Exposure Draft

To
All CEOS of
Life Insurers, Non-Life Insurers, Standalone Health Insurers and TPAs

Re: Standardization in Health Insurance

Health insurance addresses a major area of public concern. Although it is rapidly growing,
access to health insurance still remains limited and add to it complaints especially due to
variable interpretations of key policy terms are enormous. In order to address the expectation
of public more effectively, the Authority propose to stipulate the following in respect of all
health insurance policies issued by life and general insurers in the country.

1. Standard Definition for 46 commonly used terms in health insurance policies:

Standard terms would reduce ambiguity, enable all stakeholders to provide better services and
enable customers to interact more effectively with insurers, TPAs and providers. All insurers
should adhere to the stipulated definitions, annexed at Annexure I, while defining these 46
core terms in all health insurance policies.

2. Standard Nomenclature and Procedures for Critical Illnesses:

In view of resolving the differences in the definitions of terms on Critical Illnesses adopted by
the different insurers which are creating confusion in the minds of consumers and the industry
especially at the time when insurers and re-insurers have to arrive at a point where lump sum
payment is made, 11 Critical Illness terms have been standardized to be adopted uniformly
across industry. All Policies offering critical illness coverage should ensure that definitions of
the stated 11 terms are in line with the stipulated definitions annexed at Annexure II.

3. Standard Pre-authorization and Claim form:

A common industry wide pre-authorization and claim form will significantly streamline
processes at all stages. This will enhance the ability of providers to obtain a timely prior
authorization. By implementing it in an optical character recognition (OCR) format, the
ability to transfer data from a handwritten paper based form to IT systems has been enhanced
thus reducing the data entry issues for TPAs and insurers. Every company shall attach set of
claim forms to the customer along with policy terms and conditions. The forms are attached at
Annexure III.

4. Standard List of Excluded Expenses in Hospitalization Indemnity policies:

Hospitalization indemnity products are the commonest products in the Indian market and
account for most of the health insurance sold in the country. The standard listing of 203
excluded items, an area which has otherwise been fairly variable in its interpretation and
implementation, has been finalized. The same is annexed at Annexure IV. However, Insurers
may include these exclusions, if the product design allows for, or if the insurer wants to
include these as part of hospitalization expenses.

5. Standard File and Use Application Form, Database Sheet and Customer
Information Sheet:
The existing F&U form used by the non-life insurers is designed keeping in view largely the
characteristics of Non Life products other than Health. With this, the essential information
like the sum insured, the minimum and maximum age, term of the product etc that gets
captured in the F&U form is very minimal. In order to capture the relevant product design
information, the modified File and Use Application form along with the Database sheet and
Customer information sheet as annexed in the Annexure: V, VI and VII respectively shall be
submitted under File and Use procedure by the insurers.

6. Standard agreement between TPA & Insurer and Provider (Hospital) & Insurer:

The insurers enter into agreements with the TPAs health services under health insurance
contracts and with the Providers (Hospitals) for health care services under health insurance
contracts. A standard agreement with all the basic details is annexed in Annexure: VIII and
IX, which shall necessarily be included in the above service level agreements, wherever
relevant.
 Annexure - I

Standard Definitions of terminology used in Health Insurance Policies Health

Insurance Summit
1. Accident
An accident is a sudden, unforeseen and involuntary event caused by external and
visible means.
[Insurance companies can define the term accidental injury in the context of the term
'accident'].

2. Co-Payment
A co-payment is a cost-sharing requirement under a health insurance policy that
provides that the insured will bear a specified percentage of the admissible costs. A
co-payment does not reduce the sum insured.

3. Day Care Treatment

Day care treatment refers to medical treatment, and/or surgical procedure which is:
- undertaken under General or Local Anesthesia in a hospital/day care centre in less
than 24 hrs because of technological advancement, and
- which would have otherwise required a hospitalization of more than 24 hours.

Treatment normally taken on an out-patient basis is not included in the scope of this
definition.
[Insurers can, in addition, restrict coverage to a specified list].

4. Deductible
A deductible is a cost-sharing requirement under a health insurance policy that
provides that the Insurer will not be liable for a specified rupee amount of the
covered expenses, which will apply before any benefits are payable by the insurer. A
deductible does not reduce the sum insured.
[Insurers to define whether the deductible is applicable per year, per life or whether
per event and specific deductible limits would be applied].

5. Dependent Child
A dependent child refers to a child (natural or legally adopted), who is financially
dependent on the primary insured or proposer and does not have his / her
independent sources of income.
[Insurers can add additional criteria relating to age, marital status, education and
disablement].

6. Domiciliary Hospitalisation
Domiciliary hospitalization means medical treatment for a period exceeding 3 days,
for an illness/disease/injury which in the normal course would require care and
 Annexure - I

treatment at a hospital but is actually taken while confined at home under any of the
following circumstances:
- the condition of the patient is such that he/she is not in a condition to be removed to
a hospital, or
- the patient takes treatment at home on account of non availability of room in a
hospital.

7. Emergency Care
Emergency care means management for a severe illness or injury which results in
symptoms which occur suddenly and unexpectedly, and requires immediate care by a
medical practitioner to prevent death or serious long term impairment of the insured
person’s health.

8. Grace Period
Grace period means the specified period of time immediately following the premium
due date during which a payment can be made to renew or continue a policy in force
without loss of continuity benefits such as waiting periods and coverage of pre-
existing diseases. Coverage is not available for the period for which no premium is
received.

9. Hospital
A hospital means any institution established for in- patient care and day care
treatment of sickness and / or injuries and which has been registered as a hospital with
the local authorities, wherever applicable, and is under the supervision of a registered
and qualified medical practitioner AND must comply with all minimum criteria as
under:
- has at least 10 inpatient beds, in those towns having a population of less than
10,00,000 and 15 inpatient beds in all other places;
- has qualified nursing staff under its employment round the clock;
- has qualified medical practitioner (s) in charge round the clock;
- has a fully equipped operation theatre of its own where surgical procedures are
carried out
- maintains daily records of patients and will make these accessible to the Insurance
company’s authorized personnel.

10. Intensive Care Unit

Intensive care unit means an identified section, ward or wing of a hospital which is
under the constant supervision of a dedicated medical practitioner(s), and which is
specially equipped for the continuous monitoring and treatment of patients who are in
a critical condition, or require life support facilities and where the level of care and
supervision is considerably more sophisticated and intensive than in the ordinary and
other wards.
 Annexure - I

11. Inpatient Care

Inpatient care means treatment for which the insured person has to stay in a hospital
for more than 24 hours for a covered event.

12. Medical Practitioner

A Medical practitioner is 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; and is acting within the scope and jurisdiction of his license.
[Insurance companies can specify additional or restrictive criteria to the above, e.g.
that the registered practitioner should not be the insured or close family members].

13. Medically Necessary

Medically necessary treatment is defined as any treatment, tests, medication, or stay
in hospital or part of a stay in hospital which
- is required for the medical management of the illness or injury suffered by the
insured;
- must not exceed the level of care necessary to provide safe, adequate and
appropriate medical care in scope, duration, or intensity;
- must have been prescribed by a medical practitioner;
- must conform to the professional standards widely accepted in international medical
practice or by the medical community in India.

14. Network
All such hospitals, day care centers or other providers that the insurance
company/TPA have mutually agreed with, to provide services like cashless access to
policyholders. The list is available with the insurer/TPA and subject to amendment
from time to time.

15. Non- Network

Any hospital, day care centre or other provider that is not part of the network.

16. Pre-Existing Disease

Any condition, ailment or injury or related condition(s) for which you had signs or
symptoms, and / or were diagnosed, and / or received medical advice / treatment
within 48 months to prior to the first policy issued by the insurer.
[Life Insurers can define norms for applicability at reinstatement].

17. Qualified Nurse

Qualified nurse is a person who holds a valid registration from the Nursing Council of
India or the Nursing Council of any state in India.

18. Reasonable Charges

 Annexure - I

Reasonable charges means the charges for services or supplies, which are the standard
charges for the specific provider and consistent with the prevailing charges in the
geographical area for identical or similar services, taking into account the nature of
the illness / injury involved .

19. Surgery
Surgery or Surgical Procedure means manual and / or operative procedure (s) required
for treatment of an illness or injury, correction of deformities and defects, diagnosis
and cure of diseases, relief of suffering or prolongation of life, performed in a hospital
or day care centre by a medical practitioner

20. OPD treatment

OPD treatment is one in which the Insured visits a clinic / hospital or associated
facility like a consultation room for diagnosis and treatment based on the advice of a
Medical Practitioner. The Insured is not admitted as a day care or in-patient.

