efforts to provide reasonable assistance and support to the Insurer for completing empanelment of both public and private health care providers. For this purpose, the State Nodal Agency shall make reasonable efforts to: (a) (b) (c) (d) (e) (f) (g) (h) Provide the Insurer with a list of all public and private health care providers in each district, through the district administrations in the State of Meghalaya. Provide necessary support for organizing sensitization programmes for public health care providers. Provide assistance to the Insurer in conducting the district-level workshop, including encouraging representatives of each of the listed public health care providers to attend the district-level workshop conducted by the Insurer. Make available the DKM and other district level administration officials available for the inspection of listed public and private health care providers and for the approval of the inspection report submitted by the Insurer s Empanelment Team. Make available the MHC to each Empanelled Health Care Provider in an expeditious manner after receiving a request from the Insurer. Cause the public health care providers that are found to be eligible for empanelment to execute the Services Agreement with the Insurer in an expeditious manner. Respond within a reasonable time to the Insurer s request for approval of any modifications or amendments to the Services Agreements with the Empanelled Health Care Providers. Work in consultation with the Insurer to prepare and finalize the formats for the following: (i) (ii) the display to be used by the Empanelled Health Care Providers at or outside their main gates; and the display poster to be posted at the reception/admissions desks of the Empanelled Health Care Providers. (i) Extend necessary support in providing space and resources for locating MHIS help desks at the premises of the public Empanelled Health Care Providers. 92

93 16.10 De-empanelment of Empanelled Health Care Providers (a) The Insurer shall de-empanel an Empanelled Health Care Provider from the RSBY and the MHIS network, if it finds that: (i) (ii) (iii) (iv) (v) (v) the guidelines of the MHIS phase 3 are not followed by such Empanelled Health Care Provider; or the services provided by such Empanelled Health Care Provider are not satisfactory as per the standards specified in the MHIS Guidelines or otherwise specified by the Government of Meghalaya; or the Empanelled Health Care Provider is in breach of the terms of its Services Agreement with the Insurer; or in case of any financial irregularity or Fraudulent Activity being committed by the Empanelled Health Care Provider; or if at any time after the empanelment, the Empanelled Health Care Provider ceases to comply with the minimum empanelment criteria set out in Schedule 7 or is found to have made a material misrepresentation regarding its compliance with the minimum empanelment criteria, except where the Insurer has obtained specific permission of the State Nodal Agency for a dilution of the minimum empanelment criteria; or if at any time after the completion of 30 days from the date of empanelment, the Empanelled Health Care Provider is found not to have installed and operationalized the Hospital IT Infrastructure in its premises; provided that this shall apply only in the case of private Empanelled Health Care Providers. For this purpose, the Insurer shall follow the procedure for de-empanelment specified in Schedule 9. (b) (c) If the State Nodal Agency is of the reasonable belief that any Empanelled Health Care Provider has triggered any of the conditions of de-empanelment set out in Clause 16.10(a) above, then the State Nodal Agency shall issue a notice to the Insurer. Upon receipt of a notice under this Clause 16.10(b), the Insurer shall initiate and follow the procedure for de-empanelment specified in Schedule 9 against such Empanelled Health Care Provider. An Empanelled Health Care Provider once de-empanelled as a RSBY/MHIS network health care provider shall not be eligible for empanelment within the RSBY network or the MHIS network for such period determined by the State Nodal Agency, depending on the severity of the circumstances or default of the Empanelled Health Care Provider that triggered such de-empanelment. 93

94 (d) Notwithstanding a suspension or de-empanelment of an Empanelled Health Care Provider in accordance with Schedule 9, the Insurer shall ensure that it shall honour all Claims for any expenses that have been pre-authorised or blocked on the Smart Cards before the effectiveness of such suspension or de-empanelment as if such De- Empanelled Health Care Provider continues to be an Empanelled Health Care Provider. 17. DISTRICT KIOSK AND DISTRICT SERVER 17.1 District Kiosk (a) The District Kiosk is the designated office of the Insurer at the district level which will be required to provide post issuance services to the Beneficiaries and Empanelled Health Care Providers. The role and functions of the District Kiosk has been specified in Schedule 10. The MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or MHIS Operational Manuals from time to time amending the role and functions of the District Kiosk. It shall be the responsibility of the Insurer to ensure that the District Kiosk functions at all times in compliance with the latest MHIS Guidelines and/or the MHIS Operational Manual that are in force. (b) The State Nodal Agency shall, through its district administration, provide the Insurer with space for setting up the District Kiosk in each district, for which it will charge no rent from the Insurer. If the State Nodal Agency is unable to provide space for establishing and maintaining the District Kiosk, the Insurer shall use its District Office as the District Kiosk until such time that the space is provided by the State Nodal Agency. In addition, the State Nodal Agency shall make available FKOs at the District Kiosk in each district for the issuance and post-issuance services as described in Schedule 10 and in compliance with the latest MHIS Guidelines and MHIS Operational Manual that is in force. (c) The Insurer shall set up a fully functional and operational District Kiosk at each district, which will include a data management desk for the issuance and postissuance services as described in Schedule 10. The Insurer will be required to set up and operationalize such District Kiosk within 15 days of the date of signing of this Insurance Contract. The MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or MHIS Operational Manuals from time to time amending the procedures for the issuance and post-issuance services to be provided by the District Kiosk. It shall be the responsibility of the Insurer to ensure that the District Kiosk is at all times in full compliance with such MHIS Guidelines and MHIS Operational Manual that are in force. 94

95 (d) (e) The Insurer shall provide trained personnel for the operation of the District Kiosk in each district during the Term. The Insurer shall provide all the IT infrastructure (i.e., hardware and software) that is required for the functioning of the District Kiosk and that is specified in Schedule 10 at its own cost. The ownership of all such IT infrastructure provided by the Insurer at the District Kiosk shall be with the Insurer during the Term and shall be transferred to the State Nodal Agency upon the expiration or early termination of the Term District Server The MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or MHIS Operational Manuals from time to time amending the minimum specifications for the IT Infrastructure that is required to be installed and operated at the District Kiosk. It shall be the responsibility of the Insurer to ensure that the IT Infrastructure installed and operated at each District Kiosk is at all times compliant with the latest MHIS Guidelines and/or the MHIS Operational Manual that are in force. (a) (b) The District Server is the designated server/it infrastructure at the district level which will be used to: configure and store the Beneficiary Database for use at enrolment stations; collate enrolment data including fingerprints; collate transaction data; collate data related to modifications undertaken at the district kiosk; submit periodic reports to the State Nodal Agency and/or to MoHFW; and perform such other functions that are set out in this Insurance Contract. The Insurer shall set up a fully functional and operational District Server at the District Kiosk (or at any convenient location in that district) for each district that shall meet the requirements set out at Schedule 10, within 15 days of the date of signing of this Insurance Contract. The ownership of the District Server shall be with the Insurer during the Term and shall be transferred by the Insurer to the State Nodal Agency upon expiration or termination of this Insurance Contract. The MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or MHIS Operational Manuals from time to time amending the minimum specifications for the District Server. It shall be the responsibility of the Insurer to ensure that the District Servers installed and operated by the Insurer are at all times compliant with the latest MHIS Guidelines and/or the MHIS Operational Manual that are in force. (c) The Insurer shall ensure that the correct details of the Policy issued for a district are saved on the District Server before the commencement of enrolment in that district. Such details shall include at a minimum: the Policy number and the Policy Cover Period for the district. 95

96 18. IEC AND BCC INTERVENTIONS 18.1 Strategy for IEC and BCC Interventions (a) (b) The Insurer shall within 15 days of the date of signing of this Insurance Contract, prepare and implement a communication strategy in consultation with the State Nodal Agency, for launching and implementing MHIS Phase 3. The objective of these interventions will be to inform the Beneficiaries regarding enrolment and benefits of the MHIS phase 3. The Insurer shall submit the draft IEC and BCC plan to the State Nodal Agency within 30 days of the date of signing of this Insurance Contract, in line with the strategy agreed by the Parties pursuant to Clause 18.1(a). The State Nodal Agency shall within a reasonable period of such submission review the IEC and BCC plan and provide its comments to the Insurer. The Insurer shall revise such plan after incorporating the State Nodal Agency s comments and re-submit the plan (the IEC/BCC Plan) IEC and BCC Activities (a) (b) Prior to commencement of enrolment for each Policy Cover Period, the Insurer shall be responsible for conducting the IEC and BEC activities in each district in accordance with the IEC/BCC Plan. The Insurer shall bear the costs of all IEC and BCC activities. The Insurer shall complete the IEC and BCC activities before the scheduled date for commencement of enrolment. 19. CAPACITY BUILDING INTERVENTIONS 19.1 Capacity Building Programme (a) (b) (c) The Insurer shall design a training, workshop and orientation programme for the Empanelled Health Care Providers, members of hospital management societies, District Programme Managers, doctors, gram panchayat members, intermediaries, FKOs and all other stakeholders in MHIS Phase 3 (the Capacity Building Programme). The Insurer shall submit the Capacity Building Programme to the State Nodal Agency within 30 days of the date of signing of the Insurance Contract. The State Nodal Agency shall within a reasonable period of such submission review the Capacity Building Programme and provides its comments to the Insurer. The Insurer shall revise the Capacity Building Programme after incorporating the State Nodal Agency s comments and re-submit the Capacity Building Programme. In preparing the Capacity Building Programme, the Insurer shall plan for conducting quarterly stakeholder workshops with the representatives of the State Nodal 96

97 Agency, Empanelled Health Care Providers and the Insurer. The Insurer shall conduct such stakeholder workshops at least 4 times in each Policy Cover Period and shall invite representatives of the stakeholders well in advance. (d) In finalizing the Capacity Building Programme, the Parties shall jointly develop the training packages, which shall at a minimum, include training as often as is stipulated at Clause 19.2 of this Insurance Contract Minimum Training to be Provided by Insurer The Insurer shall, at a minimum, conduct the following training: (a) (b) Training for Enrolment Teams: The Insurer shall complete the training of each Enrolment Team prior to the commencement of enrolment in a district where such Enrolment Team will be conducting enrolment of the Beneficiary Family Units. Empanelled Health Care Provider Training: (i) (ii) (iii) The Insurer shall provide training to the IT technicians/mhis help desk personnel for all Empanelled Health Care Providers in a district at least once every 6 months, i.e., at least twice during each Policy Cover Period for such district. Such training shall include: list of covered procedures and prices, pre-authorization procedures and requirements, IT training for making online Claims and ensuring proper installation and functioning of the Hospital IT Infrastructure for each Empanelled Health Care Provider. The Insurer shall organize training workshops for each public Empanelled Health Care Providers (including CHCs and PHCs) at the hospital premises at least once every 6 months, i.e., at least twice during each Policy Cover Period for a district and at any other time requested by the Empanelled Health Care Provider, to increase knowledge levels and awareness of the hospital staff. If a particular Empanelled Health Care Provider frequently submits incomplete documents or incorrect information in Claims or in its request for authorization as part of the pre-authorization procedure, then the Insurer shall undertake a follow-up training for such Empanelled Health Care Provider. (c) State and District Officers of the Insurer: At least once every 6 months, i.e., at least twice during each Policy Cover Period for a district, the Insurer shall provide training for the Insurer s state-level and district-level officers Implementation of the Capacity Building Programme (a) The Insurer shall implement the Capacity Building Programme with the support of the State Nodal Agency and other government agencies, as necessary. 97

98 (b) (c) The cost of all capacity building interventions associated with the implementation of the Capacity Building Programme shall be borne by the Insurer. The Insurer shall submit to the State Nodal Agency at the end of every 6 months, a detailed report specifying the capacity building and training conducted by the Insurer and the progress made by the Insurer against the Capacity Building Programme during those 6 months. 20. OTHER PRE-ENROLMENT OBLIGATIONS 20.1 Insurer s Pre-Enrolment Obligations In addition to the Insurer s obligations under Clauses 15 to 19 of this Insurance Contract, the Insurer shall mandatorily complete the following activities before the start of the enrolment in each district: (a) (b) (c) Setting up of a fully functional and operational state toll free helpline number facility for the provision of the Call Centre Services in accordance with Clause 25 of this Insurance Contract. Setting up a fully functional District Kiosk and District Server in accordance with Clause 17 of this Insurance Contract. Printing of sufficient number of booklets which have to be given to each Beneficiary Family Unit being enrolled in such district. Such booklets shall contain at least the following details: (i) Details about MHIS Phase 3and the Covers; (ii) Process for utilizing the Covers under MHIS Phase 3; (iii) List of Exclusions; (iv) Start and end date of the Policy Cover Period for that district; (v) List of the Empanelled Health Care Providers along with addresses and contact details; (vi) Package Rates fixed in accordance with Clause 5.2; (vii) Location and address of the District Kiosk and its functions; (viii) The names and details of the District Coordinator of the Insurer in that district; (ix) Toll-free number of the call centre established by the Insurer; (x) Process for filing complaints or grievances; (xi) Process for modification, splitting and re-issuance of Smart Cards; and (xii) All other details required for smooth usage of the Smart Card. The Insurer shall comply with this obligation before the commencement of each Policy Cover Period for a district. (d) Ensuring availability of Policy number for the Policy for each district that is issued by the Insurer. 98

99 (e) (f) Ensuring that contact details of the District Coordinator of the Insurer, the nodal officer of the TPA and the nodal officer of the other service providers appointed by the Insurer are updated on the RSBY website: before the commencement of each Policy Cover Period. Conducting focussed awareness campaigns and publicity of MHIS Phase 3 and the visit of the Enrolment Team for enrolment of Beneficiary Family Units well in advance of the commencement of enrolment in the selected district. Such awareness campaigns and advance publicity shall be conducted in consultation with the State Nodal Agency and the district administration in respective villages and urban areas to ensure the availability of maximum number of Beneficiary Family Units for enrolment on the date(s) specified in the Enrolment Schedule. The awareness campaign shall include announcements of the proposed enrolment plan in the local newspapers and on other social media and the documents to be carried by the proposed Beneficiaries for authentication by the FKOs at the enrolment stations. (g) (h) (i) The Insurer shall specifically inform that the head of the family shall be required to carry his/her Electoral Photo ID Card for authentication at the enrolment station. If the head of the family is absent at the time of enrolment, then the spouse of the head of the family shall be required to carry his/her Electoral Photo ID Card for identification and verification. Simultaneously with the awareness campaigns and publicity, the Insurer shall prominently post the list of identified Beneficiary Family Units eligible to be covered under MHIS Phase 3 in each village/urban area/ward. Ensuring the thorough testing of the enrolment process using the Beneficiary Database with the assistance of the Smart Card Service Provider. Standardization of the formats for Cashless Access Service, discharge summary, billing pattern and other reports that shall be developed in consultation with the State Nodal Agency State Nodal Agency s Obligations In addition to the State Nodal Agency s obligations under Clauses 15 to 19 of this Insurance Contract, the State Nodal Agency shall mandatorily complete the following activities before the start of the enrolment in each district: (a) (b) Setting up the State Server at least 15 days prior to the commencement of enrolment in the districts for the first Policy Cover Period, if the State Nodal Agency's existing State Server does not meet such minimum requirements. Ensure that the DKMA Servers, including Smart Card readers and fingerprint scanners, installed at each of the District Headquarters are made available for 99

100 implementation of the MHIS phase 3 and ensure that they are fully operational prior to the commencement of enrolment in each district. (c) (d) Installation of the DKMA software on the State Server for issue of FKO cards and for downloading of data subsequently from FKO cards, prior to the commencement of each Policy Cover Period, if the existing DKMA software does not comply with the most recent MHIS Guidelines. Preparation of the Beneficiary Database for each district in the format prescribed by the MHIS Guidelines and validation of the Beneficiary Database by MoHFW so that it can be uploaded on the RSBY website for the Insurer to download. Prior to the commencement of each Policy Cover Period, the State Nodal Agency shall provide the verified Beneficiary Database to the Insurer or the Smart Card Service Provider appointed by the Insurer at least 5 days prior to the scheduled date for commencement of enrolment for such district stated in the Enrolment Schedule. The State Nodal Agency shall comply with this obligation prior to the commencement of enrolment for each Policy Cover Period. (d) Appoint the District Key Manager (DKM) for each district and work with the DKM appointed by it to create the requisite organization structure at the district level to effectively implement and manage the MHIS phase 3 within 30 days of the signing of this Insurance Contract, if such DKM has not been appointed for the implementation of the Scheme. The role and functions of the DKM has been specified in Schedule 11. The MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or MHIS Operational Manuals from time to time amending the roles and functions of the DKM. It shall be the responsibility of the State Nodal Agency to ensure that the DKMs and other district health personnel function at all times in compliance with the latest MHIS Guidelines and/or the MHIS Operational Manual that are in force. (e) Identify the FKOs in required numbers for enrolment at least 30 days prior to commencement of enrolment in each district for each Policy Cover Period. The role and functions of the FKOs has been specified in Schedule 11. The State Nodal Agency shall ensure that the FKOs are trained in the enrolment process and sensitized about the importance of their presence at the time of enrolment and their availability at the time of enrolment. The MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or MHIS Operational Manuals from time to time amending the roles and functions of the FKOs. It shall be the responsibility of the State Nodal Agency to ensure that the FKOs at all times function in full compliance with the latest MHIS Guidelines and/or the MHIS Operational Manual that are in force. (f) Organize health camps for building awareness about MHIS Phase 3 and increase the hospitalization in the selected district prior to commencement of enrolment in each 100

101 district for each Policy Cover Period. (g) The DKM shall ensure that details of the state nodal officer and the DKM on the RSBY website are correct and up to date at all times. 21. ENROLMENT OF BENEFICIARIES Enrolment of beneficiaries under MHIS 3 will include the renewal of existing beneficiaries enrolled during MHIS Phase II whereby the Insurer will need to recharge the existing smart cart; and enrolment of new beneficiaries whereby fresh smart cards will need to be issued by the insurer as per MHIS 3 guidelines Enrolment Obligations (a) (b) (c) (d) The Insurer shall be responsible for enrolment of Beneficiary Family Units in each district, based on the data regarding Beneficiary Family Units identified in the Beneficiary Database. The Insurer shall enrol the Beneficiary Family Units and issue Smart Cards in accordance with this Clause 21 and the latest MHIS Guidelines and MHIS Operational Manual that is in force. In order to provide a risk cover to each enrolled Beneficiary Family Unit in compliance with Clause 7.4(d) in respect of the first Policy Cover Period for each district, the Insurer shall be entitled to a maximum period of 4 months from the commencement of Smart Card issuance for completion of enrolment in that district. The Insurer shall be responsible to touch at least 85% of total enrolment data.. For the avoidance of doubt, the month in which the first Smart Card is issued shall be treated as a full month, irrespective of the date on which such Smart Card is issued. In order to provide a risk cover to each enrolled Beneficiary Family Unit in compliance with Clause 7.6(c) and to avoid a delay in commencement of risk cover to each Beneficiary Family Unit in accordance with Clause 8.3(c) in respect of each renewal Policy Cover Period for each district, the Insurer shall be entitled to a maximum period of 4 months for enrolment (i.e., either issuance of new Smart Cards or renewal of existing Smart Cards) in such district. Such 4 month period for enrolment for a renewal Policy Cover Period shall commence at least 5 months prior to the date of expiration of the on-going Policy Cover Period. The insurer shall be responsible for establishing a Block Static Kiosk during the enrolment period, where the insurer shall enrol beneficiaries and acts as a block office with all information regarding the scheme 21.2 Schedule for Enrolment (a) In respect of the first Policy Cover Period, the State Nodal Agency and the Insurer shall mutually agree upon the schedule for the enrolment of Beneficiary Family 101

102 Units in the 11 districts of the State of Meghalaya (the Enrolment Schedule) within 21 days of the date of signing the Insurance Contract. (b) (c) In respect of each renewal Policy Cover Period, the State Nodal Agency and the Insurer shall mutually agree upon the Enrolment Schedule at least 6 months prior to the date of expiration of the on-going Policy Cover Period. For the purpose of preparing the Enrolment Schedule for each Policy Cover Period, the Insurer shall, along with the Smart Card Service Provider and district level administration of the State Nodal Agency, prepare a roster for enrolment stations at the defined locations, the enrolment schedule up to the village level with monthly, bi-weekly and weekly enrolment targets for each such location and the number of FKOs required for complying with such enrolment schedule. The roster shall be prepared so as to cover the entire district (rural + urban) within 4 months from start of enrolment for that district. While preparing the roster for enrolment stations, the Insurer must take into account the following factors: (i) (ii) (iii) Number of Enrolment Kits that will need to be deployed simultaneously; Location of the enrolment stations within the village or urban area; and The timing of the monsoon season for Meghalaya in respect of the commencement of each Policy Cover Period. Further, the Parties shall agree upon and prepare the Enrolment Schedule keeping in mind the commencement date of each Policy Cover Period for each district that is specified in Clause 7.1 and the monthly enrolment targets that have been set out in Clause 21.2(d). (d) The Enrolment Schedule agreed between the Insurer and the State Nodal Agency will prescribe the minimum enrolment to be achieved in each month of enrolment in each district. Such minimum enrolment target shall not be less than the following: (i) (ii) (iii) (iv) 8% of the Beneficiary Family Units in the first month of enrolment; 20% of the Beneficiary Family Units in the second month of enrolment; 40% of the Beneficiary Family Units in the third month of enrolment; and 50% of the Beneficiary Family Units in the fourth month of enrolment, such that the aggregate enrolment in such district upon completion of the enrolment period shall not be less than 50%. (e) The Insurer shall be responsible for commencing the enrolment of Beneficiary Family Units for each district in the Service Area on the scheduled date specified in the Enrolment Schedule. If, however, the Beneficiary Database is not uploaded on the RSBY website at least 5 days prior to the scheduled date for commencement of enrolment that is specified in the Enrolment Schedule, then: 102

103 (i) (ii) The Insurer shall not commence enrolment in such district, until the validated Beneficiary Database is uploaded on the RSBY website; and The Parties shall mutually agree to amend the Enrolment Schedule, taking into account delays by the State Nodal Agency in uploading the validated Beneficiary Database on the RSBY website. (f) Without prejudice to the obligation of the Insurer to commence enrolment in each district in accordance with this Clause 21.2, the Insurer agrees that it shall not commence enrolment in any district for a Policy Cover Period unless the Insurer has fully performed each of obligations set out in Clauses 15 to 20 to the satisfaction of the State Nodal Agency. Such obligations include: (i) (ii) (iii) (v) (vi) (vii) empanelment of hospitals and health care providers in such district; establishment of a functional District Kiosk and District Server in such district; establishment of an operational Call Centre at the state level; printing of booklets with information on MHIS Phase 3 and the benefits under the Covers; completion of training of all the enrolment teams and FKOs in accordance with the Capacity Building Programme; and completion of all IEC/BCC activities in accordance with the IEC/BCC Plan Enrolment Procedure The procedure for enrolment of Beneficiary Family Units under MHIS Phase 3 in each district of the State of Meghalaya for each Policy Cover Period shall be as follows: (a) (b) The Insurer or its representative will download the Beneficiary Database for the selected district from the RSBY website The Insurer is required to issue new 64kB Smart Cards to all Beneficiary Family Units that come for enrolment to the enrolment station for the first Policy Cover Period, whether or not the Beneficiary Family Units are already beneficiaries under the existing Scheme or RSBY. Unless the MHIS Guidelines or the MHIS Operational Manual require otherwise, in each renewal Policy Cover Period it shall be sufficient if the Insurer: (i) (ii) issues new 64 kb Smart Cards to Beneficiary Family Units that have not been previously enrolled in the previous Policy Cover Periods; and revalidate the 64 kb Smart Cards issued to Beneficiary Family Units in the previous Policy Cover Periods, unless the Smart Card previously issued to a Beneficiary Family Unit is lost or damaged, in which case a new Smart Card shall be issued to such Beneficiary Family Unit. 103

104 If the MHIS Guidelines or the MHIS Operational Manual require the Insurer to issue new 64 kb Smart Cards to all Beneficiary Family Units for the renewal Policy Cover Period, then the Insurer shall be responsible for taking back the previous Smart Cards issued to the Beneficiary Family Units during the enrolment drive. (c) The Insurer or its representative will arrange for the Smart Cards as per the requirements set out in Schedule 12. Only software certified by MoHFW shall be used for the issuance of the Smart Cards. The MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or MHIS Operational Manuals from time to time amending the Smart Card specifications or the enrolment software. It shall be the responsibility of the Insurer to ensure that the Smart Cards issued to the Beneficiary Family Units are at all times compliant with the latest MHIS Guidelines and/or the MHIS Operational Manual that are in force. (d) The minimum requirements regarding the Enrolment Kits and the manpower deployment for enrolment have been specified in Schedule 13. The Insurer shall ensure that the Enrolment Kits are in working condition and the manpower deployed meet the requirements specified in Schedule 13 and that these resources are provided from the day of commencement of enrolment in the selected district. In addition, the Insurer shall provide for at least 10% additional enrolment kits that shall be handed over to the DKM and district level health officials for emergency use. The MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or MHIS Operational Manuals from time to time amending the minimum enrolment kit and enrolment personnel requirements. It shall be the responsibility of the Insurer to ensure that the enrolment kits and personnel deployed by it for undertaking enrolment shall at all times be compliant with the latest MHIS Guidelines and/or the MHIS Operational Manual that are in force. (e) (f) The Insurer shall be responsible for choosing the location of the enrolment stations within each village/urban area that is easily accessible to the maximum number of Beneficiary Family Units within that area. The State Nodal Agency shall ensure the availability of sufficient number of FKOs to accompany the enrolment teams in order to meet the timelines specified in the Enrolment Schedule, for verification of identified Beneficiary Family Units at the time of enrolment. The role of the FKOs has been specified in Schedule 11. The Insurer shall be responsible for conducting the training of the FKOs before commencement of the enrolment process. (g) The Insurer shall place a banner in the local language at the enrolment station providing information about the enrolment programme and details of the MHIS 104

105 Phase 3. In addition, the Insurer shall prominently display the list of Beneficiary Family Units in each village/ward within the Service Area. (h) (i) The enrolment team shall visit each enrolment station on the dates in the Enrolment Schedule for enrolment and issuance of the Smart Cards to the Beneficiary Family Units. Based on the Beneficiary details (Name, Father s/husband s name, Village), the record would be pulled out from the Beneficiary Database and displayed to the Beneficiary. For enrolment of the Beneficiary Family Unit: (i) (ii) (iii) (iv) (v) (vi) The head of the household of a Beneficiary Family Unit shall show his/her electoral photo ID card for identification to the FKO. If the head of the household is not available, then the spouse shall be the head of the family and shall be required to show his/her electoral photo ID card for verification. If neither the head of the household nor his/her spouse are available, then the next oldest family member who is available shall be the head of the family and shall be required to show his/her electoral photo ID card for verification. The FKO will cross-check the details of the head of household's details in the Beneficiary Database against the details on such head of household's electoral photo ID card. The text details already available for all members of the family whose names are included in the Beneficiary Database shall then be verified by the FKO in the presence of the Beneficiary. The age and gender of all members of the Beneficiary Family Unit, including head of the family, can be corrected and modified on the Beneficiary Database. Names of ONLY dependants may be modified on the Beneficiary Database. Photographs of the head of family and of the nominated members to be enrolled shall be taken. Two fingerprints of each family member being enrolled shall be captured. The primary fingerprints to be captured would be right and left thumb. However, in case the print is not of good quality or either/both thumbs are missing, sequence of other fingers is defined in the enrolment specification in the MHIS Guidelines and can be referred from The Insurer shall be responsible for maintaining a back-up of the enrolment and personalization data at the District Server. The Insurer shall also be responsible for submitting the amended Beneficiary Database for each district to the State Nodal Agency for uploading on the State Server. 105

106 If all or some of the Beneficiary Family Unit members are not present at the enrolment station, they can subsequently be enrolled on the Smart Card at the District Kiosk. The enrolment stations shall not cater to issuance of duplicate Smart Cards or modification of Smart Cards, which shall only be carried out at the District Kiosk in the first Policy Cover Period. However, modification of Smart Cards may be carried out by an enrolment station or at a District Kiosk in a renewal Policy Cover Period in accordance with the procedure set out in Schedule 10. (j) Upon collection of the data and processing of the Smart Card by the enrolment team, the FKO shall: (i) (ii) (iii) verify the Smart Card and the data on the chip; confirm the head of the family details, in the presence of the Insurer's enrolment team; and insert the FKO card into the card reader and authenticate it through his fingerprint. Unique keys for the Smart Card will then be generated by the FKO card and written to the chip of the Smart Card being issued to the Beneficiary Family Unit. (k) (l) (m) (n) (o) (p) Once the Smart card has been personalised the FKO shall ensure that the Smart Card is re-verified by the Beneficiary by providing his/her fingerprints so as to ensure that the Smart Card is in working condition. It is mandatory for the enrolment team to hand over the activated Smart Card to the Beneficiary Family Unit at the time of enrolment itself. At the time of handing over the Smart Card, the Insurer shall collect the registration fee of 50 from each Beneficiary Family Unit. The Insurer s representative shall provide each Beneficiary Family Unit with a booklet prepared in accordance with Clause 20.1(c), along with the Smart Card. The Insurer shall print and make these booklets available in sufficient numbers at each of the enrolment stations in the selected district, based on the number of Beneficiary Family Units identified in the Beneficiary Database. To prevent damage to the Smart Card, the Insurer shall provide each Beneficiary Family Unit with a good quality plastic jacket to protect the Smart Card. The jacket provided to each Beneficiary Family Unit shall carry the logo of MHIS Phase 3, as notified by the State Nodal Agency to the Insurer. The Beneficiary Family Unit shall also be informed about the date on which the Smart Card will become operational (month) and the date on which the Policy Cover Period will expire. 106

107 The Beneficiaries shall be entitled for cashless treatment at the Empanelled Health Care Providers on presentation of the Smart Card on and from the date of commencement of the Policy Cover Period. (q) (r) (s) The FKO should carry the data collection form to fill in the details of people protesting against exclusion from the Beneficiary Database or requesting for addition of dependants or requesting the correction of data in the Beneficiary Database. This set of forms should be deposited back at the DKMA office along with the FKO card at the end of the enrolment camp. The Insurer shall submit the digitally signed enrolment data generated by the enrolment software to the DKM and Mo on a weekly basis. In addition, the Insurer shall send daily reports and periodic data to both the State Nodal Agency and MoHFW in accordance with the MHIS Guidelines. The biometric data (including photographs and fingerprints) shall thereafter be provided to the State Nodal Agency in the prescribed format at the end of each month of enrolment along with the invoice submitted by the Insurer to the State Nodal Agency. The MoHFW or the State Nodal Agency may issue MHIS Guidelines and/or MHIS Operational Manuals from time to time amending the procedure to be followed for enrolment of Beneficiary Family Units. It shall be the responsibility of the Insurer to ensure that the enrolment teams at all times conduct the enrolment process in full compliance with the latest MHIS Guidelines and/or the MHIS Operational Manual that are in force State Nodal Agency s Obligations in relation to Enrolment To complement the performance of the Insurer's obligations in Clause 21.3 above, the district level administration of the State Nodal Agency shall have the following obligations in relation to enrolment: (a) (b) (c) (d) (e) To provide assistance to the Insurer through the district-level administration in the preparation of Panchayat/Municipality/Corporation-wise/village-wise Enrolment Schedule. To provide the FKOs with the Master Issuance Cards (MIC) in accordance with the MHIS Guidelines, before the commencement of the enrolment process at any enrolment station. To monitor the participation of FKOs in the enrolment process by ensuring their presence at the enrolment station. To obtain FKO undertaking for each village that is part of the enrolment drive. To provide the Insurer with the logo for MHIS Phase 3 within 15 days of the date of 107

108 this Insurance Contract. (f) (g) (h) (i) To provide support to the Insurer in the enrolment by coordinating with different stakeholders at the district, block and panchayat level. To obtain enrolment data downloaded from FKO cards and upload it to the DKMA server and then reissue the FKO cards to new FKOs after formatting it and personalizing it again. To monitor the enrolment data at the DKMA server (as downloaded from FKO cards) and compare it with data provided by the Insurer to determine the Premium to be paid. To communicate with the State Nodal Agency and MoHFW in case of any problems related to DKMA software, cards or implementation issues. Upon receipt of such communication from the district-level administration, the State Nodal Agency shall promptly take necessary actions to address such issues or problems in a timely manner Hardship Allowance (a) The block-wise Enrolment Rate achieved for implementation of the Scheme in shall be provided by the State Nodal Agency prior to the commencement of the enrolment for the first Policy Cover Period. The blocks with Enrolment Rates of 35% or less (the Identified Blocks) are relatively inaccessible and face frequent power shortages. Therefore, the Insurer will need to bear additional costs in transporting power back-up, outstation enrolment teams and Enrolment Kits to the Identified Blocks. For each renewal Policy Cover Period, the State Nodal Agency shall inform the Insurer of the block-wise Enrolment Rate based on the information uploaded from the FKO cards on the DKM Server within 100 days of the date of commencement of the on-going Policy Cover Period. Blocks in which the Enrolment Rate is 35% or less shall then be deemed the Identified Blocks for the renewal Policy Cover Period. (b) (c) The Insurer shall undertake enrolment in each Identified Block, notwithstanding the accessibility or availability of transport or infrastructure in such Identified Block. In each Policy Cover Period, the State Nodal Agency shall pay the Insurer an allowance for meeting the additional costs likely to be incurred for conducting the enrolment process in such Identified Blocks (the Hardship Allowance). In each Policy Cover Period, the State Nodal Agency shall pay the Insurer a Hardship Allowance of 10 for Beneficiary Family Units that are enrolled in an Identified Block, provided that: (i) the Enrolment Rate in such Identified Block is at least 40% (the Hurdle Rate); and 108

109 (ii) the Hardship Allowance for such Identified Block will be paid to the Insurer in accordance with the following formula: HA = 10 x E x [N B - (N D + N G )] 100 Where: HA is the Hardship Allowance to be paid to the Insurer, which amount shall only be paid if E is a positive number. N B is the number of Beneficiary Family Units whose details are present in the validated Beneficiary Database uploaded on the RSBY website and for whom URNs have been generated N D is the number of Beneficiary Family Units not enrolled due to data errors in the Beneficiary Database. For the purpose of this formula, "data errors" shall mean the following errors in the Beneficiary Database: (i) the head of household and spouse are dead; (ii) the head of household has been wrongly identified; and (iii) unrelated families have been combined within the same Beneficiary Family Unit, e.g., tenant is part of the household of landlord or vice versa. N D shall be calculated using the following formula: N D = (number of data error observed on the field during enrolment) * (N B N G )/(number of persons who visited enrolment centre) [Note. The formula for N D takes into account that there are Beneficiary Family Units who would have government employees as members and also be a part of the data error.] N G is the number of Beneficiary Family Units that include one or more government employee(s). [Note: If accurate data is not available in the Beneficiary Database on the number of Beneficiary Family Units including government employee(s), it shall be assumed that 10% of the total number of Beneficiary Family Units listed in the Beneficiary Database will qualify as families with one or more government employees.] E is the difference between the actual Enrolment Rate and the Hurdle Rate, which will be calculated in accordance with the following formula: Where: E = E - H 109

110 E is the actual Enrolment Rate in the Identified Block, which will be calculated in accordance with the following formula: E = N E x 100 [N B - (N D + N G )] H is the Hurdle Rate of 40%. (d) The Insurer shall provide details of the Identified Blocks, the enrolment of Beneficiary Family Units completed in the Identified Blocks and the Hardship Allowance payable by the State Nodal Agency to the Insurer in its invoice for the second Premium instalment for the last month of enrolment in the district where such Identified Blocks are located. The State Nodal Agency shall pay the Hardship Allowance along with the second Premium instalment for such last month of enrolment, after verifying the enrolment data submitted by the Insurer with the enrolment data uploaded from the FKO Cards onto the DKM Server. 22. LIQUIDATED DAMAGES On the fifteenth day after completion of the 4 month enrolment period for each Policy Cover Period, the performance of the Insurer shall be evaluated against the Performance KPIs in the manner set out in Section 2 of Schedule 16 (the Performance KPI Evaluation) Enrolment Liquidated Damages Upon completion of the Performance KPI Evaluation, if the State Nodal Agency determines that the Insurer has failed to achieve: (a) (b) (c) the baseline Enrolment Rate specified in Section 1.1 of Table 1 in Schedule 16 for all the districts in the Service Area, then the Insurer shall pay as liquidated damages the amount specified in the column "Liquidated Damages" in Section 1.1 of Table 1 of Schedule 16; the baseline Enrolment Rate specified in Section 1.2 of Table 1 in Schedule 16 at the end of 3 months of enrolment in each district of the Service Area, then the Insurer shall pay as liquidated damages the amount specified in the column "Liquidated Damages" in Section 1.2 of Table 1 of Schedule 16; and the baseline Average Family Size specified in Section 1.3 of Table 1 in Schedule 16 at the end of enrolment in all districts of the Service Area, then the Insurer shall pay as liquidated damages the amount specified in the column "Liquidated Damages" in Section 1.3 of Table 1 of Schedule 16. The liquidated damages payable under this Clause 22.1 shall be the Enrolment Liquidated Damages. 110

111 22.2 Empanelment Liquidated Damages Upon completion of the Performance KPI Evaluation, if the State Nodal Agency determines that the Insurer has failed to empanel the minimum number of: (a) (b) (c) (d) (e) (f) eligible private health care providers in Meghalaya that is set out in Section 2.1 of Table 1 in Schedule 16, then the Insurer shall pay as liquidated damages the amount specified in the column "Liquidated Damages" in Section 2.1 of Table 1 in Schedule 16; eligible specialty hospitals in Guwahati that is set out in Section 2.2 of Table 1 in Schedule 16, then the Insurer shall pay as liquidated damages the amount specified in the column "Liquidated Damages" in Section 2.2 of Table 1 in Schedule 16; Specialty Hospitals located outside Meghalaya, i.e., in the cities of Delhi, Kolkata and at least 3 of the following cities: Mumbai, Bengaluru, Hyderabad and Chennai, that is set out in Section 2.3 of Table 1 in Schedule 16, then the Insurer shall pay as liquidated damages the amount specified in the column "Liquidated Damages" in Section 2.3 of Table 1 in Schedule 16; eligible NABH accredited hospitals across India, that is set out in Section 2.4 of Table 1 in Schedule 16, then the Insurer shall pay as liquidated damages the amount specified in the column "Liquidated Damages" in Section 2.4 of Table 1 in Schedule 16; eligible Specialty Hospitals with a specialty in oncosurgery and cancer therapy that is set out in Section 2.5 of Table 1 in Schedule 16, then the Insurer shall pay as liquidated damages the amount specified in the column "Liquidated Damages" in Section 2.5 of Table 1 in Schedule 16; eligible public or private hospitals within the Service Area that is set out in Section 2.6 of Table 1 in Schedule 16, then the Insurer shall pay as liquidated damages the amount specified in the column "Liquidated Damages" in Section 2.6 of Table 1 in Schedule 16. The liquidated damages payable under this Clause 22.2 shall be the Empanelment Liquidated Damages Cap on Aggregate Liquidated Damages (a) (b) The Insurer's liability for Enrolment Liquidated Damages for failing to meet the overall Enrolment Rate shall be limited to the amount specified in the column "Cap on Liquidated Damages" in Section 1.1 of Table 1in Schedule 16. The Insurer's liability for Enrolment Liquidated Damages for failing to meet the Enrolment Rate at the end of 3 months of enrolment in each district shall be limited 111

112 to the amount specified in the column "Cap on Liquidated Damages" in Section 1.2 of Table 1 in Schedule 16. (c) (d) (d) The Insurer s liability for Enrolment Liquidated Damages shall be limited to the amount specified in the column "Cap on Liquidated Damages" in Section 1.3 of Table 1 in Schedule 16. The Insurer's liability for Empanelment Liquidated Damages shall be limited to the amount specified in the column "Cap on Liquidated Damages" in Section 2 of Table 1 in Schedule 16. The Insurer's total liability for Liquidated Damages shall be limited to the Aggregate Liquidated Damages Cap. (e) Notwithstanding anything to the contrary contained in Clause 22.1 or in Clause 22.2, the Insurer shall not be liable to pay any Liquidated Damages to the extent that the Insurer's performance has been affected by a Force Majeure Event Payment of Liquidated Damages (a) The Insurer shall pay the Liquidated Damages to the State Nodal Agency within 30 days of receipt of a written notice from the State Nodal Agency requesting payment thereof. (b) If the Insurer delays payment of or fails to pay the Liquidated Damages within 30 days of receipt of a written notice from the State Nodal Agency, then the Insurer shall be liable to pay interest at the rate of 0.5% of the amount of Liquidated Damages due and payable to the State Nodal Agency for every 15 days of delay beyond the period stipulated above. (c) If the Insurer fails to pay the Liquidated Damages within such 30 day period and/or the default interest thereon, the State Nodal Agency shall be entitled to deduct such amount from the Premium due and payable to the Insurer or to recover such amount as a debt due from the Insurer. Provided that no such deduction made by the State Nodal Agency from the renewal Premium shall be deemed as a failure to pay the renewal Premium for the renewal Policy Cover Period on or before the Renewal Premium Payment Date or the expiration of the Grace Period Liquidated Damages Reasonable (a) The Parties hereby acknowledge and agree that the provisions of this Clause 22 and Schedule 16 are reasonable, considering the losses and the actual costs that the State Nodal Agency and/or the Beneficiaries are likely to incur if the Insurer fails to achieve the Performance KPIs. 112

113 (b) The amounts of these Liquidated Damages are agreed upon and fixed hereunder by the Parties because of the difficulty of ascertaining the exact amount of losses and/or costs that will be actually incurred by the State Nodal Agency and/or the Beneficiaries in such event, and the Parties hereby agree that such amounts are a reasonable and genuine pre-estimate of State Nodal Agency and/or Beneficiaries' probable loss (and are not in the nature of a penalty) and that such amounts shall be applicable regardless of actual costs and losses incurred General Provisions Regarding Liquidated Damages (a) The payment of Liquidated Damages by the Insurer to the State Nodal Agency in any Policy Cover Period shall not affect the State Nodal Agency's right to: (i) refuse renewal of all the Policies for the next Policy Cover Period in accordance with Section 3 of Schedule 16; or (ii) cause a termination of this Insurance Contract in accordance with Clause 31. (b) (c) (d) (e) (f) The Insurer irrevocably undertakes that it shall not, whether by legal proceedings or otherwise, contend that the Liquidated Damages are not reasonable or put the State Nodal Agency to the proof thereof, or further contend that its agreement to such sum and undertaking as aforesaid were arrived at by force, duress, coercion, mistake or misrepresentation on the part of the State Nodal Agency. The Insurer represents and warrants to the State Nodal that it is not prohibited by any applicable Laws, including but not limited to the Insurance Act and the Health Insurance Regulations, to pay the Liquidated Damages in accordance with this Clause 22. The Insurer makes this representation and warranty on the date of entering into this Insurance Contract and shall be deemed to repeat such representation and warranty on each day of each Policy Cover Period. If, for any reason, this Clause 22 is found to be void, invalid or otherwise inoperative so as to disentitle the State Nodal Agency from claiming Liquidated Damages, then the State Nodal Agency will be entitled to claim damages at law for the Insurer's failure to meet the Performance KPIs. The Insurer waives its right to claim a set-off of the Liquidated Damages payable by it to the State Nodal Agency against any Premium due and payable or to become due to it by the State Nodal Agency. The payment of Liquidated Damages shall not relieve the Insurer from its obligations under the Insurance Contract. 113

114 PART III OTHER OBLIGATIONS REGARDING IMPLEMENTATION OF THE MHIS PHASE SERVICES BEYOND SERVICE AREA (a) To ensure true portability of the Smart Cards and to provide the Beneficiaries with seamless access to health care services across the Empanelled Health Care Providers and the RSBY Network Hospitals anywhere across India, the Insurer shall enter into arrangements with ALL other insurance companies that have been awarded contracts under the RSBY or that utilize the RSBY framework to allow the sharing of RSBY Network Hospitals, transfer of Claims and transaction data arising in areas beyond the Service Area. Notwithstanding anything to the contrary in the foregoing paragraph, the Parties agree that persons/families eligible under the RSBY who are not residents in the Service Area shall not have access to Tertiary Care services provided by the Specialty Hospitals that are empanelled by the Insurer. (b) The Insurer and such other insurance companies shall share inter-insurance Claims in the prescribed format through web based interface and within the timelines as prescribed by the MHIS Guidelines. Thereafter, the Insurer and such other insurance companies shall settle such inter-insurance Claims within the timelines prescribed in the MHIS Guidelines. 24. BUSINESS CONTINUITY PLAN 24.1 Acknowledgement by the Insurer The Insurer acknowledges that: (a) (b) the implementation of MHIS Phase 3 depends on technology and related aspects of Smart Card operations, in order to provide Cashless Access Services to the Beneficiaries under the MHIS phase 3 ; and unforeseen technology and delivery issues may interrupt the provision of Cashless Access Services Business Continuity Measures The Insurer agrees that if, in the implementation of MHIS Phase 3 and use of the prescribed technology and systems, there is an issue causing interruption in the provision of Cashless Access Services, the Insurer shall: (a) make all efforts to put in place an alternate mechanism to ensure continued provision of Cashless Access Services to the Beneficiaries in accordance with the methodology prescribed in the MHIS Guidelines; 114

115 (b) (c) take all necessary measures to fix the technology or related issues to bring the Cashless Access Services back onto the online platform; and furnish all data/information in relation to the cause of interruptions, the delay or other consequences of interruptions, the mitigating measures taken by the Insurer and any other related issues to the State Nodal Agency and MoHFW in the format prescribed by the MHIS Guidelines. 25. CALL CENTRE SERVICES 25.1 Call Centre Services Call Centre Services shall mean toll free telephone services provided for the guidance and benefit of the Beneficiaries regarding utilization of the Covers and usage of the Smart Card Insurer s Obligations in relation to Call Centre Services (a) The cost of operating the Call Centre Services, including the cost of operating the toll free number, the telecom equipment, the call centre and the manpower, shall be borne solely by the Insurer. Attempts will be made by the State Nodal Agency to leverage the call centre services with the GVK EMRI 108 call centre services, in doing so the insurer will only be required to bear the manpower cost. (b) The insurer should ensure that the call centre should have a dedicated line exclusively for MHIS and located in Shillong. (c) The Call Centre Services shall be operated for 24 hours a day, 7 days a week and round the year. (d) The Insurer shall ensure that in providing the Call Centre Services, it shall provide all necessary information regarding MHIS Phase 3, benefits available to Beneficiaries, information on the hospital network under the MHIS phase 3 and information on Medical Treatments, Surgical Procedures, Day Care Treatments, OPD Benefits and Follow-up Care provided by the Empanelled Health Care Providers, to any person calling the state toll-free number. The call centre shall have access to all relevant information, including the Beneficiary details and details of their usage of the Covers, so that any queries raised can be satisfactorily answered Toll Free Number The Insurer shall operate a state toll free number with a facility of a minimum of 5 lines. The toll free numbers will be restricted to the incoming calls of the Beneficiaries only. Outward facilities from those numbers will be barred to prevent misuse. A separate line shall be established to address the health insurance related Claims and grievances of senior citizens Language The Insurer undertakes to provide the Call Centre Services to the Beneficiaries in Hindi, English and in the local languages (Khasi and Garo). 115

116 25.5 Insurer to Inform Beneficiaries The Insurer shall inform all the Beneficiaries about the state toll free number along with addresses and other telephone numbers of the Insurer s Project Office. 26. MANAGEMENT INFORMATION SYSTEMS (MIS) SERVICE (a) The Insurer shall maintain a MIS dashboard that will act as a visual interface to provide at-a-glance views on key ratios and measures of data regarding the implementation of MHIS Phase 3. This shall be done through a web based system. The Insurer should set up the MIS Dashboard within 1 month from the day of signing of contract The MIS dashboard shall consist of a few pages, with various modules on each page. The MIS dashboard modules should include: pre-enrolment, post-enrolment, preauthorization, empanelment and transaction data. The Insurer shall update the information on the MIS dashboard every 2 days and shall provide the State Nodal Agency and the MoH&FW with access to the various modules on the MIS dashboard. The State Nodal Agency and the MoHFW shall have the right to download, print or store the data available on the MIS dashboard. An indicative format of the MIS dashboard and the various reports to be reflected on the MIS dashboard is set out in Annexure 5. These formats may be modified from time to time as and when SNA requires and change. (b) In addition, the Insurer shall submit reports to the State Nodal Agency regarding enrolment, health-service usage patterns, Claims data, customer grievances and such other information regarding the delivery of benefits as may be required by the State Nodal Agency. Such reports will be submitted on a monthly basis and in the formats specified in Annexure 6. The format of the reports may be modified by mutual agreement of the Parties. In addition, the Insurer shall be responsible for submitting such other data and information as may be requested by the State Nodal Agency and/or to the MoHFW and to submit such reports in formats specified by the State Nodal Agency in order to enable it to meet its reporting requirements to MoHFW under the MHIS Guidelines and/or the MHIS Operational Manual. (c) All data generated by the Insurer in relation to the implementation and management of MHIS Phase 3 and/or in performing its obligations under this Insurance Contract shall be the property of the State Nodal Agency and MoHFW. The Insurer undertakes to handover all such information and data to the State Nodal Agency and MoHFW within 10 days of the expiration or cancellation of any Policy for that district and on the expiration or early termination of this Insurance Contract. 116

117 27. REPORTING, MONITORING AND CONTROL 27.1 Automated Reports and Automated Queries/Alerts (a) (b) Without prejudice to the Insurer s obligations under Clause 26 above, the Insurer shall ensure that the District Server/District Kiosks generate automated reports and automated queries/alerts which shall then be immediately shared with the State Nodal Agency through the State Server. Such automated reports and automated queries/alerts shall include those that are listed at Schedule 14 and shall cover the potential frauds also listed at Schedule 14. On the basis of these reports, queries or alerts, the Insurer shall also prepare periodic analysis of trends and shall promptly provide written reports on such trends analysis to the State Nodal Agency Medical Audits (a) (b) (c) The Insurer shall carry out regular inspection of the Empanelled Health Care Providers and conduct periodic medical audits, to ensure proper care and counselling for the Beneficiaries at Empanelled Health Care Providers, by coordinating with the authorities of the Empanelled Health Care Providers. The Insurer shall share its plan for conducting medical audits with the State Nodal Agency. The plan shall include at least one audit of an Empanelled Health Care Provider in each week, with four such audits being conducted in a month and at least one audit outside the Service Area. The medical audit will include a review of medical notes and a review of the medical appropriateness in the formats specified in Annexure 7. The medical cases to be audited will be identified randomly or can be specified by the Insurer's audit team for specific conditions or cases. The medical audit should compulsorily be done by a qualified Medical Practitioner who is a part of the Insurer s or the TPA s organization or is otherwise duly authorized to undertake such medical audit by the Insurer or the TPA. (d) The process of conducting medical audit is set out below: (i) (ii) (iii) The auditor shall check the POS data before meeting the Beneficiaries, and all admitted Beneficiaries at that time are to be audited apart from the triggered Claims. The audit should preferably be conducted in the presence of the hospital physician/treating doctor. While cross examining the Beneficiaries, the indoor Claims file should be made available by the authority of the Empanelled Health Care Provider. The auditor shall review the complete file and note down the anomalies 117