21. Hospitalisation
Means admission in a Hospital for a minimum period of 24 In patient Care
consecutive hours except for specified procedures/ treatments, where such admission
could be for a period of less than 24consecutive hours.

22. Illness
Illness means a sickness or a disease or pathological condition leading to the
impairment of normal physiological function which manifests itself during the Policy
Period and requires medical treatment.

23a Acute condition - Acute condition is a medical condition that can be cured by
Treatment

23b. Chronic condition - A chronic condition is defined as a disease, illness, or

injury that has one or more of the following characteristics:—it needs ongoing
or long-term monitoring through consultations, examinations, check-ups, and /
or tests—it needs ongoing or long-term control or relief of symptoms— it
requires your rehabilitation or for you to be specially trained to cope with it—it
continues indefinitely—it comes back or is likely to come back.

23. Day care centre

A day care centre means any institution established for day care treatment of sickness
and / or injuries or a medical set –up within a hospital and which has been registered
with the local authorities, wherever applicable, and is under the supervision of a
registered and qualified medical practitioner AND must comply with all minimum
criteria as under:- has qualified nursing staff under its employment ;- has qualified
medical practitioner (s) in charge ;- has a fully equipped operation theatre of its own
 Annexure - I

where surgical procedures are carried out- maintains daily records of patients and will
make these accessible to the Insurance company’s authorized personnel.

24. Injury
Injury means accidental physical bodily harm excluding illness or disease solely and
directly caused by external, violent and visible and evident means which is verified
and certified by a Medical Practitioner.

25. Medical Advise

Any consultation or advice from a Medical Practitioner including the issue of any
prescription or repeat prescription.

26. Medical expenses

Medical Expenses means those expenses that an Insured Person has necessarily and
actually incurred for medical treatment on account of Illness or Accident on the
advice of a Medical Practitioner, as long as these are no more than would have been
payable if the Insured Person had not been insured and no more than other hospitals
or doctors in the same locality would have charged for the same medical treatment.
6 Health Insurance Summit 2012 th
27. Pre hospitalisation "Pre-hospitalization Medical Expenses
Means Medical Expenses incurred immediately before the Insured Person is
Hospitalised, provided that :i. Such Medical Expenses are incurred for the same
condition for which the Insured Person’s Hospitalisation was required, and ii. The In-
patient Hospitalization claim for such Hospitalization is admissible by the Insurance
Company.

28. Post hospitalization "Post-hospitalization Medical Expenses

Means Medical Expenses incurred immediately after the Insured Person is
Hospitalised, provided that :i. Such Medical Expenses are incurred for the same
condition for which the Insured Person’s Hospitalisation was required, and ii. The In-
patient Hospitalization claim for such Hospitalization is admissible by the Insurance
Company.

29. New Born Baby

Newborn Baby means those babies born to you and your spouse during the Policy
Period Aged between 1 day and 90 days.

30. Cumulative Bonus

Cumulative Bonus shall mean any increase in the sum assured / Mallus granted by the
insurer without an associated increase in premium.

31. Maternity expense/

 Annexure - I

Maternity expense / treatment shall include the following Medical treatment

Expenses: a) Medical Expenses for a delivery (including complicated deliveries and
caesarean sections) incurred during Hospitalization b) the lawful medical termination
of pregnancy during the Policy Period limited to 2 deliveries or terminations or either
during the lifetime of the Insured Person, c) Pre-natal and post-natal Medical
Expenses for delivery or termination.

32. Dental Treatment

Dental treatment is treatment carried out by a dental practitioner including
examinations, fillings (where appropriate), crowns, extractions and surgery excluding
any form of cosmetic surgery/implants.

33. Any one illness

Any one illness means continuous Period of illness and it includes relapse within 45
days from the date of last consultation with the Hospital/Nursing Home where
treatment may have been taken.

34. Congenital Anomaly

Congenital Anomaly refers to a condition(s) which is present since birth, and which is
abnormal with reference to form, structure or position.

35a. Internal Congenital Anomaly

which is not in the visible and accessible parts of the body is called Internal
Congenital Anomaly

35b. External Congenital Anomaly

which is in the visible and accessible parts of the body is called External
Congenital Anomaly.

35. Unproven/Experimental treatment

Unproven/Experimental treatment is treatment, including drug Experimental therapy,
which is based on established medical practice in India, is treatment experimental or
unproven.

36. Condition Precedent

Condition Precedent shall mean a policy term or condition upon which the Insurer's
liability under the policy is conditional upon.
6 Health Insurance Summit 2012
37. Notification of Claim
Notification of claim is the process of notifying a claim to the insurer or TPA by
specifying the timelines as well as the address / telephone number to which it should
be notified.
 Annexure - I

38. Disclosure to information norm

The Policy shall be void and all premium paid hereon shall be forfeited to the
Company, in the event of misrepresentation, mis-description or non-disclosure of any
material fact.

39. Cashless service / definition

Cashless facility means the TPA / Insurer may authorize upon the definition insured's
request for the direct settlement of admissible claim as per agreed charges between
Network hospitals and the TPA / Insurer. In such cases, the TPA/ Insurer will directly
settle all eligible amounts with the Network Hospitals and the Insured person may not
have to pay any bills after the end of the treatment at hospital to the extent the claim is
covered under the Policy.

40. Subrogation
Subrogation shall mean the right of the insurer to assume the rights of the insured
person to recover expenses paid out under the policy that may be recovered from any
other source.

41. Contribution
Contribution is essentially the right of an insurer to call upon other insurers, liable to
the same insured, to share the cost of an indemnity claim on a ratable proportion.

42. Cancellation
Cancellation defines the terms on which the policy contract can be terminated either
by the insurer or the insured by giving sufficient notice to other which is not lower
than a period of fifteen days. The terms of cancellation may differ from insurer to
insurer.

43. Renewal
Renewal defines the terms on which the contract of insurance can be renewed on
mutual consent with a provision of grace period for treating the renewal continuous
for the purpose of all waiting periods.

44. Portability
Portability means the right accorded to an individual health insurance policy holder
(including family cover) to transfer the credit gained by the insured for pre-existing
conditions and time bound exclusions if the policyholder chooses to switch from one
insurer to another insurer or from one plan to another plan of the same insurer,
provided the previous policy has been maintained without any break.

45. Room rent

Room Rent shall mean the amount charged by a hospital for the deductibles
occupying of a bed and associated medical expenses. Deductible is a cost sharing
 Annexure - I

requirement that provides that We will not be liable for the amount of covered
Medical Expenses, as specifically mentioned in the Policy Schedule, which has to be
borne by You for each and every Claim during the Policy Period, before it becomes
payable by Us under the Policy. This is to clarify that a deductible does not reduce the
sum insured.

46. Alternative treatments

Alternative treatments are forms of treatments other than treatment "Allopathy" or
"modern medicine" and includes Ayurveda, Unani, Sidha and Homeopathy in the
Indian context
 Annexure - II

1. CANCER OF SPECIFIED SEVERITY

A malignant tumour characterised by the uncontrolled growth & spread of malignant cells with
invasion & destruction of normal tissues. This diagnosis must be supported by histological
evidence of malignancy & confirmed by a pathologist. The term cancer includes leukemia,
lymphoma and sarcoma.

The following are excluded –

(1) Tumours showing the malignant changes of carcinoma in situ & tumours which are
histologically described as premalignant or non invasive, including but not limited to:
Carcinoma in situ of breasts, Cervical dysplasia CIN-1, CIN -2 & CIN-3.
(2) Any skin cancer other than invasive malignant melanoma
(3) All tumours of the prostate unless histologically classified as having a Gleason score greater
than 6 or having progressed to at least clinical TNM classification T2N0M0.........
(4) Papillary micro - carcinoma of the thyroid less than 1 cm in diameter
(5) Chronic lymphocyctic leukaemia less than RAI stage 3
(6) Microcarcinoma of the bladder
(7) All tumours in the presence of HIV infection.

2. FIRST HEART ATTACK – OF SPECIFIED SEVERITY

The first occurrence of myocardial infarction which means the death of a portion of the heart
muscle as a result of inadequate blood supply to the relevant area. The diagnosis for this will be
evidenced by all of the following criteria:

a) a history of typical clinical symptoms consistent with the

diagnosis of Acute Myocardial Infarction (for e.g. typical chest pain)
b) new characteristic electrocardiogram changes
c) elevation of infarction specific enzymes, Troponins or other specific biochemical markers.

The following are excluded:

(1).Non-ST-segment elevation myocardial infarction (NSTEMI) with elevation of Troponin I or T;
(2).Other acute Coronary Syndromes (3).Any type of angina pectoris.

3. OPEN CHEST CABG

The actual undergoing of open chest surgery for the correction of one or
more coronary arteries, which is/are narrowed or blocked, by coronary
artery bypass graft (CABG). The diagnosis must be supported by a coronary
angiography and the realization of surgery has to be confirmed by a
specialist medical practitioner.

Excluded are:
(1) Angioplasty and/or any other intra-arterial procedures
 Annexure - II

(2) any key-hole or laser surgery.

4. OPEN HEART REPLACEMENT OR REPAIR OF HEART VALVES

The actual undergoing of open-heart valve surgery is to replace or repair one or more heart
valves, as a consequence of defects in, abnormalities of, or disease-affected cardiac valve(s).
The diagnosis of the valve abnormality must be supported by an echocardiography and the
realization of surgery has to be confirmed by a specialist medical practitioner. Catheter based
techniques including but not limited to, balloon valvotomy/valvuloplasty are excluded.

5. COMA OF SPECIFIED SEVERITY

A state of unconsciousness with no reaction or response to external stimuli or internal needs.

This diagnosis must be supported by evidence of all of the following:

Ø no response to external stimuli continuously for at least 96 hours;

Ø life support measures are necessary to sustain life; and
Ø permanent neurological deficit which must be assessed at least 30 days after the onset of the
coma.

The condition has to be confirmed by a specialist medical practitioner. Coma resulting directly
from alcohol or drug abuse is excluded.

6. KIDNEY FAILURE REQUIRING REGULAR DIALYSIS

End stage renal disease presenting as chronic irreversible failure of both kidneys to function, as
a result of which either regular renal dialysis (hemodialysis or peritoneal dialysis) is instituted or
renal transplantation is carried out. Diagnosis has to be confirmed by a specialist medical
practitioner.

7. STROKE RESULTING IN PERMANENT SYMPTOMS

Any cerebrovascular incident producing permanent neurological [Link] includes

infarction of brain tissue, thrombosis in an intracranial vessel, haemorrhage and embolisation
from an extracranial source. Diagnosis has to be confirmed by a specialist medical practitioner
and evidenced by typical clinical symptoms as well as typical findings in CT Scan
or MRI of the brain. Evidence of permanent neurological deficit lasting for atleast 3 months has
to be produced.

The following are excluded:

Ø Transient ischemic attacks (TIA)

Ø Traumatic injury of the brain
Ø Vascular disease affecting only the eye or optic nerve or vestibular functions.
 Annexure - II

8. MAJOR ORGAN /BONE MARROW TRANSPLANT

The actual undergoing of a transplant of:

Ø One of the following human organs: heart, lung, liver, kidney, pancreas, that resulted from
irreversible end-stage failure of the relevant organ, or
Ø Human bone marrow using haematopoietic stem cells The undergoing of a transplant has to
be confirmed by a specialist medical practitioner.

The following are excluded:

• Other stem-cell transplants

• Where only islets of langerhans are transplanted

9. PERMANENT PARALYSIS OF LIMBS

Total and irreversible loss of use of two or more limbs as a result of injury or disease of the
brain or spinal cord. A specialist medical practitioner must be of the opinion that the paralysis
will be permanent with no hope of recovery and must be present for more than 3 months.

10. MOTOR NEURONE DISEASE WITH PERMANENT SYMPTOMS

Motor neurone disease diagnosed by a specialist medical practitioner as spinal muscular

atrophy, progressive bulbar palsy, amyotrophic lateral sclerosis or primary lateral sclerosis.
There must be progressive degeneration of corticospinal tracts and anterior horn cells or bulbar
efferent neurons. There must be current significant and permanent functional neurological
impairment with objective evidence of motor dysfunction that has persisted for a continuous
period of at least 3 months.

11. MULTIPLE SCLEROSIS WITH PERSISTING SYMPTOMS

The definite occurrence of multiple sclerosis. The diagnosis must be supported by all of the
following:
• investigations including typical MRI and CSF findings, which unequivocally confirm the
diagnosis to be multiple sclerosis;
• there must be current clinical impairment of motor or sensory function, which must have
persisted for a continuous period of at least 6 months, and
• well documented clinical history of exacerbations and remissions of said symptoms or
neurological deficits with atleast two clinically documented episodes atleast one month apart.

Other causes of neurological damage such as SLE and HIV are excluded.
 Annexure - III

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 Annexure - III

DECLARATION BY THE INSURED:

I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement,
suppression or concealment of any material fact, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company, to seek necessary I

SECTION H
medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have
included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.

□□D
Date: D
□□
M M
□□
Y Y Place: Signature of the Insured
c________JI I
GUIDANCE FOR FILLING CLAIM FORM – PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. Enter the policy number As allotted by the insurance company
Enter the social insurance number or the certificate number of
b) SI. No/ Certificate No. As allotted by the organization
social health insurance scheme
License number as allotted by IRDA and
c) Company TPA ID No. Enter the TPA ID No
printed in TPA documents.
d) Name Enter the full name of the policyholder Surname, First name, Middle name
e) Address Enter the full postal address Include Street, City and Pin Code
SECTION B - DETAILS OF INSURANCE HISTORY
a) Currently covered by any other Mediclaim / Health Indicate whether currently covered by another Mediclaim /
Tick Yes or No
Insurance? Health Insurance
b) Date of Commencement of first Insurance without break Enter the date of commencement of first insurance Use dd-mm-yy format
c) Company Name Enter the full name of the insurance company Name of the organization in full
Policy No. Enter the policy number As allotted by the insurance company
Sum Insured Enter the total sum insured as per the policy In rupees
d) Have you been Hospitalized in the last 4 years Indicate whether hospitalized in the last 4 years Tick Yes or No
Date Enter the date of hospitalization Use mm-yy format
Diagnosis Enter the diagnosis details Open Text
e) Previously Covered by any other Mediclaim/ Health Indicate whether previously covered by another Mediclaim /
Tick Yes or No
Insurance? Health Insurance
f) Company Name Enter the full name of the insurance company Name of the organization in full
SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED
a) Name Enter the full name of the patient Surname, First name, Middle name
b) Gender Indicate Gender of the patient Tick Male or Female
c) Age Enter age of the patient Number of years and months
d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format
e) Relationship to primary Insured Indicate relationship of patient with policyholder Tick the right option. If others, please specify.
f) Occupation Indicate occupation of patient Tick the right option. If others, please specify.
g) Address Enter the full postal address Include Street, City and Pin Code
h) Phone No Enter the phone number of patient Include STD code with telephone number
i) E-mail ID Enter e-mail address of patient Complete e-mail address
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full
b) Room category occupied Indicate the room category occupied Tick the right option
c) Hospitalization due to Indicate reason of hospitalization Tick the right option
d) Date of Injury/Date Disease first detected/ Date of
Enter the relevant date Use dd-mm-yy format
Delivery
e) Date of admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh:mm format
g) Date of discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh:mm format
i) If Injury give cause Indicate cause of injury Tick the right option
If Medico legal Indicate whether injury is medico legal Tick Yes or No
Reported to Police Indicate whether police report was filed Tick Yes or No
MLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached Tick Yes or No
j) System of Medicine Enter the system of medicine followed in treating the patient Open Text
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (Do not enter paise values)
b) Claim for Domiciliary Hospitalization Indicate whether claim is for domiciliary hospitalization Tick Yes or No
c) Details of Lump sum/ cash benefit claimed Enter the amount claimed as lump sum/ cash benefit In rupees (Do not enter paise values)
d) Claim Documents Submitted-Check List Indicate which supporting documents are submitted Tick the right option
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amounts in rupees
SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT
a) PAN Enter the permanent account number As allotted by the Income Tax department
b) Account Number Enter the bank account number As allotted by the bank
c) Bank Name and Branch Enter the bank name along with the branch Name of the Bank in full
Enter the name of the beneficiary the cheque/ DD should be
d) Cheque/ DD payable details Name of the individual/ organization in full
made out to
e) IFSC Code Enter the IFSC code of the bank branch IFSC code of the bank branch in full
SECTION H - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
 Annexure - III