118 observed in the audit sheet. (iv) (v) (vi) If any triggered Beneficiary is already discharged, only the indoor file shall be examined and the auditor shall note down the anomalies observed in the audit sheet. Scanned/photocopy of indoor files of all examined/triggered Beneficiaries shall be compulsorily collected from the Empanelled Health Care Provider, along with a pre-texted format mentioning complete documents pertaining to the Beneficiaries are handed over to the auditorduly signed by the authority of the Empanelled Health Care Provider. Finally, the auditor shall discuss all anomalies observed with the treating doctor and seek his explanation/opinion on a case to case basis and the report shall be signed by both the auditor and the authority of the Empanelled Health Care Provider. The report should also mention any Fraudulent Activity identified during the medical audit. (e) During the medical audit, the Insurer's audit team shall also conduct Beneficiary surveys with Beneficiaries who are admitted by the Empanelled Health Care Provider during the audit period. At least 60 Beneficiaries should be involved in the audits in each month. The Beneficiary survey should include a formal interview of the Beneficiary documented in the format set out in Annexure Beneficiary Audit If the Insurer suspects that a Beneficiary has been discharged by an Empanelled Health Care Provider in a fraudulent or suspicious manner, the Insurer shall visit the Beneficiaries residence to confirm the admission and treatment taken from the Empanelled Health Care Provider. The process for such beneficiary audit is set out below and the format of the audit report is set out at Annexure 8. (a) (b) (c) (d) The auditor shall meet either the Beneficiary or the head of the family of the relevant Beneficiary Family Unit. The auditor should either take a photograph or make a video recording of the Beneficiary or the head of the household holding the Smart Card to certify that the auditor has met the correct person. The auditor should collect the statement of the Beneficiary or the head of the household in the prescribed beneficiary survey format. The auditor shall cross-check the laboratory or diagnostic reports to understand the diagnosis of the Beneficiary s disease, illness or accident that results in a requirement for a medical or surgical treatment, procedure or intervention requiring Hospitalization or Day Care Treatment. The auditor shall collect one copy of all such reports and cross-check them against copies of reports collected from the 118

119 Empanelled Health Care Provider. (e) Where the auditor has made a house-visit to the Beneficiary, the documentary evidence collected (like Beneficiary statement, videography) shall be studied and its authenticity shall be tested Audit Reports (a) The Insurer shall submit a report to the State Nodal Agency within 7 days of the end of each month during the Policy Cover Period regarding the medical audits conducted in that month. Such audit report shall include the following information: (i) (ii) (iii) (iv) the number of Empanelled Health Care Providers selected for the medical audit in that month; the number of Empanelled Health Care Providers for which the medical audit has been completed; the Insurer's plans for conducting medical audit in the next month (i.e., the month in which the medical audit report is submitted); and a summary of the names of the Empanelled Health Care Providers, size, location, ownership, level of care and audit details in the formats prescribed at Annexure 7. (b) In addition to the medical audit report, the Insurer shall submit a report to the State Nodal Agency within 7 days of the end of each month during the Policy Cover Period regarding the Beneficiary surveys conducted in that month. Such audit report shall include the following information: (i) (ii) the number of Beneficiaries surveyed in that month; a summary of the Beneficiary responses with a frequency count of: Beneficiaries who were not informed of the value of the Medical Treatment or Surgical Procedure or Day Care Treatment or Followup Care or OPD Benefits provided or conducted by the Empanelled Health Care Provider Beneficiaries who were not informed of the remaining balance on their Smart Card Beneficiaries who were not provided the transportation expense or the economic loss compensation Beneficiaries who were asked to pay for medicines or Screening during Hospitalization, Follow-up Care or OPD Benefits 119

120 (iii) (iv) Details of the Beneficiary and the Empanelled Health Care Provider that provided the care should be included in an annexure to the beneficiary survey report; and Summary of actions taken or proposed actions of the Insurer against the Empanelled Health Care Providers based on the findings of the Beneficiary surveys State Nodal Agency's Rights in Relation to Monitoring and Control The State Nodal Agency may either directly or through an independent third party: (a) (b) (c) (d) collect feedback regarding the implementation of MHIS Phase 3 (including feedback from Beneficiaries regarding awareness of MHIS Phase 3), the availability of the benefits under the Covers to the Beneficiaries and the effectiveness of the Cashless Access Service; or conduct periodic audits of the pre-authorization, Claims and medical audits conducted by the Insurer or the TPA; or conduct periodic audits of the District Kiosks maintained by the Insurer, to check the post-issuance obligations of the District Kiosks in relation to the Smart Cards issued to the Beneficiary Family Units; or conduct periodic audits of complaints, complaint resolution and the management of the grievance redressal committees. at such times and in such formats as it considers appropriate. The Insurer agrees to cooperate with the State Nodal Agency and provide it with access to its records for this purpose State Nodal Agency s Obligations in Relation to Monitoring and Control The State Nodal Agency shall have the following obligations in relation to monitoring and control of the implementation of MHIS Phase 3 and the Insurer s performance of its obligations: (a) (b) (c) To organize periodic review meetings with the Insurer to review the implementation of the MHIS phase 3. In the first 6 months of the first Policy Cover Period, such periodic review meetings shall be held on a fortnightly basis. Thereafter, the Parties shall meet on a monthly basis. To set-up a server at the State level to store the enrolment, Hospitalization and other data received from the Insurer for all the districts. To work with the technical team of the Insurer to study and analyse the data for improving the implementation of MHIS Phase

121 (d) (e) To issue FKO cards and maintain data regarding issuance of FKO cards and data downloaded from FKO cards by the DKM in the specified format. To run the District Grievance Redressal Committee and the State Grievance Redressal Committee in accordance with the MHIS Guidelines. 28. PROVISION OF SERVICES BY INTERMEDIARIES 28.1 Right to Appoint Intermediaries or Service Providers (a) (b) (c) (d) (e) (f) Subject to Clause 15.3, the Insurer may enter into service agreement(s) with one or more intermediary institutions or service providers, to ensure effective implementation and outreach of MHIS Phase 3 to Beneficiary Family Units and to facilitate usage of the Covers provided by the Insurer to the Beneficiaries. The Insurer shall be responsible for compensating any intermediaries or service providers that are appointed by it, without seeking any change or increase in the Premium or charging the State Nodal Agency with any additional commission or fee. The appointment of intermediaries or service providers shall not relieve the Insurer from any liability or obligation arising under or in relation to the performance of obligations under this Insurance Contract and the Insurer shall at all times remain solely responsible for any act or omission of its intermediaries or service providers, as if it were the acts or omissions of the Insurer. The Insurer shall be responsible for ensuring that its service agreement(s) with intermediaries and service providers include provisions that vest the Insurer with appropriate recourse and remedies, in the event of non-performance or delay in performance by such intermediary or service provider. The Insurer shall procure that each service agreement that it enters into with an intermediary or service provider shall contain provisions that entitle the State Nodal Agency or its nominee to step into such service agreement, in substitution of the Insurer, upon the expiration and/or termination of this Insurance Contract in accordance with the terms hereof. The Insurer shall notify the State Nodal Agency of the intermediaries or service providers that it wishes to appoint on or before the date of execution of this Insurance Contract Appointment of Third Party Administrators (a) The Insurer may appoint TPAs, Smart Card Service Providers or similar agencies to: (i) (ii) manage and operate the enrolment process; manage and operate the empanelment and de-empanelment process; 121

122 (iii) (iv) (v) (vi) (vii) manage and operate the District Kiosk(s); manage and operate the Call Centre Services; manage and operate the Claims settlement process, provided that the TPA shall not exercise the right to settle or reject Claims other than in accordance with the Health Insurance Regulations; conduct field audits at enrolment stations, medical audits of Empanelled Health Care Providers and Beneficiary audits; and undertake IEC and BCC activities for enrolment. (b) The Insurer shall only hire a TPA that meets the criteria set out in Schedule 15. (c) The Insurer shall enter into a services agreement with the TPA at the time of signing of this Insurance Contract and submit a redacted copy to the State Nodal Agency. The services agreement with the TPA shall contain the mandatory clauses provided in Schedule Appointment of Smart Card Service Providers (a) The Insurer may appoint Smart Card Service Provider(s) to: (i) (ii) (iii) (iv) (v) manage and operate the enrolment process; procure, install and maintain the Hospital IT Infrastructure at the premises of the public Empanelled Health Care Providers; manage and conduct the training of the Empanelled Health Care Providers and their personnel on the Cashless Access Services and the Claims process; conduct field audits at enrolment stations; and undertake IEC and BCC activities for enrolment. (b) (c) The Insurer shall only hire a Smart Card Service Provider that has been accredited by the Quality Council of India, in accordance with the MHIS Guidelines. The Insurer shall enter into a services agreement with the Smart Card Service Provider at the time of signing of this Insurance Contract and submit a redacted copy to the State Nodal Agency Non-Government Organisations (NGOs) or other Similar Agencies (a) The Insurer may appoint non-government organisations (NGOs) or similar agencies to: (i) (ii) conduct awareness campaigns on a rolling basis in villages to increase awareness of MHIS Phase 3 and its key features; mobilize all eligible Beneficiary Family Units in all districts of the State for enrolment under MHIS Phase 3 and to facilitate their enrolment or subsequent re-enrolment as the case may be; 122

123 (iv) (v) (vi) (vi) (vii) ensure that the Beneficiary Database is publicly available and displayed, in collaboration with government officials; provide guidance to the Beneficiary Family Units wishing to avail of benefits provided under MHIS Phase 3 and facilitating their access to such services as may be needed; provide publicity in their catchment areas on basic performance indicators of MHIS Phase 3 and the Empanelled Health Care Providers; assist the Beneficiary Family Units in making complaints or raising grievances with the relevant Grievance Redressal Committee; or provide any other service as may be mutually agreed between the Insurer and such intermediary agency. (b) The Insurer shall enter into services agreements with non-governmental organisations or such other parties as the Insurer deems necessary, to ensure effective outreach and delivery of Covers and benefits under MHIS Phase

124 29. COORDINATION COMMITTEE 29.1 Constitution of Coordination Committee PART IV COORDINATION AND GRIEVANCE REDRESSAL (a) (b) The State Nodal Agency and the Insurer shall establish, within 7 days of the date of execution of this Insurance Contract, a coordination committee (the Coordination Committee). The Coordination Committee shall be constituted as follows: (i) (ii) the State Nodal Officer and one other member nominated by the State Nodal Agency; and the State Coordinator of the Insurer and one other member nominated by the Insurer. (c) The State Nodal Officer of the State Nodal Agency shall be the chairperson of the Coordination Committee Role and Functions of the Coordination Committee (a) The key functions and role of the Coordination Committee shall include: (i) (ii) (iii) (iv) Ensuring smooth interaction and process flow between the State Nodal Agency and the Insurer. Reviewing the implementation and functioning of the MHIS phase 3 and initiating discussions between the Parties to ensure efficient management and implementation of MHIS Phase 3. Reviewing the performance of the Insurer under the Insurance Contract. Any other matter that the Parties may mutually agree. (b) (c) The role of the Coordination Committee shall be consultative and its decisions shall not be binding on either Party, unless ratified by such Party. For the purpose of carrying out its key functions and role, the Coordination Committee shall meet regularly. In the first 6 months following the execution of this Insurance Contract, the Coordination Committee shall meet at least once every week. 124

125 30. GRIEVANCE REDRESSAL 30.1 Constitution of Grievance Redressal Committees The Insurer and the State Nodal Agency shall establish the following Grievance Redressal Committees to address grievances of various stakeholders at different levels: (a) District Grievance Redressal Committee (DGRC) The State Nodal Agency shall constitute the DGRC in each district within 15 days of execution of this Insurance Contract. The constitution of each DGRC shall be as follows: (i) (ii) (iii) the District Magistrate or an officer of the rank of Addl. District Magistrate or Chief Medical Officer, who shall be the Chairman of the DGRC; the District Coordinator of the Insurer, who shall be a member of the DGRC; and the DGNO, who shall be the Convenor of the DGRC. The DGRC may invite other experts for their inputs for specific cases. (b) State Grievance Redressal Committee (SGRC) The State Nodal Agency shall constitute the SGRC within 15 days of execution of this Insurance Contract. The constitution of the SGRC shall be as follows: (i) (ii) (iii) (iv) (v) The Principal Secretary or the Secretary of Department of Health & Family Welfare, who shall be the Chairman of the SGRC; Regional Director, DGHS (Directorate General Health Services_-Member the State Nodal Officer of the State Nodal Agency (SGNO), who shall be the Convenor; the State Coordinator of the Insurer, who shall be a Member of the SGRC; and the Labour Commissioner in charge of Meghalaya, Ministry of Labour & Employment, Government of India. The SGRC may invite other experts for their inputs on specific cases. (c) National Grievance Redressal Committee (NGRC) National Grievance redressal Committee (NGRC) shall be proposed by the Ministry of Health and Family Welfare from time to time at the National level. The present constitution of National Redressal Committee is as under 125

126 i. Joint Secretary (RSBY), Ministry of Health & Family Welfare- Chairman. ii. iii. iv. Director (Vigilance)- Ministry of Health & Family Welfare- Member. Representative of Ministry of Labour & Employment- Member. Director e Governance, Ministry of Health & Family Welfare- Member Lodging of Complaints v. Deputy Secretary (RSBY), Ministry of Health & Family Welfare- Member Convener. (a) If any stakeholder has a complaint (complainant) against any other stakeholder during the subsistence of the Policy Cover Period or thereafter, in connection with the validity, interpretation, implementation or alleged breach of this Insurance Contract or a Policy or of the terms of their agreement (for example, the Services Agreement between the Insurer, the TPA and an Empanelled Health Care Provider; or the services agreement between the Insurer and the TPA), then such complainant may lodge a complaint by phone, letter or . For the purpose of this Clause 30.2, a stakeholder includes: any Beneficiary; an Empanelled Health Care Provider; a De-empanelled Health Care Provider; the Insurer or its employees; a TPA; any other intermediary appointed by the Insurer; the State Nodal Agency or its employees or nominated functionaries for implementation of the MHIS phase 3 (i.e., FKOs, DKMs, State Nodal Officer, etc.); and any other person having an interest or participating in the implementation of MHIS Phase 3 or entitled to benefits under the Covers. (b) A complainant may lodge a complaint in the following manner: (i) (ii) directly with the DGNO of the district where such stakeholder is located or where such complaint has arisen and if the stakeholder is located outside the Service Area, then with any DGNO located in the Service Area; or with the State Nodal Agency or with MoHFW. If a complaint has been lodged with the State Nodal Agency or with MoHFW, they shall forward such complaint to the concerned DGNO. (c) Upon a complaint being received by the DGNO, the DGNO shall decide whether the substance of the complaint is a matter that can be addressed by the stakeholder against whom the complaint is lodged or whether such matter requires to be dealt with under the grievance redressal mechanism. 126

127 If the DGNO decides that the complaint must be dealt with under the grievance redressal mechanism, the DGNO shall refer such complaint to the convenor of the relevant Grievance Redressal Committee depending on the nature of the complaint after which the procedure set out in Clause 30.4 shall apply. Such decision will be made by reference to the matrix set out in Schedule 17. If the DGNO decides that the complaint need not be dealt with under the grievance redressal mechanism, then the procedure set out in Clause 30.3 shall apply Redressal of Complaints (a) (b) (c) (d) (e) (f) The DGNO shall enter the particulars of the complaint on the Web-based Central Complaints and Grievance Management System (CCGMS) established by MoHFW. The CCGMS will automatically: (i) generate a Unique Complaint Number (UCN); (ii) categorize the nature of the complaint; and (iii) an or letter to be sent to the appropriate stakeholder to which such category of complaint is to be referred. Once the UCN is generated, the DGNO shall send or cause to be sent an acknowledgement /phone call to the complainant and provide the complainant with the UCN. Upon receipt of the UCN, the complainant will have the ability to track the progress of complaint resolution online through CCGMS. The stakeholder against whom a complaint has been lodged must send its comments/response to the complaint to the DGNO within 15 days. If the complaint is not addressed within such 15 day period, the DGNO shall send a reminder to such stakeholder for redressal within a time period specified by the DGNO. If the DGNO is satisfied that the comments/response received from the stakeholder will address the complaint, then the DGNO shall communicate this to the complainant by and update the CCGMS. If the DGNO is not satisfied with the comments/response received or if no comments/response is received from the stakeholder despite a reminder, then the DGNO shall refer such complaint to the convenor of the relevant Grievance Redressal Committee depending on the nature of the complaint after which the procedure set out in Clause 30.4 shall apply. 127

128 30.4 Grievance Redressal Mechanism Upon escalation of a complaint for grievance Redressal under this Clause 30.4 in accordance with Clause 30.2 or Clause 30.3, the following procedure shall apply: (a) (b) (c) (d) (e) (f) The DGNO shall update the CCGMS to change the status of the complaint to a grievance, after which the CCGMS shall categorize the grievance and automatically refer it to the convenor of the relevant Grievance Redressal Committee by way of e- mail. The convenor of the relevant Grievance Redressal Committee shall place the grievance before the Grievance Redressal Committee for its decision at its next meeting. Each grievance shall be addressed by the relevant Grievance Redressal Committee within a period of 30 days of receipt of the grievance. For this purpose, each Grievance Redressal Committee shall be convened at least once every 30 days to ensure that all grievances are addressed within this time frame. The relevant Grievance Redressal Committee shall arrive at a reasoned decision within 30 days of receipt of the grievance. The decision of the relevant Grievance Redressal Committee shall be taken by majority vote of its members. Such decision shall be given after following the principles of natural justice, including giving the parties a reasonable opportunity to be heard. If any party to a grievance is not satisfied with the decision of the relevant Grievance Redressal Committee, it may appeal against the decision within 30 days to the relevant Grievance Redressal Committee or other authority having powers of appeal. If an appeal is not filed within such 30 day period, the decision of the original Grievance Redressal Committee shall be final and binding. The Grievance Redressal Committees and other authorities having powers of appeal are as follows: (i) (ii) (iii) (iv) (v) Beneficiary grievances shall be referred to the SGRC. Empanelled Health Care Provider grievances shall be referred to the SGRC. Insurer grievances against Beneficiaries shall be referred to the SGRC. Insurer grievances against district level functionaries of the State Nodal Agency shall be referred to the NGRC. Insurer grievances against the State Nodal Agency shall be referred to the MoHFW. 128

129 (vi) State Nodal Agency grievances against Insurer shall be referred to the MoHFW. (g) A Grievance Redressal Committee or other authority having powers of appeal shall dispose of an appeal within 30 days of receipt of the appeal. The decision of the Grievance Redressal Committee or other authority with powers of appeal shall be taken by majority vote of its members. Such decision shall be given after following the principles of natural justice, including giving the parties a reasonable opportunity to be heard. The decision of the Grievance Redressal Committee or other authority having powers of appeal shall be final and binding Proceedings Initiated by the State Nodal Agency The State Nodal Agency shall have standing to initiate proceedings and to file a complaint on behalf of itself and Beneficiaries under this Insurance Contract Compliance with Orders of Grievance Redressal Committees (a) (b) (c) The Insurer shall ensure that all orders of the Grievance Redressal Committees by which it is bound are complied with within 30 days of the issuance of the order, unless such order has been stayed on appeal. If the Insurer fails to comply with the order of any Grievance Redressal Committee within such 30 day period, the Insurer shall be liable to pay a penalty of 25,000 for the first month of such non-compliance and 50,000 per month thereafter until the order of such Grievance Redressal Committee is complied with. The Insurer shall be liable to pay such penalty to the State Nodal Agency within 15 days of receiving a written notice. On failure to pay such penalty, the Insurer shall incur an additional interest at the rate of 0.5% of the total outstanding penalty amount for every 15 days for which such penalty amount remains unpaid. 129

130 PART V OTHER TERMS AND CONDITIONS 31. TERM & TERMINATION 31.1 Term This Insurance Contract shall become effective on the date of its execution and shall continue to be valid and in full force and effect until: (a) (d) (e) expiration of the Policy Cover Period under each Policy issued under this Insurance Contract, including all renewals thereof; the discharge of all the Insurer's liabilities for all Claims made by the Empanelled Health Care Providers on or before the date of expiration of the Policy Cover Period for each Policy, including all renewals thereof. For the avoidance of doubt, this shall include a discharge of the Insurer's liability for all amounts blocked on the Smart Cards of the Beneficiaries before the date of expiration of such Policy Cover Period; and the discharge of all the Insurer s liabilities to the State Nodal Agency, including for refund of any Premium for any of the previous Policy Cover Periods and for payment of Liquidated Damages. The Insurer undertakes that it shall discharge all its liabilities in respect of all such Claims raised in respect of each Policy and all of its liabilities to the State Nodal Agency within 45 days of the date of expiration of the Policy Cover Period (including all renewals thereof) for that Policy. The period of validity of this Insurance Contract shall be the Term, unless this Insurance Contract is terminated earlier in accordance with Clause Termination by the State Nodal Agency (a) The State Nodal Agency shall have the right to terminate this Insurance Contract upon the occurrence of any of the following events (each an Insurer Event of Default), provided that such event is not attributable to a Force Majeure Event: (i) (ii) the Insurer fails to duly obtain a renewal of its registration with the IRDA or the IRDA revokes or suspends the Insurer s registration for the Insurer s failure to comply with applicable Insurance Laws or the Insurer s failure to conduct the general or health insurance business in accordance with applicable Insurance Laws or the code of conduct issued by the IRDA; or the Insurer has not commenced enrolment in any district within 30 days of the proposed date of commencement of enrolment as specified in the Enrolment Schedule, other than due to the State Nodal Agency's failure to 130

131 upload the Beneficiary Database on the RSBY website in accordance with Clause 21.2; or (iii) (iv) (v) (vi) (vii) (viii) (ix) (x) the Insurer has failed to make any Claim Payments in respect of Claims validly raised in accordance with this Insurance Contract, where its outstanding liabilities in respect of such Claims is in excess of 10,000,000; or the Insurer s average Turn-around Time over a period of 90 days is in excess of 45 days per Claim; or the Insurer's Pure Claim Ratio is found to be less than 30% in any Policy Cover Period, based on the actuarial certificate submitted by the Insurer's Appointed Actuary in accordance with Clause 8.3(a); or the Insurer has failed to pay any of the Liquidated Damages within 60 days of receipt of a written notice from the State Nodal Agency requesting payment thereof under Clause 22.4; or the Insurer's liability for Liquidated Damages for any Policy Cover Period would (but for those limits) exceed the Aggregate Liquidated Damages Liability Cap; or the Insurer amends or modifies or seeks to amend or modify the Premium or the terms and conditions of the Covers for any renewal Policy Cover Period in breach of Clause 8.8; or the Insurer is otherwise in material breach of this Insurance Contract that remains uncured despite receipt of a 60 day cure notice from the State Nodal Agency; or any representation, warranty or undertaking given by the Insurer proves to be incorrect in a material respect or is breached. (b) Upon the occurrence of an Insurer Event of Default, the State Nodal Agency may, without prejudice to any other right it may have under this Insurance Contract, in law or at equity, issue a notice of its intention to terminate this Insurance Contract to the Insurer (Preliminary Termination Notice). If the Insurer fails to remedy or rectify the Insurer Event of Default stated in the Preliminary Termination Notice within 30 days of receipt of the Preliminary Termination Notice, the State Nodal Agency will be entitled to terminate this Insurance Contract by issuing a final termination notice (Final Termination Notice). (c) However, in the event of occurrence of the Insurer Events of Default listed at paragraphs (i), (ii), (vi), (vii), (viii) or (x) of Clause 31.2(a) of this Insurance Contract, the State Nodal Agency shall not be required to issue any Preliminary Termination 131

132 Notice and may immediately terminate this Insurance Contract by serving a Final Termination Notice State Nodal Agency Event of Default (a) (b) The Insurer shall be entitled to terminate this Insurance Contract upon the occurrence of a material breach of this Insurance Contract by the State Nodal Agency that remains uncured despite receipt of a 60 day cure notice from the Insurer (a State Nodal Agency Event of Default), provided that such event is not attributable to a Force Majeure Event. Upon the occurrence of a State Nodal Agency Event of Default, the Insurer may, without prejudice to any other right it may have under this Insurance Contract, in law or at equity, issue a Preliminary Termination Notice to the State Nodal Agency. If the State Nodal Agency fails to remedy or rectify the State Nodal Agency Event of Default stated in the Preliminary Termination Notice issued by the Insurer within 60 days of receipt of the Preliminary Termination Notice, the Insurer will be entitled to terminate this Insurance Contract by issuing a Final Termination Notice Termination Date The Termination Date upon termination of this Insurance Contract for: (a) (b) (c) (d) an Insurer Event of Default pursuant to Clause 31.2(c), shall be the date of issuance of the Final Termination Notice; an Insurer Event of Default, other than a termination pursuant to Clause 31.2(c), shall be the date falling 180 Business Days from the date of the Final Termination Notice issued by the State Nodal Agency; a State Nodal Agency Event of Default, shall be the date falling 120 Business Days from the date of the Final Termination Notice issued by the Insurer; and a Force Majeure Event pursuant to Clause 32.6, shall be the date of expiration of the written notice issued under Clause Consequences of Termination Upon termination of this Insurance Contract, the Insurer shall: (a) (b) Continue to provide the benefits in respect of the Covers to the Beneficiaries until the Termination Date. Subject to Clause 31.6(f), pay to the State Nodal Agency on the Termination Date (where termination is due to an Insurer Event of Default or a Force Majeure Event), a sum that shall be calculated as follows for each district: 132

133 Where: TC = P x N x UT 365 TC is the sum to be paid by the Insurer to the State Nodal Agency on the Termination Date in respect of each district; P is the Premium per Beneficiary Family Unit that has been paid by the State Nodal Agency to the Insurer for the Policy Cover Period in which the Termination Date occurs; N is the total number of Beneficiary Family Units enrolled in that district, for whom the Premium has been paid by the State Nodal Agency to the Insurer for the Policy Cover Period in which the Termination Date occurs; and UT is the unexpired term of the Policy for that district, calculated as the number of days between the Termination Date and the date of expiration of the Policy Cover Period (had such Policy continued). Such payment shall be made by the Insurer to the State Nodal Agency exclusive of all applicable taxes and duties. The Insurer shall bear and pay all applicable taxes and duties in respect of such amount. (c) Continue to be liable for all Claims made by the Empanelled Health Care Providers on or before the Termination Date, including: (i) (ii) all amounts blocked on the Smart Cards of the Beneficiaries before the Termination Date, where the Beneficiaries were discharged after the Termination Date; and all amounts that were pre-authorized for Claim Payment before the Termination Date, where the pre-authorization has occurred prior to the Termination Date but the Beneficiaries were discharged after the Termination Date Portability The Insurer undertakes that it shall discharge its liabilities in respect of all such Claims raised within 45 days of the Termination Date. (a) At least 120 days' prior to the expiration of this Insurance Contract or the Termination Date, other than due to a termination in accordance with Clause 31.2(c), the State Nodal Agency may issue a written request to the Insurer seeking a migration of the Policies for all the districts in the Service Area (Migration Request) to another insurance company (New Insurer). 133

134 (b) Once the State Nodal Agency has issued a Migration Request in accordance with Clause 31.6(a): (i) The State Nodal Agency shall have the right to nominate the New Insurer to whom the Policies will be migrated up to 30 days' prior to the expiration date or the Termination Date. If the State Nodal Agency chooses to nominate a New Insurer for migration, then the remaining provisions of this Clause 31.6 shall apply. (ii) Alternatively, the State Nodal Agency shall have the right to withdraw the Migration Request at any time prior to the 30 day period immediately preceding the expiration date or the Termination Date. If the State Nodal Agency chooses to withdraw the Migration Request, then the remaining provisions of this Clause 31.6 shall not apply from the date of such withdrawal and this Insurance Contract shall terminate forthwith upon the withdrawal of the Migration Request. (c) (d) (e) Upon receiving the Migration Request, the Insurer shall commence preparing Claims data, empanelment data, current status of implementation of MHIS Phase 3such as: list of empanelled hospitals, details of de-empanelment, IEC/BCC activities undertaken, training provided to Empanelled Health Care Providers and any other information sought by the State Nodal Agency in the format prescribed on the IRDA website or such other format prescribed in the MHIS Guidelines. Within 7 days' of receiving notice of the New Insurer, the Insurer shall promptly make available all of the data prepared by it in accordance with Clause 31.6(c) to the New Insurer. The Insurer shall not be entitled to: (i) (ii) (iii) refuse to honour any Claims made by the Empanelled Health Care Providers on or before the date of expiration or the Termination Date until the migration process has been completed and the New Insurer assumes all of the risks under the Policies for the Service Area; or cancel the Policies for the Service Area until the migration process has been completed and the New Insurer assumes all of the risks under the Policies for the Service Area; or charge the State Nodal Agency, the New Insurer or any third person with any commission, additional charges, loading charges or otherwise for the purpose of migrating the Policies to the New Insurer. (f) The Insurer shall be entitled to retain the proportionate Premium for the period between the date on which a termination notice has been issued and the earlier to 134

135 occur of: (x) the date on which the New Insurer assumes all the risks under the Policies; and (y) the date of withdrawal of the Migration Request (the Migration Termination Date). Upon the assumption by the New Insurer of the risks under the Policies or the withdrawal of the Migration Request, as the case may be, the Insurer shall pay to the State Nodal Agency the sum calculated in accordance with Clause 31.5(b); provided that in such case the unexpired term of the Policy for a district shall be calculated as the number of days between the Migration Termination Date and the date of expiration of the Policy Cover Period for such district (had such Policy continued). Further, the Insurer shall comply with the provisions of Clause 31.5(c) in respect of all amounts blocked on the Smart Cards or pre-authorizations made prior to the Migration Termination Date Hand-Over Obligations Without prejudice to the provisions of Clause 31.6, on expiration of the Term or on the Termination Date, the Insurer shall: (a) (b) (c) (d) (e) assign all of its rights, but not any payment or other obligations or liabilities, under its Services Agreements with the Empanelled Health Care Providers and any other agreements with its intermediaries or service providers for the implementation of MHIS Phase 3 in favour of the State Nodal Agency or to the New Insurer, provided that the Insurer has received a written notice to this effect at least 30 days prior to the date of expiration of the Term or the Termination Date; hand-over, transfer and assign all rights and title to and all intellectual property rights in all data, information and reports in favour of the State Nodal Agency or to the New Insurer, whether such data, information or reports have been collected, collated, created, generated or analysed by the Insurer or its intermediaries or service providers on its behalf and whether such data, information and reports is in electronic or physical form; withdraw its personnel from the District Kiosks and hand-over possession of the District Kiosks for all the districts, including the District Servers and all other IT infrastructure installed by the Insurer to the State Nodal Agency or to the New Insurer, free of cost and without any liabilities attached; hand-over possession of all Hospital IT infrastructure (including hardware, software and devices) installed at the premises of the Empanelled Health Care Providers or allow the Empanelled Health Care Providers to retain possession of such Hospital IT Infrastructure, at the option of the State Nodal Agency; and notify all Beneficiary Family Units of the expiration of the Term or of the Termination Date at least 30 days' in advance of such expiration or the Termination Date, by 135

136 32. FORCE MAJEURE issuing a notice in at least 1 local newspaper and at least 2 national newspapers that have a wide circulation in Meghalaya; provided that the Insurer shall agree the terms of such notice with the State Nodal Agency before issuing such notice Definition of Force Majeure Event A Force Majeure Event shall mean the occurrence in the State of Meghalaya of any of the following events after the date of execution of this Insurance Contract, which was not reasonably foreseeable at the time of execution of this Insurance Contract and which is beyond the reasonable control and influence of a Party (the Affected Party) and which causes a delay and/or inability for that Party to fulfil its obligations under this Insurance Contract: (i) fire, flood, atmospheric disturbance, lightning, storm, typhoon, tornado, earthquake, washout or other Acts of God; (ii) (iii) war, riot, blockade, insurrection, acts of public enemies, civil disturbances, terrorism, sabotage or threats of such actions; and strikes, lock-out or other disturbances or labour disputes, not involving the employees of such Party or any intermediaries appointed by it, but regardless of the extent to which the conditions in the first paragraph of this Clause 32.1 are satisfied, Force Majeure Event shall not include: (a) (b) (c) (d) (e) a mechanical breakdown; or weather conditions which should reasonably have been foreseen by the Affected Party claiming a Force Majeure Event and which were not unusually adverse; or non-availability of or increase in the cost (including as a result of currency exchange rate fluctuations) of suitably qualified and experienced labour, equipment or other resources, other than the non-availability of equipment due to an event that affected an intermediary of the Insurer and that, if it had happened to the Insurer hereunder, would have come within the definition of Force Majeure Event under Clause 32.1; or economic hardship or lack of money, credit or markets; or events of physical loss, damage or delay to any items during marine, air or inland transit to the State of Meghalaya unless the loss, damage or delay was directly caused by an event that affected a intermediary of the Insurer and that, if it had happened to the Insurer hereunder, would have come within the definition of Force Majeure Event under Clause 32.1; or 136

137 (f) (g) (h) (i) (j) late performance or other breach or default by the Insurer (including the consequences of any breach or default) caused by the acts, omissions or defaults of any intermediary appointed by the Insurer unless the event that affected the intermediary and caused the act, omission or default would have come within the definition of Force Majeure Event under Clause 32.1 if it had affected the Insurer; or a breach or default of this Insurance Contract (including the consequences of any breach or default) unless it is caused by an event that comes within the definition of Force Majeure Event under Clause 32.1; or the occurrence of a risk that has been assumed by a Party to this Contract; or any strike or industrial action that is taken by the employees of the Insurer or any intermediary appointed by the Insurer or which is directed at the Insurer; or the negligence or wilful recklessness of the Insurer, the intermediaries appointed by it, their employees or other persons under the control and supervision of the Insurer Limitation on the Definition of Force Majeure Event Any event that would otherwise constitute a Force Majeure Event pursuant to Clause 32.1 shall not do so to the extent that the event in question could have been foreseen or avoided by the Affected Party using reasonable bona fide efforts, including, in the case of the Insurer, obtaining such substitute goods, works, and/or services which were necessary and reasonable in the circumstances (in terms of expense and otherwise) for performance by the Insurer of its obligations under or in connection with this Insurance Contract Claims for Relief (a) (b) (c) If due to a Force Majeure Event the Affected Party is prevented in whole or in part from carrying out its obligations under this Insurance Contract, the Affected Party shall notify the other Party accordingly (Force Majeure Notice). The Affected Party shall not be entitled to any relief for or in respect of a Force Majeure Event unless it has notified the other Party in writing of the occurrence of the Force Majeure Event as soon as reasonably practicable and in any event within 7 days after the Affected Party knew, or ought reasonably to have known, of the occurrence of the Force Majeure Event and it has complied with the requirements of Clause 32.4 of this Insurance Contract. Each Force Majeure Notice shall: (i) (ii) fully describe the Force Majeure Event; specify the obligations affected by the Force Majeure Event and the extent to which the Affected Party cannot perform those obligations; 137

138 (iii) (iv) estimate the time during which the Force Majeure Event will continue; and specify the measures proposed to be adopted to mitigate or minimise the effects of the Force Majeure Event. (d) As soon as practicable after receipt of the Force Majeure Notice, the Parties shall consult with each other in good faith and use reasonable endeavours to agree appropriate mitigation measures to be taken to mitigate the effect of the Force Majeure Event and facilitate continued performance of this Insurance Contract. If Parties are unable to arrive at a mutual agreement on the occurrence of a Force Majeure Event or the mitigation measures to be taken by the Affected Party within 15 days of receipt of the Force Majeure Notice, then the other Party shall have a right to refer such dispute to grievance redressal in accordance with Clause 30. (e) Subject to the Affected Party having complied with its obligations under Clause 32.3 and Clause 32.4, the Affected Party shall be excused from the performance of the obligations that is affected by such Force Majeure Event for the duration of such Force Majeure Event and the Affected Party shall not be in breach of this Insurance Contract for such failure to perform for such duration; provided however that no payment obligations (including Claim Payments) shall be excused by the occurrence of a Force Majeure Event Mitigation of Force Majeure Event Upon receipt of a Force Majeure Notice, each Party shall: (a) (b) mitigate or minimise the effects of the Force Majeure Event to the extent reasonably practicable; and take all actions reasonably practicable to mitigate any loss suffered by the other Party as a result of the Affected Party's failure to carry out its obligations under this Insurance Contract Resumption of Performance When the Affected Party is able to resume performance of the obligations affected by the Force Majeure Event, it shall give the other Party a written notice to that effect and shall promptly resume performance of its affected obligations under this Insurance Contract Termination upon Subsistence of Force Majeure Event If a Force Majeure Event continues for a period of 4 weeks or more within a continuous period of 365 days, either Party may terminate this Insurance Contract by giving the other Party 90 days' written notice. On termination of this Insurance Contract under this Clause 32.6, the provisions of Clause 31.4, Clause 31.5, Clause 31.6 and Clause 31.7 shall apply. 138

139 33. ASSIGNMENT 33.1 Assignment by Insurer Except as approved in advance by the State Nodal Agency in writing, this Insurance Contract, no Policy and no right, interest or Claim under this Insurance Contract or Policy or any obligations or liabilities of the Insurer arising under this Insurance Contract or Policy or any sum or sums which may become due or owing to the Insurer, may be assigned, transferred, pledged, charged or mortgaged by the Insurer Assignment by State Nodal Agency The State Nodal Agency shall not assign or transfer all or any part of its rights or obligations under this Insurance Contract or any Policy without the prior consent of the Insurer Effect of Assignment (a) (b) If this Insurance Contract or any Policy or any rights, obligations or liabilities arising under this Insurance Contract or such Policy are assigned or transferred in accordance with this Clause 33, then this Insurance Contract and such Policy shall be fully binding upon, inure to the benefit of and be enforceable by the Parties hereto and their respective successors and permitted assigns. Any assignment not expressly permitted under this Insurance Contract shall be null and void and of no further force and effect Assignment by Beneficiaries or Empanelled Health Care Providers (a) (b) The Parties agree that each Policy shall specifically state that no Beneficiary shall have the right to assign or transfer any of the benefits or the Covers made available to it under this Insurance Contract or any Policy. The Parties agree that the Empanelled Health Care Providers may assign, transfer, pledge, charge or mortgage any of their rights to receive any sums due or that will become due from the Insurer in favour of any third party. Without limiting the foregoing, the Parties acknowledge that the public Empanelled Health Care Providers in the Service Area that are under the management of Rogi Kalyan Samitis may assign all or part of their right to receive Claims Payments from the Insurer in favour of the Government of Meghalaya or any other department, organization or public body that is under the ownership and/or control of the Government of Meghalaya. On and from the date of receipt of a written notice from the public Empanelled Health Care Providers in the Service Area or from the Government of Meghalaya, the Insurer shall pay all or part of the Claims Payments to the person(s) so notified. 139

140 34. ENTIRE AGREEMENT This Insurance Contract entered into between the Parties represents the entire agreement between the Parties setting out the terms and conditions for the provision of benefits in respect of the Base Cover to the Beneficiaries that are enrolled by the Insurer. 35. RELATIONSHIP (a) (b) (c) The Parties to this Insurance Contract are independent contractors. Neither Party is an agent, representative or partner of the other Party. Neither Party shall have any right, power or authority to enter into any agreement or memorandum of understanding for or on behalf of, or incur any obligation or liability of, or to otherwise bind, the other Party. This Insurance Contract shall not be interpreted or construed to create an association, agency, joint venture, collaboration or partnership between the Parties or to impose any liability attributable to such relationship upon either Party. The engagement of any intermediaries or service providers by the Insurer shall not in any manner create a relationship between the State Nodal Agency and such third parties. 36. VARIATION OR AMENDMENT (a) (b) No variation or amendment of this Insurance Contract shall be binding on either Party unless and to the extent that such variation is recorded in a written document executed by both Parties but where any such document exists and is so signed, neither Party shall allege that such document is not binding by virtue of an absence of consideration. Notwithstanding anything to the contrary in Clause 36(a) above, the Insurer agrees that the MoHFW and the State Nodal Agency shall be free to issue MHIS Guidelines from time to time (including pursuant to the issuance of recommendations of the Working Group constituted by the MoHFW) and the Insurer shall comply with all such MHIS Guidelines issued during the Term, whether or not the provisions or terms of such MHIS Guidelines have the effect of varying or amending the terms of this Insurance Contract. 37. SEVERABILITY If any provision of this Insurance Contract is invalid, unenforceable or prohibited by law, this Insurance Contract shall be considered divisible as to such provision and such provision shall be inoperative and the remainder of this Insurance Contract shall be valid, binding and of the like effect as though such provision was not included herein. 140

141 38. NOTICES Any notice given under or in connection with this Insurance Contract shall be in writing and in the English language. Notices may be given, by being delivered to the address of the addressees as set out below (in which case the notice shall be deemed to be served at the time of delivery) by courier services or by fax (in which case the original shall be sent by courier services). To: Insurer Attn: Mr. / Ms. Phone: Fax: To: State Nodal Agency Attn: Mr. / Ms. Phone: Fax: 39. NO WAIVER Except as expressly set forth in this Insurance Contract, no failure to exercise or any delay in exercising any right, power or remedy by a Party shall operate as a waiver. A single or partial exercise of any right, power or remedy does not preclude any other or further exercise of that or any other right, power or remedy. A waiver is not valid or binding on the Party granting that waiver unless made expressly in writing. 40. GOVERNING LAW AND JURISDICTION (a) (b) This Insurance Contract and the rights and obligations of the Parties under this Insurance Contract shall be governed by and construed in accordance with the Laws of the Republic of India. The courts in Shillong shall have the exclusive jurisdiction over any disputes arising under, out of or in connection with this Insurance Contract. 141

142 IN WITNESS WHEREOF, the Parties have caused this Insurance Contract to be executed by their duly authorized representatives as of the date stated above. SIGNED, SEALED and DELIVERED SIGNED, SEALED and DELIVERED For and on behalf of The Governor of the State of Meghalaya For and on behalf of [ ] Represented by Secretary, Health & Family Welfare Department and CEO, Megha Health Insurance Scheme [ ] Represented by In the presence of: In the presence of: (1) (1) (2) (2) 142

143 SCHEDULE 1 EXCLUSIONS The Insurer shall not be liable to make any payment under any of the Covers in respect of any expenses whatsoever incurred by any Beneficiary in connection with or in respect of: A. IN-PATIENT CARE & DAY CARE TREATMENTS 1. Conditions that do not require Hospitalization (a) (b) (c) Conditions that do not require Hospitalization and can be treated under Out Patient Care, i.e., Screening or OPD medical and surgical procedures, other than: (i) the Day Care Treatments identified in Schedule 2; and (ii) the OPD consultations and Screening covered under the OPD Benefits. Expenses incurred at an Empanelled Health Care Provider primarily for Screening, i.e., evaluation or diagnostic purposes only during the Hospitalization and expenses on vitamins and tonics etc., other than such expenses that are required as a part of the expenses for: (i) Hospitalization expenses for a Medical Treatment or Surgical Procedure, as certified by the attending physician; (ii) Follow-up Care; or (iii) the OPD consultations and Screening covered under the OPD Benefits. Any dental treatment or Surgical Procedure which is corrective, cosmetic or of aesthetic nature, filling of cavity, root canal including wear and tear etc., is excluded, unless arising from the disease, illness or injury and which requires Hospitalization for treatment, other than: the OPD consultations or dental treatment provided as part of the child care benefits under Clause 3.1(h). 2. Congenital Anomalies and Convalescence (a) (b) (c) Treatment or procedures for external Congenital Anomalies, other than the Congenital Anomalies listed in Schedule 3 or Schedule 4. Convalescence or treatment for general debility, "run down" condition or rest cure. Any treatment received in a convalescent home, convalescent hospital, health hydro, nature care clinic or similar establishments or as mutually agreed between the State Nodal Agency and the Insurer. 3. Drugs and Alchohol Induced illness Diseases, illness or injury due to or arising from use, misuse or abuse of drugs or alcohol or use of intoxicating substances, or such abuse or addiction 4. Sterilization, Fertility and Sex Change procedures 143

144 (a) (b) (c) Sterilization Any fertility, sub-fertility or assisted conception procedure Hormone replacement therapies, sex change or treatments which result from or are in any way related to sex change. 5. Vaccinations and Cosmetic Treatments (a) (b) (c) Vaccination or inoculation, other than such expenses that are required as a part of the expenses for the OPD Benefits. Change of life or cosmetic or aesthetic treatments of any description, plastic surgery other than as may be necessitated due to an accident or as a part of any illness. Circumcision, unless necessary for treatment of a disease or illness not excluded hereunder or as may be necessitated by any accident. 6. War, Nuclear invasion Disease, illness or injury directly or indirectly caused by or arising from or attributable to war, invasion, act of foreign enemy, war like operations (whether war be declared or not) or by nuclear weapons/materials. 7. Suicide Intentional self-injury/suicide. B. EXCLUSIONS: MATERNITY BENEFITS 1. Termination of Pregnancy Voluntary medical termination of pregnancy is not covered, except in the case of a lawful termination or induced by accident or other medical emergency to save the life of mother. 2. Minimum Hospitalization period Normal Hospitalization period is less than 24 hours from the time of delivery or operations associated therewith for this benefit. 3. Pre-Natal Expenses Pre-natal expenses incurred prior to delivery, other than: (i) the ante-natal and post-natal benefits covered under the OPD Benefits; and (ii) any complications in the pregnancy for which a Medical Treatment or Surgical Procedure is provided in respect of the mother and/or unborn child and which requires Hospitalization prior to delivery, provided that such Medical Treatment or Surgical Procedure is listed in Schedule

145 SCHEDULE 2 LIST OF ELIGIBLE DAY CARE TREATMENTS The list of eligible Day Care Treatments included within the scope of the Base Cover and the Replenishment Cover are: (1) Haemo-Dialysis (2) Parenteral Chemotherapy (3) Radiotherapy (4) Eye Surgery (5) Lithotripsy (kidney stone removal) (6) Tonsillectomy (7) D&C (8) Dental surgery following an accident (9) Surgery of Hydrocele (10) Surgery of Prostrate (11) Gastrointestinal Surgeries (12) Genital Surgery (13) Surgery of Nose (14) Surgery of Throat (15) Surgery of Ear (16) Surgery of Urinary System (17) Treatment of fractures/dislocation (excluding hair line fracture), Contracture releases and minor reconstructive procedures of limbs which otherwise require Hospitalization (18) Laparoscopic therapeutic surgeries that can be done as a Day Care Treatment. (19) Identified surgeries under General Anaesthesia. (20) Psychiatric & Psychosomatic illness (21) Any other Day Care Treatment that is mutually agreed upon by the Parties or that is listed in Schedule 3 or Schedule 4. (22) Screening and Follow Up care including medicine cost without Diagnostic Tests 145

146 SCHEDULE 3 PACKAGE RATES FOR MEDICAL TREATMENTS AND SURGICAL PROCEDURES 1. Package Rates: Hospitalization for Unlisted Medical Treatments (a) Flat bed day rate for stay in General Ward: 1,000 Per Day (b) Flat bed day rate for stay in ICU: 2,500 Per Day 2. Package Rates: Hospitalization and Day Care Treatments for Surgical Procedures and Listed Medical Treatments Notes: # Procedure which is repeated in this Schedule (Prices to be finalized by the Insurer in consultation with State Nodal Agency before commencement of first Policy Cover Period, subject to approval from MoHFW Authorization Type LoS Please refer to Schedule 5 for description of various categories of pre-authorization and Claim procedures. The procedure described in the category mentioned in this Schedule must be applied by the Empanelled Health Care Provider in making a Claim against the Insurer. In this column, the expected length of stay is mentioned. D: this is a Day Care Treatment that does not require Hospitalization 24 hours. For packages which have LoS mentioned in Schedule 3, the LoS shall be indicative. For packages for which Package Rates are fixed or indicative and have no LoS mentioned in the Schedule 3, LoS shall be defined by the Insurer in consultation with State Nodal Agency before commencement of first Policy Cover Period, subject to approval from MoHFW Package Rate without Service Tax These Package Rates will apply to Empanelled Health Care Providers, other than those that have obtained accreditation from NABH or an equivalent national or international body. The Insurer shall determine the enhanced Package Rates that will apply to Empanelled Health Care Providers that have obtained accreditation from NABH or an equivalent national or international body in accordance with Clause 5.2(b). Package Rates Fixed/Indicative NF: The prices are indicative. Package Rates for the first Policy Cover Period are to be finalized by the Insurer in consultation with State Nodal Agency before commencement of empanelment, subject to approval from MoHFW in accordance with Clause 5.2(a). Once these Package Rates are fixed for the first Policy Cover Period, they can be revised for renewal Policy Cover Period in accordance with Clause 5.2(c). F: The prices are fixed for the first Policy Cover Period. These Package Rates can be revised for renewal Policy Cover Periods in accordance with Clause 5.2(c). Package Type SC: Secondary Care. A package marked with SC can be provided by any Empanelled Health Care Provider that has been empanelled for such package. TC: Tertiary Care. A package marked with TC can only be provided by a Specialty Hospital that is empanelled by the Insurer and that has been empanelled for such package. OD: OPD Diagnostic Care. A package marked with OD can only be provided by a Specialty Hospital or a Diagnostics Lab that is empanelled by the Insurer and that has been empanelled for such package. 146

147 S No. Code No. ICD 10 Code 1 DENTAL Category LoS Package Rate without Service Tax Authorization Type Package Rates Fixed/Indicative 1 FP K05 Fistulectomy NA F SC 2 FP S02 Fixation of fracture of jaw NA F SC 3 FP K10 Sequestrectomy NA F SC 4 FP D16 Tumour excision NA F SC 5 FP Apisectomy including LA D 900 NA F SC 6 FP Complicated Ext. per Tooth including D 500 NA F SC 7 FP Cyst under LA (Large) D 1900 NA F SC 8 FP Cyst under LA (Small) D 1350 NA F SC 9 FP Extraction of tooth including LA D 500 NA F SC 10 FP Flap operation per Tooth D 600 NA F SC 11 FP Fracture wiring including LA D 7200 NA F SC 12 FP Gingivectomy per Tooth D 500 NA F SC 13 FP Impacted Molar including LA D 900 NA F SC 14 FP Intra oral X-ray D 500 NA F SC 15 FP Root Canal Treatment - Anterior (per sitting with a maximum of 5 sitting chargeable) D 500 NA F SC Package Type 147

148 16 FP Root Canal Treatment - Posterior (per sitting with a maximum of 5 sitting chargeable) 17 FP Metal Capping subsequent to Posterior Root Canal D 700 NA F SC D 1300 NA F SC 18 FP Metal Capping subsequent to acrylic facing for anterior (Root Canal) 19 FP Metal Capping subsequent to ceramic facing for anterior (Root Canal) D 1500 NA F SC D 1900 NA F SC 20 FP Dental Apical Apses D 600 NA F SC 21 FP Splinting of Tooth D 600 NA F SC 2 EAR 22 FP H74 Aural polypectomy NA F SC 23 FP H81 Decompression sac NA F SC 24 FP H80 Fenestration NA F SC 25 FP H81 Labyrinthectomy NA F SC 26 FP H 65 Mastoidectomy NA F SC 27 FP H70 Mastoidectomy corticol module radical 28 FP H 65 Mastoidectomy With Myringoplasty NA F SC NA F SC 148