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 Annexure - III

GUIDANCE FOR FILLING CLAIM FORM – PART B (To be filled in by the hospital)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF HOSPITAL
a) Name of Hospital Enter the name of hospital Name of hospital in full
b) Hospital ID Enter ID number of hospital As allocated by the TPA
c) Type of Hospital Indicate whether In network or non network nospital Tick the right option
d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full
e) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications
Enter the registration number of the doctor along with the state
f) Registration No. with State Code As allocated by the Medical Council of India
code
g) Phone No. Enter the phone number of doctor Include STD code with telephone number
SECTION B – DETAILS OF THE PATIENT ADMITTED
a) Name of Patient Enter the name of hospital Name of hospital in full
b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider
c) Gender Indicate Gender of the patient Tick Male or Female
d) Age Enter age of the patient Number of years and months
e) Date of Admission Enter date of admission Use dd-mm-yy format
f) Time Enter time of admission Use hh:mm format
g) Date of Discharge Enter date of discharge Use dd-mm-yy format
h) Time Enter time of discharge Use hh:mm format
i) Type of Admission Indicate type of admission of patient Tick the right option
j) If Maternity
Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format
Gravida Status Enter Gravida status if maternity Use standard format
k) Status at time of discharge Indicate status of patient at time of discharge Tick the right option
SECTION C – DETAILS OF AILMENT DIAGNOSED (PRIMARY)
a) ICD 10 Code
Enter the ICD 10 Code and description of the primary
Primary Diagnosis Standard Format and Open text
diagnosis
Enter the ICD 10 Code and description of the additional
Additional Diagnosis Standard Format and Open text
diagnosis
Co-morbidities Enter the ICD 10 Code and description of the co-morbidities Standard Format and Open text
b) ICD 10 PCS
Procedure 1 Enter the ICD 10 PCS and description of the first procedure Standard Format and Open text
Procedure 2 Enter the ICD 10 PCS and description of the second procedure Standard Format and Open text
Procedure 3 Enter the ICD 10 PCS and description of the third procedure Standard Format and Open text
Details of Procedure Enter the details of the procedure Open text
Indicate whether present ailment is a complication of some pre-
c) Present Ailment is a Complication of PED Tick Yes or No
existing disease
d) Pre-authorization obtained Indicate whether pre-authorization obtained Tick Yes or No
e) Pre-authorization Number Enter pre-authorization number As allotted by TPA
f) If authorization by network hospital not obtained, give
Enter reason for not obtaining pre-authorization number Open text
reason
g) Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No
Cause Indicate cause of injury Tick the right option
If injury due to substance abuse/alcohol consumption,
Indicate whether test conducted Tick Yes or No
test conducted to establish this
Medico Legal Indicate whether injury is medico legal Tick Yes or No
Reported To Police Indicate whether police report was filed Tick Yes or No
FIR No. Enter first information report number As issued by police authorities
If not reported to police, give reason Enter reason for not reporting to police Open Text
SECTION D – CLAIM DOCUMENTS SUBMITTED-CHECK LIST
Indicate which supporting documents are submitted
SECTION E – DETAILS IN CASE OF NON NETWORK HOSPITAL
a) Address Enter the full postal address Include Street, City and Pin Code
b) Phone No. Enter the phone number of hospital Include STD code with telephone number
c) Registration No. Enter the registration number of patient As allocated by the Hospital
d) PAN Enter the permanent account number As allotted by the Income Tax department
e) Number of Inpatient Beds Enter the number of inpatient beds Digits
f) Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify
SECTION F - DECLARATION BY THE INSURED
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign.
SECTION G - DECLARATION BY THE HOSPITAL
Read declaration carefully and mention date (in dd:mm:yy format), place (open text) and sign and stamp
 Annexure - III

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 Annexure - III

PAGE 2: NOT TO BE FAXED/SCANNED

DECLARATION BY THE PATIENT / REPRESENTATIVE

1. I agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/T.P.A after the discharge. I agree to sign on the Final Bill & the Discharge Summary,
before my discharge.

2. Payment to hospital is governed by the terms and conditions of the policy. In case the Insurer / TPA is not liable to settle the hospital bill, I undertake to settle the bill as per the terms and
conditions of the policy.

3. All non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the Insurer/T.P.A not governed by the terms
and conditions of the policy will be paid by me. In case any clarification is needed on admissibility of a particular item I shall contact T.P.A at the Toll Free Number on the reverse of this
form.

4. I hereby declare to abide by the terms and conditions of the policy and if at any time the facts disclosed by me are found to be false or incorrect I forfeit my claim and
agree to indemnify the Insurer / T.P.A

5. I agree and understand that T.P.A is in no way warranting the service of the hospital & that the Insurer / TPA is in no way guaranteeing that the services provided by the hospital
will be of a particular quality or standard.

6. I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment, my right to
claim reimbursement of the said expenses shall be absolutely forfeited. I further declare that, in respect of the above treatment, no benefits are admissible under any other Medical
Scheme or Insurance

7. I agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer / TPA.

a) Patient’s / Insured’s Name:

b) Contact number: d) Patient’s / Insured’s Signature:

HOSPITAL DECLARATION

1. We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to hospitalization.

2. All valid original documents duly countersigned by the insured / patient as per the checklist below will be sent to TPA / Insurance Company within 7 days of the patient's discharge.

3. All non medical expenses , OR expenses not relevant to hospitalization or illness, OR expenses disallowed in the Authorization Letter of the TPA / Insurance Co, OR arising out of incorrect
information in the pre-authorisation form will be collected from the patient.

4. WE AGREE THAT TPA / INSURANCE COMPANY WILL NOT BE LIABLE TO MAKE THE PAYMENT IN THE EVENT OF ANY DISCREPANCY BETWEEN THE FACTS IN THIS FORM
AND DISCHARGE SUMMARY or other documents.

5. The patient declaration has been signed by the patient or by his representative in our presence.

6. We agree to provide clarifications for the queries raised regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications.

7. We will abide by the terms and conditions agreed in the MOU.

Hospital Seal Doctor's Signature

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM

1. Detailed Discharge Summary and all Bills from the hospital

2. Cash Memos from the Hospitals / Chemists supported by proper prescription.

3. Receipts and Pathological Test Reports from Pathologists, supported by note from the attending Medical Practitioner / Surgeon recommending such pathological Tests.

4. Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt.

5. Certificates from attending Medical Practitioner / Surgeon that the patient is fully cured.
 Annexure - IV

List of Expenses Generally excluded in Hospitalisation Policy

S List of Expenses Generally Excluded ("Non-Medical") SUGGESTIONS

N in Hospital Indemnity Policy -
O.

TOILETRIES/ COSMETICS/ PERSONAL COMFORT OR CONVENIENCE ITEMS

1 ANNE FRENCH CHARGES Not Payable
2 BABY CHARGES (UNLESS SPECIFIED/INDICATED) Not Payable
3 BABY FOOD Not Payable
4 BABY UTILITES CHARGES Not Payable
5 BABY SET Not Payable
6 BABY BOTTLES Not Payable
7 BOTTLE Not Payable
8 BRUSH Not Payable
9 COSY TOWEL Not Payable
10 HAND WASH Not Payable
11 MOISTURISER PASTE BRUSH Not Payable
12 POWDER Not Payable
13 RAZOR Payable
14 TOWEL Not Payable
15 SHOE COVER Not Payable
16 BEAUTY SERVICES Not Payable
17 BELTS/ BRACES Essential and should be
paid at least specifically
for cases who have
undergone surgery of
thoracic or lumbar spine.
18 BUDS Not Payable
19 BARBER CHARGES Not Payable
20 CAPS Not Payable
21 COLD PACK/HOT PACK Not Payable
22 CARRY BAGS Not Payable
23 CRADLE CHARGES Not Payable
24 COMB Not Payable
25 DISPOSABLES RAZORS CHARGES ( for site preparations) Payable
26 Not Payable
EAU-DE-COLOGNE / ROOM FRESHNERS
27 EYE PAD Not Payable
28 EYE SHEILD Not Payable
29 EMAIL / INTERNET CHARGES Not Payable
30 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED Not Payable
BY HOSPITAL)
31 FOOT COVER Not Payable
32 GOWN Not Payable
33 LEGGINGS Essential in bariatric and
varicose vein surgery and
may be considered for at
least these conditions
where surgery itself is
payable.
34 LAUNDRY CHARGES Not Payable
35 MINERAL WATER Not Payable
 Annexure - IV

36 OIL CHARGES Not Payable

37 SANITARY PAD Not Payable
38 SLIPPERS Not Payable
39 TELEPHONE CHARGES Not Payable
40 TISSUE PAPER Not Payable
41 TOOTH PASTE Not Payable
42 TOOTH BRUSH Not Payable
43 GUEST SERVICES Not Payable
44 BED PAN Not Payable
45 BED UNDER PAD CHARGES Not Payable
46 CAMERA COVER Not Payable
47 CARE FREE Not Payable
48 CLINIPLAST Not Payable
49 CREPE BANDAGE Not Payable/ Payable by
the patient
50 CURAPORE Not Payable
51 DIAPER OF ANY TYPE Not Payable
52 DVD, CD CHARGES Not Payable ( However if
CD is specifically sought
by Insurer/TPA then
payable)
53 EYELET COLLAR Not Payable
54 FACE MASK Not Payable
55 FLEXI MASK Not Payable
56 GAUSE SOFT Not Payable
57 GAUZE Not Payable
58 HAND HOLDER Not Payable
59 HANSAPLAST/ ADHESIVE BANDAGES Not Payable
60 LACTOGEN/ INFANT FOOD Not Payable
61 SLINGS Reasonable costs for one
sling in case of upper arm
fractures may be
considered

ITEMS SPECIFICALLY EXCLUDED IN THE POLICIES

62 WEIGHT CONTROL PROGRAMS/ SUPPLIES/ SERVICES Exclusion in policy unless
otherwise specified
63 COST OF SPECTACLES/ CONTACT LENSES/ HEARING AIDS Exclusion in policy unless
ETC., otherwise specified
64 DENTAL TREATMENT EXPENSES THAT DO NOT REQUIRE Exclusion in policy unless
HOSPITALISATION otherwise specified
65 HORMONE REPLACEMENT THERAPY Exclusion in policy unless
otherwise specified
66 HOME VISIT CHARGES Exclusion in policy unless
otherwise specified
67 INFERTILITY/ SUBFERTILITY/ ASSISTED CONCEPTION Exclusion in policy unless
PROCEDURE otherwise specified
68 OBESITY (INCLUDING MORBID OBESITY) TREATMENT Exclusion in policy unless
otherwise specified
69 PSYCHIATRIC & PSYCHOSOMATIC DISORDERS Exclusion in policy unless
otherwise specified
70 CORRECTIVE SURGERY FOR REFRACTIVE ERROR Exclusion in policy unless
otherwise specified
 Annexure - IV

71 TREATMENT OF SEXUALLY TRANSMITTED DISEASES Exclusion in policy unless

otherwise specified
72 DONOR SCREENING CHARGES Exclusion in policy unless
otherwise specified
73 ADMISSION/REGISTRATION CHARGES Exclusion in policy unless
otherwise specified
74 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC Exclusion in policy unless
PURPOSE otherwise specified
75 EXPENSES FOR INVESTIGATION/ TREATMENT IRRELEVANT Not Payable - Exclusion in
TO THE DISEASE FOR WHICH ADMITTED OR DIAGNOSED policy unless otherwise
specified
76 ANY EXPENSES WHEN THE PATIENT IS DIAGNOSED WITH Not payable as per
RETRO VIRUS + OR SUFFERING FROM /HIV/ AIDS ETC IS HIV/AIDS exclusion
DETECTED/ DIRECTLY OR INDIRECTLY
77 STEM CELL IMPLANTATION/ SURGERY Not Payable except Bone
Marrow Transplantation
where covered by policy

ITEMS WHICH FORM PART OF HOSPITAL SERVICES WHERE SEPARATE

CONSUMABLES ARE NOT PAYABLE BUT THE SERVICE IS
78 WARD AND THEATRE BOOKING CHARGES Payable under OT
Charges, not payable
separately
79 ARTHROSCOPY & ENDOSCOPY INSTRUMENTS Rental charged by the
hospital payable.
Purchase of Instruments
not payable.
80 MICROSCOPE COVER Payable under OT
Charges, not separately
81 SURGICAL BLADES,HARMONIC SCALPEL,SHAVER Payable under OT
Charges, not separately
82 SURGICAL DRILL Payable under OT
Charges, not separately
83 EYE KIT Payable under OT
Charges, not separately
84 EYE DRAPE Payable under OT
Charges, not separately
85 X-RAY FILM Payable under Radiology
Charges, not as
consumable
86 SPUTUM CUP Payable under
Investigation Charges, not
as consumable
87 BOYLES APPARATUS CHARGES Part of OT Charges, not
seperately
88 BLOOD GROUPING AND CROSS MATCHING OF DONORS Part of Cost of Blood, not
SAMPLES payable
89 SAVLON Not Payable-Part of
Dressing Charges
90 BAND AIDS, BANDAGES, STERLILE INJECTIONS, NEEDLES, Not Payable - Part of
SYRINGES Dressing charges
91 COTTON Not Payable-Part of
Dressing Charges
92 COTTON BANDAGE Not Payable- Part of
 Annexure - IV

Dressing Charges

93 MICROPORE/ SURGICAL TAPE Not Payable-Payable by

the patient when
prescribed, otherwise
included as Dressing
Charges
94 BLADE Not Payable
95 APRON Not Payable -Part of
Hospital Services/
Disposable linen to be
part of OT/ICU chatges
96 TORNIQUET Not Payable (service is
charged by hospitals,
consumables cannot be
separately charged)
97 ORTHOBUNDLE, GYNAEC BUNDLE Part of Dressing Charges
98 URINE CONTAINER Not Payable

ELEMENTS OF ROOM CHARGE

99 LUXURY TAX Actual tax levied by
government is
[Link] of room
charge for sub limits
10 HVAC Part of room charge not
0 payable separately
10 HOUSE KEEPING CHARGES Part of room charge not
1 payable separately
10 SERVICE CHARGES WHERE NURSING CHARGE ALSO Part of room charge not
2 CHARGED payable separately
10 TELEVISION & AIR CONDITIONER CHARGES Payable under room
3 charges not if separately
levied
10 SURCHARGES Part of Room Charge, Not
4 payable separately
10 ATTENDANT CHARGES Not Payable - Part of
5 Room Charges
10 IM IV INJECTION CHARGES Part of nursing charges,
6 not payable
10 CLEAN SHEET Part of
7 Laundry/Housekeeping
not payable separately
10 EXTRA DIET OF PATIENT(OTHER THAN THAT WHICH FORMS Patient Diet provided by
8 PART OF BED CHARGE) hospital is payable
10 BLANKET/WARMER BLANKET Not Payable- part of room
9 charges

ADMINISTRATIVE OR NON-MEDICAL CHARGES

11 ADMISSION KIT Not Payable
0
11 BIRTH CERTIFICATE Not Payable
1
11 BLOOD RESERVATION CHARGES AND ANTE NATAL Not Payable
2 BOOKING CHARGES
 Annexure - IV

11 CERTIFICATE CHARGES Not Payable

3
11 COURIER CHARGES Not Payable
4
11 CONVENYANCE CHARGES Not Payable
5
11 DIABETIC CHART CHARGES Not Payable
6
11 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES Not Payable
7
11 DISCHARGE PROCEDURE CHARGES Not Payable
8
11 DAILY CHART CHARGES Not Payable
9
12 ENTRANCE PASS / VISITORS PASS CHARGES Not Payable
0
12 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE To be claimed by patient
1 under Post Hosp where
admissible
12 FILE OPENING CHARGES Not Payable
2
12 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED) Not Payable
3
12 MEDICAL CERTIFICATE Not Payable
4
12 MAINTAINANCE CHARGES Not Payable
5
12 MEDICAL RECORDS Not Payable
6
12 PREPARATION CHARGES Not Payable
7
12 PHOTOCOPIES CHARGES Not Payable
8
12 PATIENT IDENTIFICATION BAND / NAME TAG Not Payable
9
13 WASHING CHARGES Not Payable
0
13 MEDICINE BOX Not Payable
1
13 MORTUARY CHARGES Payable upto 24 hrs,
2 shifting charges not
payable
13 MEDICO LEGAL CASE CHARGES (MLC CHARGES) Not Payable
3

EXTERNAL DURABLE DEVICES

13 WALKING AIDS CHARGES Not Payable
4
13 BIPAP MACHINE Not Payable
5
13 COMMODE Not Payable
6
13 CPAP/ CAPD EQUIPMENTS Device not payable
7
 Annexure - IV

13 INFUSION PUMP - COST Device not payable

8
13 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL) Not Payable
9
14 PULSEOXYMETER CHARGES Device not payable
0
14 SPACER Not Payable
1
14 SPIROMETRE Device not payable
2
14 SPO2 PROBE Not Payable
3
14 NEBULIZER KIT Not Payable
4
14 STEAM INHALER Not Payable
5
14 ARMSLING Not Payable
6
14 THERMOMETER Not Payable (paid by
7 patient)
14 CERVICAL COLLAR Not Payable
8
14 SPLINT Not Payable
9
15 DIABETIC FOOT WEAR Not Payable
0
15 KNEE BRACES ( LONG/ SHORT/ HINGED) Not Payable
1
15 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER Not Payable
2
15 LUMBO SACRAL BELT Essential and should be
3 paid at least specifically
for cases who have
undergone surgery of
lumbar spine.
15 NIMBUS BED OR WATER OR AIR BED CHARGES Payable for any ICU
4 patient requiring more
than 3 days in ICU, all
patients with
paraplegia/quadriplegia
for any reason and at
reasonable cost of
approximately Rs 200/
day

15 AMBULANCE COLLAR Not Payable

5
15 AMBULANCE EQUIPMENT Not Payable
6
15 MICROSHEILD Not Payable
7
 Annexure - IV

15 ABDOMINAL BINDER Essential and should be

8 paid at least in post
surgery patients of major
abdominal surgery
including TAH, LSCS,
incisional hernia repair,
exploratory laparotomy
for intestinal obstruction,
liver transplant etc.