149 29 FP H 65 Mastoidectomy with tympanoplasty NA F SC 30 FP H72 Myringoplasty NA F SC 31 FP H72 Myringoplasty with NA F SC Ossiculoplasty 32 FP H72 Myringotomy - Bilateral NA F SC 33 FP H72 Myringotomy - Unilateral NA F SC 34 FP H72 Myringotomy with Grommet - One ear 35 FP H72 Myrinogotomy with Grommet Both ear NA F SC NA F SC 36 FP H74 Ossiculoplasty NA F SC 37 FP C44 Partial amputation Pinna NA F SC 38 FP Q17 Preauricular sinus NA F SC 39 FP H80 Stapedectomy NA F SC 40 FP H72 Tympanoplasty NA F SC 41 FP J30 Vidian neurectomy - Micro NA F SC 42 FP Ear lobe repair single D 900 NA F SC 43 FP Excision of Pinna for Growth (Squamous/Basal/ Injuries) Skin and Cartilage D 3800 NA F SC 44 FP Excision of Pinna for Growth (Squamous/Basal/ Injuries) Skin Only D 2600 NA F SC 45 FP Facial nerve decompression NA F SC 149

150 46 FP Pharyngectomy and reconstruction NA F SC 47 FP Skull base surgery NA F TC 48 FP Total Amputation & Excision of External Auditory Meatus NA F SC 49 FP Total amputation of Pinna NA F SC 50 FP Tympanotomy NA F SC 51 FP Foreign body removal from ear (external canal) D 800 NA F SC 52 FP Syringing of ear (unilateral) D 500 NA F SC 53 FP Syringing of ear (bi lateral) D 800 NA F SC 54 FP Packing & dressing of ear D 500 NA F SC 3 NOSE 55 FP R04 Ant. Ethmoidal artery ligation NA F TC 56 FP J32 Antrostomy - Bilateral NA F SC 57 FP J32 Antrostomy - Unilateral NA F SC 58 FP J32 Caldwell - luc - Bilateral NA F SC 59 FP J32 Caldwell - luc- Unilateral NA F SC 60 FP C30 Cryosurgery NA F SC 61 FP J00 Rhinorrhoea - Repair NA F SC 62 FP H04 Dacryocystorhinostomy (DCR) NA F SC 63 FP J32 Septoplasty + FESS NA F SC 64 FP J32 Ethmoidectomy - External NA F SC 65 FP S02 Fracture reduction nose with septal correction NA F SC 66 FP S02 Fracture - setting maxilla NA F SC 150

151 67 FP S02 Fracture - setting nasal bone NA F SC 68 FP J01 Functional Endoscopic Sinus NA F SC (FESS) 69 FP J01 Intra Nasal Ethmoidectomy NA F SC 70 FP D14 Rhinotomy - Lateral NA F SC 71 FP J33 Nasal polypectomy - Bilateral NA F SC 72 FP J33 Nasal polypectomy - Unilateral NA F SC 73 FP J34 Turbinectomy Partial - Bilateral NA F SC 74 FP J34 Turbinectomy Partial - Unilateral NA F SC 75 FP C31 Radical fronto ethmo sphenodectomy NA F SC 76 FP J34 Rhinoplasty NA F SC 77 FP J34 Septoplasty NA F SC 78 FP J33 Sinus Antroscopy NA F SC 79 FP J34 Submucos resection NA F SC 80 FP J01 Trans Antral Ethmoidectomy NA F SC 81 FP J31 Youngs operation NA F SC 82 FP Angiofibrom Exision NA F SC 83 FP Cranio-facial resection NA F SC 84 FP Endoscopic DCR NA F SC 85 FP Endoscopic Hypophysectomy NA F SC 86 FP Endoscopic surgery NA F SC 87 FP Intranasal Diathermy NA F SC 88 FP Lateral Rhinotomy NA F SC 89 FP Rhinosporosis NA F SC 151

152 90 FP Septo-rhinoplasty NA F SC 91 FP Diagnostic nasal endoscopy NA F SC 92 FP Nasal packing with catheter/sponge NA F SC 93 FP Nasal packing NA F SC 4 THROAT 94 FP J35 Adeno Tonsillectomy NA F SC 95 FP J35 Adenoidectomy NA F SC 96 FP C32 Arytenoidectomy NA F SC 97 FP Q30 Choanal atresia NA F SC 98 FP J03 Tonsillectomy + Myrinogotomy NA F SC 99 FP Q38 Pharyngeal diverticulum's - Excision NA F SC 100 FP C32 Laryngectomy NA F SC 101 FP C41 Maxilla - Excision NA F SC 102 FP K03 Oro Antral fistula NA F SC 103 FP J39 Parapharyngeal - Exploration NA F SC 104 FP J39 Parapharyngeal Abscess - Drainage NA F SC 105 FP D10 Parapharyngeal -Tumour excision NA F SC 106 FP Q38 Pharyngoplasty NA F SC 107 FP Q38 Release of Tongue tie NA F SC 108 FP J39 Retro pharyngeal abscess - Drainage D 5000 NA F SC 109 FP D11 Styloidectomy - Both side NA F SC 110 FP D11 Styloidectomy - One side NA F SC 152

153 111 FP J03 Tonsillectomy + Styloidectomy NA F SC 112 FP Q89 Thyroglossal Cyst - Excision NA F SC 113 FP Q89 Thyroglossal Fistula - Excision NA F SC 114 FP J03 Tonsillectomy - Bilateral NA F SC 115 FP J03 Tonsillectomy - Unilateral NA F SC 116 FP C07 Total Parotidectomy NA F SC 117 FP C05 Uvulophanyngo Plasty NA F SC 118 FP Abbe Operation NA F SC 119 FP Cleft palate repair NA F SC 120 FP Commondo Operation NA F SC 121 FP Estlander Operation NA F SC 122 FP Excision of Branchial Cyst NA F SC 123 FP Excision of Branchial Sinus NA F SC 124 FP Excision of Cystic Hygroma Extensive NA F SC 125 FP Excision of Cystic Hygroma Major NA F SC 126 FP Excision of Cystic Hygroma Minor NA F SC 127 FP Excision of the Mandible Segmental NA F SC 128 FP Excision of the Maxilla NA F SC 129 FP Hemiglossectomy NA F TC 130 FP Hemimandibulectomy NA F TC 131 FP Palatopharyngoplasty NA F SC 132 FP Parotidectomy - Conservative NA F TC 133 FP Parotidectomy - Radical Total NA F TC 153

154 134 FP Parotidectomy - Superficial NA F TC 135 FP Partial Glossectomy NA F TC 136 FP Ranula excision NA F SC 137 FP Removal of Submandibular Salivary gland NA F SC 138 FP Repair of Parotid Duct NA F SC 139 FP Total Glossectomy NA F TC 140 FP Q38 Release of Tongue tie D 4800 NA F SC 141 FP Comprehensive neck dissection NA F TC 142 FP Flexible bronchoscopy NA F SC 143 FP Mastoidectomy cortical/modified NA F SC 144 FP Mostoidectomy NA F SC cortical/modified 145 FP Radical neck dissection NA F TC 146 FP Rigid bronchoscopy NA F SC 147 FP Rigid direct laryngoscopy NA F SC 148 FP Selective neck dissection NA F SC 149 FP Tracheal resection and anastomosis 5 GENERAL SURGERY NA F SC 150 FP C20 Abdomino Perineal Resection NA F TC 151 FP M70 Adventious Burse - Excision NA F SC 152 FP K35 Appendicectomy NA F SC 153 FP K35 Appendicular Abscess - Drainage NA F SC 154 FP D18 Arteriovenous (AV) Malformation of Soft Tissue Tumour Excision NA F SC 154

155 155 FP Axillary Lymphnode - Excision NA F SC 156 FP M71 Bakers Cyst - Excision NA F SC 157 FP D36 Bilateral Inguinal block dissection NA F TC 158 FP K25 Bleeding Ulcer - Gastrectomy & vagotomy 159 FP K25 Bleeding Ulcer - Partial gastrectomy NA F SC NA F SC 160 FP C77 Block dissection Cervical Nodes NA F TC 161 FP Q18 Branchial Fistula NA F SC 162 FP C50 Breast Excision NA F SC 163 FP D25 Breast Lump - Left - Excision NA F SC 164 FP D25 Breast Lump - Right - Excision NA F SC 165 FP D25 Breast Mass - Excision NA F SC 166 FP J98 Bronchial Cyst NA F SC 167 FP M06 Bursa - Excision NA F SC 168 FP Bypass - Inoprablaca of Pancreas NA F SC 169 FP K56 Caecopexy NA F SC 170 FP L02 Carbuncle back NA F SC 171 FP B44 Cavernostomy NA F SC 172 FP C96 Cervial Lymphnodes - Excision NA F SC 173 FP K83 Cholecysostomy NA F SC 174 FP K80 Cholecystectomy & exploration NA F SC 175 FP C67 Colocystoplasty NA F SC 176 FP K57 Colostomy NA F SC 155

156 177 FP C14 Commando Operation NA F TC 178 FP L84 Corn - Large Excision D 2500 NA F SC 179 FP N49 Cyst over Scrotum - Excision NA F SC 180 FP Q61 Cystic Mass - Excision NA F SC 181 FP L72 Dermoid Cyst - Large - Excision D 6000 NA F SC 182 FP L72 Dermoid Cyst - Small - Excision D 2500 NA F SC 183 FP K86 Distal Pancrcatectomy with Pancreatico Jejunostomy NA F SC 184 FP K57 Diverticulectomy NA F SC 185 FP N47 Dorsal Slit and Reduction of Paraphimosis D 2500 NA F SC 186 FP K61 Drainage of Ischio Rectal Abscess NA F SC 187 FP Drainage of large Abscess D 4800 NA F SC 188 FP K92 Drainage of Peripherally Gastric NA F SC 189 FP L02 Drainage of Psoas Abscess NA F SC 190 FP K92 Drainage of Subdiaphramatic Abscess NA F SC 191 FP I31 Drainage Pericardial Effusion NA F SC 192 FP K57 Duodenal Diverticulum NA F SC 193 FP K31 Duodenal Jejunostomy NA F SC 194 FP D13 Duodenectomy NA F SC 195 FP Dupcrytren's (duputryen's contracture ) NA F SC 196 FP Q43 Duplication of Intestine NA F SC 156

157 197 FP N43 Hydrocelectomy + Orchidectomy NA F SC 198 FP N45 Epidedectomy NA F SC 199 FP N45 Epididymal Swelling -Excision NA F SC 200 FP N50 Epidymal Cyst D 3800 NA F SC 201 FP N50 Evacuation of Scrotal Hematoma NA F SC 202 FP D13 Excision Benign Tumor -Small Intestine NA F SC 203 FP A15 Excision Bronchial Sinus D 9500 NA F SC 204 FP K75 Excision of liver Abscess NA F SC 205 FP N43 Excision Filarial Scrotum NA F SC 206 FP N61 Excision Mammary Fistula NA F SC 207 FP Q43 Excision Meckel's Diverticulum NA F SC 208 FP L05 Excision Pilonidal Sinus NA F SC 209 FP K31 Excision Small Intestinal Fistulla NA F SC 210 FP K11 Excision Submandibular Gland NA F SC 211 FP C01 Excision of Large Growth from Tongue 212 FP C01 Excision of Small Growth from Tongue 213 FP L02 Excision of Swelling in Right Cervial Region NA F SC D 3600 NA F SC NA F SC 214 FP L02 Excision of Large Swelling in Hand 215 FP L02 Excision of Small Swelling in Hand D 4200 NA F SC D 3000 NA F SC 157

158 216 FP D33 Excision of Neurofibroma NA F SC 217 FP L05 Excision of Siniuds and Curetage NA F SC 218 FP G51 Facial Decompression NA F SC 219 FP Fibro Lipoma of Right Sided Spermatic with Lord Excision NA F SC 220 FP D24 Fibroadenoma - Bilateral NA F SC 221 FP D24 Fibrodenoma - Unilateral NA F SC 222 FP Fibroma - Excision NA F SC 223 FP K60 Fissurectomy NA F SC 224 FP I84 Fissurectomy and Haemorrhoidectomy 225 FP K60 Fissurectomy with Eversion of Sac Bilateral NA F SC NA F SC 226 FP K60 Fissurectomy with NA F SC Sphincterotomy 227 FP K60 Fistula Repair NA F SC 228 FP K05 Fistulectomy NA F SC 229 FP Foreign Body Removal in Deep Region NA F SC 230 FP Fulguration NA F SC 231 FP K21 Fundoplication NA F SC 232 FP K25 G J Vagotomy NA F SC 233 FP K25 Vagotomy NA F SC 234 FP M67 Ganglion - large - Excision NA F SC 235 FP M67 Ganglion (Dorsum of Both Wrist) -Excision NA F SC 158

159 236 FP M67 Ganglion - Small - Excision D 3000 NA F SC 237 FP K28 Gastro jejunal ulcer NA F SC 238 FP K63 Gastro jejuno Colic Fistula NA F SC 239 FP C17 Gastrojejunostomy NA F SC 240 FP K25 Gastrotomy NA F SC 241 FP Graham's Operation NA F SC 242 FP A58 Granuloma - Excision NA F SC 243 FP Growth - Excision D 4800 NA F SC 244 FP D18 Haemangioma - Excision NA F SC 245 FP D13 Haemorrage of Small Intestine NA F SC 246 FP C01 Hemi Glossectomy NA F SC 247 FP D16 Hemi Mandibulectomy NA F SC 248 FP C18 Hemicolectomy NA F SC 249 FP J38 Hemithyroplasty NA F SC 250 FP C34 Hepatic Resection (lobectomy) NA F SC 251 FP K43 Hernia - Epigastric NA F SC 252 FP K43 Hernia - Incisional NA F SC 253 FP K40 Hernia - Repair & release of obstruction NA F SC 254 FP K42 Hernia - Umbilical NA F SC 255 FP K43 Hernia - Ventral Lipectomy/Incisional NA F SC 256 FP K41 Hernia - Femoral NA F SC 257 FP K40 Hernioplasty NA F SC 258 FP Herniorraphy and Hydrocelectomy Sac Excision NA F SC 159

160 259 FP K44 Hernia - Hiatus NA F SC 260 FP B67 Hydatid Cyst of Liver NA F SC 261 FP Nodular Cyst D 3800 NA F SC 262 FP N43 Hydrocelectomy - Excision NA F SC 263 FP Hydrocelectomy+Hernioplasty - Excision NA F SC 264 FP N43 Hydrocele - Excision - Unilateral NA F SC 265 FP N43 Hydrocele - Excision - Bilateral NA F SC 266 FP C18 Ilieo Sigmoidostomy NA F SC 267 FP M20 Infected Bunion Foot - Excision NA F SC 268 FP Inguinal Node (bulk dissection) axial NA F TC 269 FP K57 Instestinal perforation NA F SC 270 FP K56 Intestinal Obstruction NA F SC 271 FP K56 Intussusception NA F SC 272 FP C16 Jejunostomy NA F SC 273 FP K56 Closure of Perforation NA F SC 274 FP C67 Cysto Reductive Surgery NA F SC 275 FP K63 Gastric Perforation NA F SC 276 FP K56 Intestinal Perforation (Resection Anastomosis) NA F SC 277 FP K35 Appendicular Perforation NA F SC 278 FP Burst Abdomen Obstruction NA F SC 279 FP K56 Closure of Hollow Viscus Perforation NA F SC 160

161 280 FP Laryngectomy & Pharyngeal Diverticulum NA F SC 281 FP Q42 Anorectoplasty NA F SC 282 FP C32 Laryngectomy with Block NA F TC Dissection 283 FP C32 Laryngo Fissure NA F SC 284 FP C13 Laryngopharyngectomy NA F SC 285 FP K51 Ileostomy NA F SC 286 FP D17 Lipoma D 6000 NA F SC 287 FP K56 Loop Colostomy Sigmoid NA F SC 288 FP I84 Lords Procedure (haemorrhoids) NA F SC 289 FP D24 Lumpectomy - Excision NA F SC 290 FP C50 Mastectomy NA F SC 291 FP K66 Mesenteric Cyst - Excision NA F SC 292 FP K76 Mesenteric Caval Anastomosis NA F SC 293 FP D14 Microlaryngoscopic Surgery NA F SC 294 FP T18 Oeshophagoscopy for foreign body removal D 7200 NA F SC 295 FP D13 Oesophagectomy NA F SC 296 FP I85 Oesophagus Portal Hypertension NA F SC 297 FP N73 Pelvic Abscess - Open Drainage NA F SC 298 FP C61 Orchidectomy NA F SC 299 FP C61 Orchidectomy + Herniorraphy NA F SC 300 FP Q53 Orchidopexy NA F SC 301 FP Q53 Orchidopexy with Circumsion NA F SC 161

162 302 FP Q53 Orchidopexy With Eversion of NA F SC Sac 303 FP Orchidopexy with Herniotomy NA F SC 304 FP N45 Orchititis NA F SC 305 FP K86 Pancreatrico Deodeneotomy NA F SC 306 FP D12 Papilloma Rectum - Excision NA F SC 307 FP I84 Haemorroidectomy+ Fistulectomy 308 FP Phytomatous Growth in the Scalp Excision NA F SC NA F SC 309 FP K76 Porto Caval Anastomosis NA F TC 310 FP K25 Pyeloroplasty NA F SC 311 FP C50 Radical Mastectomy NA F SC 312 FP C49 Radical Neck Dissection - Excision NA F TC 313 FP K43 Hernia - Spigelian NA F SC 314 FP K62 Rectal Dilation NA F SC 315 FP K62 Prolapse of Rectal Mass NA F SC Excision 316 FP K62 Rectal polyp NA F SC 317 FP K62 Rectopexy NA F SC 318 FP K83 Repair of Common Bile Duct NA F SC 319 FP C18 Resection Anastomosis (Large Intestine) 320 FP C17 Resection Anastomosis (Small Intestine) NA F SC NA F SC 321 FP D20 Retroperitoneal Tumor - Excision NA F TC 162

163 322 FP I84 Haemorroidectomy NA F SC 323 FP K11 Salivary Gland - Excision NA F SC 324 FP L72 Sebaceous Cyst - Excision D 3000 NA F SC 325 FP N63 Segmental Resection of Breast NA F SC 326 FP Scrotal Swelling (Multiple) - Excision NA F SC 327 FP K57 Sigmoid Diverticulum NA F SC 328 FP K25 Simple closure - Peptic NA F SC perforation 329 FP L05 Sinus - Excision NA F SC 330 FP D17 Soft Tissue Tumor - Excision NA F SC 331 FP C80 Spindle Cell Tumor - Excision NA F SC 332 FP Submandibular Lymphs - Excision NA F SC 333 FP K11 Submandibular Mass Excision NA F SC Reconstruction 334 FP K11 Submandibular Salivary Gland Removal NA F SC 335 FP D11 Superficial Parodectomy NA F SC 336 FP R22 Swelling in Rt and Lt Foot - Excision NA F SC 337 FP R22 Swelling Over Scapular Region NA F SC 338 FP K57 Terminal Colostomy NA F SC 339 FP J38 Thyroplasty NA F SC 340 FP C18 Coloectomy - Total NA F SC 341 FP C67 Cystectomy Total NA F SC 163

164 342 FP C01 Glossectomy - Total NA F SC 343 FP C33 Pharyngectomy & Reconstruction FP Q32 Tracheal Stenosis (End to end Anastamosis) NA F SC NA F SC 345 FP Q32 Tracheoplasty NA F SC 346 FP K56 Tranverse Colostomy NA F SC 347 FP Q43 Umbilical Sinus - Excision NA F SC 348 FP K25 Vagotomy & Drainage NA F SC 349 FP K25 Vagotomy & Pyloroplasty NA F SC 350 FP I84 Varicose Veins - Excision and NA F SC Ligation 351 FP Vasco Vasostomy NA F SC 352 FP K56 Volvlous of Large Bowel NA F SC 353 FP K76 Warren's Shunt NA F SC 354 FP Abbe Operation NA F SC 355 FP Aspiration of Empymema NA F SC 356 FP Benign Tumour Excisions NA F SC 357 FP Carotid artery aneurism NA F TC 358 FP Carotid Body Excision NA F TC 359 FP Cholecystectomy & Exploration of CBD NA F SC 360 FP Cholecystostomy NA F SC 361 FP Congential Arteriovenus Fistula D NA F SC 362 FP Decortication (Pleurectomy) D NA F TC 164

165 363 FP Diagnostic Laproscopy D NA F SC 364 FP Dressing under GA D 1350 NA F SC 365 FP Estlander Operation NA F SC 366 FP Examination under Anesthesia NA F SC 367 FP Excision and Skin Graft of Venous D NA F SC Ulcer 368 FP Excision of Corns D 800 NA F SC 369 FP Excision of Lingual Thyroid NA F SC 370 FP Excision of Moles D 3000 NA F SC 371 FP Excision of Molluscumcontagiosum 372 FP Excision of Parathyroid Adenoma/Carcinoma D 1900 NA F SC NA F TC 373 FP Excision of Sebaceous Cysts D 1700 NA F SC 374 FP Excision of Superficial Liipoma D 2000 NA F SC 375 FP Excision of Superficial Neurofibroma 376 FP Excision of Thyroglossal Cyst/Fistula D 600 NA F SC NA F SC 377 FP Exploratory Thorocotomy NA F TC 378 FP Exploratory Thorocotomy NA F TC 379 FP Femoropopliteal by pass procedure NA F TC 380 FP Free Grafts - Large Area 10% NA F TC 165

166 381 FP Free Grafts - Theirech- Small Area 5% NA F SC 382 FP Free Grafts - Very Large Area D 8900 NA F TC 20% 383 FP Free Grafts - Wolfe Grafts NA F TC 384 FP Haemorrhoid - injection D 1900 NA F SC 385 FP Hemithyroidectomy D NA F SC 386 FP Isthmectomy NA F SC 387 FP Laaproscopic Hernia Repair NA F SC 388 FP Lap. Assisted left Hemicolectomy NA F SC 389 FP Lap. Assisted Right Hemicolectomy 390 FP Lap. Assisted small bowel resection NA F SC NA F SC 391 FP Lap. Assisted Total Colectomy NA F SC 392 FP Lap. Cholecystectomy & CBD exploration NA F SC 393 FP Lap. For intestinal obstruction NA F SC 394 FP Lap. Hepatic resection NA F SC 395 FP Lap. Hydatid of liver surgery NA F SC 396 FP Laproscopic Adhesiolysis NA F SC 397 FP Laproscopic Adrenalectomy NA F SC 398 FP Laproscopic Appenjdicectomy NA F SC 166

167 399 FP Laproscopic Cholecystectomy NA F SC 400 FP Laproscopic Coliatomus NA F SC 401 FP Laproscopic cystogastrostomy NA F SC 402 FP Laproscopic donor Nephroctomy NA F SC 403 FP Laproscopic Gastrostomy NA F SC 404 FP Laproscopic Gastrostomy NA F SC 405 FP Laproscopic Hiatus Hernia Repair NA F SC 406 FP Laproscopic Pyelolithotomy NA F SC 407 FP Laproscopic Pyloromyotomy NA F SC 408 FP Laproscopic Rectopexy NA F SC 409 FP Laproscopic Spleenectomy NA F SC 410 FP Laproscopic Thyroidectomy NA F SC 411 FP Laproscopic umbilical hernia repair NA F SC 412 FP Laproscopic ureterolithotomy NA F SC 413 FP Laproscopic ventral hernia repair NA F SC 414 FP Laprotomy-peritonitis lavage and drainage NA F SC 415 FP Ligation of Ankle Perforators NA F SC 416 FP Lymphatics Excision of Subcutaneous Tissues In Lymphoedema NA F SC 167

168 417 FP Repair of Main Arteries of the Limb NA F TC 418 FP Operation for Bleeding Peptic Ulcer NA F SC 419 FP Operation for Carcinoma Lip Vermilionectomy NA F SC 420 FP Operation for Carcinoma Lip Wedge Excision and Vermilonectomy 421 FP Operation for Carcinoma Lip Wedge- Excision NA F SC NA F SC 422 FP Operation for Gastrojejunal Ulcer NA F SC 423 FP Operation of Choledochal Cyst NA F SC 424 FP Operations for Acquired Arteriovenous Fistula NA F SC 425 FP Operations for Replacement of Oesophagus by Colon NA F SC 426 FP Operations for Stenosis of Renal Arteries NA F TC 427 FP Partial Thyroidectomy NA F SC 168

169 428 FP Partial/Subtotal Gastrectomy for Carcinoma 429 FP Partial/Subtotal Gastrectomy for Ulcer NA F TC NA F TC 430 FP Peritoneal dialysis NA F TC 431 FP Phimosis Under LA D 6000 NA F SC 432 FP Pneumonectomy NA F TC 433 FP Portocaval Anastomosis NA F TC 434 FP Removal of Foreign Body from Trachea or Oesophagus 435 FP Procedures Requiring Bypass Techniques NA F SC NA F SC 436 FP Resection Enucleation of NA F SC Adenoma 437 FP Rib Resection & Drainage NA F TC 438 FP Skin Flaps - Rotation Flaps NA F SC 439 FP Soft Tissue Sarcoma NA F SC 440 FP Splenectomy - For Hypersplenism NA F SC 441 FP Splenectomy - For Trauma NA F SC 442 FP Splenorenal Anastomosis NA F TC 443 FP Superficial Veriscosity NA F SC 444 FP Surgery for Arterial Aneursysm Carotid NA F TC 169

170 445 FP Surgery for Arterial Aneursysm Renal Artery 446 FP Surgery for Arterial Aneursysm Spleen Artery 447 FP Surgery for Arterial Aneursysm Vertebral 448 FP Suturing of wounds with local anesthesia NA F TC NA F TC NA F TC D 700 NA F SC 449 FP Suturing without local anesthesia D 500 NA F SC 450 FP Sympathetectomy - Cervical NA F SC 451 FP Sympathetectomy - Lumbar NA F SC 452 FP Temporal Bone resection NA F TC 453 FP Temporary Pacemaker NA F TC Implantation (EXCLUDING DEVICE) 454 FP Thorachostomy NA F SC 455 FP Thoracocentesis NA F SC 456 FP Thoracoplasty NA F TC 457 FP Thoracoscopic Decortication NA F TC 170

171 458 FP Thoracoscopic Hydatid Cyst excision NA F TC 459 FP Thoracoscopic Lebectomy NA F TC 460 FP Thoracoscopic Pneumonectomy NA F TC 461 FP Thoracoscopic Segmental Resection NA F TC 462 FP Thoracoscopic Sympathectomy NA F TC 463 FP Thrombendarterectomy NA F TC 464 FP Thymectomy NA F TC 465 FP Thorax ( penetrating wounds) NA F TC 466 FP Total Laryngectomy NA F TC 467 FP Total Thyroidectomy and Block Dissection NA F TC 468 FP Trendelenburg Operation NA F SC 171

172 469 FP Urtheral Dilatation D 1200 NA F SC 470 FP Vagotomy Pyleroplasty / Gastro Jejunostomy NA F SC 471 FP Varicose veins - injection D 900 NA F SC 472 FP Vasectomy D 2000 NA F SC 473 FP Excision biopsy (small tumourr) D 3800 NA F SC 474 FP Breast Lumpectomy (Small) D 9400 NA F SC 475 FP Breast Abscess Drainage D 4800 NA F SC 476 FP Peritoneal dialysis D 2000 NA F SC 477 FP Renal Dialysis D 2600 NA F TC 478 FP Accidental injury with lacerated wound NA F SC 479 FP Acute cholecystitis NA F SC 480 FP Breast abscess NA F SC 481 FP Chronic cholecystitis NA F SC 482 FP Chronic Cholecystitis with Cholelithiasis NA F SC 483 FP Cut injury with big sutiring NA F SC 484 FP Cut injury with medium suturing NA F SC 485 FP Cut injury(suturing) NA F SC 486 FP First Aid for RTA NA F SC 487 FP Helmenthiasis in GB NA F SC 488 FP Helmenthiasis with cholecystitis NA F SC 489 FP Lap needle assisted repair hernia NA F SC 490 FP Renal calculi with UTI NA F TC 491 FP Rigid oesophagoscopy NA F SC 172

173 492 FP Scrotal abscess NA F SC 493 FP Tracheo oesophageal fistula NA F SC repair 494 FP Tracheostomy NA F SC 495 FP Cut injury ( Suturing ) D 4800 NA F SC 496 FP Drainage of peritonsillar abscess NA F SC 497 FP RTA with hospital admission NA F SC 498 FP RTA with head injury NA F SC 6 GYNAECOLOGY 499 FP Abdominal open for stress incision NA F SC 500 FP N75 Bartholin abscess I & D D 3600 NA F SC 501 FP N75 Bartholin cyst removal D 3600 NA F SC 502 FP N84 Cervical Polypectomy NA F SC 503 FP N84 Cyst - Labial D 4800 NA F SC 504 FP D28 Cyst -Vaginal Enucleation D 6000 NA F SC 505 FP N83 Ovarian Cystectomy NA F SC 506 FP N81 Cystocele - Anterior repair NA F SC 173

174 507 FP N96 D&C ( Dilatation & curretage) D 4800 NA F SC 508 FP Electro Cauterisation Cryo Surgery D 5400 NA F SC 509 FP Fractional Curretage D 5400 NA F SC 510 FP Gilliams Operation NA F SC 511 FP Haemato Colpo/Excision Vaginal Septum 512 FP N89 Hymenectomy & Repair of Hymen D 7100 NA F SC D NA F SC 513 FP C53 Hysterectomy - abdominal NA F SC 514 FP C53 Hysterectomy - Vaginal NA F SC 515 FP C53 Hysterectomy - Wertheims operation NA F SC 516 FP D25 Hysterotomy -Tumors removal NA F SC 517 FP D25 Myomectomy - Abdominal NA F SC 518 FP D27 Ovarectomy/Oophrectomy NA F SC 519 FP O70 Perineal Tear Repair D 7100 NA F SC 174

175 520 FP N81 Prolapse Uterus -L forts NA F SC 521 FP N81 Prolapse Uterus - Manchester NA F SC 522 FP N82 Retro Vaginal Fistula -Repair NA F SC 523 FP C56 Salpingoophrectomy NA F SC 524 FP N97 Tuboplasty NA F SC 525 FP O70 Vaginal Tear -Repair D 8250 NA F SC 526 FP D28 Vulvectomy NA F SC 527 FP D28 Vulvectomy - Radical NA F SC 528 FP D28 Vulval Tumors - Removal NA F SC 529 FP Normal Delivery NA F SC 530 FP Casearean delivery NA F SC 531 FP Caesarean Hysterectomy NA F SC 532 FP Conventional Tubectomy NA F SC 175

176 533 FP D&C ( Dilatation & curetage ) > 12 wks 534 FP D&C ( dilatation & Curretage) upto 12 wks 535 FP D&C ( Dilatation & curretage)upto 8 wks NA F SC D 7100 NA F SC D 5400 NA F SC 536 FP Destructive operation NA F SC 537 FP Hysterectomy- Laproscopy NA F SC 538 FP Insertion of IUD Device D 2500 NA F SC 539 FP Laproscopy Salpingoplasty/ ligation 540 FP Laprotomy -failed laproscopy to explore D 9400 NA F SC NA F SC 541 FP Laprotomy for ectopic repture NA F SC 542 FP Low Forceps NA F SC 543 FP Low midcavity forceps NA F SC 544 FP Lower Segment Caesarean NA F SC Section 545 FP Manual removel of Plecenta NA F SC 176

177 546 FP Nomal delivery with episiosty and P repair 547 FP Perforamtion of Uterus after D/E laprotomy and closure 548 FP Repair of post coital tear, perineal injury 549 FP Rupture Uterus, closer and repoar with tubal ligation NA F SC NA F SC NA F SC NA F SC 550 FP Salphingo-oophorectomy NA F SC 551 FP Shirodhkar Mc. Donalds stich NA F SC 552 FP st ANC check up (USG, Blood test, medicines) 1 Visit 18 yrs and above 553 FP nd ANC check up(usg Screening, medicines) 1 Visit 18 yrs and above D 3600 NA F D 3000 NA F 554 FP rd ANC check up(usg, Screening blood test, medicines) 1 Visit 18 yrs and above D 3600 NA F 555 FP Anaemia with pregnancy NA F SC 556 FP Home delivery with sepsis NA F SC 557 FP Lap assisted vagical hysterectomy 558 FP Lap ovariotomy/ovarian cystectomy NA F SC NA F SC 177

178 559 FP Lap salpingectomy B/L NA F SC 560 FP Lap salpingectpmy for ectopic pregnancy NA F SC 561 FP Laproscopic hystrectomy NA F SC 562 FP U T I with pregnancy NA F SC 563 FP Pregnancy with urinary unfection NA F SC 564 FP Threatened preterm labour NA F SC 7 ENDOSCOPIC 565 FP N80 Ablation of Endometriotic Spot D NA F SC 566 FP Adhenolysis D NA F SC 567 FP K35 Appendictomy NA F SC 568 FP K80 Cholecystectmy NA F SC 569 FP K80 Cholecystectomy and Drainage of Liver abscess 570 FP K80 Cholecystectomy with Excision of TO Mass NA F SC NA F SC 571 FP Cyst Aspiration D NA F SC 572 FP Endometria to Endometria Anastomosis NA F SC 573 FP N97 Fimbriolysis NA F SC 574 FP C18 Hemicolectomy NA F SC 178

179 575 FP C53 Hysterectomy with bilateral Salpingo Operectomy NA F SC 576 FP K43 Incisional Hernia - Repair NA F SC 577 FP K40 Inguinal Hernia - Bilateral NA F SC 578 FP K40 Inguinal hernia - Unilateral NA F SC 579 FP K56 Intestinal resection NA F SC 580 FP D25 Myomectomy NA F SC 581 FP D27 Oophrectomy NA F SC 582 FP N83 Ovarian Cystectomy D NA F SC 583 FP Peritonitis NA F SC 584 FP C56 Salpingo Ophrectomy NA F SC 179

180 585 FP N97 Salpingostomy NA F SC 586 FP Q51 Uterine septum D 2500 NA F SC 587 FP I86 Varicocele Bilateral NA F SC 588 FP I86 Varicocele - Unilateral NA F SC 589 FP N28 Repair of Ureterocele NA F TC 590 FP Esophageal Sclerotheraphy for varies first sitting 591 FP Esophageal Sclerotheraphy for varies subseqent sitting D 1900 NA F SC D 1600 NA F SC 592 FP Upper GI endoscopy D 1900 NA F SC 593 FP Upper GI endoscopy with biopsy D 2500 NA F SC 594 FP Upper GI Scopy D 1900 NA F SC 180

181 595 FP Upper GI scopy with biopsy D 2500 NA F SC 596 FP Upper GI scopy with sclerotherapy NA F SC 597 FP Upper GI scopy with banding NA F SC 598 FP Upper GI scopy with injection NA F SC 599 FP Upper GI scopy with ng tube placement 600 FP Upper GI scopy with oesophageal dilatation(savary) NA F SC NA F SC 601 FP Upper GI scopy with foreign body removal NA F SC 602 FP ERCP D NA F SC 603 FP ERCP+ Sphincterotomy NA F TC 604 FP ERCP+ Balloon sweep NA F TC 181

182 605 FP ERCP+ Basket Stone/Worm extraction NA F TC 606 FP Sigmoidoscopy with biopsy NA F SC 607 FP Sigmoidoscopy with formalin injection NA F SC 608 FP Colonoscopy NA F SC 609 FP Colonoscopy with biopsy NA F SC 610 FP Colonoscopy with injection NA F SC 611 FP Colonoscopy with snaring NA F SC 612 FP Bronchoscopy (flexible) NA F SC 613 FP Bronchoscopy (flexible) with biopsy 614 FP Bronchoscopy (flexible) with broncho-alveolar lavage (bal) NA F SC NA F SC 615 FP Cystoscopy NA F TC 182

183 616 FP Cystoscopy & biopsy NA F TC 617 FP Cystoscopy & RGP NA F TC 8 HYSTEROSCOPIC 618 FP N80 Ablation of Endometrium D NA F SC 619 FP N97 Hysteroscopic Tubal Cannulation D NA F SC 620 FP N84 Polypectomy D NA F SC 621 FP N85 Uterine Synechia - Cutting D NA F SC 9 NEURO-SURGERY 622 FP Cranioplasty NA F TC 623 FP S02 Cerebrospinal Fluid (CSF) Rhinorrohea NA F TC 624 FP Local Neurectomy NA F TC 625 FP S12 Skull Traction NA F TC 626 FP C71 Tumours - Supratentorial NA F TC 627 FP K25 Vagotomy - Selective NA F SC 628 FP C17 Vagotomy with NA F SC Gastrojejunostomy 629 FP K25 Vagotomy with Pyeloroplasty NA F SC 630 FP K25 Vagotomy - Highly Selective NA F SC 631 FP G00 Ventricular Puncture NA F TC 632 FP Nerve Biopsy excluding Hensens NA F TC 633 FP R.F. Lesion for Trigeminal Neuralgia NA F TC 183

184 634 FP Subdural Tapping NA F TC 10 OPHTHALMOLOGY 635 FP H00 Abscess Drainage of Lid D 1900 NA F SC 636 FP H40 Anterior Chamber NA F SC Reconstruction 637 FP H33 Buckle Removal NA F SC 638 FP H04 Canaliculo Dacryocysto Rhinostomy NA F SC 639 FP H25 Capsulotomy NA F SC 640 FP H25 Cataract - Bilateral D NA F SC 641 FP H25 Cataract - Unilateral D 6000 NA F SC 642 FP H25 Cataract + Pterygium D 9400 NA F SC 643 FP H18 Corneal Grafting D NA F SC 644 FP H33 Cryoretinopexy - Closed NA F SC 645 FP H33 Cryoretinopexy - Open NA F SC 646 FP H40 Cyclocryotherapy D 4800 NA F SC 647 FP H04 Cyst D 2500 NA F SC 648 FP H04 Dacrocystectomy With Pterygium Excision D 9400 NA F SC 649 FP H11 Pterigium + Conjunctival D 5400 NA F SC Autograft 650 FP H04 Dacryocystectomy D 9400 NA F SC 651 FP H46 Endoscopic Optic Nerve Decompression 652 FP E05 Endoscopic Optic Orbital Decompression D NA F SC D NA F SC 184

185 653 FP C69 Enucleation NA F SC 654 FP C69 Enuleation with Implant NA F SC 655 FP C69 Exentration D 6000 NA F SC 656 FP H02 Ectropion Correction D 8250 NA F SC 657 FP H40 Glaucoma surgery (trabeculectomy) NA F SC 658 FP H44 Intraocular Foreign Body D NA F SC Removal 659 FP H18 Keratoplasty NA F SC 660 FP H52 Lensectomy D NA F SC 661 FP H04 Limbal Dermoid Removal D 6000 NA F SC 662 FP H33 Membranectomy D 9400 NA F SC 663 FP S05 Perforating corneo - Scleral NA F SC Injury 664 FP H11 Pterygium (Day care) D 3600 NA F SC 665 FP H02 Ptosis D 7100 NA F SC 666 FP H52 Radial Keratotomy NA F SC 667 FP H21 IRIS Prolapse - Repair NA F SC 668 FP H33 Retinal Detachment Surgery NA F SC 669 FP D31 Small Tumour of Lid - Excision D 1900 NA F SC 670 FP D31 Socket Reconstruction NA F SC 671 FP H40 Trabeculectomy - Right D NA F SC 672 FP H40 Iridectomy D 4800 NA F SC 673 FP D31 Tumours of IRIS NA F SC 674 FP H33 Vitrectomy NA F SC 675 FP H33 Vitrectomy + Retinal Detachment NA F SC 185

186 676 FP Acid and alkali burns D 3000 NA F SC 677 FP Cataract with IOL by Phoco emulsification tech. Unilateral D NA F SC 678 FP Cataract with IOL with Phoco emulsification Bilateral 679 FP Cauterisation of ulcer/subconjuctival injection - both eye D NA F SC D 800 NA F SC 680 FP Cauterisation of ulcer/subconjuctival D 600 NA F SC 681 FP Chalazion - both eye D 2500 NA F SC 682 FP Chalazion - one eye D 1350 NA F SC 683 FP Conjuntival Melanoma D 1500 NA F SC 684 FP H04 Dacryocystectomy D 9400 NA F SC 685 FP Dacryocystectomy (DCY) D 8250 NA F SC 686 FP DCR ( Dacryocystorhinostomy) D 9400 NA F SC 687 FP Decompression of Optic nerve NA F SC 688 FP EKG/EOG D 1700 NA F SC 689 FP Entropion correction D 6000 NA F SC 690 FP Epicantuhus correction D 3600 NA F SC 691 FP Epiliation D 800 NA F SC 692 FP ERG D 1350 NA F SC 693 FP Eviseration D 4200 NA F SC 694 FP Laser for retinopathy D 3000 NA F SC 695 FP Laser inter ferometry D 2500 NA F SC 186

187 696 FP Lid tear D 3000 NA F SC 697 FP Orbitotomy D NA F SC 698 FP Squint correction NA F SC 699 FP Trabeculectomy D NA F SC 700 FP Investigation Test-FFA D 2500 NA F SC 701 FP Investigation Test-OCT per eye D 1150 NA F SC 702 FP Investigation Test-OCT both eyes D 1900 NA F SC 703 FP Investigation Test-FUNDUS PHOTOGRAPH D 800 NA F SC 704 FP Investigation Test-A- SCAN D 500 NA F SC 705 FP Investigation Test-B-SCAN D 500 NA F SC 706 FP Investigation Test-KERATOMETRY D 500 NA F SC 707 FP Investigation Test-(A-SCAN, B- D 1000 NA F SC SCAN + KERATOMETRY) PACKAGE 708 FP Investigation Test-RBS D 300 NA F SC 709 FP Investigation Test-HFA D 600 NA F SC 710 FP Investigation Test-Specular Microscope D 300 NA F SC 711 FP Investigation Test-APPLANATION D 260 NA F SC 712 FP Investigation Test-IDO per eye D 300 NA F SC 713 FP Investigation Test-IDO both eyes D 500 NA F SC 714 FP Investigation Test-Corneal Staining per eye 715 FP Investigation Test-Corneal Staining both eyes D 230 NA F SC D 260 NA F SC 187

188 716 FP Investigation Test-Schirmer Test & BUT D 270 NA F SC 717 FP Investigation Test-FDT D 300 NA F SC 718 FP Investigation Test-Squint Evaluation 719 FP Investigation Test-Amblyopia Therapy 720 FP Investigation Test-Diplopia Testing D 300 NA F SC D 260 NA F SC D 260 NA F SC 721 FP Investigation Test-Hess Screening D 300 NA F SC 722 FP Investigation Test-diurnal variation D 1350 NA F SC 723 FP Investigation Test-Gonioscopy D 300 NA F SC 724 FP Investigation Test-Registration D 220 NA F SC 725 FP Investigation Testcomprehensive D 500 NA F SC examination/consultation 726 FP Investigation Test-Refraction D 300 NA F SC 727 FP Investigation Test-Dressing D 300 NA F SC 728 FP Investigation Test-Syringing D 300 NA F SC 729 FP Investigation Test-NS wash D 260 NA F SC 730 FP Investigation Test-BCCT D 260 NA F SC 11 ORTHOPAEDIC 731 FP S42 Acromion reconstruction NA F SC 732 FP Q79 Accessory bone - Excision NA F SC 733 FP S48 Ampuation - Upper Fore Arm NA F SC 188

189 734 FP S68 Amputation - Index Fingure NA F SC 735 FP S58 Amputation - Forearm NA F SC 736 FP Amputation - Wrist Axillary Node Dissection NA F TC 737 FP Amputation - 2nd and 3rd Toe NA F SC 738 FP Amputation - 2nd Toe NA F SC 739 FP Amputation - 3rd and 4th Toes NA F SC 740 FP Amputation - 4th and 5th Toes NA F SC 741 FP Amputation - Ankle NA F SC 742 FP Amputation - Arm NA F SC 743 FP M20 Amputation - Digits NA F SC 744 FP Amputation - Fifth Toe NA F SC 745 FP S98 Amputation - Foot NA F SC 746 FP Amputation - Forefoot NA F SC 747 FP Amputation - Great Toe NA F SC 748 FP S68 Amputation - Wrist NA F SC 749 FP S88 Amputation - Leg NA F SC 750 FP Amputation - Part of Toe and Fixation of K Wire NA F SC 751 FP S78 Amputation - Thigh NA F SC 752 FP M41 Anterior & Posterior Spine NA F TC Fixation 753 FP Arthoplasty - Excision NA F SC 754 FP Arthorotomy NA F SC 755 FP Q66 Arthrodesis Ankle Triple NA F SC 756 FP Arthrotomy + Synevectomy NA F SC 189

190 757 FP Q65 Arthroplasty of Femur head - Excision NA F SC 758 FP S82 Bimalleolar Fracture Fixation NA F SC 759 FP Bone Tumour and Reconstruction - Major Excision NA F TC 760 FP Bone Tumour and Reconstruction - Minor Excision NA F TC 761 FP M77 Calcaneal Spur - Excision of Both NA F SC 762 FP S42 Clavicle Surgery NA F SC 763 FP S62 Close Fixation - Hand Bones NA F SC 764 FP S92 Close Fixation - Foot Bones NA F SC 765 FP Close Reduction - Small Joints NA F SC 766 FP Closed Interlock Nailing + Bone Grafting NA F SC 767 FP Closed Interlocking Intermedullary 768 FP S82 Closed Interlocking Tibia + Orif of Fracture Fixation 769 FP Closed Reduction and Internal Fixation 770 FP Closed Reduction and Internal Fixation with K wire NA F SC NA F SC NA F SC NA F SC 190

191 771 FP Closed Reduction and Percutaneous Screw Fixation NA F SC 772 FP Closed Reduction and Percuteneous Pinning 773 FP Closed Reduction and Percutaneous Nailing 774 FP Closed Reduction and Proceed to Posterior Stabilization NA F SC NA F SC NA F SC 775 FP Debridement & Closure - Major NA F SC 776 FP Debridement & Closure - Minor NA F SC 777 FP M48 Decompression and Spinal Fixation 778 FP M48 Decompression and Stabilization with Steffiplate 779 FP M43 Decompression L5 S1 Fusion with Posterior Stabilization 780 FP G56 Decompression of Carpal Tunnel Syndrome NA F TC NA F TC NA F TC NA F SC 191

192 781 FP M51 Decompression Posteier D12+L NA F TC 782 FP M51 Decompression Stabilization and Laminectomy NA F TC 783 FP S53 Dislocation - Elbow D 4800 NA F SC 784 FP S43 Dislocation - Shoulder D 3000 NA F SC 785 FP S73 Dislocation- Hip NA F SC 786 FP S83 Dislocation - Knee NA F SC 787 FP Drainage of Abscess Cold D 6000 NA F SC 788 FP M72 Dupuytren Contracture NA F SC 789 FP M89 Epiphyseal Stimulation NA F SC 790 FP M89 Exostosis - Small bones -Excision NA F SC 791 FP M89 Exostosis - Femur - Excision NA F SC 792 FP M89 Exostosis - Humerus - Excision NA F SC 793 FP M89 Exostosis - Radius - Excision NA F SC 794 FP M89 Exostosis - Ulna - Excision NA F SC 795 FP M89 Exostosis - Tibia- Excision NA F SC 796 FP M89 Exostosis - Fibula - Excision NA F SC 797 FP M89 Exostosis - Patella - Excision NA F SC 798 FP Exploration and Ulnar Repair NA F SC 799 FP S72 External fixation - Long bone NA F SC 800 FP External fixation - Small bone NA F SC 801 FP S32 External fixation - Pelvis NA F SC 802 FP M62 Fasciotomy NA F SC 803 FP Fixater with Joint Arthrolysis NA F SC 192

193 804 FP S32 Fracture - Acetabulam NA F SC 805 FP S72 Fracture - Femoral neck - MUA & Internal Fixation 806 FP S72 Fracture - Femoral Neck Open Reduction & Nailing NA F SC NA F SC 807 FP S82 Fracture - Fibula Internal Fixation NA F SC 808 FP S72 Fracture - Hip Internal Fixation NA F SC 809 FP S42 Fracture - Humerus Internal Fixation NA F SC 810 FP S52 Fracture - Olecranon of Ulna NA F SC 811 FP S52 Fracture - Radius Internal NA F SC Fixation 812 FP S82 Fracture - TIBIA Internal Fixation NA F SC 813 FP S82 Fracture - Fibula Internal Fixation NA F SC 814 FP S52 Fracture - Ulna Internal Fixation NA F SC 815 FP Fractured Fragment Excision NA F SC 816 FP M16 Girdle Stone Arthroplasty NA F SC 817 FP M41 Harrington Instrumentation NA F SC 818 FP S52 Head Radius - Excision NA F SC 819 FP M17 High Tibial Osteotomy NA F SC 820 FP Hip Region Surgery NA F SC 821 FP S72 Hip Spica D 6000 NA F SC 822 FP S42 Internal Fixation Lateral Epicondyle 823 FP Internal Fixation of other Small Bone NA F SC NA F SC 193

194 824 FP Joint Reconstruction NA F SC 825 FP M89 Leg Lengthening NA F SC 826 FP S72 Llizarov Fixation NA F SC 827 FP M66 Multiple Tendon Repair NA F SC 828 FP Nerve Repair Surgery NA F SC 829 FP Nerve Transplant/Release NA F SC 830 FP Neurolysis NA F TC 831 FP Open Reduction Internal Fixation (2 Small Bone) 832 FP Open Reduction Internal Fixation (Large Bone) NA F SC NA F SC 833 FP Q65 Open Reduction of CDH NA F SC 834 FP Open Reduction of Small Joint NA F SC 835 FP Open Reduction with Phemister Grafting NA F SC 836 FP Osteotomy -Small Bone NA F SC 837 FP Osteotomy -Long Bone NA F SC 838 FP M17 Patellectomy NA F SC 839 FP S32 Pelvic Fracture - Fixation NA F SC 840 FP M16 Pelvic Osteotomy NA F SC 841 FP Percutaneous - Fixation of Fracture 842 FP M70 Prepatellar Bursa and Repair of MCL of Knee NA F SC NA F SC 843 FP S83 Reconstruction of ACL/PCL NA F SC 844 FP M76 Retrocalcaneal Bursa - Excision NA F SC 194

195 845 FP M86 Sequestrectomy of Long Bones NA F SC 846 FP M75 Shoulder Jacket D 8250 NA F SC 847 FP Sinus Over Sacrum Excision NA F SC 848 FP Skin Grafting NA F SC 849 FP M43 Spinal Fusion NA F TC 850 FP M05 Synovectomy NA F SC 851 FP M71 Synovial Cyst - Excision NA F SC 852 FP Q66 Tendo Achilles Tenotomy NA F SC 853 FP Tendon Grafting NA F SC 854 FP S86 Tendon Nerve Surgery of Foot NA F SC 855 FP G56 Tendon Release NA F SC 856 FP M67 Tenolysis NA F SC 857 FP M67 Tenotomy NA F SC 858 FP S82 Tension Band Wiring Patella NA F SC 859 FP M65 Trigger Thumb D 3200 NA F SC 860 FP Wound Debridiment D NA F SC 861 FP Application of Functional Cast Brace 862 FP Application of P.O.P. casts for Upper & Lower Limbs 863 FP Application of P.O.P. Spicas & Jackets D 1700 NA F SC D 1900 NA F SC D 4200 NA F SC 864 FP Application of Skeletal Tractions D 2000 NA F SC 865 FP Application of Skin Traction D 1200 NA F SC 866 FP Arthroplasty (joints) - Excision NA F SC 195

196 867 FP Aspiration & Intra Articular Injections 868 FP Bandage & Stapping for Fractures 869 FP Close Reduction of Fractures of Limb 870 FP Internal Wire Fixation of Mandible & Maxilla 871 FP Reduction of Compound Fractures 872 FP Reduction of Facial Fractures of Maxilla 873 FP Reduction of Fractures of Mandible & Maxilla - Cast Netal Splints 874 FP Reduction of Fractures of Mandible & Maxilla - Eye Let Splinting 875 FP Reduction of Fractures of Mandible & Maxilla - Gumming Splints 876 FP Accidents injury with compound fracture D 900 NA F SC D 800 NA F SC D 4200 NA F SC D NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC 877 FP Child immunization D 1000 NA F SC 12 PAEDIATRIC 878 FP Q42 Anal Dilatation NA F SC 196

197 879 FP Q43 Anal Transposition for Ectopic Anus NA F SC 880 FP Q54 Chordee Correction NA F SC 881 FP Q43 Closure Colostomy NA F SC 882 FP Q43 Colectomy NA F SC 883 FP Q39 Colon Transplant NA F SC 884 FP N21 Cystolithotomy NA F TC 885 FP Q39 Esophageal Atresia (Fistula) NA F SC 886 FP R62 Gastrostomy NA F SC 887 FP Q79 Hernia - Diaphragmatic NA F SC 888 FP K43 Hernia - Epigastric NA F SC 889 FP K42 Hernia - Umbilical NA F SC 890 FP K40 Hernia-Inguinal - Bilateral NA F SC 891 FP K40 Hernia-Inguinal -Unilateral NA F SC 892 FP Q43 Meckel's Diverticulectomy NA F SC 893 FP N20 Nephrolithotomy NA F TC 894 FP Q53 Orchidopexy - Bilateral NA F SC 895 FP Q53 Orchidopexy - Unilateral) NA F SC 896 FP N20 Pyelolithotomy NA F TC 897 FP Q62 Pyeloplasty NA F SC 898 FP Q40 Pyloric Stenosis (Ramsted OP) NA F SC 899 FP K62 Rectal Polyp NA F SC 900 FP Resection & Anastamosis of Intestine NA F SC 901 FP N21 Supra Pubic Drainage - Open NA F SC 197

198 902 FP N44 Torsion Testis NA F SC 903 FP Q39 Tracheo Esophageal Fistula NA F SC 13 ENDOCRINE 904 FP D35 Adenoma Parathyroid Excision NA F SC 905 FP D35 Adrenal Gland Tumour - Excision NA F SC 906 FP Axillary lymphnode - Excision NA F SC 907 FP D11 Parotid Tumour - Excision NA F SC 908 FP C25 Pancreatectomy NA F SC 909 FP K80 Sphineterotomy NA F SC (sphincterotomy) 910 FP D34 Thyroid Adenoma Resection NA F SC 911 FP E05 Thyroidectomy Hemi NA F SC Enucleation 912 FP E05 Thyroidectomy - Partial NA F SC 913 FP C73 Thyroidectomy - Total NA F SC 914 FP C73 Total thyroidectomy & block NA F SC 915 FP C73 Totol Thyroidectomy + Reconstruction 916 FP Trendal Burge Ligation and Stripping NA F SC NA F SC 917 FP Post Fossa D NA F SC 14 UROLOGY 918 FP N21 Bladder Calculi- Removal NA F TC 919 FP C67 Bladder Tumour (Fulgration) NA F TC 920 FP Q64 Correction of Extrophy of Bladder NA F TC 198

199 921 FP N21 Cystilithotomy NA F TC 922 FP K86 Cysto Gastrostomy NA F TC 923 FP K86 Cysto Jejunostomy NA F TC 924 FP N20 Dormia Extraction of Calculus NA F TC 925 FP N15 Drainage of Perinepheric Abscess NA F TC 926 FP N21 Cystolithopexy NA F TC 927 FP N36 Excision of Urethral Carbuncle NA F TC 928 FP Exploration of Epididymus (Unsuccesful Vasco vasectomy) NA F TC 929 FP Q64 Urachal Cyst NA F TC 930 FP Q54 Hydrospadius NA F TC 931 FP N35 Internal Urethrotomy NA F TC 932 FP N20 Litholapexy NA F TC 933 FP N20 Lithotripsy NA F TC 934 FP N36 Meatoplasty NA F SC 935 FP N36 Meatotomy NA F SC 936 FP Neoblastoma NA F SC 937 FP Q61 Nephrectomy NA F TC 938 FP C64 Nephrectomy (Renal tumour) NA F TC 939 FP C64 Nephro Uretrectomy NA F TC 940 FP N20 Nephrolithotomy NA F TC 941 FP N28 Nephropexy NA F TC 942 FP N13 Nephrostomy NA F TC 943 FP C64 Nephrourethrotomy ( is it Nephrourethrectomy) NA F TC 199

200 944 FP C67 Open Resection of Bladder Neck NA F TC 945 FP N28 Operation for Cyst of Kidney NA F TC 946 FP N28 Operation for Double Ureter NA F TC 947 FP Q62 Fturp NA F TC 948 FP S37 Operation for Injury of Bladder NA F TC 949 FP C67 Partial Cystectomy NA F TC 950 FP C64 Partial Nephrectomy NA F TC 951 FP N20 PCNL (Percutaneous nephro lithotomy) Biilateral 952 FP N20 PCNL (Percutaneous nephro lithotomy) Unilateral NA F TC NA F TC 953 FP Q64 Post Urethral Valve NA F TC 954 FP N20 Pyelolithotomy NA F TC 955 FP N13 Pyeloplasty & Similar Procedures NA F TC 956 FP C64 Radical Nephrectomy NA F TC 957 FP N47 Reduction of Paraphimosis D 5400 NA F SC 958 FP N82 Repair of Uretero Vaginal Fistula NA F SC 959 FP N28 Repair of Ureterocele NA F TC 960 FP C61 Retropubic Prostatectomy NA F TC 961 FP K76 Spleno Renal Anastomosis NA F TC 962 FP N35 Stricture Urethra NA F TC 963 FP N40 Suprapubic Cystostomy - Open NA F TC 964 FP N40 Suprapubic Drainage - Closed NA F SC 965 FP N44 Torsion testis NA F SC 966 FP N40 Trans Vesical Prostatectomy NA F TC 200

201 967 FP N40 Transurethral Fulguration NA F TC 968 FP D30 TURBT (Transurethral Resection of the Bladder Tumor) NA F TC 969 FP N40 TURP + Circumcision NA F TC 970 FP N41 TURP + Closure of Urinary Fistula NA F TC 971 FP N40 TURP + Cystolithopexy NA F TC 972 FP N40 TURP + Cystolithotomy NA F TC 973 FP K60 TURP + Fistulectomy NA F TC 974 FP N40 TURP + Cystoscopic Removal of Stone NA F TC 975 FP C64 TURP + Nephrectomy NA F TC 976 FP C61 TURP + Orchidectomy NA F TC 977 FP N40 TURP + Suprapubic NA F TC Cystolithotomy 978 FP C61 TURP + TURBT NA F TC 979 FP N40 TURP + URS NA F TC 980 FP N40 TURP + Vesicolithotripsy NA F TC 981 FP N40 TURP + VIU (visual internal urethrotomy) NA F TC 982 FP I84 TURP + Haemorrhoidectomy NA F TC 983 FP N40 TURP + Hydrocele NA F TC 984 FP N40 TURP + Hernioplasty NA F TC 985 FP N40 TURP with Repair of Urethra NA F TC 986 FP TURP + Herniorraphy NA F TC 987 FP N40 TURP (Trans-Urethral Resection of Bladder)Prostate NA F TC 201

202 988 FP K60 TURP + Fissurectomy NA F TC 989 FP N40 TURP + Urethrolithotomy NA F TC 990 FP N40 TURP + Urethral dilatation NA F TC 991 FP N82 Uretero Colic Anastomosis NA F TC 992 FP N20 Ureterolithotomy NA F TC 993 FP N20 Ureteroscopic Calculi - Bilateral NA F TC 994 FP N20 Ureteroscopic Calculi - Unilateral NA F TC 995 FP N35 Ureteroscopy Urethroplasty NA F TC 996 FP N20 Ureteroscopy PCNL NA F TC 997 FP N20 Ureteroscopic stone Removal And DJ Stenting NA F TC 998 FP N35 Urethral Dilatation NA F TC 999 FP Urethral Injury NA F TC 1000 FP N81 Urethral Reconstuction NA F TC 1001 FP C53 Ureteric Catheterization - Cystoscopy NA F TC 1002 FP C67 Uretrostomy (Cutanie) NA F TC 1003 FP N20 URS + Stone Removal NA F TC 1004 FP N20 URS Extraction of Stone Ureter Bilateral 1005 FP N20 URS Extraction of Stone Ureter - Unilateral NA F TC NA F TC 1006 FP N20 URS with DJ Stenting With ESWL NA F TC 1007 FP URS with Endolitholopexy NA F TC 1008 FP N20 URS with Lithotripsy NA F TC 202

203 1009 FP N20 URS with Lithotripsy with DJ Stenting NA F TC 1010 FP N21 URS+Cysto+Lithotomy NA F TC 1011 FP N82 V V F Repair NA F TC 1012 FP N13 Vesico uretero Reflux - Bilateral NA F TC 1013 FP N13 Vesico Uretero Reflux NA F TC Unilateral 1014 FP N21 Vesicolithotomy NA F TC 1015 FP N35 VIU (Visual Internal Urethrotomy NA F TC ) 1016 FP N21 VIU + Cystolithopexy NA F TC 1017 FP N43 VIU + Hydrocelectomy NA F TC 1018 FP N35 VIU and Meatoplasty NA F TC 1019 FP N35 VIU for Stricture Urethra NA F TC 1020 FP N35 VIU with Cystoscopy NA F TC 1021 FP L02 Drainage of Psoas Abscess NA F SC 1022 FP Operation for ectopic ureter NA F TC 1023 FP Repair of ureterocele - open NA F TC 1024 FP TURP + Cystolithotripsy NA F TC 1025 FP TURP with removal of the verical calculi NA F TC 1026 FP TURP with vesicolithotomy NA F TC 1027 FP Ureteroscopic removal of lower ureteric 1028 FP Ureteroscopic removal of ureteric calculi NA F TC NA F TC 203

204 1029 FP Varicocele NA F SC 1030 FP VIU + TURP NA F TC 1031 FP Dialatation of Urethra LA D 3000 NA F SC 1032 FP Dialatation of Urethra GA D 4200 NA F SC 1033 FP Prostatic biopsy NA F SC 1034 FP Ultra sound guided Biopsy NA F SC 15 ONCOLOGY 1035 FP Adenoma Excision NA F SC 1036 FP C74 Adrenalectomy - Bilateral NA F TC 1037 FP C74 Adrenalectomy - Unilateral NA F TC 1038 FP C00-C97 Chemotherapy - Per sitting D 3000 NA F TC 1039 FP C56 Malignant ovarian NA F TC 1040 FP Operation for Neoblastoma NA F TC 1041 FP C16 Partial Subtotal Gastrectomy & Ulcer NA F SC 1042 FP Radiotherapy - Per sitting D 3000 NA F TC 1043 FP Chemotherapy - per siting plus cost of injections 1044 FP In area of Tumor - Excisional Biopsy (Cheek, mouth, skin) 1045 FP In area of Tumor - Excisional Biopsy (Cheek, mouth, skin) 1046 FP Skin Graft/Flap Repair (Cheek, Mouth, Skin) 1047 FP Wide Excision of Large Tumour (Cheek, Mouth, Skin) D 6100 NA F TC D 5000 NA F TC NA F SC NA F SC NA F TC 204

205 1048 FP Partial glossectomy (Tongue) NA F TC 1049 FP Hemi glossectomy (Tongue) NA F TC 1050 FP Reconstruction wide excision glossectomy (Tongue) 1051 FP Wide Local Excision of Small Tongue Ulcer (Tongue) 1052 FP Modified Radical Neck dissection (Throat) NA F TC NA F SC NA F TC 1053 FP Laryngectomy (Throat) NA F TC 1054 FP Laryngopharyngectomy (Throat) NA F TC 1055 FP Full thickness buccal mucosa reconstruction (Mouth/Cheek) 1056 FP Gastrectomy (Partial / Subtotal) _ Abdomen NA F TC NA F TC 1057 FP Breast - Mastectomy simple NA F SC 1058 FP Breast - Mastectomy radical NA F TC 1059 FP Bony Operation with Implant (Jaw) 1060 FP Radiofrequency Ablation of Tumour (Lung, Liver, Kidney, Bone, Breast) 1061 FP Radiofrequency Ablation of Tumour (Lung, Liver, Kidney, Bone, Breast) 1062 FP PTBD (Percutaneous Transhepatic Biliary Drainage) NA F SC D NA F TC NA F TC NA F SC 205

206 1063 FP Radiotherapy - Radical Treatment - Cobalt FP Radiotherapy - Palliative - Cobalt FP Radiotherapy - Adjuvant - Cobalt FP Linear acclerator - Radical Treatment NA F TC D NA F TC D NA F TC D NA F TC 1067 FP Linear acclerator - Palliative D NA F TC 1068 FP Linear acclerator- Adjuvant D NA F TC 1069 FP Brachytherapy per application- Intracavitary LDR 1070 FP Brachytherapy per application- Intracavitary HDR 1071 FP Brachytherapy per application- Interstitial LDR 1072 FP Interstitial HDR I application & multiple dose fractions 16 OTHER COMMONLY USED PROCEDURE D 6100 NA F TC D 3200 NA F TC D NA F TC D NA F TC 1073 FP Upto 30% burns first dressing D 800 NA F SC 1074 FP Upto 30% burns subsequent dressing 1075 FP Snake bite / scorpion / insect / animal /unknown bites. 17 NEO-NATAL CARE D 500 NA F SC NA F SC 1076 FP Basic Package for Neo Natal Care NA F SC 206

207 18 LISTED MEDICAL TREATMENTS 1077 FP A15 Respiratory tuberculosis,bacteriologically and histologically confirmed NA F SC 1078 FP B15 Acute hepatitis A NA F SC 1079 FP B16 Acute hepatitis B NA F TC 1080 FP B17 Other acute viral hepatitis NA F SC 1081 FP B18 Chronic viral hepatitis NA F SC 1082 FP B19 Unspecified viral hepatitis NA F SC 1083 FP A09 Diarrhoea and gastroenteritis of presumed infectious origin 1084 FP A08 Viral and other specified intestinal infections 1085 FP A04 Other bacterial intestinal infections Other bacterial foodborne 1086 FP A05 intoxications, not elsewhere classified NA F SC NA F SC NA F SC NA F SC 1087 FP A90 Dengue fever (classical dengue) NA F SC 1088 FP A91 Dengue haemorrhagic fever NA F SC 1089 FP B50 Plasmodium falciparum malaria NA F SC 1090 FP B51 Plasmodium vivax malaria NA F SC 1091 FP B52 Plasmodium malariae malaria NA F SC 1092 FP B53 Other parasitologically confirmed malaria NA F SC 1093 FP B54 Unspecified malaria NA F SC 207

208 1094 FP A01 Typhoid and paratyphoid fevers NA F SC 1095 FP I10 Essential (primary) hypertension NA F SC 1096 FP J45 Asthma NA F SC 1097 FP J12 Viral pneumonia, not elsewhere classified 1098 FP J13 Pneumonia due to Streptococcus pneumoniae 1099 FP J14 Pneumonia due to Haemophilus influenzae 1100 FP J15 Bacterial pneumonia, not elsewhere classified 1101 FP J16 Pneumonia due to other infectious organisms, not elsewhere classified 1102 FP J17 Pneumonia in diseases classified elsewhere 1103 FP J18 Pneumonia, organism unspecified 1104 FP O13 Gestational [pregnancy-induced] hypertension without significant proteinuria 1105 FP O14 Gestational [pregnancy-induced] hypertension with significant proteinuria NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC 1106 FP O14 Pneumothorax NA F SC 1107 FP I60 Subarachnoid haemorrhage NA F TC 1108 FP I61 Intracerebral haemorrhage NA F TC 208

209 1109 FP I62 Other nontraumatic intracranial haemorrhage NA F TC 1110 FP I63 Cerebral infarction NA F TC 1111 FP I64 Stroke, not specified as haemorrhage or infarction 1112 FP J40 Bronchitis, not specified as acute or chronic NA F TC NA F SC 1113 FP J41 Bronchitis NA F SC 1114 FP J42 Unspecified chronic bronchitis NA F SC 1115 FP J43 Emphysema NA F SC 1116 FP J44 Other chronic obstructive pulmonary disease NA F SC 1117 FP N10 Acute tubulo-interstitial nephritis NA F SC 1118 FP N17 Acute renal failure NA F TC 1119 FP P58 Neonatal jaundice NA F SC 1120 FP P59 Neonatal jaundice from other and unspecified causes NA F SC 1121 FP I33 Acute and subacute endocarditis NA F TC 1122 FP A87 Viral meningitis NA F SC 1123 FP A06 Amoebiasis NA F SC 1124 FP E10 Insulin-dependent diabetes mellitus 1125 FP E11 Non-insulin-dependent diabetes mellitus 1126 FP E12 Malnutrition-related diabetes mellitus NA F SC NA F SC NA F SC 209

210 1127 FP E13 Other specified diabetes mellitus NA F SC 1128 FP E14 Unspecified diabetes mellitus NA F SC 1129 FP Acid peptic diseases per day n 1000 NA F SC 1130 FP Acute gastritis NA F SC 1131 FP AGE with LRTI NA F SC 1132 FP AGE with scrub typhus NA F SC 1133 FP AGE with URTI NA F SC 1134 FP AGE with UTI NA F SC 1135 FP Anaemia with Fever NA F SC 1136 FP Appendicitis for conservative treat 1137 FP Appendicitis for Conservative treatment NA F SC NA F SC 1138 FP Cerebral malaria NA F SC 1139 FP Chronic gastritis NA F SC 1140 FP Enteric fever NA F SC 1141 FP Enteric fever per day n 1000 NA F SC 1142 FP Gastritis with AGE NA F SC 1143 FP Helminthiasis NA F SC 1144 FP LRTI NA F SC 1145 FP LRTI with multiple infection NA F SC 1146 FP Migration of worm with NA F SC ascariasiis 1147 FP Migration of worm with NA F SC ascariasis 1148 FP Opportunistic infections NA F SC 210

211 1149 FP Scrub typhus Complicated NA F SC 1150 FP Scrub typhus per day n 1000 NA F SC 1151 FP Scrub typhus with LRTI NA F SC 1152 FP Tuberculosis NA F SC 1153 FP Typhoid fever NA F SC 1154 FP Typhoid fever with complications NA F SC 1155 FP U T I NA F SC 1156 FP U.R.I NA F SC 1157 FP U.R.I with multiple infection NA F SC 1158 FP V.F. with Scrub Typhyus NA F SC 1159 FP Viral Fever NA F SC 1160 FP Cirrhosis of liver with ascites NA F SC 1161 FP Septic shock NA F SC 1162 FP Malaria complicated-mods NA F SC 1163 FP Hepatic encephalopathy NA F SC 1164 FP Severe anaemia requiring blood transfusion-moderate 1165 FP Severe anaemia requiring blood transfusion-severe 1166 FP Severe anaemia requiring blood transfusion-diabetis keto acidosis 19 COMBINE PACKAGES 1167 FP Accessory bone - Excision + Acromion reconstruction NA F SC NA F SC NA F SC NA F SC 1168 FP Anorectoplasty NA F SC 211

212 Appendicectomy 1169 FP Adeno tonsillectomy + Aural polypectomy D NA F SC 1170 FP Adhenolysis + Appendicectomy NA F SC 1171 FP Clavicle Surgery + Closed reduction and internal fixation with K wire 1172 FP Bartholin abscess I & D + Cyst - Vaginal Enucleation 1173 FP Adhenolysis + Cystocele Anterior repair 1174 FP Ablation of Endometrium + D&C ( Dilatation & curretage) NA F SC NA F SC NA F SC D 7200 NA F SC 1175 FP Haemorroidectomy NA F SC Fistulectomy 1176 FP S52 Fracture - Olecranon of Ulna NA F SC 1177 FP Fracture - Fibula Internal Fixation + Fracture - TIBIA Internal Fixation 1178 FP Fracture - Radius Internal Fixation + Fracture - Ulna Internal Fixation 1179 FP Head radius - Excision + Fracture - Ulna Internal Fixation 1180 FP Septoplasty + Functional Endoscopic Sinus (FESS) NA F SC NA F SC NA F SC D NA F SC 212

213 1181 FP Ablation of Endometrium + Hysterectomy abdominal 1182 FP Oophrectomy + Hysterectomy abdominal 1183 FP Ovarian Cystectomy + Hysterectomy abdominal 1184 FP Salpingoophrectomy + Hysterectomy abdominal 1185 FP Hysterectomy (Abdominal and Vaginal) + Cystocele - Anterior Repair 1186 FP Hysterectomy (Abdominal and Vaginal) + Perineal Tear Repair 1187 FP Hysterectomy (Abdominal and Vaginal) + Salpingoophrectomy 1188 FP Cystocele - Anterior Repair + Perineal Tear Repair 1189 FP Cystocele - Anterior Repair + Salpingoophrectomy 1190 FP Perineal Tear Repair + Salpingoophrectomy 1191 FP Hysterectomy (Abdominal And Vaginal) + Cystocele - Anterior Repair + Perineal Tear Repair 1192 FP Hysterectomy (Abdominal and Vaginal) + Cystocele - Anterior Repair + Salpingoophrectomy NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC NA F SC 213

214 1193 FP Hysterectomy (Abdominal and Vaginal) + Cystocele - Anterior Repair + Perineal Tear Repair + Salpingoophrectomy 1194 FP Cystocele - Anterior Repair + Perineal Tear Repair + Salpingoophrectomy 1195 FP For All the Unspecified packages in case of surgical interventions 20 OTHER PROCEDURES 1196 FP Radiofrequency Ablation For Trigeminal neuralgia NA F SC NA F SC NA F SC D 8250 NA F TC 1197 FP FESS for antrochonal polyp NA F SC 1198 FP Hyoid Suspension NA F SC 1199 FP Digital subtraction angiography- Peripheral artery 1200 FP Digital substraction angiographyvenogram NA F TC NA F TC 1201 FP Endomyocardial biopsy D 8250 NA F TC 1202 FP Heller s Operation NA F SC 1203 FP Achalasia Cardia Abdominal, Per Oral Endoscopic Myotomy (POEM) 1204 FP Anterior Resection of rectum (laparoscopic) NA F SC NA F SC 1205 FP Rectal Biopsy Megacolon NA F SC 214

215 1206 FP Imperforate Anus High Anomaly - Closure of Colostomy NA F SC 1207 FP Arthroscopy - Diagnostic NA F SC 1208 FP Radical Treatment with Photons D 2500 NA F TC 1209 FP Renal Angioplasty NA F TC 1210 FP Post-Transplant Immunosuppressive Treatment from 1st to 6 th Month after Transplantation NA F TC 1211 FP Post-Transplant Immunosuppressive Treatment from 7 th to 12 th Month after Transplantation NA F TC 1212 FP Oesophageal Intubation (Mausseau Barbin Tube) 1213 FP Operations for Cyst of the Kidney -Lap/endoscopic NA F SC NA F TC 1214 FP Laproscopy assisted orchidopexy NA F SC 1215 FP Gastrostomy Closure NA F SC 1216 FP Ileostomy Closure NA F SC 1217 FP Laparoscopic Assisted Vaginal Hysterectomy (LAVH) NA F SC 1218 FP Laparoscopic Cystectomy NA F TC 1219 FP Diagnostic cystoscopy D 4800 NA F TC 1220 FP Hysteroscopy Removal of IUCD D 6000 NA F SC 215

216 1221 FP Vestibuloplasty - Maxilla / Mandible- G.A FP Bronchoscopy with foreign body removal NA F SC D 4800 NA F SC 1223 FP Excision of Brain Abcess NA F TC 1224 FP Ventriculoatrial /Ventriculoperitoneal Shunt NA F TC 1225 FP Median Nerve Decompression NA F SC 1226 FP Posterior Cervical Discectomy NA F TC 1227 FP Lumbar Discectomy NA F TC 1228 FP Anterior Cervical Dissectomy NA F TC 1229 FP AV Fistula NA F TC 1230 FP Balloon valvotomy/ptmc (Percutaneous mitral balloon valvotomy ) NA F TC 1231 FP Anorectal Malformations Stage NA F SC 1232 FP Arthroscopy anterior cruciate ligament (acl) repair 1233 FP Arthroscopy - Operative Meniscectomy 1234 FP Operations for Hydronephrosis Endoplyelotomy retrograde NA F SC NA F SC NA F TC 1235 FP Total amputation of the Penis NA F SC 1236 FP Partial Amputation of the Penis NA F SC 1237 FP Eclampsia with Complications Requiring Ventilatory Support NA F SC 216

217 1238 FP Phono Surgery For Vocal Cord Paralysis 1239 FP Adrenal Gland Surgeries In Paediatric patients 1240 FP Neuro Vascular Repair with Crush Injury NA F TC NA F TC NA F TC 1241 FP Syndactyly of Hand for each hand NA F TC 1242 FP Median Nerve Decompression NA F SC 1243 FP Breast Reconstruction Surgery + cost of implants NA F TC 1244 FP Post Burn Contracture Surgeries NA F SC 1245 FP Surgical Management Of Cleft Lip NA F SC 1246 FP Burns Above 40% with Scalds NA F SC 21 HEMODIALYSIS/CHEMOTHERAPY 1248 FP Dialysis D 3000 NA F TC 1249 FP Post-Natal OPD Package within 30 days of delivery Limited 3 Visit 22 OPD DIAGNOSTICS 1250 FP Dog/Cat Bite subject to completion of 3/5 injections plus dressing D 1900 NA F OD D 4200 NA F SC 1251 FP MRI Head - Without Contrast D 4600 NA F OD 1252 FP MRI Head - with Contrast D 5800 NA F OD 1253 FP MRI Orbits - without Contrast D 5400 NA F OD 1254 FP MRI Orbits - with Contrast D 5100 NA F OD 217

218 1255 FP MRI Nasopharynx and PNS - Without Contrast 1256 FP MRI Nasopharynx and PNS - with Contrast D 4200 NA F OD D 5800 NA F OD 1257 FP MRI Neck - Without Contrast D 3900 NA F OD 1258 FP MRI Neck - with Contrast D 5000 NA F OD 1259 FP MRI Shoulder - Without Contrast D 4200 NA F OD 1260 FP MRI Shoulder - with Contrast D 5700 NA F OD 1261 FP MRI Shoulder both Joint - Without Contrast 1262 FP MRI Shoulder both Joint - with Contrast 1263 FP MRI Wrist Single Joint - Without Contrast 1264 FP MRI Wrist Single Joint - with Contrast 1265 FP MRI Wrist both Joint - Without Contrast 1266 FP MRI Wrist both Joint - with Contrast 1267 FP MRI Knee Single Joint - Without Contrast 1268 FP MRI Knee Single Joint - with Contrast 1269 FP MRI Knee both Joint - Without Contrast D 4400 NA F OD D 5400 NA F OD D 4800 NA F OD D 5900 NA F OD D 4200 NA F OD D 6100 NA F OD D 4600 NA F OD D 6000 NA F OD D 4400 NA F OD 218

219 1270 FP MRI Knee both Joint - with Contrast 1271 FP MRI Ankle Single - Without Contrast D 5800 NA F OD D 4200 NA F OD 1272 FP MRI Ankle Single - with Contrast D 6000 NA F OD 1273 FP MRI Ankle Both - Without D 4200 NA F OD Contrast 1274 FP MRI Ankle Both - with Contrast D 5700 NA F OD 1275 FP MRI Hip - Without Contrast D 3900 NA F OD 1276 FP MRI Hip - with Contrast D 6200 NA F OD 1277 FP MRI Pelvis - Without Contrast D 4200 NA F OD 1278 FP MRI Pelvis - with Contrast D 5400 NA F OD 1279 FP MRI Extremities - Without D 3900 NA F OD Contrast 1280 FP MRI Extremities - with Contrast D 5800 NA F OD 1281 FP MRI Temporomandibular Single Joint - Without Contrast 1282 FP MRI Temporomandibular Single Joint - with Contrast 1283 FP MRI Temporomandibular Double Joints - Without Contrast 1284 FP MRI Temporomandibular Double Joints - with contrast D 4200 NA F OD D 5800 NA F OD D 4350 NA F OD D 6000 NA F OD 1285 FP MRI Abdomen - Without D 3900 NA F OD Contrast 1286 FP MRI Abdomen - with Contrast D 5500 NA F OD 1287 FP MRI Breast - Without Contrast D 4000 NA F OD 219

220 1288 FP MRI Breast - with Contrast D 5400 NA F OD 1289 FP MRI Spine Screening - Without Contrast 1290 FP MRI Spine Screening - with Contrast D 3600 NA F OD D 5100 NA F OD 1291 FP MRI Chest - Without Contrast D 3600 NA F OD 1292 FP MRI Chest - with Contrast D 4600 NA F OD 1293 FP MRI Cervical Spine - Without Contrast 1294 FP MRI Cervical Spine - with Contrast 1295 FP MRI Lumber Spine - Without Contrast D 3900 NA F OD D 5500 NA F OD D 4300 NA F OD 1296 FP MRI Lumber Spine - with D 5900 NA F OD Contrast 1297 FP MRI Screening - Without D 3900 NA F OD Contrast 1298 FP MRI Screening - with Contrast D 5800 NA F OD 1299 FP MRI Angiography - Without Contrast D 4200 NA F OD 1300 FP MRI Angiography - with Contrast D 5800 NA F OD 1301 FP Mammography (Single side) D 3000 NA F OD 1302 FP Mammography (Both sides) D 4200 NA F OD 1303 FP Pulmonary function test D 500 NA F OD 1304 FP Fibroptic Bronchoscopy with Washing/Biopsy D 2700 NA F OD 1305 FP Uroflow Study (Micturometry) D 1350 NA F OD 220

221 1306 FP Urodynamic Study (Cystometry) D 1150 NA F OD 1307 FP Cystoscopy with Retrograde Catheter -Unilateral 1308 FP Cystoscopy with Retrograde Catheter - Bilateral D 4700 NA F OD D 6000 NA F OD 1309 FP Cystoscopy Diagnostic D 4200 NA F OD 1310 FP Cystoscopy with Bladder Biopsy D NA F OD 1311 FP Cat Scan (C.T.) Head/ Brain - Without Contrast 1312 FP Cat Scan (C.T.) Head / Brain - with Contrast 1313 FP C.T. Head Scan involving special Investigation - Without Contrast 1314 FP C.T. Head involving special. Investigation -with Contrast 1315 FP C.T. Chest (HRCT) - Without Contrast D 1600 NA F OD D 2500 NA F OD D 2500 NA F OD D 2500 NA F OD D 2500 NA F OD 1316 FP C.T. Chest (HRCT) - with Contrast D 2500 NA F OD 1317 FP C.T. Spine (Cervical, Dorsal, Lumbar, Sacral) -Without Contrast 1318 FP C.T. Spine (Cervical, Dorsal, Lumbar, Sacral) - with Contrast 1319 FP C.T. Cervical C.T. 3D Reconstruction only D 3900 NA F OD D 3900 NA F OD D 3600 NA F OD 1320 FP C.T. Guided Biopsy D 2000 NA F OD 221

222 1321 FP C.T. Guided percutaneous catheter drainage 1322 FP C.T. Myelogram (Cervical Spine) - Without Contrast 1323 FP C.T. Myelogram (Cervical Spine) - with Contrast 1324 FP C.T. Myelogram (Lumbar Spine or D/S) - Without Contrast 1325 FP C.T. Myelogram (Lumbar Spine or D/S)- with Contrast D 2000 NA F OD D 2000 NA F OD D 2000 NA F OD D 2000 NA F OD D 2000 NA F OD 1326 FP C.T. Scan Chest - Without D 3000 NA F OD Contrast 1327 FP C.T. Scan Chest - with Contrast D 3600 NA F OD 1328 FP C.T. Scan Upper Abdomen - Without Contrast 1329 FP C.T. Scan Upper Abdomen - with Contrast 1330 FP C.T. Scan Lower Abdomen - Without Contrast 1331 FP C.T. Scan Lower Abdomen - with Contrast 1332 FP C.T. Scan Whole Abdomen - Without Contrast 1333 FP C.T. Scan Whole Abdomen - with Contrast 1334 FP C.T. Scan Neck (Thyroid Soft Tissue) - Without Contrast D 3000 NA F OD D 4200 NA F OD D 3000 NA F OD D 3900 NA F OD D 4300 NA F OD D 6500 NA F OD D 2800 NA F OD 222

223 1335 FP C.T. Scan Neck (Thyroid Soft Tissue) - with Contrast 1336 FP C.T. Scan Orbits - Without Contrast D 4200 NA F OD D 3000 NA F OD 1337 FP C.T. Scan Orbits - with contract D 3000 NA F OD 1338 FP C.T. Scan Limbs - Without D 3500 NA F OD Contrast 1339 FP C.T. Scan Limbs - with Contrast D 4600 NA F OD 1340 FP C.T. Scan Whole Body - Without Contrast 1341 FP C.T. Scan Whole Body - with Contrast 1342 FP C.T. Scan of Para Nasal Sinus - Without Contrast 1343 FP C.T. Scan of Para Nasal Sinus - with Contrast D 4350 NA F OD D 4200 NA F OD D 3000 NA F OD D 4200 NA F OD 1344 FP Whole Blood per unit D 2500 NA F OD 1345 FP Platelets per unit D 1900 NA F OD 1346 FP Plasma per unit D 2500 NA F OD 1347 FP Packed cells per unit D 2200 NA F OD 1348 FP Ultrasound Sonography Test - UPPER ABDOMEN 1349 FP Ultrasound Sonography Test - LOWER ABDOMEN 1350 FP Ultrasound Sonography Test - WHOLE ABDOMEN D 650 NA F OD D 650 NA F OD D 900 NA F OD 223

224 1351 FP Ultrasound Sonography Test - KUB ABDOMEN D 650 NA F OD 3. Package Rates: OPD Benefits S No. Code No. Package Category No. of OPD Visits 1 ANTE-NATAL AND POST -NATAL CARE OPD Package Rate without Service Tax Authorization Type 1 FP Ante-Natal Care Package 1 : First Trimester F 2 FP Ante-Natal Care Package 2 : Second Trimester F 3 FP Ante-Natal Care Package 3 : Third Trimester F 4 FP Post -Natal Care Package Within 30 days of Delivery F Package Rates Fixed/Indicative S No. Code No. Package Category No. of OPD Visits 2 CHILD CARE OPD Package Rate without Service Tax Authorization Type 1 FP Infant Package-1 (0-6 Months) F 2 FP Infant Package-2 (6-12 Months) F 3 FP Toddler Package-1 (1-5 Years) F Package Rates Fixed/Indicative S No. Code No. Package Category No. of OPD Visits 3 CARDIAC AND BIABETIC PREVENTIVE CARE OPD Package Rate without Service Tax 1 FP OPD (inclusive of 3 consultations + diagnostics + medicine) Authorization Type 1 F Package Rates Fixed/Indicative 224

225 SCHEDULE 4 PART 1 CRITICAL ILLNESSES AND RELATED PACKAGE RATES 1. Package Rates for Critical Illnesses (not including Follow-up Care expenses): Notes LoS In this column, the expected length of stay is mentioned. D: this is a Day Care Treatment that does not require Hospitalization 24 hours. For packages which have LoS mentioned in Schedule 3, the LoS shall be indicative. For packages for which Package Rates are fixed or indicative and have no LoS mentioned in the Schedule 3, LoS shall be defined by the Insurer in consultation with State Nodal Agency before commencement of first Policy Cover Period, subject to approval from MoHFW Package Rate without Service Tax The following Package Rates for any Medical Treatment, Surgical Procedure or Day Care Treatment required for Critical Illness are indicative only. These tariffs are indicative costs of the procedures based on costing study of a representative set of hospitals and review of package costs of similar procedures in other social insurance schemes. The costs as calculated from the costing study were adjusted to counter the limited sample, self-reported rates for professional fee and efficiency/ capacity factors of the hospitals. The Insurer shall propose the Package Rates and finalize these Package Rates within 30 days of the date of the Insurance Contract, in accordance with Clause 5.2(a). The Insurer can determine the enhanced Package Rates that will apply to Empanelled Health Care Providers that have obtained accreditation from NABH or an equivalent national or international body in accordance with Clause 5.2(b). Authorization Type Please refer to Schedule 5 for description of various categories of pre-authorization and Claim procedures. The procedure described in the category mentioned in this Schedule must be applied by the Empanelled Health Care Provider in making a Claim against the Insurer. Package Rates Fixed/Indicative NF: The prices are indicative. Package Rates for the first Policy Cover Period are to be finalized by the Insurer in consultation with State Nodal Agency before commencement of first Policy Cover Period, subject to approval from MoHFW in accordance with Clause 5.2(a). Once these Package Rates are fixed for the first Policy Cover Period, they can be revised for renewal Policy Cover Period in accordance with Clause 5.2(c). F: The prices are fixed for the first Policy Cover Period. These Package Rates can be revised for renewal Policy Cover Periods in accordance with Clause 5.2(c). Package Type SC: Secondary Care. A package marked with SC can be provided by any Empanelled Health Care Provider that has been empanelled for such package. TC: Tertiary Care. A package marked with TC can only be provided by a Specialty Hospital that is empanelled by the Insurer and that has been empanelled for such package. 225

226 S No. Code No. ICD 10 Code Category LoS MHIS III Package Rate without Service Tax Authorization Type Package Rates Indicative/ Fixed Package Type (A) SURGICAL PROCEDURES (d) CARDIO VASCULAR SURGERY 1. FP Coronary Artery Bypass Grafting (CABG) 9 105,650 5 NF TC 2. FP FP Coronary Artery Bypass Grafting (CABG) with IABP ( Intra-Aortic Balloon Pump ) TOF/ TAPVC/ TCPC/ REV/ VSOV repair (Tetrallogy of Fallot/ Total Anomalous Pulmonary Venous Connection / Total Cavo-Pulmonary Connection / Reparation l'etage Ventriculaire 9 121,750 5 NF TC 8 109,100 5 NF TC 4. FP Peripheral Angioplasty 1 55,050 5 NF TC 5. FP Patent ductus arteriosus (PDA) Stenting 5 88,400 5 NF TC 6. FP Total correction of tetralogy of fallot ,150 5 NF TC 7. FP Pericardiectomy 6 36,650 5 NF TC 8. FP Surgery for Intracardiac tumours 8 88,400 5 NF TC 9. FP Coarctation of Aorta - With Stent 5 71,150 5 NF TC 10. FP Coarctation of Aorta - Without Stent 5 36,650 5 NF TC 11. FP Annulus Aortic Ectasia with Valved Conduits 7 95,300 5 NF TC 12. FP Aorto-Aorto Bypass with Graft 8 71,150 [1] 5 NF TC 13. FP Sennings Procedure for Transposition of the Great Arteries 8 109,100 5 NF TC 14. FP Carotid Embolectomy 7 59,650 5 NF TC 15. FP Ruptured Sinus of Valsalva Correction 7 95,300 5 NF TC 16. FP TAPVC (Total Anomalous Pulmonary Venous Connection) Correction 8 109,100 5 NF TC 226

227 17. FP Systemic Pulmonary Shunts with Graft 9 42,400[2] 5 NF TC 18. FP Systemic Pulmonary Shunts without Graft 9 42,400 5 NF TC 19. FP Rotablation 3 42,400 5 NF TC 20. FP Aorta femoral bypass 7 95,300[3] 5 NF TC 21. FP Embolization 5 68,850 5 NF TC 22. FP Excision of Vascular Tumor 4 48,150 5 NF TC 23. FP Directional coronary atherectomy 5 68,850 5 NF TC 24. FP Cardiac radiofrequency ablation 4 55,050 5 NF TC 25. FP Femoro- Poplitial Bypass with Graft 8 71,150[4] 5 NF TC 26. FP Conduit repair for complex congenital heart disease ,550 5 NF TC 27. FP Coronary Balloon Angioplasty 3 42,400 5 NF TC 28. FP FP FP FP FP FP FP FP Intra cardiac repair of ASD + cost of implants Intra cardiac repair of VSD + cost of implants Permanent Pacemaker Implantation - VVI + cost of implants Permanent Pacemaker Implantation DDD + cost of implants Permanent Pacemaker Implantation Biventricular + cost of implants Mitral Valve replacement + cost of implants Aortic Valve replacement + cost of implants Tricuspid valve replacement + cost of implants 7 95,300 5 NF TC 7 95,300 5 NF TC 2 28,600 5 NF TC 2 28,600 5 NF TC 4 53,900 5 NF TC 7 95,300 5 NF TC 7 95,300 5 NF TC 7 95,300 5 NF TC 36. FP Mitral valve repair + cost of implants 7 95,300 5 NF TC 37. FP Additional Stent (PTCA) 12,500[5] 5 NF TC (II) GASTROENTEROLOGY SURGERY 227

228 38. FP FP Abdomino Perineal Resection (APR) + Sacrectomy Laparoscopic pull through surgeries for Hirshprung Disease 10 59,650 5 NF TC 5 38,950 5 NF TC 40. FP Distal Pancreatectomy + Splenectomy 10 75,750 5 NF TC 41. FP Diaphragmatic Eventeration 7 48,150 5 NF TC 42. FP Central Pancreatectomy 9 67,700 5 NF TC 43. FP Anorectal Malformations Stage ,650 5 NF TC 44. FP Retro Peritoneal Lymph Node Dissection(RPLND) (for Residual Disease) 5 38,950 5 NF TC 45. FP Operations for Volvulus of Large Bowel 6 45,850 5 NF TC 46. FP FP Operations for Hirschsprungs Disease (open method) Atresia of Oesophagus and Tracheo Oesophageal Fistula 7 53,900 5 NF TC 8 60,800 5 NF TC 48. FP Pull Through Abdominal Resection 6 45,850 5 NF TC 49. FP Omphalocele 1st Stage (Hernia Repair) 10 75,750 5 NF TC 50. FP Omphalocele 2nd Stge (Hernia Repair) 9 67,700 5 NF TC 51. FP Gastrochisis Repair 5 38,950 5 NF TC 52. FP Pancreatic Ring Operation 8 60,800 5 NF TC 53. FP Meconium Ileus Operation 8 60,800 5 NF TC 54. FP Malrotation of Intestines Operation 5 38,950 5 NF TC 55. FP Duodenal Perforation 6 36,650 5 NF TC 56. FP Lap- Pancreatic Necrosectomy 12 48,150 5 NF TC 57. FP Excision of Small Intestine Fistula 5 38,950 5 NF TC 58. FP Operations for Recurrent Intestinal Obstruction (Noble Plication & Other Operations for Adhesions 6 45,850 5 NF TC 228

229 59. FP FP FP GENERAL SURGERY Oesophagectomy with Three field Lymphadenectomy Oesophagectomy with Two field Lymphadenectomy Oesophago Gastrectomy for mid 1/3 lesion 10 71,150 5 NF TC 8 60,800 5 NF TC 7 53,900 5 NF TC 62. FP Gunshot injury 5 41,250 5 NF TC 63. FP Modified Radical Mastectomy 5 53,900 5 NF TC 64. FP Surgical Intervention for severe abdominal injuries involving (perforation/ rupture) of multiple organs 7 57,350 5 NF TC 65. FP Splenectomy 10 47,000 5 NF TC (IV) NEUROSURGERY 66. FP Excision of Brain Tumors -Subtentorial 7 57,350 5 NF TC 67. FP Excision of Lobe (Frontal,Temporal,Cerebellum etc.) 8 74,600 5 NF TC 68. FP Excision of Parasagital Brain tumour 8 59,650 5 NF TC 69. FP Excision of Basal Brain tumour 8 71,150 5 NF TC 70. FP Excision of Brain Stem Brain tumour 8 82,650 5 NF TC 71. FP Excision of C P Angle Brain tumour 8 82,650 5 NF TC 72. FP Excision of Other Brain tumours (example: supratentorial tumors, pineal gland tumors, pituitary gland, cerebellar tumors etc.) 7 48,150 5 NF TC 73. FP Cervical Sympathectomy 5 36,650 5 NF TC 74. FP Corrective Surgery for Craniosynostosis 7 59,650 5 NF TC 75. FP Craniotomy and Evacuation of Haematoma Extradural 6 48,150 5 NF TC 76. FP DVT - IVC (Inferior vena cava) Filter 5 110,250 5 NF TC 229

230 77. FP Decompression/Excision of Optic nerve lesions 4 53,900 5 NF TC 78. FP External Ventricular Drainage (EVD) 5 48,150 5 NF TC 79. FP Subtotal Temporal bone resection 5 59,650 5 NF TC 80. FP Temporal lobectomy plus Depth Electrodes 7 93,000 5 NF TC 81. FP Total Temporal bone resection 6 71,150 5 NF TC 82. FP Syringomyelia decompression surgery 4 53,900 5 NF TC 83. FP Surgical Management of C.S.F. Rhinorrhoea 4 48,150 5 NF TC 84. FP Encephalocele repair 6 48,150 5 NF TC 85. FP Cranioplasty With Impants 6 51,600[6] 5 NF TC 86. FP FP Craniotomy and Evacuation of Haematoma Subdural Microsurgical excision of Acoustic tumour 8 74,600 5 NF TC 3 41,250 5 NF TC 88. FP Vertebral Angioplasty 4 88,400 5 NF TC 89. FP Operations for Neuroblastoma 4 48,150 5 NF TC 90. FP De-Compressive Craniectomy (Non Traumatic) 9 71,150 5 NF TC 91. FP Conservative management head injury 5 56,200 5 NF TC 92. FP Decompressive cranectomy for hemishpherical acute subdural haematoma/brain swelling/large infarct 9 48,150 5 NF TC 93. FP Conservative management spinal injury 5 56,200 5 NF TC 94. FP Craniotomy with excision of brain tumour 8 48,150 5 NF TC 95. FP Haematoma - Brain (head injuries) 9 42,400 5 NF TC 96. FP Haematoma - Brain (hypertensive) 9 42,400 5 NF TC 97. FP Haematoma (Child irritable subdural) 10 47,000 5 NF TC 98. FP Microdiscectomy - Cervical 10 47,000 5 NF TC 230

231 99. FP Microdiscectomy - Lumber 10 47,000 5 NF TC (V) ONCOSURGERY 100. FP Supra Levator Exenteration 8 84,950 5 NF TC 101. FP Posterior Exenteration 8 59,650 5 NF TC 102. FP Radical Cystectomy 5 53,900 5 NF TC 103. FP Radical Prostatectomy 5 53,900 5 NF TC 104. FP Lobectomy (Lung cancer) 7 59,650 5 NF TC 105. FP FP FP Hepato Cellular Carcinoma(Advanced) Radio Frequency Ablation Partial/Subtotal Gastrectomy for Carcinoma Resection of Nasopharyngeal Tumor in malignant conditions 5 36,650 5 NF TC 8 84,950 5 NF TC 7 59,650 5 NF TC 108. FP Pneumonectomy for Carcinoma Lung 7 59,650 5 NF TC 109. FP Decortication Lung 8 59,650 5 NF TC 110. FP Radical surgery for gastric cancer 7 74,600 5 NF TC (VI) ORTHOPEDICS 111. FP Arthroscopic ACL Repair with Internal Fixation of Tibial Spine + Excision of Spinal Burge 4 42,400[7] 5 NF TC 112. FP FP FP Total hip replacement cemented unilateral Total hip replacement uncemented Unilateral Bipolar hemiarthroplastyof Hip without cement 6 88,400 5 NF TC 6 87,250 5 NF TC 6 45,850 5 NF TC 115. FP Hemiarthroplasty of Hip uncemented 6 42,400 5 NF TC 116. FP FP Congenital Talipes Equino Varus (CTEV) correction Curettage & Bone Cement in malignant conditions 5 48,150 5 NF TC 4 38,950 5 NF TC 231

232 118. FP FP (VII) PAEDIATRIC SURGERY Total knee replacement surgery Unilateral Cancellous screw/pins fixations for fracture neck of Femur 5 76,900 5 NF TC 3 43,550 5 NF TC 120. FP Paediatric Splenectomy (Non Traumatic) 9 42,400 5 NF TC 121. FP Gastrochisis Repair 5 38,950 5 NF TC (VIII) PLASTIC SURGERY 122. FP Radical vaginectomy + Reconstruction 6 53,900 5 NF TC 123. FP Radical vaginectomy with or without prosthesis 6 48,150[8] 5 NF TC 124. FP Mixed Burns Above 40% with Surgeries 7 80,350 5 NF TC (IX) UROLOGY 125. FP Renal Transplantation Surgery ,600 5 NF TC 126. FP Adreneclectomy Unilateral/Bilateral for Tumor/For Carcinoma -Lap/Endoscopic 8 65,400 5 NF TC 127. FP Operations for Cyst of the Kidney -open 5 41,250 5 NF TC (B) MEDICAL TREATMENTS (I) CARDIOLOGY 128. FP Acute MI (Conservative Management with Angiogram) 6 49,300 5 NF TC 129. FP Acute MI Requiring IABP Pump 8 78,050 5 NF TC 130. FP Complex Arrhythmias 4 30,900 5 NF TC 131. FP Stroke Syndrome 8 70,000 5 NF TC 132. FP Myocarditis 7 64,250 5 NF TC 133. FP Congestive Heart Failure 7 55,050 5 NF TC (II) GENERAL MEDICINE 134. FP Medical Management of Meningo- Encephalitis(Ventilated) 9 52,750 5 NF TC 232

233 135. FP Encephalopathy 9 52,750 5 NF TC (III) NEUROLOGY 136. FP (IV) PAEDIATRICS Other Neuropathy (GB syndrome, mononeuritis, other cranial nerve disorders etc.) 6 49,300 5 NF TC 137. FP Exchange Transfusion 4 40,100 5 NF TC 138. FP FP FP FP Preterm Baby/ Clinical Sepsis/ Hyperbilirubinemia (Non-Ventilated) Preterm Baby/ Hyaline Membrane Disease Clinical/Culture Positive Sepsis/Hyperbilirubinemia Mechanical Ventilation Term Baby With Severe Perinatal Asphyxia - Non-Ventilated clinical Sepsis with or without Hyperbilirubinemia Term Baby With Persistent Pulmonary Hypertension/Meconium Aspiration Syndrome/Mechanical Ventilation/with or Without- Clinical Sepsis/with or without-hyperbilirubinemia/ 9 47,000 5 NF TC 9 41,250 5 NF TC 9 41,250 5 NF TC 11 41,250 5 NF TC 142. FP Term Baby with Seizures Ventilated 5 44,700 5 NF TC 143. FP (V) RESPIRATORY Term Baby, Septic Shock, Ventilated, Hyperbilirubinemia,with or without Renal Failure 11 41,250 5 NF TC 144. FP Pulmonary, Embolism 6 49,300 5 NF TC 145. FP (C) (I) OTHER TERTIARY CARE PACKAGES GENERAL SURGERY ARDS (Acute Respiratory Distress Syndrome) 7 63,100 5 NF TC 146. FP C20 Anterior Resection for CA 5 43,550 5 NF TC 233