ITEMS PAYABLE IF SUPPORTED BY A PRESCRIPTION

15 BETADINE \ HYDROGEN PEROXIDE\SPIRIT\\DETTOL May be payable when
9 \SAVLON\ DISINFECTANTS ETC prescribed for patient, not
payable for hospital use in
OT or ward or for
dressings in hospital
16 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES Post hospitalization
0 nursing charges not
Payable
16 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- Patient Diet provided by
1 DIET CHARGES hospital is payable
16 ALEX SUGAR FREE Payable -Sugar free
2 variants of admissable
medicines are not
excluded
16 CREAMS POWDERS LOTIONS (Toileteries are not payable,only Payable when prescribed
3 prescribed medical pharmaceuticals payable)
16 DIGENE GEL/ ANTACID GEL Payable when prescribed
4
16 ECG ELECTRODES Upto 5 electrodes are
5 required for every case
visiting OT or ICU. For
longer stay in ICU, may
require a change and at
least one set every second
day must be payable.
16 GLOVES Sterilized Gloves payable /
6 unsterilized gloves not
payable
16 HIV KIT Payable - payable Pre
7 operative screening
16 LISTERINE/ ANTISEPTIC MOUTHWASH Payable when prescribed
8
16 LOZENGES Payable when prescribed
9
17 MOUTH PAINT Payable when prescribed
0
17 NEBULISATION KIT If used during
1 hospitalization is payable
reasonably
17 NEOSPRIN Payable when prescribed
2
17 NOVARAPID Payable when prescribed
3
17 VOLINI GEL/ ANALGESIC GEL Payable when prescribed
 Annexure - IV

4
17 ZYTEE GEL Payable when prescribed
5
17 VACCINATION CHARGES Routine Vaccination not
6 Payable / Post Bite
Vaccination Payable

PART OF HOSPITAL'S OWN COSTS AND NOT PAYABLE

17 AHD Not Payable - Part of
7 Hospital's internal Cost
17 ALCOHOL SWABES Not Payable - Part of
8 Hospital's internal Cost
17 SCRUB SOLUTION/STERILLIUM Not Payable - Part of
9 Hospital's internal Cost

OTHERS
18 VACCINE CHARGES FOR BABY Not Payable
0
18 AESTHETIC TREATMENT / SURGERY Not Payable
1
18 TPA CHARGES Not Payable
2
18 VISCO BELT CHARGES Not Payable
3
18 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, Not Payable
4 ORTHOKIT, RECOVERY KIT, ETC]
18 EXAMINATION GLOVES Not payable
5
18 KIDNEY TRAY Not Payable
6
18 MASK Not Payable
7
18 OUNCE GLASS Not Payable
8
18 OUTSTATION CONSULTANT'S/ SURGEON'S FEES Not payable, except for
9 telemedicine consultations
where covered by policy
19 OXYGEN MASK Not Payable
0
19 PAPER GLOVES Not Payable
1
19 PELVIC TRACTION BELT Should be payable in case
2 of PIVD requiring
traction as this is
generally not reused
19 REFERAL DOCTOR'S FEES Not Payable
3
19 ACCU CHECK ( Glucometery/ Strips) Not payable pre
4 hospitilasation or post
hospitalisation / Reports
and Charts required/
Device not payable
19 PAN CAN Not Payable
5
 Annexure - IV

19 SOFNET Not Payable

6
19 TROLLY COVER Not Payable
7
19 UROMETER, URINE JUG Not Payable
8
19 AMBULANCE Payable-Ambulance from
9 home to hospital or
interhospital shifts is
payable/ RTA as specific
requirement is payable
20 TEGADERM / VASOFIX SAFETY Payable - maximum of 3
0 in 48 hrs and then 1 in 24
hrs
20 URINE BAG Payable where medicaly
1 necessary till a reasonable
cost - maximum 1 per 24
hrs
20 SOFTOVAC Not Payable
2
20 STOCKINGS Essential for case like
3 CABG etc. where it
should be paid.
 Annexure - V

FORM: IRDA-HEALTH PRODUCTS

File and Use Application form for ‘health products’:

S No Item Particulars (to be filled in by insurer)

1 Name of Non-Life Insurer

1.1 Registration [Link] by IRDA

2 Name of Appointed Actuary [Please

note that his appointment should be in
force as on the date of this application]
3 Brand Name [Give the name of the
product which will be printed in Sales
Literature and known in the market.
This name should not be
altered/modified in any form after
launching in the market. This name
shall appear in all returns etc. which
would be submitted to IRDA.]
3.1 Unique ID no. (allotted by IRDA, if
this application is for modification of
an exisitng product)
4 Date of introduction of the product
(proposed in case of new products;
actual date in case of existing
products): [ In case of new products
being launched for the first time in the
market, give the proposed date
(However the date cannot be within 30
days from date of this application) from
which Insurer wants to market. In case
of existing products, the actual date
from which product was launched in
the product.]
5 Date of modificiation/withdrawal
(proposed in case of existing products,
but not applicable for new products):
[(a)This must be filled as “Not
Applicable” for all the new products.
(b) Proposed date of modification of
the features of the product, where such
product is already in use in the market.
(c) In case the Insurer wishes to
withdraw the existing product from the
market, the date of withdrawal must be
furnished under this item. ]
6 General Terms and Conditions [All the items should be filled in properly and carefully. No item must
be left blank.]
 Annexure - V

6.1 Whether the health product is offered to/through: [Answer YES/NO]

6.1.1 Individuals YES / NO
6.1.2 Family Floater YES / NO
6.1.3 Groups YES / NO
6.1.4 Specify geographic locations YES / NO
in India [if YES, specify the
locations.]
6.1.5 All geographic locations in YES / NO
India
6.1.6 Rural population YES / NO
6.1.7 Micro Insurance YES / NO
6.1.8 Government Schemes YES / NO
6.1.9 Indemnity basis YES / NO
6.1.1 Benefit basis YES / NO
0
6.2 Specify the following:
6.2.1 Target population [This
section should discuss the
target market for which the
product is designed. Also
please enclose separately the
details of any market research
conducted for this purpose.]
6.2.2 Grace period allowed for
renewal—specify the number
of days allowed for renewal of
the contract.
6.2.3 Grace period allowed for
payment of premiums in
installments—specify the
number of days allowed for
payment of premium when
premiums are not paid on
stiuplated dates.
6.2.4 Minimum Group Size (state
the minimum membership of
the group)
6.2.5 Basic Sum Insured (for groups, per member details to be furnished):
[Link] Minimum offered
[Link] Maximum offered
[Link] Sum insured
rebates /discounts
offered, if any
(please provide
objective and
transparent criteria
to offer rebates and
financial
justifications)
 Annexure - V

6.2.6 Policy Period:

[Link] Minimum Policy
period offered
[Link] Maximum Policy
period offered
[Link] Premium paying
terms, if different
from policy term
6.2.7 Modes of Premium Payment Offered:
[Link] State the modes of
premium payment
allowed- (Single
premium /annual/
halfy-yearly, etc.)
[Link] Rebates/charges for
different modes
offered, with
justifications:
6.2.8 Annualised Premium (for group give the details per member)
[Link] Minimum:
[Link] Maximum:
[Link] Premium rebates
/discounts offered,
if any (please
provide objective
and transparent
criteria to offer
rebates and
financial
justifications)
6.2.9 Entry Age:
[Link] Minimum:
[Link] Maximum:
6.2.1 Maximum renewal Age, for
0 age specific products
6.2.1 Restrictions on travel outside YES/NO
1 India (If YES, specify the
conditions]
6.2.1 Any other restrictions [If YES/NO
2 there is restriction proposed,
the same should be furnished,
e.g. future occupation]
6.2.1 Deductibles allowed
3
6.2.1 Co-pay allowed
4
6.2.1 Staff rebates or any other
5 Rebates offered—(please
provide objective and
 Annexure - V

transparent criteria to offer

rebates and financial
justifications)
6.2.1 Any other discounts offered—
6 (please provide objective and
transparent criteria to offer
rebates and financial
justifications)
6.2.1 Any loadings proposed—
7 (please provide objective and
transparent criteria for
loadings and financial
justifications)
6.2.1 Subrogation
8