234 147. FP Aneurysm not Requiring Bypass Techniques 5 43,550 5 NF TC 148. FP Aneurysm Resection & Grafting 43,550 5 NF TC 149. FP Aorta-Femoral Bypass 60,225 5 NF TC 150. FP Arterial Embolectomy 43,550 5 NF TC 151. FP Dissecting Aneurysms 60,225 5 NF TC 152. FP Distal Abdominal Aorta 43,550 5 NF TC 153. FP Flap Reconstructive Surgery 41,250 5 NF SC 154. FP FP Intrathoracic Aneurysm -Aneurysm not Requiring Bypass Techniques Intrathoracic Aneurysm -Requiring Bypass Techniques 7 60,225 5 NF TC 7 60,225 5 NF TC 156. FP Mediastinal Tumour 60,225 5 NF TC 157. FP Oesophagectomy for Carcinoma Easophagus 7 60,225 5 NF TC 158. FP Parapharyngeal tumor - Excission 5 43,550 5 NF TC 159. FP Parapharyngeal Tumour Excision 7 60,225 5 NF TC 160. FP Partial Pericardectomy 8 68,850 5 NF TC 161. FP Patch Graft Angioplasty 8 68,850 5 NF TC 162. FP Pericardiostomy 10 85,525 5 NF TC 163. FP Removal Tumours of Chest Wall 8 68,850 5 NF TC 164. FP Renal Artery aneurysm and dissection 8 70,000 5 NF TC 165. FP Total Thyroidectomy (Cancer) 8 68,850 5 NF TC (II) NEURO-SURGERY 166. FP I67 Anneurysm ,225 5 NF TC 167. FP Q01 Anterior Encephalocele ,225 5 NF TC 168. FP I60 Burr hole 8 122,325 5 NF TC 169. FP I65 Carotid Endartrectomy ,950 5 NF TC 234

235 170. FP G56 Carpal Tunnel Release 5 59,650 5 NF TC 171. FP Q76 Cervical Ribs - Bilateral 7 83,225 5 NF TC 172. FP Q76 Cervical Ribs - Unilateral 5 59,650 5 NF TC 173. FP Cranio Ventrical 9 137,275 5 NF TC 174. FP Q75 Craniostenosis 7 106,915 5 NF TC 175. FP Duroplasty 5 76,900 5 NF TC 176. FP M48 Laminectomy with Fusion 6 91,850 5 NF TC 177. FP M51 Lumbar Disc 5 76,900 5 NF TC 178. FP Q05 Meningocele - Anterior ,375 5 NF TC 179. FP Q05 Meningocele - Lumbar 8 122,325 5 NF TC 180. FP Q01 Meningococle - Ocipital ,225 5 NF TC 181. FP M54 Neurolysis 7 106,915 5 NF TC 182. FP Peripheral Nerve Surgery 7 106,915 5 NF TC 183. FP I82 Posterior Fossa Decompression 8 122,325 5 NF TC 184. FP Repair & Transposition Nerve 3 46,425 5 NF TC 185. FP S14 Brachial Plexus - Repair 7 106,915 5 NF TC 186. FP Q05 Spina Bifida - Large - Repair ,225 5 NF TC 187. FP Q05 Spina Bifida - Small - Repair ,225 5 NF TC 188. FP G91 Shunt 7 106,915 5 NF TC 189. FP Spine - Anterior Decompression 8 122,325 5 NF TC 190. FP M54 Spine - Canal Stenosis 6 91,850 5 NF TC 191. FP M54 Spine - Decompression & Fusion 6 91,850 5 NF TC 192. FP M54 Spine - Disc Cervical/Lumber 6 91,850 5 NF TC 193. FP C72 Spine - Extradural Tumour 7 106,915 5 NF TC 194. FP C72 Spine - Intradural Tumour 7 106,915 5 NF TC 195. FP C72 Spine - Intramedullar Tumour 7 106,915 5 NF TC 235

236 196. FP P10 Subdural aspiration 3 46,425 5 NF TC 197. FP G50 Temporal Rhizotomy 5 76,900 5 NF TC 198. FP Trans Sphenoidal 6 91,850 5 NF TC 199. FP D32 Tumours Meninges - Gocussa 7 106,915 5 NF TC 200. FP D32 Tumours Meninges - Posterior 7 106,915 5 NF TC 201. FP Brain Biopsy 5 76,900 5 NF TC 202. FP Cranial Nerve Anastomosis 5 76,900 5 NF TC 203. FP Depressed Fracture Skull 7 106,915 5 NF TC 204. FP Peripheral Neurectomy (Tirgeminal) 5 76,900 5 NF TC 205. FP Peritoneal Shunt 5 76,900 5 NF TC 206. FP Twist Drill Craniostomy 3 46,425 5 NF TC (III) ORTHOPAEDIC 207. FP M48 Laminectomy 9 106,225 5 NF TC (IV) PAEDIATRIC 208. FP Q79 Abdomino Perioneal (Exomphalos) 5 43,550 5 NF TC 209. FP Q74 Meniscectomy 3 36,075 5 NF TC 210. FP Q62 Ureterotomy 5 43,550 5 NF TC 211. FP N35 Urethroplasty 5 43,550 5 NF TC 212. FP Q62 Vesicostomy 5 43,550 5 NF TC (V) UROLOGY 213. FP N36 Reimplanation of Urethra 5 44,125 5 NF TC 214. FP N32 Reimplantation of Bladder 5 44,125 5 NF TC 215. FP N13 Reimplantation of Ureter 5 44,125 5 NF TC 216. FP N13 Retroperitoneal Fibrosis Renal 5 44,125 5 NF TC 217. FP Q54 Hypospadias Repair and Orchiopexy 5 44,125 5 NF TC 218. FP N32 Y V Plasty of Bladder Neck 5 44,125 5 NF TC 236

237 (VI) ONCOLOGY 219. FP C00 Carcinoma lip - Wedge excision 5 43,550 5 NF TC 220. FP D44 Excision Cartoid Body tumour 5 43,550 5 NF TC 221. FP Parapharyngeal Tumor excision (Throat) 5 43,550 5 NF TC (VII) NEO-NATAL CARE 222. FP Specialised Package for Neo Natal Care between 3 to 8 days 71,725 5 NF TC 223. FP Advanced Package for Neo Natal Care more than 8 days 113,700 5 NF TC (VIII) LISTED MEDICAL TREATMENT 224. FP Myocardial infarction 53,900 5 NF TC (IX) CARDIOLOGY 225. FP Valvular heart disease with LVF 68,275 5 NF TC [1] Additional synthetic material / graft/ implant or prosthetic (as applicable) cost to be approved on pre-authorization [2] Additional synthetic graft cost to be approved on pre-authorization [3] Additional synthetic material / graft/ implant or prosthetic (as applicable) cost to be approved on pre-authorization [4] Additional synthetic material / graft/ implant or prosthetic (as applicable) cost to be approved on pre-authorization [5] The cost of additional stent payable for each additional stent for an angioplasty procedure [6] Additional synthetic material / graft/ implant or prosthetic (as applicable) cost to be approved on pre-authorization [7] Additional synthetic material / graft/ implant or prosthetic (as applicable) cost to be approved on pre-authorization [8] Additional synthetic material / graft/ implant or prosthetic (as applicable) cost to be approved on pre-authorization 2. Package Rates for Follow-up Care for Critical Illnesses: Note. Package Rate without Service Tax The Package Rates cover the entire cost of Follow-Up Care for Tertiary Care procedures and treatments, i.e. consultation, medicines, diagnostic tests, transportation benefits and economic loss compensation benefits. For operational convenience, the Package Rate is apportioned to 4 visits. As the frequency of visits and investigations are common during first visit, a higher amount is allocated for first visit. However the entire Package Rate must be treated as a single rate and an Empanelled Health Care Provider shall not refuse to conduct investigations free of cost under the Package Rate at any time during the on-going Policy Cover Period. 237

238 The following Package Rates for Follow-up Care required for Critical Illness are indicative only. These tariffs are indicative costs of the procedures based on costing study of a representative set of hospitals and review of package costs of similar procedures in other social insurance schemes. The costs as calculated from the costing study were adjusted to counter the limited sample, self-reported rates for professional fee and efficiency/ capacity factors of the hospitals. The Insurer shall propose the Package Rates for such Follow-up Care and finalize these Package Rates within 30 days of the date of the Insurance Contract, in accordance with Clause 5.2(a). The Insurer can determine the enhanced Package Rates that will apply to Empanelled Health Care Providers that have obtained accreditation from NABH or an equivalent national or international body in accordance with Clause 5.2(b). S No. Code No. Procedure Package Rate without Service Tax (A) FOLLOW-UP CARE: SURGICAL First Visit Subsequen t 3 Visits Authorization Type Package Rates(F/NF) 1 SF Total Thyroidectomy 4,370 1, NF TC 2 SF1.4.2 Portocaval Anastomosis 12,420 4,200 2,530 1 NF TC 3 SF1.6.1 Operation of Adernal glands bilateral 5,520 1,800 1,150 1 NF TC 4 SF1.7.2 Splenorenal Anastomosis 12,420 4,200 2,530 1 NF TC 5 SF1.7.3 Warren shunt 12,420 4,200 2,530 1 NF TC 6 SF6.8.2 Spleenectomy + Devascularisation + 12,420 4,200 2,530 1 NF TC Spleno Renal Shunt 7 SF6.9.1 Lap- Pancreatic Necrosectomy 10,120 3,700 1,955 1 NF TC 8 SF6.9.3 Pancreatic Necrosectomy (open) 10,120 3,700 1,955 1 NF TC 9 SF Coronary Balloon Angioplasty 12,420 4,200 2,530 1 NF TC 10 SF Renal Angioplasty 12,420 4,200 2,530 1 NF TC 11 SF Peripheral Angioplasty 12,420 4,200 2,530 1 NF TC Package Type 238

239 12 SF Vertebral Angioplasty 12,420 4,200 2,530 1 NF TC 13 SF Coronary Bypass Surgery 12,420 4,200 2,530 1 NF TC 14 SF Coronary Bypass Surgery-post 12,420 4,200 2,530 1 NF TC Angioplasty 15 SF CABG with IABP pump 12,420 4,200 2,530 1 NF TC 16 SF CABG with aneurismal repair 12,420 4,200 2,530 1 NF TC 17 SF With Prosthetic Ring 12,420 4,200 2,530 1 NF TC 18 SF Without Prosthetic Ring 12,420 4,200 2,530 1 NF TC 19 SF Open Pulmonary Valvotomy 12,420 4,200 2,530 1 NF TC 20 SF Closed mitral valvotomy 12,420 4,200 2,530 1 NF TC 21 SF Mitral Valvotomy (Open) 12,420 4,200 2,530 1 NF TC 22 SF Mitral Valve Replacement (With 12,420 4,200 2,530 1 NF TC Valve) 23 SF Aortic Valve Replacement (With 12,420 4,200 2,530 1 NF TC Valve) 24 SF Tricuspid Valve Replacement 12,420 4,200 2,530 1 NF TC 25 SF Double Valve Replacement (With 12,420 4,200 2,530 1 NF TC Valve) 26 SF Carotid Embolectomy 12,420 4,200 2,530 1 NF TC 27 SF8.6.4 Encephalocele 5,520 1,800 1,150 1 NF TC 28 SF Surgeries on adrenal gland in 5,520 1,800 1,150 1 NF TC Children 29 SF9.2.1 Open Pyelolithotomy 3,220 1, NF TC 30 SF9.2.2 Open Nephrolithotomy 3,220 1, NF TC 31 SF9.2.3 Open Cystolithotomy 3,220 1, NF TC 32 SF9.2.4 Laparoscopic Pyelolithotomy 3,220 1, NF TC 33 SF9.3.1 Cystolithotripsy 3,220 1, NF TC 34 SF9.3.2 PCNL 3,220 1, NF TC 35 SF9.3.3 ESWL 3,220 1, NF TC 36 SF9.3.4 URSL 3,220 1, NF TC 239

240 37 SF9.7.1 Endoscope Removal of stone in 3,220 1, NF TC Bladder 38 SF9.9.1 Transurethral resection of prostate 3,220 1, NF TC (TURP) 39 SF9.9.2 TURP Cyst lithotripsy 3,220 1, NF TC 40 SF9.9.3 Open prostatectomy 3,220 1, NF TC 41 SF Craniotomy and Evacuation of Haematoma(subdural) 10,120 3,400 2,070 1 NF TC 42 SF Craniotomy and Evacuation of Haematoma (extra dural) 10,120 3,400 2,070 1 NF TC 43 SF Evacuation of Brain Abscess-burr 10,120 3,400 2,070 1 NF TC hole 44 SF Excision of Lobe 10,120 3,400 2,070 1 NF TC (Frontal,Temporal,Cerebellum etc.) 45 SF Excision of Brain Tumor 10,120 3,400 2,070 1 NF TC Supratentorial 46 SF Parasagital 10,120 3,400 2,070 1 NF TC 47 SF Basal 10,120 3,400 2,070 1 NF TC 48 SF Brain Stem 10,120 3,400 2,070 1 NF TC 49 SF C P Angle Tumor 10,120 3,400 2,070 1 NF TC 50 SF Other tumors 10,120 3,400 2,070 1 NF TC 51 SF Excision of Brain Tumors 10,120 3,400 2,070 1 NF TC (subtentorial) 52 SF Ventriculoatrial 10,120 3,400 2,070 1 NF TC /Ventriculoperitoneal Shunt 53 SF Subdural Tapping 10,120 3,400 2,070 1 NF TC 54 SF Ventricular Tapping 10,120 3,400 2,070 1 NF TC 55 SF Abscess Tapping 10,120 3,400 2,070 1 NF TC 56 SF Vascular Malformations 10,120 3,400 2,070 1 NF TC 57 SF Peritoneal Shunt 10,120 3,400 2,070 1 NF TC 240

241 58 SF Atrial Shunt 10,120 3,400 2,070 1 NF TC 59 SF Meningo Encephalocele 10,120 3,400 2,070 1 NF TC 60 SF Meningomyelocele 10,120 3,400 2,070 1 NF TC 61 SF Ventriculo-Atrial Shunt 10,120 3,400 2,070 1 NF TC 62 SF Excision of Brain Abcess 10,120 3,400 2,070 1 NF TC 63 SF Aneurysm Clipping 10,120 3,400 2,070 1 NF TC 64 SF External Ventricular Drainage (EVD) 10,120 3,400 2,070 1 NF TC 65 SF Trans Sphenoidal Surgery 10,120 3,400 2,070 1 NF TC 66 SF Trans Oral Surgery 10,120 3,400 2,070 1 NF TC 67 SF Endoscopy procedures 10,120 3,400 2,070 1 NF TC 68 SF Intra-Cerebral Hematoma 10,120 3,400 2,070 1 NF TC evacuation 69 SF Temporal Lobectomy 10,120 3,400 2,070 1 NF TC 70 SF Lesionectomy type 1 10,120 3,400 2,070 1 NF TC 71 SF Lesionectomy type 2 10,120 3,400 2,070 1 NF TC 72 SF Temporal lobectomy plus Depth Electrodes 10,120 3,400 2,070 1 NF TC 73 SF Stay in General Ward@Rs.500/day 10,120 3,400 2,070 1 NF TC 74 SF Stay in Neuro ICU@Rs.4000/day 10,120 3,400 2,070 1 NF TC 75 SF Surgical Treatment (Up to) 10,120 3,400 2,070 1 NF TC (B) FOLLOW-UP CARE: MEDICAL 76 MF1.1 Acute severe asthma with Acute respiratory failure 12,420 4,200 2,530 1 NF TC 77 MF1.2 COPD Respiratory Failure (infective exacerbation) 78 MF Term baby with persistent pulmonary hypertension Ventilation- HFO Hyperbilirubinemia Clinical 12,420 4,200 2,530 1 NF TC 7,820 3,200 1,380 1 NF TC 241

242 sepsis 79 MF Term baby with seizures ventilated 6,670 2,200 1,380 1 NF TC 80 MF Acute Severe Asthma 5,520 1,800 1,150 1 NF TC (Ventilated) NF TC 81 MF Infective Endocarditis 12,420 4,200 2,530 1 NF TC 82 MF Meningo- encephalitis 8,395 2,200 1,955 1 NF TC 82 MF Meningo- encephalitis (Non NF TC Ventilated) 83 MF Meningo- encephalitis 8,395 2,200 1,955 1 NF TC ( Ventilated) NF TC 84 MF Status Epilepticus 8,395 2,200 1,955 1 NF TC 85 MF Intra cranial bleed 8,395 2,200 1,955 1 NF TC 86 MF Congenital heart disease with congestive cardiac failure 6,670 2,200 1,380 1 NF TC 87 MF Acquired heart disease with congestive cardiac failure 6,670 2,200 1,380 1 NF TC 88 MF Steroid Resistant Nephritic 6,670 2,200 1,380 1 NF TC syndrome Complicated or Resistant NF TC 89 MF Anaemia of unknown cause 6,670 2,200 1,380 1 NF TC 90 MF Pyogenic meningitis 6,670 2,200 1,380 1 NF TC 91 MF Neuro tuberculosis 6,670 2,200 1,380 1 NF TC 92 MF Neuro tuberculosis with ventilation 6,670 2,200 1,380 1 NF TC 93 MF Convulsive Disorders/Status Epilepticus (Fits) 6,670 2,200 1,380 1 NF TC 94 MF Encephalitis / Encephalopathy 6,670 2,200 1,380 1 NF TC 242

243 95 MF5.1.1 Acute Mi (Conservative Management Without Angiogram) 96 MF5.1.2 Acute Mi (Conservative Management With Angiogram) 12,420 4,200 2,530 1 NF TC 12,420 4,200 2,530 1 NF TC 97 MF5.1.3 Acute Mi With Cardiogenic Shock 12,420 4,200 2,530 1 NF TC 98 MF5.1.4 Acute Mi Requiring Iabp Pump 12,420 4,200 2,530 1 NF TC 99 MF5.1.5 Refractory Cardiac Failure 12,420 4,200 2,530 1 NF TC 100 MF5.2 Infective Endocarditis 12,420 4,200 2,530 1 NF TC 101 MF5.4 Complex Arrhythmias 12,420 4,200 2,530 1 NF TC 102 MF6.2 Nephrotic Syndrome 6,670 2,200 1,380 1 NF TC 103 MF7.1 ADEM or Relapse in Multiple 6,670 2,200 1,380 1 NF TC sclerosis 104 MF7.2 CIDP 6,670 2,200 1,380 1 NF TC 105 MF7.3 Hemorrhagic Stroke/Strokes 6,670 2,200 1,380 1 NF TC 106 MF7.4 Ischemic Strokes 6,670 2,200 1,380 1 NF TC 107 MF7.6 NEUROINFECTIONS -Fungal 6,670 2,200 1,380 1 NF TC Meningitis 108 MF7.7 NEUROINFECTIONS -Pyogenic Meningitis 6,670 2,200 1,380 1 NF TC 109 MF7.8 NEUROINFECTIONS -Viral Meningoencephalitis ( Including Herpes encephalitis) 6,670 2,200 1,380 1 NF TC 110 MF7.9 Neuromuscular (myasthenia gravis) 5,520 1,800 1,150 1 NF TC 111 MF8.4 Interstitial Lung diseases 12,420 4,200 2,530 1 NF TC 112 MF8.5 Pneumoconiosis 12,420 4,200 2,530 1 NF TC 113 MF9.1 Pemphigus / Pemphigoid 4,945 1, NF TC 114 MF10.1 SLE (SYSTEMIC LUPUS ERYTHEMATOSIS) 7,820 2,600 1,610 1 NF TC 115 MF10.2 SCLERODERMA 7,820 2,600 1,610 1 NF TC 243

244 116 MF10.3 MCTD MIXED CONNECTIVE TISSUE DISORDER 117 MF10.4 MCTD MIXED CONNECTIVE TISSUE DISORDER 7,820 2,600 1,610 1 NF TC 7,820 2,600 1,610 1 NF TC 118 MF10.5 VASCULITIS 7,820 2,600 1,610 1 NF TC 119 MF Hypopitutarism 10,120 3,700 1,955 1 NF TC 120 MF Pituitary Acromegaly 8,395 2,200 1,955 1 NF TC 121 MF Delayed Puberty Hypogonadism 8,970 2,700 1,955 1 NF TC (ex.turners synd, Kleinfelter synd) NF TC 122 MF12.9 Gastric varices 8,970 2,700 1,955 1 NF TC 123 MF12.13 Chronic pancreatitis with severe pain 8,970 2,700 1,955 1 NF TC 124 MF12.15 Cirrhosis with Hepatic Encephalopathy 125 MF12.16 Cirrhosis with hepato renal syndrome 8,970 2,700 1,955 1 NF TC 8,970 2,700 1,955 1 NF TC 244

245 SCHEDULE 4 PART 2 Provisional/Suggested List for Medical and Surgical Interventions / Procedures in General Ward for SCHIS Part I: General Speciality SL CARDIOLOGY - SENIOR CITIZEN Package No Cost 1 PTCA - single stent (medicated, inclusive of diagnostic angiogram) 45,000 2 PTCA - double stent (medicated, inclusive of diagnostic angiogram) 60,000 3 Balloon Mitral Valvotomy 32,050 4 Balloon Pulmonary Valvotomy 30,000 5 Balloon Aortic Valvotomy 30,000 6 Peripheral Angioplasty with single stent (medicated) 55,050 7 Peripheral Angioplasty with double stent (medicated) 60,000 8 Renal Angioplasty with single stent (medicated) 45,000 9 Renal Angioplasty with double stent (medicated) 60, Vertebral Angioplasty with single stent (medicated) 88, Vertebral Angioplasty with double stent(medicated) 88, Temporary Pacemaker implantation 12, Permanent pacemaker (single chamber) implantation (only VVI) including Pacemaker value/pulse generator replacement 50, Permanent pacemaker (double chamber) implantation (only VVI) including Pacemaker value/pulse generator replacement 60,

246 15 Pericardiocentesis 4, Medical treatment of Acute MI with Thrombolysis /Stuck Valve Thrombolysis 15, Coarctoplasty with stenting 45,000 CARDIO THORACIC SURGERY - SENIOR CITIZEN 18 Coronary artery bypass grafting (CABG) 1,05, Coronary artery bypass grafting (CABG) with Intra-aortic balloon pump (IABP) 1,21, Coronary artery bypass grafting (CABG) with Aneurysmal repair 90, Coronary artery bypass grafting (CABG) with Mitral Valve repair 90, Open Mitral Valvotomy 75, Closed Mitral Valvotomy 32, Open Aortic Valvotomy 75, Open Pulmonary Valvotomy 75, Aortaplasty with stent (Aorta Repair) for Coarctation 45, Pericardiectomy 40, Lung Cyst 50, Space-Occupying Lesion (SOL) mediastinum 50, Surgical Correction of Bronchopleural Fistula. 50, Diaphragmatic Eventeration 48, Oesophageal Diverticula /Achalasia Cardia 40, Diaphragmatic Injuries/Repair 40, Bronchial Repair Surgery for Injuries due to FB 40, Oesophageal tumour excision and follow up care (open preferred) 60,000 CARDIO VASCULAR SURGERY - SENIOR CITIZEN 36 Femoropopliteal by pass procedure with graft (exogenous) 45, Femoropopliteal by pass procedure with graft (endogenous) 30, Thromboembolectomy 20,

247 39 Intrathoracic Aneurysm (without graft)-aneurysm not Requiring Bypass 60, Intrathoracic Aneurysm (with graft) -Requiring Bypass Techniques 60, Dissecting Aneurysms with Cardiopulmonary bypass (CPB) (inclu. Graft) 60, Dissecting Aneurysms without Cardiopulmonary bypass (CPB) (incl. graft) 60, Aorto Bi lliac / Bi femoral /Axillo bi femoral bypass with (single) Synthetic Graft 45, Aorto Bi lliac / Bi femoral /Axillo bi femoral bypass with (double) Synthetic Graft 60, Aorto Bi lliac / Bi femoral /Axillo bi femoral bypass with vein Synthetic Graft 30, Femoro Distal / Femoral - Femoral / Femoral infra popliteal Bypass with (double) synthetic Graft 71, Femoro Distal / Femoral - Femoral / Femoral infra popliteal Bypass with (single) Synthetic Graft 45, Femoro Distal / Femoral - Femoral / Femoral infra popliteal Bypass with (vein) Graft 30, Brachio - Radial Bypass with Synthetic Graft 45, Excision of Carotid body Tumor with vascular repair 45, Carotid artery bypass with Synthetic Graft 60, Deep Vein Thrombosis (DVT) - Inferior Vena Cava (IVC) filter 60, Carotid endarterectomy 1,53,950 NEURO SURGERY - SENIOR CITIZEN 54 Excision of Brain Tumor 57, Carotid Endarterectomy 1,53,

248 56 Spinal Intra Medullary Tumours 50, Corpectomy for Spinal Fixation + cost of implant 50, Corpectomy for Spinal Fixation (without implant) 25,000 POLYTRAUMA & REPAIR - SENIOR CITIZEN 59 Viseral injury requiring surgical intervention along with fixation of fracture of single long bone. 30, Viseral injury requiring surgical intervention along with fixation of fracture of 2 or more long bones. 45, Chest injury with one fracture of long bone 25, Chest injury with fracture of 2 or more long bones 30, Arthroscopic Meniscus Repair 60, Total Knee Replacement 76, Total Hip Replacement 88,400 BURNS - SENIOR CITIZEN 66 Up To - 40% With Scalds (Conservative) 34, Upto - 40% Mixed Burns (With Surgeries) 35, Upto - 50% With Scalds (Conservative) 45, Up To - 50% Mixed Burns (With Surgeries) 80, Between 50% to 60% Burns 70, More than 60% Burns 90, Mild Contracture Surgeries For Functional Improvement (including splints,pressure garments And Physiotherapy) 20, Severe Contracture Surgeries For Functional Improvement (including splints,pressure garments And Physiotherapy) 40,

249 Part II: Oncology Sub Category Package Rates SURGICAL ONCOLOGY - SENIOR Procedures Sl No (in Rs) CITIZEN 74 Breast Chest Wall Resection 20, Breast Lumpectomy Breast 9, Breast Breast Reconstruction 30, Genitourinary Emasculation 30, Genitourinary Partial Penectomy 15, Genitourinary Total Penectomy 25, Limb Salvage Surgery Internal Hemipelvectomy 50, Limb Salvage Surgery Curettage & Bone Cement 25, Limb Salvage Surgery Forequarter Amputation 40, Limb Salvage Surgery Hemipelvectomy 45, Limb Salvage Surgery Sacral Resection 40, Limb Salvage Surgery Bone Resection 25, Limb Salvage Surgery Shoulder Girdle Resection 40, Lung Lung Metastatectomy Solitary 35, Urinary Bladder Total Exenteration 60, Urinary Bladder Bilateral Pelvic Lymph Node Dissection(BPLND) for CA Urinary Bladder 45, Esophagus Oesophagectomy With Two Field Lymphadenectomy 60, Esophagus Oesophagectomy With Three Field Lymphadenectomy 71, Lung Lung Metastatectomy Multiple 60, Lung Sleeve Resection Of Lung Cancer 50, Testis Cancer Retro Peritoneal Lymph Node Dissection(RPLND) (For Residual Disease) 45,

250 95 Testis Cancer Retro Peritoneal Lymph Node Dissection (RPLND) As Part Of Staging 45, Urinary Bladder Anterior Exenteration 40, Testis Cancer Urinary Diversion 35, Limb Salvage Surgery Limb Salvage Surgery Without Prosthesis 40, Limb Salvage Surgery Limb Salvage Surgery With Custom Made Prosthesis 50, Limb Salvage Surgery Limb Salvage Surgery With Modular Prosthesis 60, Ca Git Whipples Any Type 60, Ca Git Triple Bypass 25, Ca Git Abdominoperineal Resection 40, Ca Git Abdomino Perineal Resection (APR) + Sacrectomy 59, Ca Rectum Posterior Exenteration 59, Ca Rectum Total Exenteration 60, Ca Cervix Supra Levator Exenteration 84, Head And Neck Maxillectomy Any Type 40, Head And Neck Wide Excision for tumour 30, Head And Neck Composite Resection and Reconstruction 60, Head And Neck Voice Prosthesis 30, Head And Neck Laryngo-pharyngo-esophagectomy 60, Head And Neck Laser surgery of Larynx 30, Bronchoplural Fistula Surgical Correction Of Bronchoplural Fistula.Myoplasty 35, Bronchoplural Fistula Surgical Correction Of Bronchoplural Fistula Trans Plural (BFP closure) 35, Palliative Surgeries Tracheostomy 5, Oral Cavity Full Thickness Buccal Mucosal Resection & Reconstruction 40, Ca Parathyroid Parathyroidectomy 30, Ca.Eye/ Maxilla /Para Nasal Sinus Maxillectomy + Orbital Exenteration 40,

251 120 Ca.Eye/ Maxilla /Para Nasal Sinus Maxillectomy + Infratemporal Fossa Clearance 50, Ca.Soft Palate Palatectomy Any Type 30, Ca.Ear Sleeve Resection 25, Nasopharynx Resection Of Nasopharyngeal Tumour 45, Reconstruction Micro Vascular Reconstruction 45, Reconstruction Myocutaneous / Cutaneous Flap 25, Palliative Surgeries Substernal Bypass 40, Soft Tissue /Bone Tumours Wide Excision + Reconstruction soft tissue/bone Tumours 30, Skin Tumours Skin Tumours Wide Excision + Reconstruction 25, Skin Tumours Skin Tumours Amputation 8, Lung Lung Cancer Decortication 59, Soft Tissue /Bone Tumours Amputation for soft tissue/bone Tumours 10, Lung Lung Cancer Pnumenectomy 59, Breast Wide Excision of Breast for Tumour 28, Ca Cervix Posterior Exenteration 59, Ca Cervix Total Pelvic Exenteration 60, Soft Tissue /Bone Tumours. Chest Wall Chest Wall Resection + Reconstruction 25, Gynec Bilateral Pelvic Lymph Node Dissection(BPLND) 20, Gynec Radical Trachelectomy 40, Ca Abdominal Wall Tumour Abdominal Wall Tumour Resection 25, Gynec Radical Vaginectomy 48, Gynec Radical Vaginectomy + Reconstruction 53, General Iliac lymph node dissection 15, Head & Neck Functional Neck dissection 20, Head & Neck Supra-Omohyoid Neck dissection 20, Colon Anterior resection rectum 40, Stomach Total Gastrectomy 30,

252 147 Ovarian Cancer TAH+BSO+Omentectomy 30, Brain Tumor Excision of Brain tumor 30, Brain Tumor V-P Shunt 30,900 RADIATION ONCOLOGY - SENIOR CITIZEN 150 Cobalt 60 External Beam Palliative Treatment 11,815 Radiotherapy 151 Cobalt 60 External Beam Radical/ Adjuvant Treatment 17,565 Radiotherapy 152 Brachytherapy Intracavity Intracavitary HDR per fraction (max 4 session) 4, Brachytherapy Intracavity Intracavitary LDR per fraction (max 4 session) 6, Brachytherapy Interstitial Interstitial LDR, adjuvant 17, Brachytherapy Interstitial Interstitial HDR one application and multiple dose fractions 29, External Beam Radiotherapy (On Linear Acclerator) 157 External Beam Radiotherapy (On Linear Acclerator) 158 Specialized Radiation Therapy 3DCRT (3-D ConformationalRadiotherapy) 159 Specialized Radiation Therapy - IMRT (Intensity Modulated Radiotherapy) 160 Specialized Radiation Therapy - SRS/ SRT 161 Specialized Radiation Therapy - IMRT with IGRT Palliative Treatment With Photons 20,000 Radical/ Adjuvant Treatment With Photons/Electrons 35,000 Linear accelerator teletherapy 3DCRT, Definitive, Adjuvant (inclusive of RT planning - Rs. 15,000) Linear accelerator teletherapy IMRT /VMAT, Definitive, Adjuvant (inclusive of RT planning - Rs. 20,000 75,000 90,000 Definitive, Adjuvant, SRS/SRT (guidelines enclosed as 75,000 Annexure 4) IMRT+IGRT-Up To 40 Fractions In 8 Weeks 90,

253 162 Specialized Radiation Rapid Ax Therapy-Up To 40 Fractions In 8 Weeks 90,000 Therapy Rapid Ax Therapy MEDICAL ONCOLOGY - SENIOR CITIZEN 163 Lymphoma, Non-Hodgkin s Cyclophosphamide - Doxorubicin Vincristine - 3,500 Prednisone (CHOP)- max 8 cycles (Per cycle) 164 Multiple Myeloma Vincristine, Adriamycin,Dexamethasone(VAD) -cycle 4,000 max 6 cycles 165 Multiple Myeloma Thalidomide+Dexamethasone(Oral)/ month - max 12 months 3, Colon Rectum 5-Fluorouracil-Oxaliplatin - Leucovorin (FOLFOX) - Max. 6, cycles (Per cycle) 167 Bone Tumors/Osteosarcoma Cisplatin/carboplatin - Adriamycin- max 6 cycles (Per cycle) 3, Lymphoma, Hodgkin'S Adriamycin Bleomycin Vinblastin Dacarbazine (ABVD) - 3,000 max 8 cycles (Per cycle) (Day 1 & Day 15) 169 Cervix Cisplatin/Carboplatin (AUC2) along with RT- max 6 2,000 cycles (Per cycle) 170 Childhood B-Cell Lymphomas Variable Regimen-Lukemia,Lymphoma and Plasmacell 12,000 (Per cycle) max. 8 cycles. 171 Neuroblastoma Stage I III Variable Regimen Neuroblastoma - max 1 year (Per cycle) 9, Multiple Myeloma Melphalan -Prednisone (oral) per month (max 12 months) - 1,500 Ovarian CA, Bone CA 173 Wilm's Tumor SIOP/National Wilms Tumour Study Group (NWTS) 7,000 regimen(stages I - V)- max 6 months (Per month) - Wilm's tumour 174 Hepatoblastoma -Operable Cisplatin/carboplatin - Adriamycin- max 6 cycles (Per cycle) 4,

254 175 Colon Rectum Monthly 5-FU 4, Breast Paclitaxel weekly x 12 weeks 4, Breast Cyclophosphamide/Methotrexate/5Fluorouracil (CMF) 1,500 (Per cycle) 178 Breast Tamoxifen tabs - maximum 12 cycles (Per month) Breast Adriamycin/Cyclophosphamide (AC) per cycle 3,000 (Maximum 4 cycles) 180 Breast 5- Fluorouracil A-C (FAC) per cycle (Maximum 6 cycles) 3, Breast AC (AC Then T) 3, Small Cell Lung Cancer Cisplastin/Etoposide (IIIB) per cycle (Max. 6 cycles only) 4, Oncology oesophagus Cisplatin + 5 FU(Neoadjuvant Chemotherapy)/Adjuvant (ADJ)- per cycle (Max. of 6 cycles only) 3, Stomach 5-Fu Leucovorin (MCDONALD Regimen) 4, Breast Aromatase Inhibitors (Anastazole/Letrozole/Exemestane) maximum 12 cycles (Per month) 186 Urinary Bladder Weekly Cisplatin/Carboplatin- max 6 cycles with RT (Per week) 2, Urinary Bladder Methotraxate Vinblastin Adriamycin 5,000 Cyclophosphamide (MVAC) 188 Retinoblastoma Carbo/Etoposide/Vincristine-max 6 cycles (Per cycle) 4, Febrile Neutropenia IV antibiotics and other supportive therapy (Per episode) 9, Vaginal Cancer Cisplastin/5-FU 3, Ovary Carboplatin/Paclitaxel-max 6 cycles (Per cycle) 6, Rectal Cancer Stage 2 And 3 Xelox Along With Adjuvant Chemotherapy Of AS-I 4,

255 193 Multiple Myeloma Zoledronic acid - Max 12 cycles (Per month) 2, Gestational Trophoblast Ds. Etoposide-Methotrexate-Actinomycin /Cyclophosphamide - 3,000 High Risk Vincristine (EMA-CO)-max 6 cycles (Per cycle) 195 Gestational Trophoblast Ds. Low Risk Actinomycin- max 10 cycles (Per cycle) 1, Gestational Trophoblast Ds. Low Risk Weekly Methotrexate (Per week) max. 10 cycles Ovary Germ Cell Tumour Bleomycin-Etoposide-Cisplatin (BEP) - max cycles 4 (Per cycle) 6, Prostate Hormonal Therapy - Per month 3, Testis Bleomycin-Etoposide-Cisplatin (BEP)- max cycles 4 (Per cycle) 6, Acute Myeloid Leukemia Induction Phase, up to 60, Acute Myeloid Leukemia Consolidation Phase, up to 40, Histocytosis Variable Regimen-Histocyosis-max 1 year (Per month) 8, Rhabdomyosarcoma Vincristine-Actinomycin-Cyclophosphamide (VACTC) based chemo - max 1 year (Per month) Rhabdomyosarcoma 6, Ewing s Sarcoma Variable Regimen Inv - Hematology, Biopsy Payable 6, Unlisted Regimen Palliative CT- Max 6 cycles (Per cycle) 5, Terminally Ill Palliative And Supportive Therapy - Per month 2, Vulval Cancer Cisplastin/5-FU 3, Acute Lymphatic Leukemia Maintenance Phase - Per month 3, Acute Lymphatic Leukemia Induction 1st And 2 nd Months - Payable maximum upto 50, Acute Lymphatic Leukemia Induction 3rd, 4th, 5th months - Payable maximum upto 20, Head and Neck Tab Geftinib/Erlotinib-Max 1 Year (Per month) 3,

256 SCHEDULE 5 PROCESS FOR CASHLESS ACCESS SERVICES 1. General The Beneficiaries shall be provided treatment by Empanelled Health Care Providers free of cost for all such diseases, illnesses suffered or accidents that require Hospitalization, Day Care Treatments, Tertiary Care or specified OPD consultations or other primary care within the limits or sub-limits and subject to the Sum Insured, subject only to the Exclusions. The Services Agreement between the Insurer and the Empanelled Health Care Provider shall include the Package Rates determined in accordance with Clause 5.2(a) or Clause 5.2(b) or revised in accordance with Clause 5.2(c) for the Medical Treatments, Surgical Procedures, Day Care Treatments, Follow-up Care and OPD Benefits for which such Empanelled Health Care Provider is empanelled. The Empanelled Health Care Provider shall be reimbursed for the expenses of Hospitalization or Day Care Treatment for a Medical Treatment or Surgical Procedure, Follow-up Care or OPD Benefit as per the Package Rate specified in the Services Agreement that it executes with the Insurer. If no Package Rate is specified, then the reimbursement for the eligible expenses shall be determined in accordance with the pre-authorization process specified in this Schedule 5. The Empanelled Health Care Provider shall, at the time of discharge, debit the amount as per the agreed Package Rate or the Pre-authorized Amount. The Insurer shall ensure that the Hospital IT infrastructure is installed at the premises of each Empanelled Health Care Providers for usage of the Smart Cards conforming to the MHIS Guidelines and within 30 days of such empanelment. The software to be used on such equipment shall also be approved and certified by MoHFW. 2. Pre-Authorization and Claim Procedures There are 5 categories of pre-authorization and Claim procedures that are set out in this Section 2. A summary of the Medical Treatments, Surgical Procedures, Day Care Treatments, Follow-up Care and OPD Benefits that fall under each of these categories is set out below: Category Description 1 OPD Benefits Ante- Natal and Post Natal Care Child Care Preventive Care (Diabetes and Cardiac) OPD Diagnostics with referral from Government Doctor. Investigations and Diagnostics that require Hospitalization or that are 256

257 identified as Day Care Treatments Follow Up Care utilization under Base Cover or Replenishment Cover Follow Up Care utilization under Critical Illness Cover Benefits under Senior Citizen Cover. 2 Surgical Procedures or Day Care Treatments that qualify as Tertiary Care in Schedule 3 Miscellaneous Surgical Procedures or Day Care Treatments listed in Schedule 3 (< INR 30,000) for which Category 3 authorization type is prescribed in Schedule 3 Listed Medical Treatments* for which Package Rates are provided in Schedule 3 3 Surgical Procedures or Day Care Treatments that are not listed in Schedule 3 or in Schedule 4 Unlisted Medical Treatments** Listed Medical Treatments*, Surgical Procedures or Day Care Treatments for which no Package Rates are provided in Schedule 3 4 Listed Medical Treatments*, Surgical Procedures and Day Care Treatments not requiring any pre-authorization 5 Critical Illnesses listed in Schedule 4 *Listed Medical Treatments refer to those Medical Treatments that are listed in Schedule 3. ** Unlisted Medical Treatments refer to those Medical Treatments that are not listed in Schedule 3 or in Schedule 4. Schedule 3 and Schedule 4 indicate the category of pre-authorization and Claim procedure to be followed for each Medical Treatment, Surgical Procedure, Day Care Treatment, Followup Care and OPD Benefit that is listed in those Schedules. The Insurer shall require the Empanelled Health Care Providers to follow these pre-authorization and Claim procedures for making Claims. 2.1 Category 1 The Empanelled Health Care Provider shall follow the procedure set out below: (a) The Empanelled Health Care Provider shall first verify the identity of the Beneficiary seeking care by verifying the fingerprint of the Beneficiary. However, the Empanelled Health Care Provider may verify the identity of: 257

258 (i) any other enrolled member of the Beneficiary Family Unit by taking the fingerprint, if the Beneficiary is suffering from an emergency or is in critical condition; or (b) (ii) the mother by taking the fingerprint of the mother, if the admission is in relation to Ante-Natal or Post-Natal Care benefit, New-born Child benefit or Child Care benefit for a child. The Empanelled Health Care Provider shall forward a Request for Authorization Letter (RAL) to the Insurer in the prescribed format after obtaining sufficient details about the Beneficiary and all details of the proposed line of treatment or benefit. The RAL must be faxed/ ed to the 24-hour authorization/cashless department of the Insurer at the fax number/ address provided by the Insurer, along with the contact details of the treating doctor. The Insurer s medical team may get in touch with the treating doctor, if necessary. The Empanelled Health Care Provider must submit the 'necessary documents' along with the RAL. The 'necessary documents' shall be the documents prescribed by the Insurer from time to time in the Services Agreement with the Empanelled Health Care Provider. (c) (d) (e) (f) The RAL form should be duly filled in and must be clear, following the Yes or No format. There should be no nil or blanks, as that could delay the pre-authorization process. The RAL (along with the necessary documents) should reach the pre-authorization department of the Insurer within 2 hours of the Beneficiary reporting to the hospital for availing: (i) the OPD Benefits; (ii) the investigations and diagnostics that require Hospitalization or that are identified as Day Care Treatments; or (iii) Follow-up Care. If the Empanelled Health Care Provider fails to comply with paragraph (d), it shall provide the Insurer with reasons for such delay in submitting the RAL. The Insurer shall issue the Authorization Letter (AL), once the Insurer has: (i) (ii) (iii) (iv) received the RAL and all necessary documents; ascertained the medical details of the OPD Benefits, investigations and diagnostics or Follow-up Care required by the Beneficiary; ascertained that the Empanelled Health Care Provider that has submitted the RAL has been empanelled for providing the proposed health care services; verified the previous utilization by the Beneficiary of the OPD Benefits, the Hospitalization/Day Care benefits or the Follow-up Care benefit and 258

259 determined that the sub-limits and conditions of utilization have not been exhausted or not been triggered; (v) ascertained whether: (A) (B) the OPD diagnostic care is listed in Section 2 of Schedule 3, if the RAL is submitted for utilizing the OPD diagnostic benefit under the Base Cover or the Replenishment Cover; or the Follow-up Care is listed in Section 2 of Schedule 4, if the RAL is submitted for utilizing the Follow-up Care benefit under the Critical Illness Cover; and (vi) either: (A) (B) identified the applicable Package Rate for the OPD Benefits or the investigations and diagnostics that are admissible under the Base Cover or the Replenishment Cover or Follow-up Care for Critical Illness that is required by the Beneficiary; or negotiated the Package Rate with the Empanelled Health Care Provider for the Follow-up Care benefit being utilized under the Base Cover and/or the Replenishment Cover. Such amount shall then be the Pre-authorized Amount for the purpose of this Clause 2.1. The AL shall mention: the unique authorization number; and the Pre-Authorized Amount. The Insurer shall complete this process within 2 hours of receiving the RAL, such that the total time for the pre-authorisation does not exceed 4 hours. The Parties may mutually agree to increase the turn around time for completion of the preauthorization process for the utilization of the OPD diagnostic benefit, but not the other benefits that are subject to pre-authorization under this Category 1. (g) (h) The issuance of the AL shall be a guarantee of payment from the Insurer to the Empanelled Health Care Provider for the Pre-authorized Amount, provided that such guarantee shall only be given for the reimbursement of eligible expenses and not for any other expenses. If: (i) the proposed benefit is Excluded; or 259

260 (ii) (iii) (iv) (v) (vi) the information or documents provided by the Empanelled Health Care Provider are insufficient for the medical team of the pre-authorization department to confirm eligibility; or the medical team of the pre-authorisation department determines that the proposed treatment, procedure, diagnostics or consultation is not Medically Necessary; or the Beneficiary's prior utilization of the benefit has exhausted the applicable sub-limit or triggered the conditions on which the benefit is provided; or the RAL has originated from an Empanelled Health Care Provider that is not empanelled for providing the particular benefit; or the Follow-up Care identified in the RAL is not listed in: (1) Section 2 of Schedule 3, if the RAL has been submitted for utilizing the OPD diagnostics benefit under the Base Cover and/or the Replenishment Cover; or (2) Section 2 of Schedule 4, if the RAL has been submitted for utilizing the Follow-up Care benefit under the Critical Illness Cover, the Insurer may deny authorization by issuing a Denial of Authorization Letter (DAL) or seek further clarification/information from the Empanelled Health Care Provider. If the Insurer issues a DAL on the ground specified in (v) above, then the Insurer shall promptly inform the Beneficiary of an alternative Empanelled Health Care Provider in the vicinity that provides the particular benefit. (i) (j) (k) The Insurer shall file a report with the State Nodal Agency within 1 day of issuing a DAL, explaining the reasons for issuing a DAL in each such case of denial of a RAL. The issuance of a DAL shall by no means result in denial of benefit by the Empanelled Health Care Provider. The Empanelled Health Care Provider shall deal with such a case as per their normal rules and regulations. Upon receiving the AL from the Insurer, the Empanelled Health Care Provider shall determine the available Sum Insured as follows: (i) For utilizing the OPD Benefits (other than the OPD diagnostics benefit) or Follow-up Care benefit under the Base Cover or Replenishment Cover: (A) (B) The Empanelled Health Care Provider shall verify that the available Base Sum Insured and/or available Replenishment Sum Insured is sufficient to meet the Pre-Authorized Amount. If the available Base Sum Insured is sufficient to meet the Preauthorized Amount, then the available Base Sum Insured shall be utilized to the extent of the Pre-authorized Amount. 260

261 (C) (D) (E) If the available Base Sum Insured is insufficient to meet the Preauthorized Amount, then the available Base Sum Insured shall be utilized to the extent available and the balance of the Preauthorized Amount shall be utilised from the available Replenishment Sum Insured. If the available Base Sum Insured is zero and the Replenishment Sum Insured is insufficient to meet the Pre-authorized Amount, then the available Replenishment Sum Insured shall be utilized to the extent available and the balance of the Pre-authorized Amount shall be charged from the Beneficiary at the time of discharge or on completion of care of the Beneficiary. If the available Base Sum Insured and the available Replenishment Sum Insured are both zero, then the full amount of the Preauthorized Amount shall be charged from the Beneficiary at the time of discharge or on completion of care. (ii) For utilizing the OPD diagnostic benefit under the Base Cover or the Replenishment Cover: (A) (B) (C) (D) The Empanelled Helath Care Provider shall verify whether: (x) the available Base Sum Insured or the available Replenishment Sum Insured; and (y) the unutilized portion of the 40,000 sub-limit, are sufficient to meet the Pre-authorized Amount. If the available Base Sum Insured and the unutilized portion of the 6,000 sub-limit are both sufficient to meet the Pre-authorized Amount, then the available Base Sum Insured will be used to meet the Pre-authorized Amount. If the available Base Sum Insured is sufficient, but the unutilized portion of the 6,000 sub-limit is insufficient to meet the Preauthorized Amount, then the available Base Sum Insured will be used to the extent of the unutilized portion of the 6,000 sublimit and the balance of the Pre-authorized Amount shall be charged from the Beneficiary at the time of discharge or on completion of care. If the available Base Sum Insured is insufficient, but the unutilized portion of the 6,000 sub-limit is sufficient to meet the Preauthorized Amount, then the available Base Sum Insured shall be utilized to the extent available and the balance of the Preauthorized Amount shall be utilised from the available Replenishment Sum Insured. 261

262 (E) (F) (G) If the available Base Sum Insured is zero and the Replenishment Sum Insured is insufficient, but the unutilized portion of the 6,000 sub-limit is sufficient to meet the Pre-authorized Amount, then the available available Replenishment Sum Insured shall be utilized to the extent available and the balance of the Preauthorized Amount shall be charged from the Beneficiary at the time of discharge or on completion of care of the Beneficiary. If both the available Base Sum Insured and the unutilized portion of the 6,000 sub-limit are insufficient to meet the Pre-authorized Amount, then the available Base Sum Insured followed by the available Replenishment Sum Insured will be used to the extent of the unutilized portion of the 6,000 sub-limit and the balance of the Pre-authorized Amount shall be charged from the Beneficiary at the time of discharge or on completion of care. If the available Base Sum Insured is zero and both the Replenishment Sum Insured unutilized portion of the 6,000 sublimit are insufficient to meet the Pre-authorized Amount, then the available Replenishment Sum Insured will be used to the extent of the unutilized portion of the 6,000 sub-limit and the balance of the Pre-authorized Amount shall be charged from the Beneficiary at the time of discharge or on completion of care. (iii) For utilization of the Follow-up Care benefit under the Critical Illness Sum Cover: (A) (B) (C) The Empanelled Health Care Provider shall verify whether: (x) the available Critical Illness Sum Insured; and (y) the unutilized portion of the 40,000 sub-limit, are sufficient to meet the Pre-authorized Amount. If the available Critical Illness Sum Insured and the unutilized portion of the 40,000 sub-limit are both sufficient to meet the Pre-authorized Amount, then the available Critical Illness Sum Insured will be used to meet the Pre-authorized Amount. If the available Critical Illness Sum Insured is sufficient, but the unutilized portion of the 40,000 sub-limit is insufficient to meet the Pre-authorized Amount, then the available Critical Illness Sum Insured will be used to the extent of the unutilized portion of the 40,000 sub-limit and the balance amount of the Pre-authorized Amount shall be charged from the Beneficiary at the time of discharge or on completion of care. 262

263 (D) (E) (F) If the available Critical Illness Sum Insured is insufficient to meet the Pre-authorized Amount, then the available Critical Illness Sum Insured will be used to the extent available and the balance amount shall be charged from the Beneficiary at the time of discharge or on completion of care. If both the available Critical Illness Sum Insured and the unutilized portion of the 40,000 sub-limit are insufficient to meet the Preauthorized Amount, then the lower of the available Critical Illness Sum Insured and the unutilized portion of the 40,000 sub-limit will be used to the extent available and the balance amount shall be charged from the Beneficiary at the time of discharge or on completion of care. If both the available Critical Illness Sum Insured and the unutilized portion of the 40,000 sub-limit are zero, then the full amount of the Pre-authorized Amount shall be charged from the Beneficiary at the time of discharge or on completion of care. (l) The Empanelled Health Care Provider shall make a provisional entry for providing benefit by blocking the Pre-authorized Amount (or the available Sum Insured or the unutilized portion of the applicable sub-limit, as applicable, if lower than the Preauthorized Amount) on the Smart Card of the Beneficiary before providing the OPD Benefit, the Hospitalization or Day Care benefit for an investigation or diagnostics or the Follow-up Care benefit under the Base Cover or the Replenishment Cover. The Empanelled Health Care Provider shall not provide any of these benefits to the Beneficiary, unless a provisional entry is completed and the Pre-authorized Amount is blocked on the Smart Card. Provided that the Empanelled Health Care Provider shall not make a provisional entry on the Smart Card for utilization of the Follow-up Care benefit under the Critical Illness Cover. Instead, the Empanelled Health Care Provider shall make a manual Claim upon the Insurer or its TPA for the Pre-authorized Amount (or the amount determined in accordance with paragraph (k) above, if lower than the Preauthorized Amount) in accordance with Schedule 10. The Empanelled Health Care Provider must manually record the unique authorization number and the Pre-authorized Amount stated in the AL, while blocking the amount on the Smart Card or making a manual Claim on the Insurer, as the case may be. (m) At the time of discharge or on completion of care of the Beneficiary, the Empanelled Health Care Provider shall make a final entry on the Smart Card of the Beneficiary after verification of the Beneficiary s fingerprint to complete the transaction. 263

264 (n) The Insurer shall make the payment to the Empanelled Health Care Provider electronically, within 30 days of receipt of the Claim transaction from the Empanelled Health Care Provider in the prescribed format. 2.2 Category 2 However, the Insurer shall not be liable to honour a Claim made by the Empanelled Health Care Provider if: (i) the information provided in the RAL or any of the necessary documents submitted is found to be incorrect; or (ii) the Insurer finds any non-disclosure or misrepresentation; or (iii) the Insurer is aware of any Fraudulent Activity and exercises its rights in accordance with its rights under Clause 13(b). The Empanelled Health Care Provider shall follow the procedure set out below: (a) The Empanelled Health Care Provider shall first verify the identity of the Beneficiary seeking care by verifying the fingerprint of the Beneficiary. However, the Empanelled Health Care Provider may verify the identity of any other enrolled member of the Beneficiary Family Unit by verifying the fingerprint of such Beneficiary, if the Beneficiary is suffering from an emergency or is in critical condition. (b) The Empanelled Health Care Provider shall then forward a RAL to the Insurer in the prescribed format after obtaining sufficient details about the Beneficiary and all details of the proposed line of treatment or benefit. The RAL must be faxed/ ed to the 24-hour authorization/cashless department of the Insurer at the fax number/ address provided by the Insurer, along with the contact details of the treating doctor. The Insurer s medical team may get in touch with the treating doctor, if necessary. The Empanelled Health Care Provider must submit the 'necessary documents' along with the RAL. The 'necessary documents' shall be the documents prescribed by the Insurer from time to time in the Services Agreement with the Empanelled Health Care Provider. (c) (d) (e) The RAL form should be duly filled in and must be clear, following the Yes or No format. There should be no nil or blanks, as that could delay the pre-authorization process. The RAL (along with the necessary documents) should reach the pre-authorization department of the Insurer within 2 hours of admission, in case of an emergency; and at least 7 days prior to the expected date of admission, in case of a planned admission. If the Empanelled Health Care Provider fails to comply with paragraph (d), it shall provide the Insurer with reasons for such delay in submitting the RAL. 264

265 (f) The Insurer shall issue the AL, once the Insurer has: (i) (ii) (iii) received the RAL and all necessary documents; ascertained the medical details of the proposed Listed Medical Treatment, Surgical Procedure or Day Care Treatment; ascertained that the RAL has originated from: (A) (B) an Empanelled Health Care Provider that has been empanelled for providing the proposed Listed Medical Treatment, Surgical Procedure or Day Care Treatment; and a Specialty Hospital that has been empanelled for the relevant Tertiary Care specialty, if the proposed Listed Medical Treatment, Surgical Procedure or Day Care Treatment qualifies as Tertiary Care; and (iv) identified the applicable Package Rate for the proposed Listed Medical Treatment, Surgical Procedure or Day Care Treatment, based on the Package Rates determined in accordance with Clause 5.2 and specified in the Services Agreement with the Empanelled Health Care Provider. Such Package Rate shall then be the Pre-authorized Amount for the purpose of this Clause 2.2, provided that the Pre-authorized Amount shall not exceed 30,000. The AL shall mention the unique authorization number and the Pre-Authorized Amount. The Insurer shall complete this process within 6 hours of receiving the RAL. (g) (h) The issuance of the AL shall be a guarantee of payment from the Insurer to the Empanelled Health Care Provider for the Pre-authorized Amount, provided that such guarantee shall only be given for the reimbursement of eligible expenses of the proposed Listed Medical Treatment, Surgical Procedure or Day Care Treatment and not for any other expenses. If: (i) (ii) the proposed benefit is Excluded; or the information or documents provided by the Empanelled Health Care Provider are insufficient for the medical team of the pre-authorization department to confirm eligibility; or 265

266 (iii) (iv) the medical team of the pre-authorisation department determines that the proposed Listed Medical Treatment, Surgical Procedure or Day Care Treatment is not Medically Necessary; or if the RAL has not originated from: (A) (B) an Empanelled Health Care Provider empanelled for providing the proposed Listed Medical Treatment, Surgical Procedure or Day Care Treatment; and a Specialty Hospital that is empanelled for the relevant Tertiary Care specialty, if the proposed Listed Medical Treatment, Surgical Procedure or Day Care Treatment qualifies as Tertiary Care, the Insurer may deny authorization by issuing a DAL or seek further clarification/information from the Empanelled Health Care Provider. If the Insurer issues a DAL on the ground specified in (iv) above, then the Insurer shall promptly inform the Beneficiary of an alternative Empanelled Health Care Provider or Specialty Hospital, as the case may be, in the vicinity that provides the Listed Medical Treatment, Surgical Procedure or Day Care Treatment. (i) (j) (k) The Insurer shall file a report with the State Nodal Agency within 1 day of issuing a DAL, explaining the reasons for issuing a DAL in each such case of denial of a RAL. The issuance of a DAL shall by no means result in denial of benefit by the Empanelled Health Care Provider. The Empanelled Health Care Provider shall deal with such a case as per their normal rules and regulations. Upon receiving the AL from the Insurer, the Empanelled Health Care Provider shall determine the available Sum Insured as follows: (i) (ii) (iii) (iv) The Empanelled Health Care Provider shall verify that the available Base Sum Insured and/or available Replenishment Sum Insured is sufficient to meet the Pre-authorized Amount. If the available Base Sum Insured is sufficient to meet the Pre-authorized Amount, then the available Base Sum Insured shall be utilized to the extent of the Pre-authorized Amount. If the available Base Sum Insured is insufficient to meet the Pre-authorized Amount, then the available Base Sum Insured shall be utilized to the extent available and the balance amount shall be utilised from the available Replenishment Sum Insured. If the available Base Sum Insured is zero and the Replenishment Sum Insured is insufficient to meet the Pre-authorized Amount, then the 266

267 (v) available Replenishment Sum Insured shall be utilized to the extent available and the balance amount of the Pre-authorized Amount shall be charged from the Beneficiary at the time of discharge. If the available Base Sum Insured and the available Replenishment Sum Insured are both zero, then the full amount of the Pre-authorized Amount shall be charged from the Beneficiary at the time of discharge. (l) The Empanelled Health Care Provider shall make a provisional entry for providing the Listed Medical Treatment, Surgical Procedure or Day Care Treatment, by blocking the Pre-authorized Amount (or the available Replenishment Sum Insured, if lower than the Pre-authorized Amount) on the Smart Card of the Beneficiary before providing such benefit. The Empanelled Health Care Provider shall not provide any benefits to the Beneficiary, unless a provisional entry is completed and the amount is blocked on the Smart Card. The Empanelled Health Care Provider must manually record the unique authorization number and the Pre-authorized Amount stated in the AL, while blocking the amount on the Smart Card. (m) (n) At the time of discharge of the Beneficiary, the Empanelled Health Care Provider shall make a final entry on the Smart Card of the Beneficiary after verification of the Beneficiary s fingerprint to complete the transaction. However, if the Beneficiary seeking care is dead, then the Empanelled Health Care Provider shall make such final entry after verification of any other enrolled member's fingerprint. The Insurer shall make the payment to the Empanelled Health Care Provider electronically, within 30 days of receipt of the electronic Claim transaction from the Empanelled Health Care Provider in the prescribed format. 2.3 Category 3 However, the Insurer shall not be liable to honour a Claim made by the Empanelled Health Care Provider if: (i) the information provided in the RAL or any of the necessary documents submitted is found to be incorrect; or (ii) the Insurer finds any non-disclosure or misrepresentation; or (iii) the Insurer is aware of any Fraudulent Activity and exercises its rights in accordance with its rights under Clause 13(b). The Empanelled Health Care Provider shall follow the procedure set out below: (a) The Empanelled Health Care Provider shall first verify the identity of the Beneficiary seeking care by verifying the fingerprint of the Beneficiary. However, the Empanelled Health Care Provider may verify the identity of any other enrolled member of the Beneficiary Family Unit by verifying the fingerprint of such Beneficiary, if the Beneficiary is suffering from an emergency or is in critical condition. 267

268 (b) The Empanelled Health Care Provider shall then forward a RAL to the Insurer in the prescribed format after obtaining sufficient details about the Beneficiary and all details of the proposed line of treatment or benefit. The RAL must be faxed/ ed to the 24-hour authorization/cashless department of the Insurer at the fax number/ address provided by the Insurer, along with the contact details of the treating doctor. The Insurer s medical team may get in touch with the treating doctor, if necessary. The Empanelled Health Care Provider must submit the 'necessary documents' along with the RAL. The 'necessary documents' shall be the documents prescribed by the Insurer from time to time in the Services Agreement with the Empanelled Health Care Provider. (c) (d) (e) (f) The RAL form should be duly filled in and must be clear, following the Yes or No format. There should be no nil or blanks, as that could delay the pre-authorization process. The RAL (along with the necessary documents) should reach the pre-authorization department of the Insurer within 6 hours of admission, in case of an emergency; and at least 7 days prior to the expected date of admission, in case of a planned admission. If the Empanelled Health Care Provider fails to comply with paragraph (d), it shall provide the Insurer with reasons for such delay in submitting the RAL. The Insurer shall issue the AL, once the Insurer has: (i) (ii) (iii) received the RAL and all necessary documents; ascertained the medical details of the proposed Medical Treatment, Surgical Procedure or Day Care Treatment; ascertained that: (A) (B) (C) the proposed Surgical Procedure or Day Care Treatment is not listed in Schedule 3 or in Schedule 4; or the proposed Medical Treatment is an Unlisted Medical Treatment; or the proposed Medical Treatment, Surgical Procedure or Day Care Treatment is listed in Schedule 3, but no Package Rate has been provided for it; (iv) ascertained that the RAL has originated from: 268

269 (A) (B) any Empanelled Health Care Provider, if the proposed Medical Treatment, Surgical Procedure or Day Care Treatment is not listed in Schedule 3 or in Schedule 4; or an Empanelled Health Care Provider that has been empanelled for providing the proposed Medical Treatment, Surgical Procedure or Day Care Treatment; and (v) negotiated the Package Rate with the Empanelled Health Care Provider for the proposed Medical Treatment, Surgical Procedure or Day Care Treatment after taking into account the medical condition and the estimated length of stay (such amount shall be the Pre-authorized Amount for the purpose of this Clause 2.3), provided that: (A) if the proposed Medical Treatment is not listed in Schedule 3 or in Schedule 4, then the Pre-authorized Amount shall be determined by applying the flat daily Package Rates specified in Section 1 of Schedule 3 and the estimated length of stay; and (B) the Pre-authorized Amount shall not exceed 30,000. The AL shall mention the unique authorization number and the Pre-Authorized Amount. The Insurer shall complete this process within 12 hours of receiving the RAL. (g) (h) The issuance of the AL shall be a guarantee of payment from the Insurer to the Empanelled Health Care Provider for the Pre-authorized Amount, provided that such guarantee shall only be given for the reimbursement of eligible expenses of the proposed Medical Treatment, Surgical Procedure or Day Care Treatment and not for any other expenses. If: (i) (ii) (iii) the benefit for which an RAL has been issued by an Empanelled Health Care Provider is Excluded; or the information or documents provided by the Empanelled Health Care Provider are insufficient for the medical team of the pre-authorization department to confirm eligibility; or the medical team of the pre-authorisation department determines that the proposed Medical Treatment, Surgical Procedure or Day Care Treatment is not Medically Necessary; or 269

270 (iv) if the RAL has not originated from an Empanelled Health Care Provider, the Insurer may deny authorization by issuing a DAL or seek further clarification/information from the Empanelled Health Care Provider. If the Insurer issues a DAL on the ground specified in (iv) above, then the Insurer shall promptly inform the Beneficiary of an alternative Empanelled Health Care Provider in the vicinity. (i) (j) (k) The Insurer shall file a report with the State Nodal Agency within 1 day of issuing a DAL, explaining the reasons for issuing a DAL in each such case of denial of a RAL. The issuance of a DAL shall by no means result in denial of benefit by the Empanelled Health Care Provider. The Empanelled Health Care Provider shall deal with such a case as per their normal rules and regulations. Upon receiving the AL from the Insurer, the Empanelled Health Care Provider shall determine the available Sum Insured as follows: (i) (ii) (iii) (iv) (v) The Empanelled Health Care Provider shall verify that the available Base Sum Insured and/or available Replenishment Sum Insured is sufficient to meet the Pre-authorized Amount. If the available Base Sum Insured is sufficient to meet the Pre-authorized Amount, then the available Base Sum Insured shall be utilized to the extent of the Pre-authorized Amount. If the available Base Sum Insured is insufficient to meet the Pre-authorized Amount, then the available Base Sum Insured shall be utilized to the extent available and the balance amount shall be utilised from the available Replenishment Sum Insured. If the available Base Sum Insured is zero and the Replenishment Sum Insured is insufficient to meet the Pre-authorized Amount, then the available Replenishment Sum Insured shall be utilized to the extent available and the balance amount of the Pre-authorized Amount shall be charged from the Beneficiary at the time of discharge. If the available Base Sum Insured and the available Replenishment Sum Insured are both zero, then the full amount of the Pre-authorized Amount shall be charged from the Beneficiary at the time of discharge. (l) The Empanelled Health Care Provider shall make a provisional entry for providing the Listed Medical Treatment, Surgical Procedure or Day Care Treatment, by blocking the Pre-authorized Amount (or the available Replenishment Sum Insured, if lower than the Pre-authorized Amount) on the Smart Card of the Beneficiary before providing such benefit. The Empanelled Health Care Provider shall not provide any 270

271 benefits to the Beneficiary, unless a provisional entry is completed and the amount is blocked on the Smart Card. The Empanelled Health Care Provider must manually record the unique authorization number and the Package Rate stated in the AL, while blocking the amount on the Smart Card. (m) (n) At the time of discharge of the Beneficiary, the Empanelled Health Care Provider shall make a final entry on the Smart Card of the Beneficiary after verification of the Beneficiary s fingerprint to complete the transaction. However, if the Beneficiary seeking care is dead, then the Empanelled Health Care Provider shall make such final entry after verification of any other enrolled member's fingerprint. The Insurer shall make the payment to the Empanelled Health Care Provider electronically, within 30 days of receipt of the electronic Claim transaction from the Empanelled Health Care Provider in the prescribed format. 2.4 Category 4 However, the Insurer shall not be liable to honour a Claim made by the Empanelled Health Care Provider if: (i) the information provided in the RAL or any of the necessary documents submitted is found to be incorrect; or (ii) the Insurer finds any non-disclosure or misrepresentation; or (iii) the Insurer is aware of any Fraudulent Activity and exercises its rights in accordance with its rights under Clause 13(b). At the time of blocking the Package Rate, the Empanelled Health Care Provider must manually record the unique authorization number and the Package Rate stated in the AL. The Empanelled Health Care Provider shall follow the procedure set out below: (a) The Empanelled Health Care Provider shall first verify the identity of the Beneficiary seeking care by verifying the fingerprint of the Beneficiary. However, the Empanelled Health Care Provider may verify the identity of any other enrolled member of the Beneficiary Family Unit by verifying the fingerprint of such Beneficiary, if the Beneficiary is suffering from an emergency or is in critical condition. (b) The Empanelled Health Care Provider shall verify that: (i) the Beneficiary is being admitted for a Medical Treatment or Surgical Procedure or that the Beneficiary will undergo a Day Care Treatment for which a Package Rate has been determined by the Insurer in accordance with Clause 5.2 and that has been set out in the Services Agreement executed by it with the Insurer; 271

272 (ii) the authorization type mentioned for the proposed Medical Treatment, Surgical Procedure or Day Care Treatment in Schedule 3 is Category 4; (iii) such Package Rate is less than or equal to 30,000; and (iv) the proposed Medical Treatment, Surgical Procedure or Day Care Treatment is not Excluded. (c) The Empanelled Health Care Provider shall verify that the available Sum Insured as follows: (i) (ii) (iii) (iv) (v) The Empanelled Health Care Provider shall verify that the available Base Sum Insured and/or available Replenishment Sum Insured is sufficient to meet the Package Rate for the proposed Medical Treatment, Surgical Procedure or Day Care Treatment. If the available Base Sum Insured is sufficient to meet the Package Rate, then the available Base Sum Insured shall be utilized to the extent of the Package Rate. If the available Base Sum Insured is insufficient to meet the Package Rate, then the available Base Sum Insured shall be utilized to the extent available and the balance amount shall be utilised from the available Replenishment Sum Insured. If the available Base Sum Insured is zero and the Replenishment Sum Insured is insufficient to meet the Package Rate, then the available Replenishment Sum Insured shall be utilized to the extent available and the balance amount of the Package Rate shall be charged from the Beneficiary at the time of discharge. If the available Base Sum Insured and the available Replenishment Sum Insured are both zero, then the full amount of the Package Rate shall be charged from the Beneficiary at the time of discharge. (d) (e) The Empanelled Health Care Provider shall make a provisional entry for providing the proposed Medical Treatment, Surgical Procedure or Day Care Treatment by blocking the Package Rate on the Smart Card of the Beneficiary. The Empanelled Health Care Provider shall not provide any Medical Treatment, Surgical Procedure or Day Care Treatment, unless a provisional entry is completed and the Package Rate is blocked on the Smart Card. At the time of discharge of the Beneficiary, the Empanelled Health Care Provider shall make a final entry on the Smart Card of the Beneficiary after verification of the Beneficiary s fingerprint to complete the transaction. However, if the Beneficiary seeking care is dead, then the Empanelled Health Care Provider shall make such final entry after verification of any other enrolled member's fingerprint. 272

273 (f) The Insurer shall make the payment to the Empanelled Health Care Provider electronically, within 30 days of receipt of the electronic Claim transaction from the Empanelled Health Care Provider in the prescribed format. 2.5 Category 5 However, the Insurer shall not be liable to honour a Claim made by the Empanelled Health Care Provider if the Insurer is aware of any Fraudulent Activity and it exercises its rights in accordance with Clause 13(b). The Empanelled Health Care Provider shall follow the procedure set out below: (a) The Empanelled Health Care Provider shall first verify the identity of the Beneficiary seeking care by verifying the fingerprint of the Beneficiary. However, the Empanelled Health Care Provider may verify the identity of any other enrolled member of the Beneficiary Family Unit by verifying the fingerprint of such Beneficiary, if the Beneficiary is suffering from an emergency or is in critical condition. (b) The Empanelled Health Care Provider shall then forward a RAL to the Insurer in the prescribed format after obtaining sufficient details about the Beneficiary and all details of the proposed line of treatment or benefit. The RAL must be faxed/ ed to the 24-hour authorization/cashless department of the Insurer at the fax number/ address provided by the Insurer, along with the contact details of the treating doctor. The Insurer s medical team may get in touch with the treating doctor, if necessary. The Empanelled Health Care Provider must submit the 'necessary documents' along with the RAL. The 'necessary documents' shall be the documents prescribed by the Insurer from time to time in the Services Agreement with the Empanelled Health Care Provider. (c) (d) (e) The RAL form should be duly filled in and must be clear, following the Yes or No format. There should be no nil or blanks, as that could delay the pre-authorization process. The RAL (along with the necessary documents) should reach the pre-authorization department of the Insurer within 2 hours of admission, in case of an emergency; and at least 7 days prior to the expected date of admission, in case of a planned admission. If the Empanelled Health Care Provider fails to comply with paragraph (d), it shall provide the Insurer with reasons for such delay in submitting the RAL. 273

274 (f) The Insurer shall issue the AL, once the Insurer has: (i) (ii) (iii) (iv) received the RAL and all necessary documents; ascertained the medical details of the proposed Critical Illness; ascertained whether the proposed Critical Illness is listed in Section 1 of Schedule 4; ascertained that the RAL has originated from: (A) (B) an Empanelled Health Care Provider that has been empanelled for providing the proposed Critical Illness; and a Specialty Hospital that has been empanelled for the relevant Tertiary Care specialty, if the proposed Critical Illness qualifies as Tertiary Care; (v) (vi) verified the previous utilization by the Beneficiary of the benefits under the Critical Illness Cover and the available Critical Illness Sum Insured; and identified the applicable Package Rate for the proposed Critical Illness, based on the Package Rates determined in accordance with Clause 5.2 and specified in the Services Agreement with the Empanelled Health Care Provider. Such Package Rate shall then be the Pre-authorized Amount for the purpose of this Clause 2.2, provided that the Pre-authorized Amount shall not exceed 170,000. The AL shall mention: the unique authorization number; the Pre-authorized Amount; and the available Critical Illness Sum Insured. The Insurer shall complete this process within 6 hours of receiving the RAL. (g) (h) The issuance of the AL shall be a guarantee of payment from the Insurer to the Empanelled Health Care Provider for the Pre-authorized Amount, provided that such guarantee shall only be given for the reimbursement of eligible expenses of the proposed Critical Illness and not for any other expenses. If: (i) (ii) the proposed benefit is Excluded; or the information or documents provided by the Empanelled Health Care Provider are insufficient for the medical team of the pre-authorization department to confirm eligibility; or 274

275 (iii) (iv) (v) (vi) the medical team of the pre-authorisation department determines that the proposed treatment is not Medically Necessary; or the proposed treatment identified in the RAL is not listed as a Critical Illness in Section 1 of Schedule 4; or the Beneficiary's prior utilization of the Critical Illness Cover has exhausted the Critical Illness Sum Insured; or if the RAL has not originated from: (A) (B) an Empanelled Health Care Provider empanelled for providing the proposed Critical Illness treatment; and a Specialty Hospital that is empanelled for the relevant Tertiary Care specialty, if the proposed Critical Illness treatment qualifies as Tertiary Care, the Insurer may deny authorization by issuing a DAL or seek further clarification/information from the Empanelled Health Care Provider. If the Insurer issues a DAL on the ground specified in (vi) above, then the Insurer shall promptly inform the Beneficiary of an alternative Empanelled Health Care Provider or Specialty Hospital, as the case may be, in the vicinity that provides the proposed Critical Illness. (i) (j) (k) The Insurer shall file a report with the State Nodal Agency within 1 day of issuing a DAL, explaining the reasons for issuing a DAL in each such case of denial of a RAL. The issuance of a DAL shall by no means result in denial of benefit by the Empanelled Health Care Provider. The Empanelled Health Care Provider shall deal with such a case as per their normal rules and regulations. Upon receiving the AL from the Insurer, the Empanelled Health Care Provider shall determine the available Sum Insured as follows: (i) (ii) The Empanelled Health Care Provider shall verify whether: (x) the available Base Sum Insured and/or the available Replenishment Sum Insured is sufficient to meet the Deductible of 30,000; and (y) the available Critical Illness Sum Insured is sufficient to meet the difference between the Preauthorized Amount and the Deductible (the Excess). For utilizing the Hospitalization or Day Care benefits under the Base Cover or Replenishment Cover to the extent of the Deductible: 275

276 (A) (B) (C) (D) If the available Base Sum Insured is sufficient to meet the Deductible, then the available Base Sum Insured shall be utilized to the extent of the Deductible. If the available Base Sum Insured is insufficient to meet the Deductible, then the available Base Sum Insured shall be utilized to the extent available and the balance amount shall be utilised from the available Replenishment Sum Insured. If the available Base Sum Insured is zero and the Replenishment Sum Insured is insufficient to meet the Deductible, then the available Replenishment Sum Insured shall be utilized to the extent available and the balance amount of the Deductible shall be charged from the Beneficiary at the time of discharge. If the available Base Sum Insured and the available Replenishment Sum Insured are both zero, then the full amount of the Deductible shall be charged from the Beneficiary at the time of discharge. (iii) For utilizing the Hospitalization or Day Care benefits under the Critical Illness Cover to the extent of the Excess: (A) (B) (C) If the available Critical Illness Sum Insured is sufficient to meet the Excess, then the available Critical Illness Sum Insured will be used to meet the Excess. If the available Critical Illness Sum Insured is insufficient to meet the Excess, then the available Critical Illness Sum Insured will be used to the extent available and the balance amount of the Excess shall be charged from the Beneficiary at the time of discharge. If the available Critical Illness Sum Insured is zero, then the full amount of the Excess shall be charged from the Beneficiary at the time of discharge. (l) The Empanelled Health Care Provider shall make a provisional entry for providing the Critical Illness treatment by blocking the Deductible (or the available Base Sum Insured and/or the available Replenishment Sum Insured, if lower than the Deductible) on the Smart Card of the Beneficiary before providing the Critical Illness treatment. The Empanelled Health Care Provider shall not provide any Critical Illness benefits to the Beneficiary, unless a provisional entry is completed and the amount is blocked on the Smart Card. Provided that the Empanelled Health Care Provider shall not make a provisional entry on the Smart Card for the Excess. Instead, the Empanelled Health Care Provider shall make a manual Claim upon the Insurer or its TPA for the Excess (or 276

277 the available Critical Illness Sum Insured, if lower than the Excess) in accordance with Schedule 10. The Empanelled Health Care Provider must manually record the unique authorization number and the Pre-authorized Amount stated in the AL, while blocking the amount on the Smart Card and making a manual Claim on the Insurer. (m) (n) At the time of discharge or on completion of care of the Beneficiary, the Empanelled Health Care Provider shall make a final entry on the Smart Card of the Beneficiary after verification of the Beneficiary s fingerprint to complete the transaction. The Insurer shall make the payment to the Empanelled Health Care Provider electronically, within 30 days of receipt of the Claim transaction from the Empanelled Health Care Provider in the prescribed format. 3. Insurer's Undertakings However, the Insurer shall not be liable to honour a Claim made by the Empanelled Health Care Provider if: (i) the information provided in the RAL or any of the necessary documents submitted is found to be incorrect; or (ii) the Insurer finds any non-disclosure or misrepresentation; or (iii) the Insurer is aware of any Fraudulent Activity and exercises its rights in accordance with its rights under Clause 13(b). (a) (b) The Insurer shall ensure that the pre-authorisation procedure for the benefits under Section 2 does not exceed the number of hours specified in each Category. The Insurer shall endeavour, with the assistance of the State Nodal Agency, to develop and strengthen the IT system for reducing the requirement for preauthorisation and manual Claim procedures, with the objective of reducing the waiting time for the Beneficiary. 277

278 East Khasi Hills Draft Dated 8 September 2016 SCHEDULE 6 LIST OF EMPANELLED HEALTH CARE PROVIDERS UNDER THE SCHEME 1. Summary of Health Care Facilities Empanelled Under the Scheme Sl. No. Hospital Nos. 1 District/Civil Hospital in Meghalaya 13 2 Community Health Centres (CHCs) in Meghalaya 28 3 Primary Health Centres (PHCs) in Meghalaya Regional Medical Institute 1 5 Private Hospitals in Meghalaya 15 6 Private Hospitals outside Meghalaya List of PHCs Empanelled in Meghalaya SL No. District Name Primary Health Centre 1 Diengiei PHC TOTAL 210 Block Name Mylliem 2 Mawroh PHC Mylliem 3 Pomlum PHC Mylliem 4 Mawsiatkhnam PHC Mylliem 5 Swer PHC Laitkroh 6 Laitryngew PHC Laitkroh 7 Laitlyngkot PHC Laitkroh 8 Khatarshnong Khrang PHC Laitkroh 9 Laitkynsew PHC Shella Bholaganj 10 Shella PHC Shella Bholaganj 11 Mawsahew PHC Shella Bholaganj 12 Sohbar PHC Shella Bholaganj 13 Mawlong PHC Shella Bholaganj 14 Dangar PHC Mawsynram 15 Ryngku PHC Mawsynram 16 Mawryngkneng PHC Mawryngkneng 17 Smit PHC Mawryngkneng 18 Diengpasoh PHC Mawryngkneng 19 Nongspung PHC Mawphlang 20 Mawphlang PHC Mawphlang 21 Pongtung PHC Pynursla 22 Wahsherkhmut PHC Pynursla 23 Mawkliaw PHC Pynursla 24 Jongksha PHC Mawkynrew 278

279 East Jainti a Hills West Jaintia Hills Ri Bhoi South West Khasi Hills West Khasi Hills Draft Dated 8 September Mawkynrew PHC Mawkynrew 26 Jatah PHC Mawkynrew 27 Rambrai PHC Nongstoin 28 Maweit PHC Nongstoin 29 Kynrud PHC Mairang 30 Maroid PHC Mairang 31 Wahrit PHC Mairang 32 Nongthliew PHC Mairang 33 Nongum PHC Mairang 34 Dongki-ingding PHC Mairang 35 Shallang PHC Mawshynrut 36 Nonglang PHC Mawshynrut 37 Aradonga PHC Mawshynrut 38 Markasa PHC Mawthadraishan 39 Pariong PHC Mawthadraishan 40 Kynshi PHC Mawthadraishan 41 Myriaw PHC Mawthadraishan 42 Mawthawpdah PHC Mawkyrwat 43 Rangthong PHC Mawkyrwat 44 Mawlasnai PHC Umsning 45 Kyrdem PHC Umsning 46 Umtrai PHC Umsning 47 Mawhati PHC Umsning 48 Umden PHC Umling 49 Byrnihat PHC Umling 50 Marnagar PHC Umling 51 Warmawsaw PHC Jirang 52 Jarain PHC Amlarem 53 Pdengshakap PHC Amlarem 54 Dawki PHC Amlarem 55 Namdong PHC Thadlaskein 56 Khliehtyrshi PHC Thadlaskein 57 Nangbah PHC Thadlaskein 58 Nartiang PHC Thadlaskein 59 Shangpung PHC Laskein 60 Mynso PHC Laskein 61 Iooksi PHC Laskein 62 Barato PHC Laskein 63 Sahnsniang PHC Laskein 64 Wapung Pamra PHC Khliehriat 65 Rymbai PHC Khliehriat 279

280 North Garo Hills East Garo Hills South West Garo Hills West Garo Hills Draft Dated 8 September Bataw PHC Khliehriat 67 Umkiang PHC Khliehriat 68 Lumshnong PHC Khliehriat 69 Saipung PHC Saipung 70 Asananggiri PHC Rongram 71 Babadam PHC Rongram 72 Tikrikilla PHC Tikrikilla 73 Pedaldoba PHC Tikrikilla 74 Darengre PHC Gambegre 75 Purakhasia PHC Dalu 76 Kherapara PHC Dalu 77 Bhaitbari PHC Selsella 78 Jeldupara PHC Selsella 79 Mellim PHC Gambegre 80 Garobadha PHC Selsella 81 Zikzak PHC Zikzak 82 Nogorpara PHC Zikzak 83 Kalaichar PHC Zikzak 84 Salmanpara PHC Zikzak 85 Betasing PHC Betasing 86 Rangsakona PHC Betasing 87 Belbari PHC Betasing 88 Mangsang PHC Dambo Rongjeng 89 Bansamgre PHC Samanda 90 Samanada PHC Samanda 91 Songsak PHC Songsak 92 Dobu PHC Songsak 93 Rari PHC Songsak 94 Gabil PHC Songsak 95 Dagal PHC Songsak 96 Mendipathar PHC Resubelpara 97 Bajengdoba PHC Resubelpara 98 Sualmari PHC Resubelpara 99 Dainadubi PHC Resubelpara 100 Kharkutta PHC Kharkutta 101 Adokgiri PHC Kharkutta 102 Wageasi PHC Kharkutta Rongrong PHC 103 Songsak 280

281 South Garo Hills Draft Dated 8 September Nangal Bibra PHC Baghmara 105 Siju PHC Baghmara 106 Rongara PHC Rongara 107 Maheshkola PHC Rongara 108 Sibbari PHC Gasuapara 109 Silkigre PHC Chokpot 3. List of CHCs Empanelled in Meghalaya Community SL No. District Name Health Centre Block Name 1 Mawiong CHC Mylliem 2 Sohra CHC Shella Bholaganj 3 Ichamati CHC Shella Bholaganj East Khasi Hills 4 Mawsynram CHC Mawsynram 5 Sohiong CHC Mawphlang 6 Pynursla CHC Pynursla 7 Nongkhlaw CHC Mairang West Khasi Hills 8 Riangdo CHC Mawshynrut 9 South West Khasi Hills Mawkyrwat CHC Mawkyrwat 10 Ranikor CHC Ranikor 11 Umsning CHC Umsning 12 Ri Bhoi Bhoirymbong CHC Umsning 13 Patharkhmah CHC Jirang 14 Nongtalang CHC Amlarem 15 West Jaintia Hills Ummulong CHC Thadlaskein 16 Laskein CHC Laskein 17 Khliehriat CHC Khliehriat East Jaintia Hills 18 Sutnga CHC Saipung 19 Darengre CHC Gambegre 20 Dalu CHC Dalu 21 West Garo Hills Phulbari CHC Selsella 22 Selsella CHC Selsella 23 Alagre CHC Dalu 24 South West Garo Hills Mahendraganj CHC Zikzak 25 Ampati CHC Ampati 281

282 26 North Garo Hills Resubelpara CHC Resubelpara 27 East Garo Hills Rongjeng CHC Dambo Rongjeng 28 South Garo Hills Chockpot CHC Chockpot 3. District/Civil Hospitals Empanelled in Meghalaya Sl No District Name Name of District Hospital Block Name 1 East Khasi Hills Ganesh Das Hospital 2 East Khasi Hills Shillong Civil Hospital 3 East Khasi Hills RP Chest Hospital 4 East Khasi Hills Pasteur Institute Shillong Mylliem 5 West Khasi Hills Nongstoin Civil Hospital Nongstoin 6 West Khasi Hills Tirot Singh Memorial Hospital Mairang West Jaintia 7 Hills Jowai Civil Hospital Thadlaskein 8 Ri Bhoi Nongpoh Civil Hospital Umling 9 West Garo Hills Tura Civil Hospital 10 West Garo Hills MCH Hospital 11 West Garo Hills Tura Tuberculosis Hospital Rongram 12 East Garo Hills Williamnagar Civil Hospital Samanda 13 South Garo Hills Baghmara Civil Hospital Baghmara 4. Regional Medical Institute 1 NEIGRHIMS East Khasi Hills 5. Private Hospitals Empanelled in Meghalaya SL No. Private Hospital In Meghalaya District Name Hospital Name Location 1 East Khasi Hills Nazareth Hospital Shillong 2 East Khasi Hills Bansara Eye Care Shillong 3 East Khasi Hills Dr. H. G. Roberts Hospital Shillong 4 East Khasi Hills Children Hospital Shillong 5 East Khasi Hills Hope Clinic Shillong 282

283 6 East Khasi Hills Bawri Nethralaya Mission Trust Shillong 7 East Khasi Hills Woodland Hospital Shillong 8 East Khasi Hills Bethany Hospital Shillong 9 East Khasi Hills SuperCare Hospital Shillong 10 RiBhoi Bethany Hospital Outreach Nongpoh 11 RiBhoi Holy Cross Health Centre Umsaw 12 West Garo Hills Tura Christian Hospital Tura 13 West Garo Hills Holy Cross Hospital Tura 14 West Khasi Hills Holy Cross Health Centre Miarang 15 West Jaintia Hills Dr. Norman Tunnel Hospital Jowai 6. Private Hospitals Empanelled outside Meghalaya Sl No Name of the Hospital Outside Meghalaya City State 1 Agile Hospital Guwahati Assam 2 GNRC Hospitals Guwahati Assam 3 Hayat Hospital Guwahati Assam 4 North East Cancer Guwahati Assam 5 St. John Hospital Guwahati Assam 6 WINTROBE HOSPITAL Guwahati Assam 7 MIDLAND HOSPITAL KAMRUP Assam 8 Manipal Hospitals Bangalore Karnataka 9 MVJ Medical College Hospital Bangalore Karnataka 10 Sapthagiri Hospital Bangalore Karnataka 11 Unity Lifeline Limited Bangalore Karnataka 12 Vydehi Hospital Bangalore Karnataka 13 Kshema Hospital Chamrajnagar Karnataka 14 St. Joseph Hospital Chamrajnagar Karnataka 15 Dr. M D Sachidananda Murthy Memorial Hospital Mysore Karnataka 16 Prajwal Health Care Mysore Karnataka 17 Riverview Hospital Mysore Karnataka 18 st. Joseph Hospital Mysore Karnataka 19 Vidyaranya Hospital Pvt. Ltd. Mysore Karnataka 20 CMC Vellor Vellor Tamil Naru 21 Bangur Hospital Kolkata West Bengal 283

284 22 Care & Cure Nursing Home Kolkata West Bengal 23 KPC Medical College & Hospital Kolkata West Bengal 24 PG Hospital Kolkata West Bengal 25 Sahararhat Nursing Home Kolkata West Bengal 26 Medica Hospital Kolkata West Bengal 27 Ruby General Hospital Ltd. Kolkata West Bengal 28 Indraprastha Apollo Hospital Delhi New Delhi 29 Apollo Gleneagle Hospital Kolkata West Bengal 30 American Oncology Institute Hyderabad Andhra Pradesh 31 Basavatarakam Indo American Cancer Hospital & Andhra Hyderabad Research Pradesh 32 Sri Balaji Action Medical Delhi NCR 33 Dharamshila Cancer Hospital & Research Centre Delhi NCR 34 Sumitra Hospital Noida Uttar Pradesh 35 BLK Hospital Delhi NCR 36 Prime Hospital Hyderabad Andhra Pradesh 37 Prime Hospital Hyderabad Andhra Pradesh 38 Narayana Institute of Cardiac Sciences Bangalore Karnataka 39 Mazumdar Shaw Medical Centre Bangalore 40 Rabindranath Tagore International Institute of Cardiac Sciences Kolkata West Bengal 41 Narayana Superspeciality Hospital Howrah West Bengal 42 Narayana Multispeciality Hospital Howrah West Bengal 43 Narayana Multispeciality Hospital Kolkata West Bengal 44 Narayana Superspeciality Hospital Guwahati Assam 284

285 SCHEDULE 7 MINIMUM EMPANELMENT CRITERIA 1. Minimum Criteria for Empanelment of Public Health Care Providers within or outside Service Area All public health care providers identified by the State Nodal Agency (including CHCs and PHCs) and Employee State Insurance hospitals within the Service Area shall be empanelled provided they possess the following minimum facilities and resources: (a) (b) (c) (d) (e) (f) (g) (h) at least 10 functioning in-patient beds if the public health care provider is situated in a town with a population that is less than 10,00,000 and at least 15 functioning inpatient beds in all other areas; qualified Medical Practitioner(s) are in-charge around the clock; Qualified Nurses are under its employment around the clock; telephone/fax; if the public health care provider undertakes Surgical Procedures or Day Care Treatments, it should have a fully equipped operation theatre of its own; an operational pharmacy and diagnostic test services, or with an agreement to link to an operational pharmacy and diagnostic test services laboratory in close vicinity, so as to provide Cashless Access Services to the Beneficiaries; it has a system for maintaining and providing medical and other Beneficiary related records to the Insurer, the TPA or their representatives and the State Nodal Agency, as and when required; and a bank account which is operated by the public health care provider through Rogi Kalyan Samiti or equivalent body. The Insurer shall also make efforts to empanel public health care providers (including CHCs and PHCs) and Employee State Insurance hospitals outside the Service Area provided that they possess the minimum facilities and resources specified above. 2. Minimum Criteria for Empanelment of Private Health Care Providers within or outside the Service Area The Insurer shall empanel a willing private hospital or other private health care provider (other than a stand-alone day care centre) provided that it possesses the minimum facilities and resources specified below: (a) (b) the hospital or other private health care provider shall be registered under the Meghalaya Nursing Homes (Licensing and Registration) Act, 1993, if it is situated within the Service Area; and under the Clinical Establishments (Registration and Regulation) Act, 2010 or other similar state acts if it is situated outside the Service Area; at least 10 functioning in-patient beds if the hospital or other private health care provider is situated in a town with a population that is less than 10,00,000 and at least 15 functioning in-patient beds in all other areas; 285

286 (c) (d) (e) (f) (g) (h) (i) (j) qualified Medical Practitioner(s) are in-charge around the clock; Qualified Nurses are under its employment around the clock; if the private health care provider undertakes Surgical Procedures or Day Care Treatments, it should have a fully equipped Operating Theatre of its own; an operational pharmacy and diagnostic test services laboratory, or with an agreement to link to an operational pharmacy and diagnostic test services laboratory in close vicinity, so as to provide Cashless Access Services to the Beneficiaries; it has a system for maintaining and providing medical and other Beneficiary related records to the Insurer, the TPA or their representatives and the State Nodal Agency, as and when required; registration with the Income Tax Department and any other relevant tax authorities; bank account with electronic payment facility; and telephone/fax. 3. Minimum Criteria for Empanelment of Stand-alone Day Care Centres The Insurer shall empanel a willing stand-alone day care centre provided that it possesses the minimum facilities and resources specified below: (a) (b) (c) (d) (e) (f) (g) (h) (i) the stand-alone day care centre shall be registered under the Meghalaya Nursing Homes (Licensing and Registration) Act, 1993, if it is situated within the Service Area; and under the Clinical Establishments (Registration and Regulation) Act, 2010 or other similar state acts if it is situated outside the Service Area; at least 10 functioning day care beds; it is under the supervision of a Medical Practitioner and Medical Practitioner(s) are available at all times during working hours; Qualified Nurses are under its employment; it has a fully equipped Operating Theatre capable of carrying out Day Care Treatments; it has a system for maintaining and providing medical and other Beneficiary related records to the Insurer, the TPA or their representatives and the State Nodal Agency, as and when required; registration with the Income Tax Department and any other relevant tax authorities; bank account with electronic payment facility; and telephone/fax. 4. Minimum Criteria for Empanelment of Specialty Hospitals The Insurer shall empanel a willing specialty hospital or stand-alone day care centre having a Tertiary Care specialty, provided that: (i) it meets the minimum empanelment criteria set out in paragraph 2 or paragraph 3 above; and (ii) possesses the minimum facilities and resources for the Tertiary Care specialty (specified in the table below) for which it is seeking empanelment. 286

287 Once empanelled for a particular Tertiary Care specialty, a specialty hospital shall be deemed a Specialty Hospital only for that Tertiary Care specialty. The Insurer may empanel the same specialty hospital for more than one Tertiary Care specialties. Tertiary Care Specialty Oncosurgery and Cancer Therapy Additional Empanelment Criteria Qualified oncology surgeon Qualified medical oncologist and nuclear medicine specialist, radiation oncologist Radiotherapist Availability of Medical Practitioner and support staff Well-equipped operation theatre Equipment for Cobalt therapy, Linear accelerator and brachytherapy Evidence of a tumor board to decide comprehensive treatment plan Cardiothoracic and Cardiology surgery Cardiothoracic surgeon with MCh CTVS or equivalent degree Qualified cardiologist with DM or equivalent degree Qualified cardiologist with DM or equivalent degree and experience in interventions and procedures Specialised CTVS operation theatre Fully equipped Cardiac Catheterization laboratory (cath lab) unit with qualified and trained paramedics Post-operative ICU with ventilator support ICCU/ICU facility with cardiac monitoring equipment and ventilator support Round the clock (24x7) cardiology services Facility must have done at least 100 interventions or cardiac surgeries in the previous 1 year Neurosurgery and Neurology Qualified neuro-surgeon with MCh neurosurgery or equivalent degree Qualified neurologist with DM neurology or equivalent degree Well-equipped operation theatre with qualified paramedical staff Neuro ICU with ventilator support Post Op ventilator support Step down facility Facilitation for round the clock (24x7) MRI, CT and other support bio-chemical investigations EEG, ENMG, Angio CT facility 287

288 Tertiary Care Specialty Nephrology and Urology Surgery Additional Empanelment Criteria Nephrologist with DM or equivalent degree Qualified urologist with MCh Urology or equivalent degree Dialysis unit For transplant surgery approval o Transplant facility available o Facility should have done a minimum of 20 transplants in the previous 2 years Well-equipped operation theatre with C-ARM Endoscopy investigation support Post op ICU care with ventilator support Sew lithotripsy equipment Orthopaedic Specialist with MS (Ortho) degree Portable X-Ray Machine Modular OT Plaster room in OPD/indoor with equipment, Albee table OT Equipment like trauma fixation systems, Spine Fixation System Qualified paramedical staff 5. Minimum Empanelment Criteria for Providing OPD Diagnostic Services The State Nodal Agency or MoHFW may from time to time issue MHIS Guidelines and/or MHIS Operational Manual stipulating the minimum empanelment criteria required to be complied with for the provision of the OPD diagnostic services that are covered under the Base Cover and the Replenishment Cover. Such criteria may include KPIs and service quality indicators for providers of such OPD diagnostic services, including indicators such as, but not limited to quality and type of equipment, retention of films and other records, turnaround time, waiting time, reporting time and retest rates. Upon issuance of such guidelines by the State Nodal Agency or MoHFW, the Insurer shall ensure that it empanels only Specialty Hospitals and/or Diagnostics Labs meeting these guidelines for the provision of such OPD diagnostic services. Until such time, only Specialty Hospitals shall be permitted to provide OPD diagnostic services. 6. Minimum Empanelment Criteria for Stand-alone Out-patient Service Providers 288

289 All out-patient services covered by the OPD Benefits may be provided by the Empanelled Health Care Providers meeting the minimum empanelment criteria set out in the above paragraphs. In addition, the Insurer may empanel stand alone public or private health care providers providing solely out-patient services for the provision of the OPD services that are covered by the OPD Benefits. The Insurer shall empanel a willing stand-alone day care centre provided that it possesses the minimum facilities and resources specified below: (a) (b) (c) (d) (e) (f) (g) The facility must be managed by a registered medical practitioner whose degree is recognized by a national board of medical sciences or equivalent body. The doctor will be allowed to prescribe drugs only related to his qualification. For example a doctor of AYUSH will not be eligible to prescribe allopathic medicines and vice versa. The clinics shall have the facility to dispense drugs at the clinic itself. If the clinic does not have such a facility, it is the doctor s responsibility to have an understanding with pharmacies to carry out the required function so as to provide cashless service to the Beneficiaries. It has a system for maintaining and providing medical and other Beneficiary related records to the Insurer, the TPA or their representatives and the State Nodal Agency, as and when required. Registration with the Income Tax Department and any other relevant tax authorities. Bank account with electronic payment facility. Telephone/fax. 7. Additional Compliance Requirements At the time of conducting an inspection of the facilities and resources of a willing health care provider, the Empanelment Team shall review whether such health care provider has instituted internal mechanisms for: clinical audit protocols and monitoring infection control protocols and monitoring waste disposal policy and monitoring utilization reports (information about admission details with length of stay, diagnosis and procedures conducted for all in-patients) staff ratios and list of clinical specialists available The additional compliance requirements prescribed in this Section 5 are only for information regarding the desired quality processes of an Empanelled Health Care Provider and are not mandatory. The State Nodal Agency reserves the right to prescribe such additional 289

290 conditions as a mandatory compliance requirement for the empanelment of health care providers or for Empanelled Health Care Providers at any time during the Term. 290

291 SCHEDULE 8 SPECIFICATIONS FOR HOSPITAL IT INFRASTRUCTURE 1. Hardware (a) TWO Smart Card readers with following configuration: PCSC and ISO 7816 compliant Read and write all microprocessor cards with T=0 and T=1 protocols USB 2.0 full speed interface to PC with simple command structure (b) ONE Biometric finger print recognition device with following configuration: 2. Software 5v DC 500mA (Supplied via USB port) Operating temperature range: 0 ºC to 40 ºC Operating humidity range: 10% to 80% Compliance: FCC Home or Office Use, CE and C-Tick 500 dpi optical fingerprint scanner (22 x 24mm) USB 1.1 Interface Drivers for the device should be available on Windows or Linux platform High quality computer based fingerprint capture (enrolment) Capable of converting Fingerprint image to RBI approved ISO template. Transaction software for Hospitals approved by MoHFW for RSBY 3. Maintenance Support ONE year warranty for all hardware devices supplied Free Service Calls for Software maintenance for 1 year Unlimited Telephonic Support 291

292 SCHEDULE 9 PROCESS NOTE FOR DE-EMPANELMENT OF EMPANELLED HEALTH CARE PROVIDERS 1. Background This process note provides broad operational guidelines regarding de-empanelment of Empanelled Health Care Providers by the Insurer. The process to be followed and roles of different stakeholders have been outlined. 2. Process to be followed for De-Empanelment of Empanelled Health Care Providers Step 1 Putting the Empanelled Health Care Provider on "Watch-list" (a) (b) (c) If the Insurer believes that any of the events listed in Clause has occurred or if the Insurer believes that the performance of the Empanelled Health Care Provider raises any doubts, based on the Claims data analysis and/or the medical audit conducted by the Insurer, then the Insurer or its representative shall put that Empanelled Health Care Provider on the watch list. The data of such Empanelled Health Care Provider shall be analysed very closely on a daily basis by the Insurer or its representatives for patterns, trends and anomalies. The Insurer shall immediately inform the State Nodal Agency about the Empanelled Health Care Provider which has been put on the watch list, within 24 hours of taking such action. Step 2 Suspension of the Hospital (a) An Empanelled Health Care Provider may be temporarily suspended in the following cases: (i) (ii) (iii) If an Empanelled Health Care Provider which is on the "Watch-list", if the Insurer observes continuous patterns or strong evidence of irregularity based on either Claims data or medical audits. If an Empanelled Health Care Provider is not on the "Watch-list", but the Insurer observes at any time that it has data/evidence that suggests that the Empanelled Health Care Provider is: (x) involved in any unethical practice; (y) in material breach of the provisions of the Services Agreement with the Insurer; or (z) its representative(s) is/are involved in financial fraud related to the Beneficiaries; or (aa) the Empanelled Health Care Provider is engaged in any other Fraudulent Activity. If a directive is given by State Nodal Agency based on the complaints received by it or data analysis or field visits done by the State Nodal Agency. 292