6.3 Product details:

6.3.1 Is the Product filed for the Yes/No
6.3.2 first time?
6.3..1.1 If no, furnish the date of first filing of the product. If yes, please go to item no 7
directly.
[Link] Please give the proposed modifications in tabular form
S.n Existing Features / Proposed Justification for Any supporting
o assumptions/premiums rates modifications such data for such
–which are proposed to modification modification
modify

6.3.2 Whether the product Yes/No

features/assumptions/premium
rates have been modified from
the date of clearance?
[Link] If Yes, Please give the information of all the modifications carried out till date in
tabular form:-History of modifications carried out till date:
S No Date of Exisitng Features/Assump Date of clearance
modification Features/Assu tions/premium of the modification
filed with mpitons/ rates modified from the Authority
the premium rates from the and the unique
Authority as on date of first/subsequent identification
clearance of filing i.e. after number allotted
the product i.e. the clearance of
before the the modification
modification

Benefit Structure of the Product. [This section should describe the various contingencies under which
7 the benfits would be payable and how these would be determined-please do not refer to any other
document which is enclosed along with this]
Event: Benefit Amount:
7.1 On Hospitalization
7.2 On events other than (7.1) – (please
furnish the complete details)
 Annexure - V

7.3 On cancellation by the insured:

7.4 On cenaellation by the insurer
7.5 Specify Non-forfeiture conditions
[When the contract would be not null
and void]
7.6 Specify options available under the
product. (e.g. to increase or decrease
benefits, plan changes, etc.) [This
section should specify the various
options available under the [Link]
charges , if any, towards the cost of the
option shall also be specified. ]
7.7 Procedure for renewal along with the
proposed loadings, if any
7.8 Riders / ADD-ons

7.8.1 Riders / Add-ons attached to [Link] Rider/Add-on UIN alloted Date of

the product Name by IRDA clearance

7.8.2 Any other features that may be

relevant for the product.
8 Underwriting –Selection of Risks [This section should discuss how the different segments of the
population will be dealt with for the purpose of underwriting (to the extent they are relevant and a
brief detail of procedure adopted for assessment of various risk classes may be given.)
8.1 Specify Non-medical Limit [No
medical examination asked for]
8.2 Specify when and what classes of lives
would be subject to medical
examination
8.3 Specify the minimum participation of
membership for groups.
8.4 Retention Limits [Specify what limits
have been proposed for the purposes of
reinsurance]
8.5 Exclusions: please specify what
exclusions have been proposed for
payment of benefits
9 Other Terms:
9.1 Nomination
9.2 Conditions for revival of the contract,
in case of installment premiums:
10 Distribution Channels & NB Strain.
10.1 Distribution channels:
10.1. Specify the various
1 distribution channels to be
used for distributing the
product- [reply shall be
specific and can not refer to
the replies like “as approved
by IRDA]
10.1. Commission scales to
2 distribution channels—specify
the rates which are to be paid-
[reply shall be specific and can
not refer to the replies like “as
 Annexure - V

per the ACT]

10.2 Expected proportions of business to be Distribution Year Year Year Year Year
procured by each channel shall be Channel 1 2 3 4 5
indicated for the next 5 years.
[Link]
Agents
2. Corporate
Agents
3. Brokers
4. Others-
specify

5. Total
10.3 New Business Strain, if any Year 1 Year 2 Year 3 Year 4 Year 5

11 Reinsurance arrangements:
11.1 Retention limit
11..2 Name of the reinsurer (s)
11.3 Terms of reinsurance(type of
reinsurance, commissions, etc.).
11.4 Any recapture provisions shall be
described.
11.5 Reinsurance rates provided
11.6 Whether a copy of the reinsurance
program and a copy of the Treaty is Yes/NO
sumbitted to the Authority.

11.6. Whether reinsuracne program Yes/No

1 and a copy of the treaty
enclosed (required only if
these are not filed with the
Authority previously)
12 Pricing: The pricing assumptions and the methodology may vary depending on the nature of product.
Give details of the following
12.1 Give the actuarial formulae, if any,
used; if not, state how premiums are
arrived at giving briefly the
methodology and details):
12.2 Source of data (internal/industry/
reinsurance)
12.3 Rate of morbidity [The tables
whereever relevant shall be the
prescribed one.]
12.4 Rates of policy terminations. [The rates
used must be in accordance with
insurer’s experience, if such experience
is not available, this can be from the
industry/reinsurer’s experience .]
12.5 Rate of interest, if any. [The rate or
rates must be consistent with the
 Annexure - V

investment policy of the insurer.]

12.6 Commission scales [Give rates of
commission. These are explicit items.]

12.7 Expenses: Split into:- [Expense assumptions must be company specific. If such experience is not
available, the Appointed Actuary might consider industry experience or make reasonable
assumptions.]
12.7. First year expenses by : sum
1 assured related, premium
related, per policy related
12.7. Renewal expenses (including
2 overhead expenses) by : sum
assured related, premium
related, per policy related
12.7. Claim expenses
3
12.7. Future inflationary increases,
4 if any

12.8 Allowance for transfers to shareholder,

if any: [Please see section 49 of the
Insurance Act, 1938]
12.9 Taxation. [Please see the relevant
sections of the Income Tax Act, 1961]
12.10 Any other parameter relevant to pricing
of product –please specify
12.11 Reserving assumptions (please specify
all the relevant details)
12.12 Base rate (risk premium)-furnish the
rate table, if any
12.13 Gross premium- furnish the rate table,
if any
12.14 Expected loss ratio (for the product) -to
be furnished for each plan separately
12.15 Age-wise loss ratio- to be furnished for [Link] Age Loss ratio
each plan separately
12.16 Sum insured-wise- loss ratio to be [Link] SA Loss ratio
furnished for each plan separately
12.17 Age and sum insured wise loss ratio - Table given below (SI band and age bands shall be
to be furnished for each plan separately increased depending on the minimum and maximum SI
offered)
[Link] SI/Age 25000 50000 100000 150000 200000
bands
1 >=0<=2
2 >=3<=15
3 >=16<=25
4 >=26<=30
5 >=31<=35
6 >=36<=40
7 >=41<=45
8 >=46<=50
9 >=51<=55
10 >=56<=60
 Annexure - V

11 >=61<=65
12 >=66
12.18 Expected combined ratio (for the
product) -to be furnished for each plan
separately
12.19 Age-wise combined ratio- to be
furnished for each plan separately
12.20 Sum insured-wise- combined ratio to be
furnished for each plan separately
12.21 Age and sum insured wise combined Table given below (SI band and age bands shall be
ratio - to be furnished for each plan increased depending on the minimum and maximum SI
separately offered)
[Link] SI/Age 25000 50000 100000 150000 200000
bands
1 >=0<=2
2 >=3<=15
3 >=16<=25
4 >=26<=30
5 >=31<=35
6 >=36<=40
7 >=41<=45
8 >=46<=50
9 >=51<=55
10 >=56<=60
11 >=61<=65
12 >=66
12.22 Expected cross-subsidy between
age/sum insured/ plans etc
12.23 Experience of similar products, if any
[Link] Exposu Premiu Numbe Incurre Claim Averag Burnin Loss Combi
re m –Rs. r of d frequen e cost g cost- ratio ned
claims claims- cy per Rs. ratio
Rs. claim
2008-
09
2007-
08
2006-
07
2005-
06
2004-
05
1. Exposure: earned life year (no of life earned during a particular financial year);
2. Premium: premium earned during the financial year;
[Link] of claims: claims occurred during the financial year;
4. Incurred claims: Incurred amount as of today for claims mentioned in “3”;
5. Claim frequency: No. of claims/ Exposure;
6. Average cost per claim: Incurred claims / No. of claims;
7. Burning cost: Claims frequency* Average cost per claim;
8. Loss ratio: Incurred claims/ Premium;
9. Combined ratio: Loss ratio + Expense ratio;
13 Revision in pricing for existing products
13.1 Justification for change/ modification in
 Annexure - V

premium
13.2 Experience of the product across plans / In addition to the experience of similar products in Item
sum insured / age bands 12.14 t o12.23, these tables to be furnished for the product
for which revision in pricing is requested
13.3 How the pricing differs between sum
insured options
14 Results of Financial Projections/Sensitivity Analysis: [The profit margins should be shown for
various model points for base,optimistic and pessimistic scenarios in a tabular format below. The
definition of profit margin should be taken as the present value of net profits to the p.v of premiums.
Please specify assumptions made in each scenario. For terms less than or equal t oone year loss ratio
may be used and for terms more than one year, profit margin may be used.]
14.1 Risk discount rate used in the profit
margin
14.2 Average Sum Insured Assumed