293 In each of these cases, the Insurer may immediately suspend the Empanelled Health Care Provider from providing services to the Beneficiaries and institute a formal investigation in accordance with Step 3 below. (b) (c) The Empanelled Health Care Provider, the district authority and the State Nodal Agency should be informed of the decision of the Insurer to suspend an Empanelled Health Care Provider within 6 hours of taking such action so that no fresh admission of Beneficiaries may be undertaken. Further, at least 24 hours prior notice should be given to the Empanelled Health Care Provider so that no fresh admissions are made. To ensure that suspension of the Empanelled Health Care Provider results in its being barred from making fresh admissions of Beneficiaries, the Insurer shall make a provision in the software installed at the Empanelled Health Care Provider premises so that the Empanelled Health Care Provider cannot send electronic Claims to the Insurer or its representatives. Notwithstanding the suspension of an Empanelled Health Care Provider, the Insurer shall ensure that it shall honour all Claims for any expenses that have been preauthorized or blocked on the Smart Cards before the effectiveness of such suspension. (d) (e) (f) The Insurer shall immediately notify the TPA or its representatives that are responsible for Claims processing of such suspension of an Empanelled Health Care Provider. Further, the Insurer shall not and shall instruct its TPA or representatives not to process any Claims received from the suspended Empanelled Health Care Provider during the period of such suspension. The Insurer shall promptly send a formal letter to the Empanelled Health Care Provider regarding its suspension. Such notice shall specify the timeframe within which the formal investigation will be completed by the Insurer. The Insurer shall issue an advertisement in the local newspaper specifying that the health care services will be temporarily stopped at the suspended Empanelled Health Care Provider within 24 hours of such suspension. The newspaper and the content of message will be jointly decided by the insurer and the district level administration of the State Nodal Authority. Step 3 Detailed Investigation (a) The Insurer may launch a detailed investigation into the activities of an Empanelled Health Care Provider in the following situations: (i) (ii) If such Empanelled Health Care Provider has been suspended. Upon receipt of a complaint of a serious nature from any of the stakeholders in the MHIS phase

294 (b) (c) (d) (e) (f) The detailed investigation may include field visits to the Empanelled Health Care Provider, examination of case papers, meetings with the Beneficiaries (if needed), examination of hospital records, etc. The Empanelled Health Care Provider shall be required to fully cooperate with and provide access to all information to the Insurer and its representatives that are conducting such investigation. If the investigation reveals that the report, complaint or allegation against the Empanelled Health Care Provider is not substantiated, then the Insurer shall immediately revoke the suspension notice (if the Empanelled Health Care Provider has been suspended) and inform the State Nodal Agency of the revocation of such suspension. A letter regarding revocation of suspension shall be sent to the Empanelled Health Care Provider within 24 hours of the Insurer taking such decision. The Insurer shall, within 24 hours of revoking the Empanelled Health Care Provider's suspension, issue an advertisement in the local newspaper notifying Beneficiaries of the re-commencement of health care services at such Empanelled Health Care Provider's premises. The newspaper and the content of message will be jointly decided by the insurer and the district Authority. The Insurer shall activate the software installed at the Empanelled Health Care Provider premises so that the Empanelled Health Care Provider can send electronic Claims to the Insurer or its TPA or representatives. Such activation shall be done within 24 hours of the revocation of suspension. Step 4 Action by the Insurer (a) If the investigation reveals that the report, complaint or allegation against the Empanelled Health Care Provider is correct then the following procedure shall be followed: (i) (ii) (iii) The Empanelled Health Care Provider shall be issued a "show-cause" notice seeking an explanation for the aberration and a copy of the show cause notice shall be sent to the State Nodal Agency. After receipt of the explanation from the Empanelled Health Care Provider and its examination, the Insurer may either drop the charges or take any necessary action. The Insurer shall be entitled to take any one or more of the following actions against the Empanelled Health Care Provider, based on the seriousness of the issue and other factors involved: (x) issue a warning to the concerned Empanelled Health Care Provider; or (y) de-empanel the concerned Empanelled Health Care Provider. 294

295 (b) (c) The entire process shall be completed within 30 days from the date of suspension of the concerned Empanelled Health Care Provider. In addition to de-empanelment of an Empanelled Health Care Provider for cause, the Insurer shall have the right to de-empanel an Empanelled Health Care Provider at the end of a Policy Cover Period, provided that: (i) the Insurer has obtained the prior written consent of the State Nodal Agency for such de-empanelment; and (ii) the Insurer ensures that an adequate number of health care providers are available in the block/district in which such Empanelled Health Care Provider is situated. Step 5 Actions to be taken after De-empanelment Once an Empanelled Health Care Provider has been de-empanelled under MHIS Phase 3 (De-empanelled Health Care Provider), the following steps shall be taken: (a) (b) (c) (d) (e) (f) (g) A letter shall be sent to the concerned De-Empanelled Health Care Provider regarding this decision with a copy to the State Nodal Agency, the relevant District Kiosk and the Insurer s representatives that are responsible for Claims processing. The MHC issued to the concerned De-Empanelled Health Care Provider shall be collected by the Insurer and returned to the District Key Manager. Details of the De-empanelled Health Care Provider shall be sent by the State Nodal Agency to MoHFW, so that this information can be published on the RSBY national website. This information shall be sent to National Nodal Officers of all the other insurers which are participating in the RSBY. The Insurer and/or the State Nodal Agency shall lodge an FIR against the De- Empanelled Health Care Provider at the earliest, if the de-empanelment is on account of a Fraudulent Claim, a Fraudulent Activity or a potentially Fraudulent Activity. The Insurer shall publicise the fact of such de-empanelment in the local media, informing all Beneficiaries about the de-empanelment, so that the Beneficiaries do not utilize the services of the De-Empanelled Health Care Provider. If the De-Empanelled Health Care Provider appeals against the decision of the Insurer, all the aforementioned actions shall be subject to the decision of the concerned Grievance Redressal Committee. 3. Grievance by the De-empanelled Health Care Provider The De-Empanelled Health Care Provider may approach the relevant Grievance Redressaal Committee for redressal of its grievance against the actions of the Insurer. The Grievance Redressal Committee shall take a final view within 30 days of receipt of a representation 295

296 from the De-Empanelled Health Care Provider. However, such health care provider shall continue to be de-empanelled until a final view is taken by the Grievance Redressal Committee. The Grievance Redressal Mechanism shall be as set out in the Insurance Contract. 4. Special Cases for De-empanelment If at the end of the risk cover under the Policy for a district, the Insurer does not wish to continue with a particular Empanelled Health Care Provider in a district it can de-empanel that Empanelled Health Care Provider after prior approval from the State Nodal Agency and the District Key Manager. However, it should be ensured that adequate Empanelled Health Care Providers are available in the district for the Beneficiaries. 296

297 SCHEDULE 10 GUIDELINES FOR THE DISTRICT KIOSK AND DISTRICT SERVER The Insurer shall set up and operationalize the District Kiosk and District Server in all districts within 15 days of the signing of this Insurance Contract. 1. District Kiosk The Insurer shall set up a District Kiosk in each of the districts in the Service Area. 1.1 Location of the District Kiosk The District Kiosk shall be located at the district headquarters at a place that is frequented and easily accessible. The State Nodal Agency or the Government of Meghalaya may provide a place at the district headquarters to the Insurer to set up the District Kiosk. It should be located at a prominent place which is easily accessible and locatable by Beneficiaries. Alternatively, the Insurer may set up the District Kiosk at its own District Office. In either case, the Insurer shall be required to provide sitting and waiting space, utilities and water facilities for the Beneficiaries visiting the District Kiosk. 1.2 Specifications of the District Kiosk The District Kiosk should be equipped with at least the following hardware and software (according to the specifications provided by the Government of India): (a) Hardware components Computer (1 in number) Fingerprint Scanner / Reader Module (1 in number) Camera (1 in number) This should be capable of supporting all other devices required. It should be loaded with standard software as per specifications provided by MOHFW Thin optical sensor 500 ppi optical fingerprint scanner (22 x 24mm) High quality computer based fingerprint capture (enrolment) Preferably have a proven capability to capture good quality fingerprints in the Indian rural environment Capable of converting fingerprint image to RBI approved ISO template. Preferably Bio API version 1.1 compliant Sensor: High quality VGA Still Image Capture: up to 1.3 megapixels (software enhanced). Native resolution is 640 x 480 Automatic adjustment for low light conditions Smart Card Readers PC/SC and ISO 7816 compliant 297

298 (2 in number) Read and write all microprocessor cards with T=0 and T=1 protocols USB 2.0 full speed interface to PC with simple command structure PC/SC compatible Drivers Smart Card printer (1 in number) Supports Colour dye sublimation and monochrome thermal transfer Edge to edge printing standard Integrated ribbon saver for monochrome printing Prints at least 150 cards/ hour in full colour and up to 1000 cards an hour in monochrome Minimum Printing resolution of 300 dpi Compatible with Windows / Linux Automatic or manual feeder for Card Loading Compatible to Microprocessor chip personalization Telephone Line (1 in number) This is required to provide support as a helpline Internet Connection This is required to upload/send data (b) Software components Operating System Vendor can adapt any OS for their software as long as it is compatible with the software Database Vendor shall adapt a secure mechanism for storing transaction data District Server Application Software For generation of URN Configuration of enrolment stations Collation of transaction data and transmission to State Nodal Agency as well as other insurance companies Beneficiary enrolment software System Software Card personalization and issuance software Post issuance modifications to card Transaction system software [Note: It is the Insurer s responsibility to ensure in-time availability of these softwares. All these softwares must conform to the specifications laid down by MoHFW. Any modifications to the software for ease of use by the Insurer can be made only after confirmation from MoHFW. All software would have to be certified by competent authority as defined by MoHFW.] (c) Smart Card: The Smart Card issuance system should be able to personalize a 64KB NIC certified SCOSTA Smart Card for the MHIS phase 3 as per the card layout. For the avoidance of doubt, the Insurer shall, at its own cost, make available the hardware and software at each District Kiosk to facilitate the enrolment of Beneficiary Family Units at each District Kiosk. The State Nodal Agency shall make available at least one FKO at each District Kiosk to facilitate such enrolment. 298

299 (d) District Kiosk Card: In addition to the above mentioned specifications, a District Kiosk Card issued by MoHFW should be available at the District Kiosk. 1.3 Purpose of the District Kiosk: The District Kiosk is the focal point of activity at the district level, especially once the Smart Card is issued (i.e., post-issuance). The Insurer shall undertake the following activities at the District Kiosk: (a) (b) (c) (d) (e) (f) (g) re-issuing of lost Smart Cards; splitting of Smart Cards between members of same Beneficiary Family Unit; modification of Smart Cards; splitting of Smart Cards, if two or more unrelated families have their details included as part of the same Beneficiary Family Unit (e.g., if tenant family details included in family of landlord and vice versa); issuance of Smart Cards to Beneficiary Family Units who have not attended enrolment at the enrolment station, provided that such Beneficiary Family Unit comes for enrolment to the District Kiosk within 4 months from the date of commencement of enrolment in that district; issuance of Smart Cards to Beneficiary Family Units, if the head of household and his/her spouse has died, in which case the other members of the Beneficiary Family Unit whose names and details are in the Beneficiary Database can be enrolled; and issuance of Smart Cards to Beneficiary Family Units who could not be enrolled at the enrolment station, if the name of the head of household does not appear in the Beneficiary Database for the district in which enrolment was first sought, provided that the name of the head of household appears in the Beneficiary Database for another district in the Service Area. The Insurer shall carry out the functions set out in paragraphs (d) to (g) in accordance with the MHIS Guidelines issued from time to time. It should be ensured that in a single transaction only one activity/updation should be carried out over the Smart Card i.e., there should not be a combination of Smart Card re-issuance, modification and/or splitting. The District Kiosk should also enable the business continuity plan in case the Smart Card or the devices fail and electronic transactions cannot be carried out. The principal functions of a District Kiosk are as follows: 299

300 (1) Re-issuance of a Smart Card: This is done in the following cases: The Smart Card is reported as lost or missing through any of the channels mentioned by the Smart Card vendor/insurer, or, the Smart Card is damaged. (i) (ii) (iii) (iv) (v) (vi) At the District Kiosk, based on the URN, the current Smart Card serial number will be marked as hot-listed in the backend to prevent misuse of the lost/missing/damaged Smart Card. The existing data of the Beneficiary, including photograph, fingerprints and transaction details shall be pulled up from the District Server, verified by the Beneficiary and validated using the Beneficiary s fingerprints. The Beneficiary Family Unit shall be given a date (based on SLA with the State Nodal Agency) when the reissued Smart Card may be collected. It is the responsibility of the Insurer to collate transaction details of the Beneficiary Family Unit from their central server (to ensure that any transactions done in some other district are also available). The Smart Card should be personalised with details of Beneficiary Family Unit, transaction details and insurance details within the defined time using the District Kiosk card (MKC) for key insertion. The cost of the Smart Card would be paid by the Beneficiary at the District Kiosk. (2) Splitting of Smart Card: Smart Card splitting is done to help the Beneficiary to avail the services simultaneously at two diverse locations, i.e., when the Beneficiary Family Unit wishes to split the available Sum Insured on the Smart Card between two Smart Cards. The points to be kept in mind while performing a Smart Card split are: (i) (ii) (iii) (iv) (v) (vi) (vii) The Beneficiary needs to go to the District Kiosk for splitting of the Smart Card in case the Smart Card was not split at the time of enrolment. The existing data including text details, images and transaction details shall be pulled up from the District Server. The Smart Card split may be carried out only if there is no blocked transaction currently on the Smart Card. The fingerprints of any enrolled member of the Beneficiary Family Unit shall be verified against those available on the Smart Card. The splitting ratio should be confirmed by the Beneficiary. Only the available Sum Insured may be split between the two Smart Cards. The available Sum Insured on the main Smart Card shall be modified. The Beneficiary s existing data, photograph, fingerprint and transaction details shall be pulled up from the District Server and a fresh Smart Card (add-on Smart Card) will be issued immediately to the Beneficiary Family Unit. Both Smart Cards should have details of all enrolled members of the Beneficiary Family Unit. The existing Smart Card shall be modified and the add-on Smart Card shall be issued using the MKC card. Fresh and modified data shall be uploaded to the central server as well. 300

301 (viii) The cost of the add-on Smart Card would be paid by the Beneficiary at the District Kiosk. (3) Smart Card modifications: This process is to be followed in the following circumstances: (x) Only the head of the family was present at the time of enrolment and other family members need to be enrolled to the Smart Card, or, if all or some of the family members were not present at the enrolment station; and (y) in case of death of any person enrolled on the Smart Card, another family member from the Beneficiary Database shall, if applicable, have his/her details added to or modified on the Smart Card. There are certain points to be kept in mind while doing Smart Card modification: (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) (ix) Smart Card modification can only be done at the District Kiosk of the same district where the original Smart Card was issued. If split Smart Cards have been issued in the interim, both the Smart Cards would need to be presented at the time of modification. Smart Card modification during the year can only happen under the circumstances mentioned above. The Insurer must ensure that only family members listed on the original Beneficiary Database provided by the State Nodal Agency are enrolled on the Smart Card. As in the case of enrolment, no modifications shall be made except to name, age and gender. A new photograph of the family may be taken (if all the members are present or if the Beneficiary Family Unit demands it). Fingerprints of additional members needs to be captured. Data of family members has to be updated on the chip of the Smart Card. The existing details need to be modified in the Beneficiary Database (local and central server). The existing Smart Card will be modified using the MKC card. (4) Issuance of Smart Cards to Beneficiary Family Units The District Kiosk will follow the procedure for issuance of Smart Cards set out in Clause 21 of this Insurance Contract or any other procedure prescribed by the MHIS Guidelines from time to time. (5) Transferring manual transactions to electronic system (i) (ii) If the Hospital IT Infrastructure or the Smart Card fails at the Empanelled Health Care Provider s premises, the Empanelled Health Care Provider shall inform the District Kiosk and complete the transaction manually. Thereafter, the Insurer shall (or through its TPA) collect the Smart Card and documents from the Empanelled Health Care Provider and deposit them at the District Kiosk. 301

302 (iii) (iv) (v) (vi) (vii) (viii) The District Kiosk needs to check the reason for transaction failure and accordingly take action. In case of Smart Card failure: (1) the Smart Card should be checked and if found to be non-functional, the old Smart Card is to be hot-listed and a new Smart Card is to be re-issued as in the case of a duplicate Smart Card; and (2) the new Smart Card should be updated with all the transactions undertaken until the date of issuance of the duplicate Smart Card. In case of software or device failure, the device or software should be fixed/ replaced at the earliest in accordance with the Services Agreement. The District Kiosk should have the provision to update the Smart Card with the transaction. The database should be updated with the transaction as well. The Smart Card should be returned to the Empanelled Health Care Provider for handing back to the Beneficiary Family Unit. (6) Transferring of Manual Claims for Utilization of Critical Illness Cover (i) (ii) (iii) (iv) Once the treatment, procedure or intervention for a Critical Illness or a Follow-up Care required for the treatment of Critical Illness has been preauthorized in accordance with the procedure specified at Schedule 5, the Empanelled Health Care Provider shall inform the District Kiosk and complete the transaction manually. Thereafter, the Insurer shall (or through its TPA) collect the Smart Card and Claim documents from the Empanelled Health Care Provider and deposit them at the District Kiosk. The District Kiosk should update the database with the manual Claim. The Smart Card should be returned to the Empanelled Health Care Provider for handing back to the Beneficiary Family Unit. 2. District Server The District Server is responsibility of the Insurer and is required to: Set up and configure the Beneficiary data for use at the enrolment stations; Collate the enrolment data including the fingerprints and photographs and send it on to the State Nodal Agency and MoHFW periodically; Collate the transaction data and send it on to the State Nodal Agency and MoHFW periodically; and Ensure availability of enrolled data to the District Kiosk for modifications, etc at all times. 302

303 (a) (b) Location of the District Server: The District Server may be co-located with the District Kiosk or at any convenient location to enable technical support for data warehousing and maintenance. Specifications of the District Server: The minimum specifications for a District Server have been given below, however the Insurer s IT team would have to arrive at the actual requirement based on the data sizing. Intel Pentium 4 processor (2 GHz), 4 GB RAM, 250 GB HDD CPU [Note: As per actual usage, additional storage capacity may be added.] Operating System Windows 2007 Database SQL 2005 Enterprise Edition 3. Responsibilities of the Insurer/Smart Card Service Provider with respect to District Kiosk and District Server (a) (b) (c) (d) (e) (f) (g) The Insurer needs to plan, setup and maintain the District Server and District Kiosk as well as the software required to configure the validated Beneficiary Database for use in the enrolment stations. Before enrolment, the Insurer/Smart Card Service Provider will download the validated Beneficiary Database from the RSBY website and ensure that the complete, validated Beneficiary Database for the district is placed at the District Server and that the URNs are generated prior to beginning of enrolment for the district. The Enrolment Kits should contain the validated Beneficiary Database for the area where enrolment is to be carried out. The Beneficiary Family Units that are enrolled and members of PRI should be informed at the time of enrolment about the location of the District Kiosk and its functions. The Insurer needs to install and maintain the devices to read and update Smart Cards at the District Kiosk and the premises of the Empanelled Health Care Providers. The Insurer owns the hardware at the District Kiosk. It is the Insurer s responsibility to ensure in-time availability of the software(s) required, at the District Kiosk and at the Empanelled Health Care Provider premises, for issuance and usage of the Smart Cards. All software(s) must conform to the specifications laid down by MoHFW. Any modifications to the software(s) for ease of use by the Insurer can be made only 303

304 after confirmation from MOHFW. All software(s) would have to be certified by a competent authority as defined by MoHFW. (h) (i) It is the responsibility of the Insurer to back up the enrolment and personalization data to the District Server. This data (including photographs and fingerprints) will thereafter be provided to the State Nodal Agency and MoHFW in the format prescribed in the MHIS Guidelines. It is the responsibility of the Insurer or its service provider to set up a help desk and technical support centre at the district. The help desk needs to cater to Beneficiaries, Empanelled Health Care Providers, administration and any other interested parties. The technical support centre is required to provide technical assistance to the Empanelled Health Care Providers on both hardware and software issues. This may be co-located with the District Kiosk. 304

305 SCHEDULE 11 ROLE AND FUNCTIONS OF DKMs AND FKOs A. DISTRICT KEY MANAGER The District Key Manager (DKM) is the key person in RSBY, responsible for executing very critical functions for the implementation of MHIS Phase 3in the district. Following are the key issues regarding the appointment of the DKMs and the key roles, functions and responsibilities of the DKMs. 1. Identifying and Appointing DKMs 1.1 DKM Identification & Appointment The State Nodal Agency will identify one DKM for every district in the Service Area. The DKM shall be a senior government functionary at the district level. (a) Eligibility Officials designated as DKM may be: Chief Medical Officer, Chief District Health Officer, Assistant District Collector (ADC), Additional District Magistrate (ADM), District Development Officer, District Labour Officer or equivalent as decided by the State Nodal Agency. (b) Timeline The DKM shall be appointed at least 60 days prior to the commencement of each Policy Cover Period. 1.2 Providing Information on DKM to Central Government The State Nodal Agency shall convey the details of the DKM appointed for each district to the Central Key Generation Authority (CKGA). This information shall be provided through RSBY portal under the State Nodal Agency's login on within 7 days of appointment of the DKM for each district. 1.3 Issuance of personalized DKMA Card by CKGA to State Nodal Agency The CKGA shall issue personalized DKMA Card to the State Nodal agency for distribution to the DKMs based on the information received from the State Nodal Agency. Personalized DKMA Cards will be issued by CKGA to the State Nodal Agency within 10 days of receipt of the information on DKM from State Nodal agency. 305

306 The CKGA will also subsequently issue the Master Issuance Card (MIC), Master Hospital Card (MHC) and the Master Kiosk Card (MKC) based on request from the State Nodal Agency. However, the personalization of DKM card will be done at district by District Informatics officer. 1.4 Issuance of Personalized DKMA Card by State Nodal agency to DKM The State Nodal Agency shall issue the personalized DKMA Card to the relevant DKM at least 7 days before commencement of enrolment in the district for which the DKM is appointed. 2. Roles and Functions of District Key Manager (DKM) The DKM will be responsible for the overall implementation of the MHIS phase 3in the district. The roles and responsibilities of DKM include the following: (a) Identification and Appointment of an Additional DKM The DKM shall first appoint an Additional DKM to assist him/her in discharging the daily duties and responsibilities of DKM. (b) Pre-Enrolment Receive the DKMA/ADKM Card from the State Nodal Agency and use it to issue three authority cards: - Field Key Officer (FKO) - Master Issuance Card (MIC) - Hospital Authority - Master Hospital Card (MHC); and - District Kiosk - Master Kiosk Card (MKC) Issue format of FKO undertaking to the FKO along with the MIC Maintaining inventory of cards to have a record of the number of cards received from the State Nodal Agency for each type (MIC, MKC and MHC), to whom distributed, on what date, and the details of missing/ lost/ damaged cards Understand the confidentiality and PIN related matters pertaining to the DKM and the MIC. Ensure security of Key cards and PIN. Ensure the training of FKOs, IT staff and other support staff at the district level Support the Insurer in organizing the district workshop at least 15 days before commencement of enrolment in the district for which the DKM is responsible Ensure that the information relating to MHIS Phase 3has been given to the officials designated as the FKOs This information may be given either at the district workshops or in a separate meeting called by the district/block level authorities 306

307 Set up the dedicated DKMA server with the necessary hardware and software in his/her office. Understand and know the DKM software and have the IT operator trained Understand the additional features and requirements for 64 kb Smart Card migration for all concerned viz. DKM, FKO, Hospital Issue MICs to FKOs according to the specified schedule. The data relating to issuance of cards will be stored on the DKMA computer automatically by the software and can be tracked. FKO card personalization is done by using data and fingerprint of the designated FKOs stored in the database on the DKMA computer. Issue the MHC for each Empanelled Health Care Provider to the Insurer within 3 days of receiving a request from the Insurer its TPA or its representatives Issue MKC card for a District Kiosk within 3 days of receiving a request from the Insurer or its representatives Provide assistance to the Insurer or its representatives in the preparation of panchayat/municipality/corporation/village wise route plan and Enrolment Schedule Check/verify that the Insurer and its intermediaries are deploying the requisite infrastructure, resources and manpower required for the enrolment process in accordance with the Enrolment Schedule and Schedule 13 of this Insurance Contract Provide assistance to the Insurer or its representatives in the preparation of panchayat/municipality/corporation/village wise route plan and enrolment schedule. Ensure effective IEC/BCC activities by the Insurer in the district and lend all possible support Ensure empanelment of optimum number of eligible hospitals and other health care providers in the district, both public and private Assist the Insurer in undertaking inspections and reviewing the completed Empanelment Forms and the Empanelment Team's inspection reports to ensure that the hospitals and health care providers wishing to be empanelled meet the minimum empanelment criteria before the commencement of enrolment in the district Ensure that training workshops are conducted by the Insurer in accordance with Clause 19.2 and be present during such workshops Allocate space for setting up of the District Kiosk by the Insurer free of cost or at a rent-free space Ensure that the District Kiosk set up by the Insurer is functional before the commencement of enrolment (b) Enrolment Monitor and ensure the participation of FKOs in the enrolment process at the enrolment station and also fulfillment of their roles and functions 307

308 Identify additional FKOs and issue them MICs in case a designated FKO is absent at a particular enrolment station Provide support to the Insurer in the enrolment by helping them in coordinating with different stakeholders at the district, block and panchayat levels Undertake field visit to the enrolment stations and record observations in the format prescribed in the MHIS Guidelines Review the performance of the Insurer as regards the enrolment status through periodic review meetings (c) Post enrolment Get the enrolment data downloaded from the MIC to the DKMA server on a weekly basis and then reissue the MICs to new FKOs after personalizing the same again In case of any discrepancy between enrolment data downloaded from MIC and the enrolment data mentioned by FKO in FKO undertaking, receive a note on the difference from the FKO and send the note to the State Nodal Agency Collect FKO undertakings from each FKO upon completion of each day of enrolment at the enrolment station to which the FKO is assigned Ensure that the enrolment teams submit the digitally signed enrolment data created by the enrolment software on a weekly basis and ensure that this data is downloaded on the DKMA Server within 7 days Coordinate with the district administration to organize health camps for building awareness about MHIS Phase 3 and to increase the utilization/hospitalization in the district Visit the premises of the Empanelled Health Care Providers in the district to check Beneficiary facilitation and record observations as per standard format prescribed in the MHIS Guidelines Hold District Grievance Resolution Committee meetings on pre-scheduled days every month and ensure that necessary entries are made on the web site regarding all the complaints/grievances received and decisions taken there on at the District Grievance Resolution Committee Check the functioning of 24-hour Toll Free Helpline maintained by the Insurer on a regular basis Communicate with State Nodal agency in case of any problem related to DKMA software, authority cards, or other implementation issues etc. Help the State Nodal Agency/NGO appointed by the State Nodal Agency in evaluating the implementation of MHIS Phase 3 and its impact (d) On completion of enrolment Prepare a report on issues related to empanelment of hospitals, enrolment, FKO feedback and Beneficiary Database. 308

309 B. FIELD KEY OFFICER (FKO) The FKO is one of the key persons in RSBY and will carry out very critical functions which are necessary for the enrolment. FKOs are part of the Key Management System and along with DKM they are very critical for the success of MHIS Phase 3. Following are the important points regarding FKOs and their roles: 1. Identity of FKO The State Nodal Agency will identify and appoint FKOs in each district. The FKO should be a field level Government functionary. Some examples of the FKOs are Patwari, Lekhpal, Gram Vikas Adhikari, Panchayat Secretaries, etc. 2. Providing Information by State Nodal Agency The State Nodal Agency will provide detail on the number of FKO cards needed to the CKGA at Central Government in the prescribed format within 15 days of selection of the Insurer. Generally the number of FKOs required would t directly proportional to the number of Enrolment Kits that the Insurer plans to take to the field and to the number of Beneficiary Family Units in the district. Hence it would be advisable for the State Nodal Agency to consult with the Insurer and their TPA or Service provider for finalizing the requirement of FKOs. 3. Training of FKOs The DKM should ensure that the information relating to the MHIS phase 3 has been given to the officials designated as the FKOs. This information may be given either at the district workshops or in a separate meeting called by the district/block officers. The Insurer should give the FKOs an idea of the task they are expected to perform at the same time and a single page note setting out the details of MHIS Phase 3along with the MIC. They should be clearly told the documents that may be used to verify a Beneficiary. 4. Issuance of Master Issuance Card (MIC) by DKM The MIC will be personalized by the DKM at the district level. The number of MICs provided by CKGA shall be enough to serve the purpose of enrolment within the 4 month enrolment period. Some extra FKOs should also be identified and issued MICs by the DKMA so that the enrolment team has a buffer in case some FKOs are absent on a given day. While issuing the cards to the FKOs it should be kept in mind that 1 MIC can store data for approximately 400 Beneficiary Family Units to which Smart Cards can be issued. If an FKO is expected to verify Smart Cards to be issued by the Insurer to more than 400 Beneficiary Family Units, multiple MIC cards may be issued to each FKO. 5. Role of FKOs The roles of FKOs are as follows: 309

310 (a) Pre-Enrolment Receive personalized Master Issuance Card (MIC) from the DKM after providing the fingerprint. Receive information about the name of the village(s) and the location(s) of the enrolment station (s) inside the village(s) for which FKO role have to be performed Receive the contact details of the Insurer or their field agency representative who will go to the location for enrolment Receive information about the date on which enrolment has to take place Attend training conducted by the Insurer at the district workshop, to understand details of the Scheme and the additional features of the 64kB Smart Cards Provide their contact details to the DKM and the Insurer's field representative Reach the enrolment station at the given time and date (Inform the Insurer a day in advance if the FKO is unavailable) Check on the display of the Beneficiary Database in the village Make sure that the MIC is personalized with his/her own details and fingerprints and is not handed over to anyone else at any time Should ensure that at least one card for every 400 Family Beneficiary Units expected at the enrolment camp is issued to him/her i.e., in case the Beneficiary Database for a location is more than 400, they should get more than one MIC card personalized with their details & fingerprints and carry such MICs with them for the enrolment. (b) Enrolment Ensure that the Beneficiary Database is displayed at the enrolment station Identify the Beneficiary Family Units at the enrolment station either by face or with the help of identification documents Make sure that the enrolment team is correcting the name, gender and age data of dependents in the field in case of any mismatch Make sure that the enrolment team is not excluding any member of the identified family that is present for enrolment under MHIS Phase 3 Before the Smart Card is printed and personalized, the FKO should validate the enrolment by inserting his/her MIC and providing fingerprint Once the Smart Card is personalized and printed, ensure that at least one member of the family verifies his/her fingerprint against the one stored in the chip of the card, before it is handed over to the family Make sure that the Smart Card is handed over immediately to the Beneficiary Family Unit by the enrolment team after verification Make sure that the enrolment team is collecting only 30 from each Beneficiary Family Unit that is enrolled 310

311 Ensure that the details of all eligible family members (meeting the definition of Beneficiary Family Unit) as per the Beneficiary Database and available at the enrolment station are entered on the Smart Card and their fingerprints & photographs are taken Once the Smart Card has been personalized and printed, ensure that the Smart Card is re-verified by the Beneficiaries by providing their fingerprints so as to ensure that the Smart Card is in working condition Ensure that the enrolment team is providing a printed booklet to each Beneficiary Family Unit along with the Smart Card Make sure that the Smart Card is given inside a plastic cover and Beneficiaries are told not to laminate it Ensure that the enrolment team informs the Beneficiary Family Unit of the date on which the Smart Card will become operational (month) and the date on which the Policy Cover Period will expire If a Beneficiary complains that their name is missing from the Beneficiary Database, then make sure that this information is collected in the specified format and shared with the DKM If a Beneficiary cannot be enrolled due to absence of head of household due to death or if a Beneficiary Family Unit has been identified under the wrong household but have their details on the list then undertake the enrolment of such Beneficiary Family Units at the District Kiosk. If not all dependents of a Beneficiary Family Unit eligible for enrolment are present at the camp, they should be informed that such Beneficiaries can be enrolled at the District kiosk. (c) Post enrolment Return the MIC to the DKM within 2 days of the completion of enrolment at the enrolment station to which the FKO is assigned At the time of returning the MIC, ensure that the data is downloaded from the MIC and that the number of records downloaded is the same as the number he/ she verified at the enrolment station. In case of any discrepancy, make a note of the difference and ask the DKM to send the MIC and the note back to CKGA Fill and submit the FKO undertaking to the DKM in the prescribed format In the event of any discrepancy between the data uploaded onto the DKMA Server and the information in the FKO undertaking, the FKO must submit an explanatory note explaining such discrepancies to the State Nodal Agency Hand over the information collected regarding exclusions from the Beneficiary Database at the enrolment camp to the DKMA. Receive the incentive from the State Government (if any) 311

312 SCHEDULE 12 SMART CARD GUIDELINES 1. Introduction These guidelines provide in brief the technical specifications of the Smart Card, devices and infrastructure to be used for the implementation of MHIS Phase 3. The standardization is intended to serve as a reference, providing guidance for implementing an interoperable Smart Card based cashless health insurance programme. While the services are envisaged by various agencies, the ownership of the RSBY and the MHIS and thereby that of complete data whether captured or generated as well as that of Smart Cards shall vest with the State Nodal Agency and the Government of India, Ministry of Health and Family Welfare In creating a common health insurance Smart Card across India, the goals of the health insurance program are to: Allow verifiable identification of the health insurance Beneficiary at point of transaction that cannot be repudiated. Validation of available insurance cover at point of transaction without any documents Support multi vendor scenarios Allow usage of the Smart Card across states and insurance providers This document pertains to the stakeholders, tasks and specifications related to the Smart Card system only. It does not cover any aspect of other parts of MHIS Phase 3. The stakeholders need to determine any other requirements for completion of the specified tasks on their own even if they are not defined in this Schedule Enrolment Station 2.1 Components Though three separate kinds of stations have been mentioned below, it is possible to club all these functionalities into a single workstation or have a combination of workstations perform these functionalities (2 or more enrolment stations, 1 printing station and 1 issuance station). The number of stations will be purely dependant on the load expected at the location. The minimum requirements from each station are mentioned below. The enrolment team is expected to carry additional power back up in the event that electricity is not available for some time at the enrolment site. Common components Windows XP (all service packs) or above Open source database 312

313 Certified enrolment, personalisation & issuance software Data backup facility Enrolment station components Computer with power backup for at least 8 hours 1 Optical biometric scanner for fingerprint capture as per specification below 1 VGA camera for photograph capture Personalisation station components Computer with power backup for at least 8 hours 2 PCSC compliant Smart Card readers (for FKO card & split card) Smart Card printer with Smart Card encoder Issuance station components Computer with power backup for at least 8 hours 2 PCSC compliant Smart Card readers (1 for FKO card, 1 for Beneficiary card,) 1 Optical Fingerprint scanner as per specifications below (for verification of FKO & Beneficiary) 2.2 Specifications for hardware Laptop Computer Capable of supporting all devices as mentioned above It should be loaded with standard software as per specifications provided by the MoHFW Minimum configurations: dual core processor with 2 GHz, 80 GB hard drive, DVD r/w drive, 2 GB RAM, graphics card, minimum of 4 USB ports etc. Fingerprint Scanner The Fingerprint capture device at enrolment as well as verification should be single finger type. Kindly refer to the document fingerprint_image_data_standard_ver.1.0 (2) through the website All specifications confirming to Setting level 31 would be applicable for RSBY related enrolment and verification. The fingerprint scanners used at any of the verification points should be as per specified for UID. Kindly check requirements on List of Biometric Devices certified by STQC for UID authentication can be checked on In case the device in question is not already certified, they should have applied for certification and be certified within 6 months of purchase. Though authentication devices meeting the specification given should be able to work with the transaction application, it is suggested that SCSP/ scanner vendors demonstrate their compatibility with the transaction software at MoHFW before it is sent to the field. 313

314 For enrolment, the biometric devices, in addition to the setting level 31, conform to the following criteria Product Feature Technical Specification Capture type Single finger plain live scan capture Image Resolution 500dpi + 5% Platen Area Minimum 22 mm x 22 mm Image Gray Scale / Type 8 bit pixel depth ( 256 gray levels) Power Supply & Communication Via USB Interface A/V indication either at device level or at application level for indicating various events like: Audio / Visual Indication a) Indicating for placing finger b) Start of capturing c) End of capturing Image Quality : Image Quality Sensor: Must be listed on IAFIS Certified Product List posted on https;// under PIV Single Finger Capture Devices The images should be stored in png format It is advisable that the best practices suggested in the document should be followed Camera Sensor: High quality VGA Still Image Capture: min 1.3 megapixels (software enhanced). Native resolution is 640 x 480 Automatic adjustment for low light conditions Smart Card Reader PCSC compliant Read and write all microprocessor cards with T=0 and T=1 protocols Smart Card printer Supports colour dye sublimation and monochrome thermal transfer Edge to edge printing standard Prints at least 150 cards/ hour in full colour and up to 750 cards an hour in monochrome Minimum printing resolution of 300 dpi Automatic and manual feeder for card loading USB Connectivity Printer Should have hardware/software protection to disallow unauthorized usage of Printer Inbuilt encoding unit to personalize Contact cards in a single pass Compatible to microprocessor chip personalization Smart Card printing ribbon as required 314

315 [Note: The enrolment stations due to the nature of work involved need to be mobile and work under rural & rugged terrain. This should be of prime consideration while selecting the hardware matching the specifications given above.] Smart Cards 3.1 Specifications for Smart Cards Card Operating System shall comply with SCOSTA standards ver.1.2b with latest addendum and errata (refer web site The Smart Cards to be used must have the valid SCOSTA Compliance Certificate from National Informatics Centre, New Delhi (refer The exact Smart Card specifications are listed as below. SCOSTA Card Microprocessor based Integrated Circuit(s) card with Contacts, with minimum 64 Kbytes available EEPROM for application data or enhanced available EEPROM as per guidelines issued by MoHFW. Compliant with ISO/IEC ,2,3 Compliant to SCOSTA 1.2b Dt. 15 March 2002 with latest addendum and errata Supply Voltage 3V nominal. Communication Protocol T=0 or T=1. Data Retention minimum 10 years. Write cycles minimum 100,000 numbers. Operating Temperature Range 25 to +55 Degree Celsius. Plastic Construction PVC or Composite with ABS with PVC overlay. Surface Glossy 3.2 Card layout The detailed visual & machine readable card layout including the background image to be used is available on the website The Insurer agrees that the State Nodal Agency may amend the detailed visual & machine readable card layout including the background image to be used by issuing MHIS Guidelines within 15 days of the date of this Insurance Contract, for the use of MHIS Phase 3 logo. It is mandatory to follow these RSBY guidelines, as amended by the MHIS Guidelines, for physical personalization of the Smart Card. For the chip personalization, detailed specification has been provided in the RSBY KMS document available on the website Along with these NIC has issued specific component for personalization. It is mandatory to follow these specifications and use the prescribed component provided by NIC. 3.3 Cardholder authentication The Beneficiary shall be authenticated based on their finger impression at the time of verification at the time of transaction as well as card reissuance or renewal. 315

316 The authentication is 1:1 i.e. the fingerprint captured live of the Beneficiary is compared with the one stored in the Smart Card. In case of new born child, when Hospitalization or Child Care benefits are availed, the new-born child shall be authenticated through fingerprint of any of the enrolled Beneficiaries on the Smart Card, provided that the mother's name is included as a Beneficiary on the Smart Card. In case of fingerprint verification failure, verification by any other authentic document or the photograph in the Smart Card may be done at the time of admission. By the time of discharge, the Empanelled Health Care Provider/ Smart Card Service Provider should ensure verification using the Smart Card. 4. Software The Insurer must develop or procure the STQC certified Enrolment and Card Issuance software at its own cost. Software for conducting transactions at Empanelled Health Care Providers and managing any changes to the Smart Cards at the District kiosk shall be the software provided/authorised by MoHFW. In addition, the Insurer shall provide all the hardware and licensed software (database, operating system, etc) required to carry out the operations as per requirement at the agreed points for enrolment and Smart Card issuance. Any software required by the Insurer apart from the ones being provided by MoHFW shall be developed or procured by the Insurer at its own cost. 5. Mobile Handheld Smart Card Device These devices are standalone devices capable of reading and updating Smart Cards based on the programmed business logic and verifying live fingerprints against those stored on a smart card. These devices do not require a computer or a permanent power source for transacting. These devices could be used for Renewal of Smart Card when no modification is required to the Smart Card. Offline verification and transacting at Empanelled Health Care Providers or mobile camps in case computer is not available. The main features of these devices are: Reading and updating microprocessor smart cards Fingerprint verification They should be programmable with inbuilt security features to secure against tampering. Memory for data storage Capable of printing receipts without any external interface Capable of data transfer to personal computers and over GPRS, phone line Secure Application loading Application loading to be secure using KEYs Rechargeable batteries 316

317 Specifications At least 2 Full size Smart Card reader and one SAM slot Display Keypad for functioning the application Integrated Printer Optical biometric verification capability with similar specifications as mentioned for Fingerprint scanners above in the hardware section o Allowing 1:1 search in the biometric module Capability to connect to PC, telephone, modem, GPRS or any other mode of data transfer PCI Compliance 6. PC based Smart Card Device Where Computers are being used for transactions, additional devices would be attached to these computers. The computer would be loaded with the certified transaction software. The devices required for the system would be Optical biometric scanner for fingerprint verification (specifications as mentioned for fingerprint devices in hardware section) Smart card readers 2 Smart card readers would be required for each device, One each for hospital authority and Smart Card PCSC compliant Read and write all microprocessor cards with T=0 and T=1 protocols Other devices like printer, modem, etc may be required as per software. [Note. All specifications mentioned in the document for devices are minimum criteria and not exact criteria.] 317

318 SCHEDULE 13 ENROLMENT INFRASTRUCTURE AND MANPOWER REQUIREMENTS The Insurer shall be responsible for deploying infrastructure and resources as per the following requirements in order to maximise the enrolment rate in each district of the State of Meghalaya. 1. Infrastructure and Resources Each Enrolment Kit shall at least include: one Smart Card printer one Laptop two Smart Card readers one fingerprint scanner one web camera one 50 kg battery pack certified enrolment software and any other related software. In addition to the above requirements, the Insurer shall make available the following infrastructure and resources: At least one spare (functional) backup Enrolment Kit in field for every 10 functional Enrolment Kits. The head quarter of the enrolment team should not be more than 30 km away from the farthest enrolment station at any time during the enrolment drive. The number of vehicles should be determined in the Enrolment Schedule agreed between the Insurer and the district authorities of the State Nodal Agency. The Insurer shall at a minimum use the following number of Enrolment Kits set out below: (a) 1 Enrolment Kit per enrolment station, provided that if there are more than 40 Beneficiary Family Units identified for an enrolment station then the Insurer shall be required to provide an additional laptop with the Enrolment Kit. (b) Without prejudice to the requirement at paragraph 2(a) above, the Insurer shall be required to provide the following number of Enrolment Kits in a district: No. of Beneficiary Family Units in a district Minimum number of Kits Required < ,000 to 70, ,000 to 100, ,000 to 150, ,000 to 200,

319 2. Manpower Resources No. of Beneficiary Family Units in a district Minimum number of Kits Required 200,000 to 300, > 300, The Insurer shall at a minimum deploy the following manpower resources: (a) (b) (c) (d) (e) One operator per Enrolment Kit: Educational Qualification - minimum 12 pass and minimum 6 months of diploma/certificate in computer operations; Should preferably be from the district where the enrolment is taking place; and should be able to read, write and speak in Hindi and the local language. One supervisor for every 5 operators: Educational Qualification - minimum Graduate and minimum 6 months of diploma/certificate in computer operations; Should preferably be from the district where the enrolment is taking place; and should be able to read, write and speak in Hindi/local language and English. One Technician per 10 Enrolment Kits: Educational Qualification - minimum 12 pass and diploma in computer hardware; and Should be able to read, write and speak in Hindi/local language and English. 1 IEC coordinator per 5 Enrolment Kits 1 Manager for every 5 supervisors: Educational Qualification - minimum post graduate and minimum 6 months of diploma/certificate in computer operations; and should be able to read, write and speak in Hindi/local language and English 3. Time for Deployment The Insurer should deploy such infrastructure and resources from the date of commencement of enrolment in each district. 319

320 SCHEDULE 14 INDICATIVE LIST OF FRAUDS AND FRAUD CONTROL MEASURES 1. Enrolment Related Frauds Issuing Smart Cards to families who are not listed in the Beneficiary Database. Charging money in excess of 30 from any Beneficiary Family Unit. Issuing low quality Smart Cards resulting in transactional difficulties. Issuing duplicate Smart Cards with same URN number/family ID but with different chip serial numbers. Using someone else s biometrics for a genuine household and retaining the Smart Card. Not distributing Smart Cards to all the Beneficiary Family Units. Deletion of data by Insurer or Insurer's representative after enrolment to retain 30 collected from Beneficiary Family Units. Enrolment agency operators becoming de facto FKOs. Handing over Smart Cards to unauthorized persons in bulk quantity. Charging money from hospitals or other health care providers for empanelment and also for supplying/installation of Hospital IT Infrastructure. Avoiding/delaying empanelment of genuine/sufficient number of hospitals or other health care providers. 2. Hospital Related Frauds 2.1. Indicative List of Hospital Related Frauds Conversion of out-patient cases to in-patient cases. Deliberate blocking of higher-priced Package Rates to claim higher amounts. Blocking of multiple packages even though not required. Non-payment of transportation or economic loss compensation benefits to Beneficiaries. Transaction description not clear. Unwarranted ICU admissions. Not dispensing post-hospitalization medication to Beneficiaries. Not making medicines available to Beneficiaries on utilization of OPD Benefits or Follow-up Care Irregular or inordinately delayed synchronisation of transactions to avoid concurrent investigations. Treatment of diseases, illnesses or accidents for which an Empanelled Health Care Provider is not equipped or empanelled for. Showing admission in ICU though treatment is given in general ward. Huge number of complex surgeries likes amputation, joint reconstruction surgeries, abdomino perineal resection, spinal fixation etc. reported to be carried out by 320

321 Empanelled Health Care Provider without having necessary infrastructure to conduct such complex high-end surgeries. Admission of Beneficiaries in excess of the bed capacity. Single Procedure done but multiple procedures selected e.g. Hysterectomy as Hysterectomy with oophorectomy etc. Substitution of packages e.g.- Hernia as Appendicitis, Conservative treatment as Surgical Part of the expenses collected from Beneficiary for medicines and Screening in addition to amounts received by the Insurer.. Unnecessary surgery done, without actual requirement of the Beneficiaries. Non-enrolled member of family taking treatment with enrolled Beneficiaries' thumb impression, other than for utilization of new-born or child care benefits. Retaining the Smart Card with wrongful intention by the Hospitals for unethical transaction. Recruiting Beneficiaries through touts and unethical means. Transaction at Empanelled Health Care Provider but treated/ operated at different hospital. Dummy Smart Cards used. Fabricated medical/diagnostic reports and OT notes/ medical details. Diagnosis and treatment contradict each other. Excessive Screening. If Beneficiary can t explain disease or treatment when asked. Empanelled Health Care Provider making Claims for more than one OPD diagnostics services to one or more members of the same Beneficiary Family Unit in any consecutive 7 day period Empanelled Health Care Provider paying a commission or fee to the Beneficiaries for making Claims in relation to any of the OPD Benefits 2.2. Indicators/Triggers to Identify Hospital Fraud High Bed vs. Occupancy ratio. Disease not related to gender/age. Frequent blocking of multiple disease codes. Frequent blocking of high-end disease codes. Hospitals having unusual high number of Day Care Treatments/procedures. Frequency and gaps in uploading data on server. High average Claim size. Gender v/s ailment mismatch. General Ward admissions v/s ICU. Hospital facilities v/s type of admissions. Normal Delivery Claims v/s LSCS.. Empanelled Health Care Providers involving frequent incidents of customer grievances or malpractices. Claims from multiple hospitals with same owner. 321

322 Number of members enrolled in particular panchayat / block v/s no of admissions. Repeated admissions in single URN. Treatment of diseases mismatching general health profile of a district / state. Same diagnosis for all Beneficiaries. ICU/Medical Treatment blocking done for more than 5 days stay, other than in the case of Critical Illness. Overall medical management exceeds more than 5 days, other than in the case of Critical Illness. Blocking packages during odd hours - between 10 pm to 6 am the next day. Members of the same Beneficiary Family Unit getting admitted and discharged together. Multiple Claims for same Beneficiary in different hospitals. 2 or more chip serial numbers for a single URN. Single hospital with 2 hospital codes and vice versa MHC Card misuse. Colour banding applications (triggers) enabled on the Claims approval application itself, like URN Limit exhausted, Claim in last year Policy. Beneficiaries coming from other districts: - Auto Generated messages. 3. Embedding the triggers in the system (by Insurer) 3.1. Analytical reports to be generated through system Current year Claim analysis for overall picture. Overall trend analysis of the district. Provider wise number/amount of Hospitalization. Provider wise average duration of stay in general ward. Provider wise average delay in Claims submission following discharge. Provider wise Non surgical/surgical ratio. Provider wise village utilization ratio. Provider card utilization ratio: Total number of Hospitalization with respect to card. Village wise number/amount of Hospitalization. Village wise number/ amount of Hospitalization surgical procedure wise. Village wise number / amount of Hospitalization sex wise Automated Queries/alerts Analysis of the Daily Blocking data. Analysis of the weekly & monthly blocking data. Analysis on system generated triggers: Like overstaying, over billing etc. Frequent Small Medical Blockings OPD to IPD Conversion. Frequent use of same URN. Frequent blocking of High amount packages Hysterectomy, Appendectomy, etc. 322

323 Auto message to be generated when transaction upload is delayed for more than 24 hours. Auto message if ICU or Medical Treatment blocking is done for more than 5 days stay, other than in the case of Critical Illness. Discharge between 8pm and 8am: - Auto Generated message. 2 or more chip serial numbers for a single URN. Single hospital with 2 hospital codes and vice versa MHC Card misuse. Colour banding applications (triggers) enabled on the Claims approval application itself, like URN Limit exhausted, Claim in last year Policy. Beneficiaries coming from other districts: - Auto Generated messages. 323

324 SCHEDULE 15 APPOINTMENT OF THIRD PARTY ADMINISTRATORS 1. Qualification Criteria for TPAs The Insurer shall only appoint a TPA that meets the following qualification criteria: (a) (b) (c) The TPA should be licensed by the IRDA for at least 3 years as on the date of the TPA's appointment. The TPA should be empanelled by the Quality Council of India in accordance with the MHIS Guidelines at the time of its appointment. The TPA should have completed a minimum of 3 financial years of operation prior to its appointment by the Insurer. (d) The TPA should have past experience in providing services in respect of at least 10 million lives cumulatively in the 3 financial years prior to its appointment by the Insurer. (e) The TPA should have an annual turnover of more than 50 million and total revenues of more than 50 million, in the financial year immediately preceding its appointment. (f) (g) The TPA should have experience of working in an Information Technology intensive environment and must have experience in processing at least 50,000 medical reimbursement claims per annum in the previous year and in maintaining an online portal for tracking of claims. The TPA must carry the ISO Certification (ISO 9001:2008) for Quality Process, at the time of its appointment by the Insurer and such certification shall continue to be valid during such appointment. (h) The TPA must have a network of minimum 1000 empanelled hospitals. (i) The TPA should not be blacklisted or be issued a show cause by the IRDA at least 1 year preceding the bid due date. 2. Minimum Standard Clauses to be included in the Services Agreement between Insurer and the TPA All the services rendered by the TPA shall be in accordance with the provisions of the Insurance Act and all Insurance Laws. The services agreement between the Insurer and the TPA should include, as a minimum, the following clauses and any other conditions that the IRDA may prescribe from time to time: 324

325 (a) (b) The scope of services of the TPA and the manner of performance of these services, including procedure for provision of Cashless Access Services. The fee payable to the TPA for each of the services and the conditions upon which the amount becomes payable. Such fee payable to the TPA shall be based on the services rendered by the TPA to the Insurer and shall not be related to the Claims experience or the reduction of Claim costs or Pure Claim Ratio of the Insurer. The TPA shall not be entitled to charge any additional amount from the State Nodal Agency, the Empanelled Health Care Provider or the beneficiaries. (c) (d) (e) The turn-around time for each of the services rendered by the TPA and the consequences in case of default of services, provided that such turn-around times for the TPA shall always be in compliance with the Insurer's performance obligations under this Insurance Contract. The TPA shall provide the Insurer and the State Nodal Agency with inspection, audit and access rights, both on a regular and ad-hoc basis. The TPA shall be required to maintain the confidentiality of all information, data, documents and proprietary information (including medical records of Beneficiaries) received by it; provided that it shall provide the Insurer and the State Nodal Agency the right to inspect all such information, data and documents (including medical records). Upon expiration or termination of the TPA's appointment for any reason whatsoever, it shall be obliged to hand over all such information, data, documents and proprietary information or to continue to hold such information, data, documents and proprietary information for a reasonable period after such expiration or termination. (f) (g) The TPA shall be bound to perform the Insurer's obligations or exercise its rights under this Insurance Contract (including Claims processing, Claims Payments, empanelment and de-empanelment) in accordance with all applicable Insurance Laws and such procedures and following such methodology that shall be acceptable to the State Nodal Agency. The TPA shall be required to have a strong system of customer services and relations. Without prejudice to the Insurer's rights as the TPA's direct client, the TPA shall be required to extend every courtesy and cooperation to the Beneficiaries, the Empanelled Health Care Providers and the State Nodal Agency for the monitoring and supervision of the implementation of the MHIS phase 3 by the TPA (on behalf of the Insurer). 325

326 (h) (i) (j) (k) The TPA shall provide qualified, experienced and dedicated personnel for the provision of services in relation to the implementation of the MHIS phase 3. The TPA shall intimate both the Insurer and the State Nodal Agency of any changes in key personnel. Further, the TPA shall only appoint substitute persons exceeding or meeting the qualification and experience criteria specified by the Insurer. Events of default and manner of termination of services including consequences of termination shall be included in the services agreement. Prior to terminating the services agreement, the Insurer or the TPA, as the case may be, shall provide the State Nodal Agency at least 60 days' notice. The TPA should have a license at the time of its appointment and continue to maintain such license during the term of the services agreement. If the TPA s license is revoked or ceases to be valid at any time, the Insurer shall retain a right to terminate the TPA's appointment and appoint a substitute TPA within 60 days of such revocation or cession of such TPA s license. The TPA shall continue to provide the services until substituted by another TPA and ensure a seamless transition, without affecting the services to the Beneficiaries, Empanelled Health Care Providers or the Insurer. No inconvenience or hardship shall be caused to any Beneficiaries or any Empanelled Health Care Providers as a result of such change. The contact details like helpline numbers, addresses, etc. of the new TPA shall be made immediately available to all the Beneficiaries, Empanelled Health Care Providers and the State Nodal Agency. (l) Upon termination of the services agreement by either party, the TPA shall within 10 days of a termination notice being issued, provide the following information to the Insurer and the State Nodal Agency: (i) (ii) (iii) the status of cases where the pre-authorization has already been issued by the TPA; the status of cases where Claims have been submitted to the TPA for processing; and the status of Claims where processing has been completed by the TPA and Claims Payments are pending. (m) (n) The TPA shall perform all services in accordance with the Code of Conduct issued by the IRDA from time to time and in full compliance with all applicable Insurance Laws. Arbitration and dispute resolution, including a joinder of disputes permitting the State Nodal Agency to be joined as a necessary party to any dispute between the Insurer and the Appointed Actuary. 326

327 SCHEDULE 16 KEY PERFORMANCE INDICATORS 1. INTRODUCTION The key performance indicators are for assessment of the Insurer's performance and for determining whether or not the Policies for the Service Area should be renewed annually (the Key Performance Indicators or KPIs). The performance assessment of the Insurer against the KPIs, include an assessment of: the number of Beneficiaries covered; reasonableness of the network of Empanelled Health Care Providers; and timely Claim Payments by the Insurer to the Empanelled Health Care Providers. The assessment of the Insurer's performance against the KPIs for the purpose of determining the annual renewal of the Policies for all districts in the Service Area, include an assessment of: the number of Beneficiaries covered; reasonableness of the network of Empanelled Health Care Providers; installation of adequate hardware and software infrastructure for efficient provision of Cashless Access Services; information sharing by the Insurer with the State Nodal Agency on Claims; and timely Claim Payments by the Insurer to the Empanelled Health Care Providers. 2. PERFORMANCE KPIs The Performance KPIs, the manner of determination of the Performance KPIs, the baseline requirements and the Liquidated Damages payable for failure to demonstrate compliance with Performance KPIs are set out in Table 1 below. 327

328 Table 1: Performance KPIs Sl. No. KPI Measure & Explanation Baseline Source of Measuring Data Time for Evaluation of KPI Liquidated Damages Cap on Liquidated Requirements Damages 1. Extent of Beneficiaries covered 1.1 Overall Enrolment Rate E% = N E x 100. Where: [N B - (N D + N G )] E% is the Enrolment rate N E is the number of Beneficiary Family Units enrolled under the MHIS phase 3 N B is the number of Beneficiary Family Units whose details are present in the validated Beneficiary Database uploaded on the RSBY website and for whom URNs have been generated N D is the number of Beneficiary Family Units not enrolled due to data errors in the Beneficiary Database. For the purpose of this formula, "data errors" shall mean the following errors in the Beneficiary Database: (i) the head of household and spouse are dead; (ii) the head of household has been wrongly identified; and (iii) unrelated families have been combined within the same Beneficiary Family Unit, e.g., tenant is part of the household of 50% For determining the Enrolment Rate, the State Nodal Agency shall rely on the enrolment data downloaded from the FKO cards on the DKM servers. If the enrolment data is not available from the DKM Servers, then the State Nodal Agency shall rely on the signed enrolment data submitted by the Insurer along with its invoices for each enrolment round. The State Nodal Agency will determine the Enrolment Rate achieved by the Insurer upon completion of 4 months from the date of commencement of enrolment for all districts within the Service Area. If the full enrolment period of 4 months is not complete for any of the districts, then the State Nodal Agency will determine the Enrolment Rate achieved by the Insurer upon completion of 4 months from the date of commencement of enrolment for the first district within the Service Area. However, even in this case, the State Nodal Agency will determine the Enrolment Rate for all districts within the Service Area based on completed enrolments by such date. Applicable rate of Enrolment Liquidated Damages shall be 30 per Beneficiary Family Unit that has not been enrolled by the Insurer. The total Enrolment Liquidated Damages shall be calculated as follows: LD Enrol = 30 x [{50 - E%}] x [N B - (N D + N G )] 100 Where function {X} = X, if X > 0 0, if X 0 The total Enrolment Liquidated Damages payable by the Insurer in each Policy Cover Period shall be subject to a cap, determined as follows: LD EnrolCap = 0.05 x P x N E Where: LD EnrolCap is the cap on Enrolment Liquidated Damages P is the Premium per Beneficiary Family Unit applicable in the Policy Cover Period for which the Enrolment Liquidated Damages are being calculated N E is the number of Beneficiary Family Units enrolled in the Policy Cover Period for which the Enrolment Liquidated Damages are being calculated The cap on Enrolment Liquidated Damages shall 328

329 Table 1: Performance KPIs Sl. No. KPI Measure & Explanation Baseline Source of Measuring Data Time for Evaluation of KPI Liquidated Damages Cap on Liquidated Requirements Damages landlord or vice versa. N D shall be calculated using the following formula: N D = (number of data error observed on the field during enrolment) * (N B N G ) / (number of persons who visited enrolment centre) [Note. The formula for N D takes into account that there are Beneficiary Family Units who would have government employees as members and also be a part of the data error.] N G is the number of Beneficiary Family Units that include one or more government employee(s). [Note: If accurate data is not available in the Beneficiary Database on the number of Beneficiary Family Units including government employee(s), it shall be assumed that 10% of the total Beneficiary Family Units in the Beneficiary Database qualify as families with one or more government employees.] Note. The Enrolment Rate under this Performance KPI will be measured for the entire Service Area. be calculated without making any deductions for Liquidated Damages paid or payable under Clause 22 or any other deductions made or to be made in accordance with this Insurance Contract. 329

330 Table 1: Performance KPIs Sl. No. KPI Measure & Explanation Baseline Source of Measuring Data Time for Evaluation of KPI Liquidated Damages Cap on Liquidated Requirements Damages 1.2 Pace of enrolment process Minimum Enrolment Rate to be achieved in the third month of enrolment in each district Enrolment Rate in each district will be determined at the end of each month in accordance with the formula set out in % Same as above. The State Nodal Agency will determine the Enrolment Rate achieved by the Insurer in each district upon completion of 3 months from the date of commencement of enrolment in that district. Applicable rate of Enrolment Liquidated Damages shall be 10 per Beneficiary Family Unit that has not been enrolled by the Insurer in the relevant district. The Enrolment Liquidated Damages for a district shall be calculated as follows: The total Enrolment Liquidated Damages payable by the Insurer in each Policy Cover Period under this Section 1.2 shall be subject to a cap, determined as follows: LD Enrol = 10 x [{40 - E%}] x [N B - (N D + N G )] 100 LD EnrolCap = 0.02 x P x N E where function {X} = X, if X > 0 0, if X 0 For the purpose of this formula, E% shall mean the Enrolment Rate in each district for which such Enrolment Liquidated Damages are being levied. Further, [N B - (N D + N G )] will be calculated for the district for which such Enrolment Liquidated Damages are being levied. For the purpose of this formula, N E shall mean the total number of Beneficiary Family Units enrolled in the district in respect of which such Enrolment Liquidated Damages are payable. The cap on Enrolment Liquidated Damages shall be calculated without making any deductions for Liquidated Damages paid or payable under Clause 22 or any other deductions made or to be made in accordance with this Insurance Contract. 1.3 Average Family AvgFS = N Ben 3.5 For determining the At the end of 4 months of Applicable rate of Enrolment Liquidated The total Enrolment 330

331 Table 1: Performance KPIs Sl. No. KPI Measure & Explanation Baseline Source of Measuring Data Time for Evaluation of KPI Liquidated Damages Cap on Liquidated Requirements Damages Size Where: N E AvgFS is the average family size N Ben is the total number of Beneficiaries enrolled N E is the total number of Beneficiary Family Units enrolled. Average Family Size, the State Nodal Agency shall rely on the enrolment data downloaded from the FKO cards on the DKM servers. If the enrolment data is not available from the DKM Servers, then the State Nodal Agency shall rely on the signed enrolment data submitted by the Insurer along with its invoices for each enrolment round. Additionally, third party assessment agencies may conduct random checks of a sample of Beneficiary Family Units enrolled enrolment in each district of the Service Area Damages for Average Family Size shall be calculated on a district wise basis per average Beneficiary Family size per enrolled Family unit. The total Enrolment Liquidated Damages for Average Family Size shall be calculated as follows: LD size = P x N E Where function {X} = X, if X > 0 0, if X 0 And N E is the total number of Beneficiary Family Units enrolled in respect of which such Enrolment Liquidated Damages are payable P is the penalty applicable, which will be calculated as follows: i. Average Family Size between 3.0 and 3.5: ii. Average Family Size between 2.5 and 3.0: iii. Average Family Size between 2.0 and 2.5: iv. Average Family Size between 1.5 and 2.0: 24 v. Average Family Size between 1.0 and 1.5: For further clarification, in case Average family size be taken at 1 decimal place and if it is on the boundary of two values, the value yielding 34 Liquidated Damages payable by the Insurer under this Section 1.3 in each Policy Cover Period shall be subject to a cap, determined as follows: LD EnrolCap = 0.01 x P x N E For the purpose of this formula, N E shall mean the total number of Beneficiary Family Units enrolled in the district in respect of which such Enrolment Liquidated Damages are payable. The cap on Enrolment Liquidated Damages shall be calculated without making any deductions for Liquidated Damages paid or payable under Clause 22 or any other deductions made or to be made in accordance with this Insurance Contract. 331

332 Table 1: Performance KPIs Sl. No. KPI Measure & Explanation Baseline Source of Measuring Data Time for Evaluation of KPI Liquidated Damages Cap on Liquidated Requirements Damages higher penalty would apply. 2. Ensuring reasonable network of Empanelled Health Care Providers 2.1 Number of private health care providers empanelled within Meghalaya 2.2 Number of specialty hospitals empanelled in This shall be measured by counting the number of eligible private health care providers empanelled within Meghalaya This shall be measured by counting the number of eligible specialty hospitals empanelled in Guwahati for the Listed 6 (1) This number shall be determined based on the list submitted by the Insurer under Clause 16.6(a) and the monthly empanelment reports (and Empanelment Forms) submitted under Clause 16.6(c). (2) For the purpose of determining eligibility, the State Nodal Agency shall determine whether each of the empanelled health care providers meet the minimum empanelment criteria set out in Schedule 7 of the Insurance Contract. The State Nodal Agency will determine the number of eligible health care providers empanelled by the Insurer upon completion of 4 months from the date of commencement of enrolment for all districts within the Service Area. If the full enrolment period of 4 months is not complete for any of the districts, then the State Nodal Agency will determine the number of eligible health care providers empanelled by the Insurer upon completion of 4 months from the date of commencement of enrolment for the first district within the Service Area. Applicable rate of Empanelment Liquidated Damages shall be 500,000 per eligible private health care provider in Meghalaya that has not been empanelled by the Insurer. The total Empanelment Liquidated Damages payable under this Section 2.1 shall be calculated as follows: LD EmpP(Megh) = [500,000]x[{6 - Emp P(Megh) }] Where function {X} = X, if X > 0 0, if X 0 Where: LD EmpP(Megh) is the Empanelment Liquidated Damages levied for the Insurer's failure to empanel the minimum number of eligible private health care providers in Meghalaya Emp P(Megh) is the number of eligible private health care providers empanelled by the Insurer in accordance with Clause Same as above. Same as above. Applicable rate of Empanelment Liquidated Damages shall be 500,000 per eligible health care provider in Guwahati that has not The total Empanelment Liquidated Damages payable by the Insurer in each Policy Cover Period shall be subject to a cap, determined as follows: LD EmpCap = 0.05 x P x N E Where: LD EmpCap is the cap on Empanelment Liquidated Damages P is the Premium per Beneficiary Family Unit applicable in the Policy Cover Period for which the Empanelment Liquidated Damages are being calculated N E is the number of Beneficiary Family Units enrolled in the Policy Cover Period for which the Empanelment Liquidated Damages are 332

333 Table 1: Performance KPIs Sl. No. KPI Measure & Explanation Baseline Source of Measuring Data Time for Evaluation of KPI Liquidated Damages Cap on Liquidated Requirements Damages Guwahati Specialties. (i) If a single specialty hospital empanelled in Guwahati has been empanelled for all the Listed Specialties, then such specialty hospital will be treated as one hospital for the purpose of this Performance KPI. (ii) If a single specialty hospital in Guwahati cannot be empanelled for all the Listed Specialties, then so long as all the Listed Specialties have been represented once, then all the specialty hospitals will be treated as one hospital for the purpose of this Performance KPI. (iii) If a single specialty hospital in Guwahati cannot be empanelled for all the Listed Specialties, then so long as all the Listed Specialties have been represented at least twice, then all the specialty hospitals will be treated as at least two hospitals for the purpose of this Performance KPI. been empanelled by the Insurer for all the Listed Specialties. The total Empanelment Liquidated Damages payable under this Section 2.2 shall be calculated as follows: LD Emp(G) = 500,000 x [{2 - Emp (G) }] Where function {X} = X, if X > 0 0, if X 0 Where: LD Emp(G) is the Empanelment Liquidated Damages levied for the Insurer's failure to empanel the minimum number of eligible health care providers in Guwahati for all the Listed Specialties Emp (G) is the number of eligible health care providers empanelled by the Insurer in Guwahati for all the Listed Specialties in accordance with Clause 16.4 being calculated The cap on Empanelment Liquidated Damages shall be calculated without making any deductions for Liquidated Damages paid or payable under Clause 22 or any other deductions made or to be made in accordance with this Insurance Contract. Note. This cap on Empanelment Liquidated Damages applies to all Empanelment Liquidated Damages levied under Sections 2.1 to 2.6 of this Table Number of specialty hospitals empanelled outside Meghalaya for This shall be measured by counting the number of Specialty Hospitals located outside Meghalaya, i.e., in Delhi, Kolkata and at least 3 of the following cities: Mumbai, Bengaluru, 2 Specialty Hospitals per city, with a minimum of 5 cities being covered Same as above. Same as above. Applicable rate of Empanelment Liquidated Damages shall be 500,000 per eligible Specialty Hospital per city that has not been empanelled by the Insurer. The total Empanelment Liquidated Damages 333

334 Table 1: Performance KPIs Sl. No. KPI Measure & Explanation Baseline Source of Measuring Data Time for Evaluation of KPI Liquidated Damages Cap on Liquidated Requirements Damages the Listed Specialties Hyderabad and Chennai. (i) If a single specialty hospital empanelled in a city has been empanelled for all the Listed Specialties, then such specialty hospital will be treated as one Specialty Hospital in that city for the purpose of this Performance KPI. (ii) If a single specialty hospital in a city cannot be empanelled for all the Listed Specialties, then so long as all the Listed Specialties have been represented once im that city, then all the specialty hospitals will be treated as one Specialty Hospital in that city for the purpose of this Performance KPI. (iii) If a single specialty hospital in a city cannot be empanelled for all the Listed Specialties, then so long as all the Listed Specialties have been represented at least twice in that city, then all the specialty hospitals in that city will be treated as at least two Specialty Hospitals in that city for the purpose of this Performance KPI. payable under this Section 2.3 per city shall be calculated as follows: LD Emp(SH) = 500,000x[{2 - Emp (SH) }] Where function {X} = X, if X > 0 0, if X 0 Where: LD Emp(SH) is the Empanelment Liquidated Damages levied for the Insurer's failure to empanel the minimum number of eligible Specialty Hospitals per city. The LDEmp(SH) will also be applicable if the minimum number of eligible Specialty Hospitals have not been empanelled in a minimum of 5 cities Emp (SH) is the number of eligible Specialty Hospitals empanelled by the Insurer outside Meghalaya in each city in accordance with Clause Number of NABH This shall be measured by 2 Same as above. Same as above. Applicable rate of Empanelment Liquidated 334

335 Table 1: Performance KPIs Sl. No. KPI Measure & Explanation Baseline Source of Measuring Data Time for Evaluation of KPI Liquidated Damages Cap on Liquidated Requirements Damages accredited hospitals in the network counting the number of eligible NABH accredited hospitals empanelled across India Damages shall be 600,000 per NABH accredited hospital that has not been empanelled by the Insurer. The total Empanelment Liquidated Damages payable under this Section 2.4 shall be calculated as follows: LD Emp(NABH) = 600,000x[{2 - Emp (NABH) }] Where function {X} = X, if X > 0 0, if X Number of health care providers with specialty in oncosurgery and cancer therapy in the network This shall be measured by counting the number of eligible Specialty Hospitals with specialty in oncosurgery and cancer therapy empanelled across India Where: LD Emp(NABH) is the Empanelment Liquidated Damages levied for the Insurer's failure to empanel the minimum number of NABH accredited hospitals across India Emp (NABH) is the number of NABH accredited hospitals empanelled by the Insurer in accordance with Clause Same as above. Same as above. Applicable rate of Empanelment Liquidated Damages shall be 600,000 per eligible Specialty Hospital providing oncosurgery and cancer therapy that has not been empanelled by the Insurer. The total Empanelment Liquidated Damages payable under this Section 2.5 shall be calculated as follows: LD Emp(Onco) = 600,000x[{2 - Emp (Onco) }] 335

336 Table 1: Performance KPIs Sl. No. KPI Measure & Explanation Baseline Source of Measuring Data Time for Evaluation of KPI Liquidated Damages Cap on Liquidated Requirements Damages Where function {X} = X, if X > 0 0, if X 0 Where: LD Emp(Onco) is the Empanelment Liquidated Damages levied for the Insurer's failure to empanel the minimum number of Specialty Hospitals with specialty in oncosurgery and cancer therapy across India Emp (Onco) is the number of Specialty Hospitals with specialty in oncosurgery and cancer therapy empanelled by the Insurer in accordance with Clause Geographic Spread of Public or Private Empanelled Healthcare Providers within Service Area This shall be measured by counting the number of Empanelled Health Care Providers across each district in the Service Area Note. The Insurer will be excused for non-performance measured against this KPI if it submits a certificate from the district level health officials regarding nonavailability of public or private healthcare providers meeting the minimum empanelment criteria At least 2 in each block. Each should cover minimum 8000 enrolled BFUs. At least 5 hospitals in district headquarters District wise GIS map submitted by Insurer showing dispersal of Empanelled Health Care Providers within Service Area and number of Beneficiary Family Units enrolled Same as above Applicable rate of Empanelment Liquidated Damages shall be 50,000 per Block where less than 2 hospitals empanelled and 50,000 per District where less than 5 hospitals have been empanelled subject to maximum total damages of 100,000 per District In case district authorities or SNA certifies that two eligible hospitals are not available for empanelment within a certain Block or that atleast 5 eligible hospitals are not available at district level for empanelment, these shall be excluded from assessment and no damages shall be applied against this. Part of the cap on liquidated damages above. 3. Ensuring Timely Claim Settlement 3.1 Timely Claim Settlement with Empanelled Arithmetic average number of days taken by the Insurer in settling a Claim (i.e., making Claim 30 days In accordance with Clause 10 In accordance with Clause 10 No liquidated damages are applicable for the Insurer's failure to meet this Performance KPI. However, the Insurer shall be responsible for Not applicable 336

337 Table 1: Performance KPIs Sl. No. KPI Measure & Explanation Baseline Source of Measuring Data Time for Evaluation of KPI Liquidated Damages Cap on Liquidated Requirements Damages Health Care Providers Payment or completing investigation of a Claim) Note. (1) The day on which Claim was made shall be counted if the Claim is received before 1200 hours. (2) Similarly, if the Claim Payment is received after 1200 hours by the Empanelled Health Care Provider, it shall be counted in the number of days taken to make the payment. paying penal interest to the Empanelled Health Care Providers in accordance with Clause RENEWAL KPIs 3.1 Renewal KPIs and Evaluation The renewal KPIs, the manner of determination of the Renewal KPIs, the baseline requirements and the scoring of Insurer's performance against the Renewal KPIs are set out in Table 2 below. Table 2: Renewal KPIs Sl. No. KPI Measure & Explanation Baseline Requirements 1. Enrolment of beneficiaries Source of Measuring Data Scoring 1.1 Overall Enrolment Rate Enrolment Rate is to be determined for all the districts in the Service Area in the manner set out in Section 1.1 of Table 1. 50% For determining the Enrolment Rate, the State Nodal Agency shall rely on the enrolment data downloaded from the FKO cards on the DKM servers. If the enrolment data is not available from the DKM Servers, The Insurer shall be scored as follows: E% < 50% - 0 E% = 50%

338 Table 2: Renewal KPIs Sl. No. KPI Measure & Explanation Baseline Requirements 2. Empanelment Source of Measuring Data then the State Nodal Agency shall rely on the signed enrolment data submitted by the Insurer along with its invoices for each enrolment round. Scoring 50% < E% 55% % < E% 60% % < E% 65% % < E% 70% % < E% 75% - 9 E% > 75% Percentage of private health care providers empanelled within Meghalaya 2.2 Number of specialty hospitals empanelled in Guwahati Emp% = Emp P x 100 Emp T Where: Emp% is the Empanelment Rate in Meghalaya Emp P is the total number of private Empanelled Health Care Providers in Meghalaya Emp T is the total number of private health care providers in Meghalaya This shall be measured by counting the number of eligible specialty hospitals empanelled in Guwahati for the Listed Specialties. (i) If a single specialty hospital empanelled in Guwahati has been empanelled for all the Listed Specialties, then such specialty hospital will be treated as one hospital for the purpose of this Renewal KPI. 50% (1) This number shall be determined based on the list submitted by the Insurer under Clause 16.6(a) and the monthly empanelment reports (and Empanelment Forms) submitted under Clause 16.6(c). (2) The State Nodal Agency will only count those private Empanelled Health Care Providers that have remained continuously empanelled for a period of at least 180 days during the Policy Cover Period in which this Renewal KPI is being tested. (3) For the purpose of this Section 2.1, the State Nodal Agency shall only take into account those Empanelled Health Care Providers meeting the minimum empanelment criteria set out in Schedule 7 of the Insurance Contract. The Insurer shall be scored as follows: Emp% < 50% - 0 Emp% = 50% % < Emp% 60% % < Emp% 70% - 9 Emp% > 70% Same as above. The Insurer shall be scored as follows: No empanelled Specialty Hospital empanelled Speciality Hospital empanelled Specialty Hospitals

339 Table 2: Renewal KPIs Sl. No. KPI Measure & Explanation Baseline Requirements Source of Measuring Data Scoring (ii) If a single specialty hospital in Guwahati cannot be empanelled for all the Listed Specialties, then so long as all the Listed Specialties have been represented once, then all the specialty hospitals will be treated as one hospital for the purpose of this Renewal KPI. (iii) If a single specialty hospital in Guwahati cannot be empanelled for all the Listed Specialties, then so long as all the Listed Specialties have been represented at least twice, then all the specialty hospitals will be treated as at least two hospitals for the purpose of this Renewal KPI. 2.3 Number of specialty hospitals empanelled outside Meghalaya for the Listed Specialties This shall be measured by counting the number of Specialty Hospitals located outside Meghalaya and in Delhi and Kolkata and at least 3 of the following cities: Mumbai, Bengaluru, Hyderabad and Chennai. 2 Specialty Hospitals per city, with a minimum of 5 cities being covered Same as above. The Insurer shall be scored for each city as follows: No empanelled Specialty Hospital empanelled Specialty Hospital empanelled Specialty Hospitals - 2 (i) If a single specialty hospital empanelled in a city has been empanelled for all the Listed Specialties, then such specialty hospital will be treated as one Specialty Hospital in that city for the purpose of this Renewal KPI. The Insurer shall then be scored for 5 cities and the scores for each city shall be added to arrive at the Insurer's total score for this Renewal KPI. (ii) If a single specialty hospital in a city cannot be empanelled for all the Listed Specialties, then so long as all the Listed Specialties have been represented once om that city, then all the specialty hospitals will be treated as one Specialty Hospital in that 339

340 Table 2: Renewal KPIs Sl. No. KPI Measure & Explanation Baseline Requirements Source of Measuring Data Scoring city for the purpose of this Renewal KPI. (iii) If a single specialty hospital in a city cannot be empanelled for all the Listed Specialties, then so long as all the Listed Specialties have been represented at least twice in that city, then all the specialty hospitals in that city will be treated as at least two Specialty Hospitals in that city for the purpose of this Renewal KPI. 2.4 Number of NABH accredited hospitals in the network This shall be measured by counting the number of eligible NABH accredited hospitals empanelled across India 2 Same as above. The Insurer shall be scored as follows: No empanelled NABH accredited hospital empanelled NABH accredited hospital empanelled NABH accredited hospitals Number of health care providers with specialty in oncosurgery and cancer therapy in the network This shall be measured by counting the number of eligible Specialty Hospitals with specialty in oncosurgery and cancer therapy empanelled across India 2 Same as above. The Insurer shall be scored as follows: No empanelled Specialty Hospital empanelled Specialty Hospital empanelled Specialty Hospitals Hospital IT Infrastructure Installed and Operational at Premises of Empanelled Health Care Providers 3.1 Percentage of Empanelled Health Care Providers having Hospital IT Infrastructure Where: IT% = Emp IT x 100 Emp TOT IT% is the percentage of Empanelled Health Care Providers at which the Hospital IT Infrastructure has been installed and is operational 70% (1) To be verified based on monthly reports submitted by the Insurer in accordance with Clause 16.6(c) and Clause 26(b). However, the State Nodal Agency shall be entitled to make random site visits to the premises of each Empanelled Health Care Provider to determine whether or not the Hospital IT Infrastructure has been installed and is operational. (2) The State Nodal Agency will only count an The Insurer shall be scored as follows: IT% < 70% - 0 IT% = 70% % < IT% 80% % < IT% 90% % < IT% 99%

341 Table 2: Renewal KPIs Sl. No. KPI Measure & Explanation Baseline Requirements 4. Claims Emp IT is the total number of Empanelled Health Care Providers at which the Hospital IT Infrastructure has been installed and is operational within 30 days of the date of its empanelment Emp TOT is the total number of Empanelled Health Care Providers Source of Measuring Data Empanelled Health Care Providers where the Hospital IT Infrastructure has been installed and operational within 30 days of its empanelment. Scoring IT% = 100% Providing Access to District Server to the State Nodal Agency 4.2 Claims Settlement by number Number of days from the commencement of the Policy Cover Period taken by the Insurer to provide the State Nodal Agency with access to the District Server for the sharing of Claims data Claims% = C TAT x 100 Where: Claims% is the percentage of claims settled by the Insurer during the Policy Cover Period within the Turn-around Time of 30 days C TAT is the total number of Claims settled by the Insurer in accordance with Clause 10.1(i) within 30 days. C S is the total number of Claims received by the Insurer from the Empanelled Health Care Providers. 5. Maintenance of MIS Dashboard and MIS Reports C S 30 days State Nodal Agency's records The Insurer shall be scored as follows: 70% The rate of Claims settlement shall be verified by the State Nodal Agency by verifying the following information provided by the Insurer against the Claims data reflecting on the State Nodal Agency's DKMA/State servers: the reports submitted by the Insurer under Clause 10.1(m); and the monthly Claim Count summary sheet submitted by the Insurer under Clause 26(b). > 30 days of Policy Cover Period start - 0 Between days of Policy Cover Period start- 5 Between days of Policy Cover Period start- 7 Between 7-14 days of Policy Cover Period start- 8 Within 7 days of Policy Cover Period start - 9 On or before start of Policy Cover Period - 10 The Insurer will be scored as follows: Claims% < 70% - 0 Claims% = 70% % < Claims% 75% % < Claims% 80% % < Claims% 85% % < Claims% 90% - 9 Claims% > 90%

342 Table 2: Renewal KPIs Sl. No. KPI Measure & Explanation Baseline Requirements Source of Measuring Data Scoring 5.1 Maintenance and Updation of MIS Dashboard Timeliness of maintenance and updation of MIS Dashboard (including MIS reporting) in accordance with Clause 26(a). 90% The maintenance and updation of the MIS Dashboard The Insurer shall be scored as follows: (including all MIS Reports) shall be verified by the State Nodal Agency by undertaking periodic checks of the MIS Timeliness and updation < 90% - 0 Dashboard maintained by the Insurer. 90% Timeliness and updation < 95% - 5 Timeliness and updation 95% Submission of Monthly Reports to State Nodal Agency Timeliness and completeness of monthly reporting by the Insurer in accordance with Clause 26(b) and Annexure 6. 90% The timeliness and completeness of the reports submitted by the Insurer shall be verified by the State Nodal Agency on a monthly basis. The Insurer shall be scored as follows: Timeliness and completeness < 90% % Timeliness and completeness < 95% - 5 Timeliness and completeness 95% Renewal of Policies (a) The State Nodal Agency may evaluate the Insurer's performance during the first 6 months of each Policy Cover Period, no later than 190 days from the date of commencement of each Policy Cover Period. (b) The Insurer's performance in each Policy Cover Period for each Renewal KPI will be scored in the manner set out in Table 2. Once the State Nodal Agency scores the Insurer's performance against each Renewal KPI, the Insurer's scores will be added up and the Insurer's total score for such Policy Cover Period will be determined. 342

343 (c) If: (i) the Insurer has achieved a score of zero for any two Renewal KPIs based on its performance; or (ii) the Insurer's total score is less than 70 of a total possible score of 110, then it shall be deemed that the Insurer has not demonstrated performance against the Renewal KPIs to the reasonable satisfaction of the State Nodal Agency. In such a circumstance, the State Nodal Agency shall have the right to refuse the renewal of all the Policies for the next Policy Cover Period by issuing a notice to the Insurer within 200 days from the date of commencement of the on-going Policy Cover Period and in any event prior to the date on which the Insurer is required to commence enrolment for the next Policy Cover Period in accordance with Clause 21.1(c). 343

344 Beneficiary SCHEDULE 17 CLASSIFICATION OF COMPLAINTS AND GRIEVANCES Aggrieved Party Indicative Nature of Grievance Grievance Against (Category) Empanelled Health Care Provider Insurer Denied treatment Money sought for treatment, despite Sum Insured being available Demanding more than Package Rate/Pre-Authorized Amount, if Sum Hospital Insured insufficient or exhausted (Category 1) Smart Card retained by Empanelled Health Care Provider Transportation expense or economic loss compensation not paid Medicines not provided against OPD Benefits or Follow-up Care Smart Card not distributed on the spot at the time of enrolment All members of Beneficiary Family Unit not photographed despite being present or fingerprints not taken Smart Card Service Provider (Category Extra registration fee charged 2) Registration not done despite name being included in Beneficiary Database Name not found in the Beneficiary Database DKM (Category 3) Claims rejected by Insurer or full Claim amount not paid Insurer not agreeing to empanel hospitals Suspension or de-empanelment of Empanelled Health Care Provider Hospital IT Infrastructure not functioning; Insurer not assisting in solving issue or not accepting manual transaction MHC issues Smart Card issues FKO not available at enrolment station as per enrolment plan FKO not verifying Beneficiary information No space provided for District Kiosk Beneficiary Database not updated for renewal Policy Cover Period Premium not received within time prescribed at Clause 8 Insurer (Category 4) DKM (Category 3) State Nodal Agency (Category 5) Referred To (Category) DGNO/DGRC (Level I) SGNO/SGRC (Level II) DGNO/DGRC (Level I) SGNO/SGRC (Level II) MoHFW /NGRC (Level III) Note: The list of grievances above is not exhaustive. There may be other categories of grievances and the DGNO shall decide the authority to which such grievance shall be referred. 344

345 ANNEXURE 1 FORMAT OF EMPANELMENT FORM APPLICATION FORM FOR NETWORK SERVICE PROVIDER Objective of this document This document forms part of (Insert Insurance Company/ TPA s) hospital empanelment process This document is a self-assessment questionnaire which is completed by a hospital that wants to provide services to our customers This should be completed and returned to Name: Address: Note: By completing this document you are declaring that your hospital meets certain criteria as set out in the form. 345

346 APPLICATION FORM FOR NETWORK SERVICE PROVIDER HOSPITAL INFORMATION a) Name of the hospital b) Address City State c) Phone number d) Fax no. e) PAN no f) Registration number g) address h) Website CONTACT DETAILS a) Chief executive of hospital: i. ) Name ii. ) Phone number iii.) address b) Main point contact for TPA/ Insurance company: i. ) Name ii. ) Designation iii.) Phone number iv. ) address c) Insurance/ TPA coordinator: i. Name ii. Designation iii. Phone number iv. address 346

347 BANK DETAILS a) Bank name and branch b) Address City State c) Account number d) 9 Digit number appearing on the MICR cheque e) IFSC code f) Payee name TAX DETAILS a) Are you exempt from tax deduction at source? Yes No i) If yes, please attach income tax registration & income tax exemption certificate b) Service tax registration number: Note: Additional information may be required OWNERSHIP a) Type ( Only tick one) i. Government ii. Nonprofit iii. Private TOTAL NUMBER BEDS a) Room category wise i. General ii. Twin sharing iii. Single iv. Single AC v. Day care vi. ICU LEVEL OF CARE a) TYPE (Only tick one) i. Secondary + Single specialty ii. Secondary + Multi specialty iii. Tertiary + Single specialty iv. Tertiary+ Multiple specialty b) List of specialties (Tick ALL that apply) i. Internal medicine ii. Cardiology iii. Nephrology iv. Pediatrics v. Pulmonology vi. Gastro-enterology vii. General surgery viii. Orthopedics ix. Gynecology x. Obstetrics xi. Oncology xii. Urology c) Nurse bed ratio i. General ii. Twin sharing iii. Single iv. Single AC 347

348 v. ICU d) Availability i. Full time physicians CLINICAL SERVICES a) Emergency (Tick ALL that apply) i. Emergency room/ Minor OT ii. 24 hour ambulance service iii. Burns unit iv. Trauma centre b) Outpatient services i. Number of consulting rooms ii. OPD working hours c) Diagnostic facilities Investigations: (Tick ALL that apply) i. Blood biochemistry ii. Hematology iii. Microbiology iv. Cytology v. Immunology vi. Blood bank vii. Radiology viii. X-ray ix. USG x. CT Scan xi. MRI xii. Nuclear medicine Inpatient facilities i. Number of major operating rooms ii. Number of minor operating rooms ii. Cath lab facility Pharmacy i. Day/ Night INFRASTRUCTURE AND SUPPORT SERVICE (Tick ALL that apply) i. Waste disposal system ii. CSSD iii. Laundry service iv. Power back up v. Central gas supply vi. Water purification/ filtration vii. Disabled friendly COMPUTERIZATION (Tick ALL that apply) i. IT Connectivity ii. Hospital Information Systems iii. Digitisation of records iv. Coding v. IT enabled services CERTIFICATION (Requires photocopy of certification) (Tick ALL that apply) i. JCI accredited ii. ISO certified iii. NABH certified Any other certification (Please specify) OUTCOME DATA (Does hospital collect data on the following?) (Tick ALL that apply) i. Inpatient mortality ii. Neonatal mortality iii. Perioperative mortality iv. Surgical site infections v. Hospital acquired infections vi. Unplanned return to theatre filtration vii. Unplanned readmissions viii. Transfers to other hospitals 348

349 ix. Complications of anesthesia x. Transfusion reactions CHECK LIST FOR ENCLOSURES i. Tariff list ii. Hospital brochure iii. Copy of the hospital registration certificate with the local government authority iv. Copy of certification (ISO/ NABL/ JCI/ Others) DETAILS OF OFFICIAL WHO COMPLETED THIS FORM Name of person Designation Mobile number address Authorised Signatory Seal of Hospital 349

350 ANNEXURE 2 FORMAT OF SERVICES AGREEMENT [Note: To be separately provided by the State Nodal Agency.] 350

351 ANNEXURE 3 FORMAT FOR SUBMITTING LIST OF EMPANELLED HEALTH CARE PROVIDERS LIST OF EMPANELLED HEALTH CARE PROVIDERS WITHIN MEGHALAYA District Block Name of Empanelled Health Care Provider Address with phone no. Name of Incharge No. of Beds in the Empanelled Health Care Provider Own Pharmacy (Yes/ No) Own Diagnostic Services (Yes/ No) Services Offered (Specialty) Has functional OT (Yes/No) GIS Code (List should be District-wise alphabetically) SIGNATURE 351

352 LIST OF EMPANELLED HEALTH CARE PROVIDERS OUTSIDE MEGHALAYA State City Name of Health Care Provider Address with phone no. Name of Incharge No. of Beds in the Health Care Facility Own Pharmacy (Yes/ No) Own Diagnostic test lab (Yes/ No) Services Offered (Specialty) Has functional OT (Yes/No) GIS Code (List should be District-wise alphabetically) SIGNATURE 352

353 ANNEXURE 4 REPORTING FORMATS FOR EMPANELLED HEALTH CARE PROVIDERS 1. Monthly Utilization Information Collection Format (adapted from CHI2A) Modified version of CHI 2A Name of Disease as per standard definition of case ICD 10 code Outpatient cases (OPD) Male Female Male Female Monthly utilization data to be provided by Hospitals for communicable diseases Patient reported / treated during the month Inpatient cases reported Inpatient cases (IPD) reported amongst outpatients direct Average Length of Stay Male Female Total cases Total deaths Average length of stay Male Female Total Male Female Total Cholera (lab confirmed) Acute Diarrhoeal diseases Diphtheria Tetanus other than neonatal Neonatal tetanus Whooping Cough Measles Acute Respiratory Infection (ARI) including influenza and excluding pneumonia Pneumonia Enteric Fever Viral hepatitis A Viral hepatitis B Viral hepatitis C,D & E Meningococcal Meningitis Rabies Syphillis Gonococcal infection Chicken pox Encephalitis Viral meningitis Others Total Number of readmissions Neonatal deaths Maternal deaths Number of hospital acquired infections Additional Quality indicators (Inpatients) 353

354 2. Monthly Utilization Information Collection Format (adapted from CHI 2B) Modified version of CHI 3A Nature /Group of Non Communicable Diseases Monthly utilization data to be provided by Hospitals for Non communicable diseases Patient reported / treated during the month ICD 10 code Outpatient cases Inpatient cases (IPD) reported Inpatient cases reported Total cases Total deaths Average Length of Average length of Male Female Male Female Stay Male Female stay Male Female Total Male Female Total CardioVascular Diseases Hypertension Ischemic Heart Diseases Neurological Disorders Cerebro vascular Accident Other Neurological Disorders Diabetes Mellitus Type I Type II Lungs Diseases Bronchitis Emphysema Asthma Psychiatric Disorder Common Mental Disorders Severe mental Disorders Accidental injuries Cancer SnakeBite Renal Failure Acute Renal Failure Chronic renal Failure Obesity Road Traffic Accidents Total Number of readmissions Neonatal deaths Maternal deaths Number of hospital acquired infections Total number of inpatient admissions this month: Additional Quality indicators (Inpatients) 354

355 3. Average Length of Stay (ALOS) Top 25 Surgical Admissions Name of the Hospital: Report for month: Total admissions for Hospitalization: ALOS (overall for all cases of Hospitalization): Name of the Surgical Procedure (List of Top 25) Specialty Frequency Average Length of Stay 4. Monthly 'Health Quality' Summary Sheet Part 1 dated [ ] (to be submitted by each Empanelled Health Care Provider to Insurer) Name of Hospital: Category (Public/ Faith Based/ Private): District: Sl No. Name of Hospital Category (Public/ Private/ Faith based) Name of the District Total no. of beds MHIS Total beds occupied Non MHIS Average Bed Utilisation (%) Total MHIS Non MHIS Average Stay in Hospital Total MHIS Non MHIS Operative & Post Operative Deaths Total MHIS Non MHIS Maternal Mortality Total MHIS Non MHIS Needle Stick Injury Total MHIS Non MHIS Total 355

356 5. Monthly 'Health Quality' Summary Sheet Part 2 dated [ ] (to be submitted by each Empanelled Health Care Provider to Insurer) Name of Hospital: Category (Public/ Faith Based/ Private): District: Sl No. Patient Name URN No. Date of Admission Date of Discharge Patient Category (RSBY/ MHIS/ Others) Stay in Hospital Death Count Maternal Mortality Needle Stick Injury ICU Days GW Days Total Count Remarks Count Count 356

357 Transaction data Pre-authorization Post-enrolment Pre-enrolment Draft Dated 8 September 2016 ANNEXURE 5 INDICATIVE FORMATS OF MANAGEMENT INFORMATION SYSTEM (MIS) DASHBOARD AND REPORTS ON MIS DASHBOARD 1. MIS DASHBOARD Empanelment District West Jainitia Hills (Jowai) Round All Enrollment Utilization Key Performace Indicators Value Number of Claims Burnout Ratio 1 258, % Hospitalization Ratio 0.8% Parameters Number of Families % of BPL Families Value 6,984, % Hospitalization Ratio - SC/ST Hospitalization Ratio - Minority Average Expenditure per Head % 0.46% 4,374 Average Family Size 3.22 Number of Inter-State Claims 660 Number of Smart Cards Issued % Split Cards out of Total cards % Cards wastage out of Total cards Conversion Ratio 2 Conversion Ratio - SC/ST 3 Conversion Ratio Minority 4 7,449, % 16.89% 23.7% 20.2% 27.9% Number of Inter-District Claims 43,052 % Inter-District Claims 17% 357

358 2. MIS DASHBOARD REPORTS 2.1 Pre-Enrolment Reports (a) Age & Gender: Age and gender distribution of members by District, Round, and Scheme. District Round Scheme All All All Age Male Female Unspecified Grand Total 18 7,498 7,560-15, ,859 12,728-25, ,608 14,262-28, ,268 17,146-34,414 (b) Relation: Relation-wise Distribution of Members by District, Round, and Scheme. District All Round All Scheme All (c) Age Male Female Unspecified Grand Total 18 7,498 7,560-15, ,859 12,728-25, ,608 14,262-28, ,268 17,146-34,414 Families: Total Members and Family Size by District, Round, and Scheme District No. of members No. of families Average family size West Jaintia Hills (Jowai) 60,514 12, East Jaintia Hills (Khliehriat) 448,907 83, East Khasi Hills (Shillong) 545,109 95, West Khasi Hills (Nongstoin) 284,425 43, Post-Enrolment Reports (a) Enrolment Distribution by District: No. of Beneficiary Family Units and Percentage of Total District No. of enrollees % of total West Jaintia Hills (Jowai) 12, % East Jaintia Hills (Khliehriat) 89, % East Khasi Hills (Shillong) 109, % West Khasi Hills (Nongstoin) 56, % 358

359 (b) Age Distribution by District: Average Age Age West Jaintia Hills (Jowai) East Jaintia Hills (Khliehriat) East Khasi Hills (Shillong) West Khasi Hills (Nongstoin) (c) Average No. of Members: Total Number of Beneficiary Family Units, Total Number of Members Enrolled and Average Family by District District No. of families No. of enrollees Average family size West Jaintia Hills (Jowai) 2,463 12, East Jaintia Hills (Khliehriat) 16,619 89, East Khasi Hills (Shillong) 19, , West Khasi Hills (Nongstoin) 8,767 56, (d) Age-Gender Distribution: Age Gender Analysis Gender Distribution by Age Age Male Female Others Male Female Others % 32% 0% 1 22,806 14, % 38% 1% 2 26,997 18, % 40% 2% 3 33,532 24,566 1,158 57% 41% 2% 4 43,420 30,110 1,650 58% 40% 2% Age Distribution by Gender Age Male Female Others Male Female Others % 0% 0% 1 22,806 14, % 2% 1% 2 26,997 18, % 2% 3% 3 33,532 24,566 1,158 4% 4% 4% 4 43,420 30,110 1,650 6% 6% 6% 359

360 (e) Relation Distribution: Relation Distribution by District Relation West Jaintia Hills (Jowai) East Jaintia Hills (Khliehriat) East Khasi Hills (Shillong) West Khasi Hills (Nongstoin) Self 22,806 14, , Spouse 26,997 18, , Father 33,532 24,566 1,158 19, Mother 43,420 30,110 1,650 30,110 Relation West Jaintia Hills (Jowai) East Jaintia Hills (Khliehriat) East Khasi Hills (Shillong) West Khasi Hills (Nongstoin) Self 30% 33% 30% 31% 2 - Spouse 18% 14% 5% 17% 3 - Father 0% 0% 0% 0% 4 - Mother 0% 1% 1% 1% 2.3 Pre-Authorisation Reports (a) (b) (c) (d) (e) (f) (g) (h) Number of pre-authorization requests by hospital, region and reason (FP override, BCP mode, unspecified medical codes etc.) % completion of pre-authorization forms by providers, ownership and region % completion of pre-authorization forms by providers, ownership and region % pre-authorization enhancement requests % declined pre-authorization by provider and reason % cases referred for fraud/abuse investigation/ site visit by provider Average time for pre-authorization approval Frequency and reasons for delay of pre-authorization approval 2.4 Transaction Data Reports (a) Number of records: Claim records by district District No. of records West Jaintia Hills (Jowai) 110 East Jaintia Hills (Khliehriat) 256 East Khasi Hills (Shillong) 789 West Khasi Hills (Nongstoin)

361 (b) TranCode=303: Claim Distribution by district (only Transaction Code = 303) District No. of records No. of Distinct URNs West Jaintia Hills (Jowai) East Jaintia Hills (Khliehriat) East Khasi Hills (Shillong) West Khasi Hills (Nongstoin) (c) Blocking system date: Claims Blocking Period District From To West Jaintia Hills (Jowai) 17-Dec Mar-13 East Jaintia Hills (Khliehriat) 22-Nov Jul-13 East Khasi Hills (Shillong) 8-Dec-12 3-Apr-13 West Khasi Hills (Nongstoin) 4-Sep Mar-13 (d) Blocking User Date: Claims Blocking Period District From To West Jaintia Hills (Jowai) 17-Dec Mar-13 East Jaintia Hills (Khliehriat) 22-Nov Jul-13 East Khasi Hills (Shillong) 8-Dec-12 3-Apr-13 West Khasi Hills (Nongstoin) 4-Sep Mar-13 (e) Age & Gender: Claim Distribution by Age & Gender by District West Jaintia Hills (Jowai) Male Female Column1 Total amount claimedno. of claims Total amount claimed2 No. of claims , , , , , , , and above 19, ,500 1 Grand Total 58, ,000 6 (f) District: Claim Distribution by District District Total amount claimed No. of claims West Jaintia Hills (Jowai) 87, East Jaintia Hills (Khliehriat) 11,375 2 East Khasi Hills (Shillong) 50,500 4 West Khasi Hills (Nongstoin) 26,

362 (g) Claim distribution: Claim distribution by hospital state District Total amount claimed No. of claims West Jaintia Hills (Jowai) 87, West Bengal 11,375 2 Assam 50,500 4 Tamil Nadu 26,000 9 East Jaintia Hills (Khliehriat) 3,593, West Bengal 7,000 2 Assam 3,581, Tamil Nadu 5, (h) CPD: Claim probability distribution by district District All Claim Band Total Claims Total amount claimed ,497 25,087, ,128 83,598, ,266 48,223, ,268 71,047, ,439 92,229, ,290 21,823, & above 168 3,905,725 (i) Claim distribution by hospital (j) Claim distribution by length of stay District All Days Total claims Percentage 0 1,812 24% 1 1,175 15% 2 1,149 15% 3 1,032 13% % % 6 & above % Grand Total 7, % 362