14.3 Assumptions made under pessimistic

scenario
14.4 Assumptions made under optimistic
scenario
14.4 Age [PM: Profit Margin/Loss Ratio] PM (base PM (pessimistic PM (optimistic
scenario) scenario) scenario)
>=0<=2
>=3<=15
>=16<=25
>=26<=30
>=31<=35
>=36<=40
>=41<=45
>=46<=50
>=51<=55
>=56<=60
>=61<=65
>=66
15 The following specimen documents should be enclosed:
15.1 Proposal Form:
15.2 Sales Literature /Prospectus – the pamphlets made available to members of the public at the time of
sale. This is the literature which is to be used by the various distribution channels for selling the
produc in the market. This shall enumerate all the salient features of the product alongwith the
exclusions applicable for the basic benefits and shall be incomplaince with the relevant circulars
issued by the Authority at all times).
15.3 Policy Document
15.4 Underwriting Manual
15.5 Claims Manual
15.6 Premium Table

15. Certification. The Insurer shall enclose a certificate from the Appointed Actuary, countersigned by the
 Annexure - V

principal officer of the insurer, as per specimen given below: (The language of this should not be altered at all)

" I, (name of the appointed actuary), the appointed actuary, hereby solemnly declare that the information
furnished above is true. I also certify that, in my opinion, the premium rates, advantages, terms and conditions
of the above product are workable and sound, the assumptions are reasonable and premium rates are fair."

Place Signature of the Appointed Actuary.

Date:

Name and Counter Signature of the principal officer along with name, and Company’s seal.
 Annexure - VI

INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY

DATABASE FORMAT
(DETAILS FOR FILE AND USE APPROVAL OF HEALTH INSURANCE PRODUCTS)

A. PRODUCT INDEX
Insurer Code:
Product Category (3-tier codes at annexure):
(The logic of Categorization is provided at Appendix 1. Accordingly, insurers have to
provide the Categorization in the order of priority and the pricing impact)
Additional Category 1:
Additional Category 2:
Additional Category 3:

Number of Plans/ Variants within the product: ......................

Nomenclature used for Plans/ Variants: ......................
Product Commercial Name:
New or Revision: New (V00) / Revised Version (V01/V02/V03): .........
If Revision, give application/ approval dates of earlier version: .........
Unique ID no: .........
(Automatically generated field after product approval by Authority)

B. PROCESSING HISTORY (FOR INTERNAL USE ONLY)

IRDA Inward date:
IRDA Inward Number:
Nodal Officer processing the product:
IRDA File number:
Product Category: HEALTH
Last clarification received date (DDMMYY):
Approval communicated on (DDMMYY):
Text of any Major Policy Stand/ Observation by Chairman/Member on this product file:
.....................................................................
.....................................................................

1
 Annexure - VI

C. PRODUCT DETAILS

C.a. Hospitalization : Contingencies covered:

Contingency Covered Sub-Limits Sub limits in

(Y/N) in % of SI, if fixed rupee
applicable terms, if
applicable
Room charges
Boarding charges for patient
Nursing charges for patient
ICU charges
Medical Practitioners Fees
Operation Theatre charges
Surgical Consumables
Prescribed drugs
Diagnostic tests
Cost of blood
Cost of transplantation
Hospitalization expenses of
donor
Cost of artificial limbs
Cost of pacemakers
Parenteral Chemotherapy
Radiotherapy
Haemodialysis
Domiciliary Hospitalization
Ambulance charges
Maternity expenses
Neonatal expenses
Funeral expenses
Pre-hospitalization expenses
Post-hospitalization expenses
Cost of periodic health check-
up for policies without claims
Cost of periodic health check-
up for policies with claims
Day Care procedures covered
Dental Procedures
Hearing Aids
Spectacles/ contact lens
Any other contingency covered

Whether any waiver of sub-limits is available in different plans or at different terms: Y/N
If yes, details of sub-limits which can be waived and terms for the same:

2
 Annexure - VI

If any other contingency is covered, details of sub-limits which can be waived and terms
for the same.

C.b. Waiting periods and sub limits for specified diseases:

Type of waiting period Period in months Any sub- Any sub-
(Mention '0' if no limits in limits in %
waiting period) rupee terms of S.I. terms
General waiting period for new
covers (except accidents)
Pre-existing diseases
Cataract
Hernia or Hydrocele
Benign Prostate Hypertrophy
Hysterectomy (non-malignant)
Fistula in Anus, Anal Fissure, Piles
Sinusitis
Gall Bladder Stones
Joint replacement
Gastric or Duodenal ulcer
Tonsilitis or Adenoids
Breast lumps
Cysts, nodules or polyps
Intervertebral disc prolapse
Arthritis
Varicose veins/ varicose ulcers
Spondylosis/ Spondylitis
Maternity cover
Renal Failure (old product)I
Heart Disease (old product)I
Cancer (old product)I
Hypertension (old product)I
Diabetes (old product)I
Any other waiting period/ sub-limit.
If any other waiting period/ sub-limits are applicable, details of the same.

C.c. Exclusions:
Type of exclusion Applicable Special
(Y/N) conditions, if any
Pre-existing disease for non-indemnity or non-
domestic policies
War, invasion, war like operation
Circumcision unless medically necessary

3
 Annexure - VI

Vaccination/inoculation except post-bite

Venereal diseases and HIV/AIDS
Pregnancy/ Maternity except ectopic pregnancy
Voluntary termination of pregnancy
Fertility or assisted conception
Treatment of obesity
Cosmetic or aesthetic procedures except for
burns/ injuries etc.
Change of life/ sex-change
Spectacles or contact lens
Hearing Aids
Dental treatment except requiring
hospitalization
Convalescence/ debility
Intentional self-injury/ suicide attempt
Influence of intoxicating drugs or alcohol
Expenses unlinked to active treatment in
hospital
Nuclear weapons/material
OPD expenses except pre and post-
hospitalization as covered under Scope
Naturopathy or Yoga
Ayurvedic Medicine
Homeopathic Medicine
Unani Medicine
Unrecognized systems of medicine
Speed contest, racing, adventure sports
Durable or external medical equipment required
post-operatively
Personal comfort and convenience items
Hormone replacement therapy
Mental Illness
Any other
If any other exclusion applies, details of the same.

C.d. Age Limits

Minimum Age at Entry –Adult (Years)
Maximum Age at Entry –Adult (Years)
Maximum Age till which renewal is available –Adult (Years)
Minimum Age at Entry –Child (Months)
Maximum age up to which dependent children who are
unmarried and unemployed can be covered (Years)

4
 Annexure - VI

C.e. Cost sharing:

Cost Sharing Details Applicable Details

(Y/N)
Does the policy have compulsory deductibles

Does the policy have voluntary deductibles

Cost Sharing Details Applicable Percentage

(Y/N)
Does the policy require any compulsory co-pay in
network hospitals
Does the policy have option for voluntary co-pay in
network hospitals
Does the policy require any compulsory co-pay in
non-network hospitals
Does the policy require any compulsory co-pay in
hospitals outside a specified geographical area?
Does the policy require any compulsory co-pay for
pre-existing diseases?
Does the policy require any compulsory co-pay for
‘packaged’ charges by hospitals?
Any other sub-limits?
If any other cost sharing applies, details of the same.

C.f. Loyalty Benefits

Offered At first At second Maximum
(Y/N) renewal renewal
(cumulative)
Cumulative No Claim Bonus
Cumulative Loyalty Bonus
(regardless of Claim history)
Health Check up for claim-free
policies
Health check up regardless of
claim history
No Claim Discount
Loyalty Discount (regardless of
claim)
Any Other
If any other loyalty benefit applies, details of the same.

5
 Annexure - VI

C.g. Other Terms and Conditions

Terms/Conditions Applicable Details as

(Y/N) applicable
Whether the policy is only available to a restricted
group (e.g. customers of a bank)
Whether the policy is only intended for claims arising
in a specified and limited network of medical
providers?
Whether change in risk is to be intimated on renewal
Whether TPA being used for the product
Whether there is a Premium Installment option
Whether increase in sum insured permissible at
renewal
Whether change of options/plans within same
product permissible at renewal
Whether inward migration allowed from other
products of same insurer
Whether inward migration allowed from other/ similar
products of any insurer
Whether there are any restrictions on renewal of
specific sections/ components before the maximum
renewal age for the product
Whether parents are covered under the policy?
Whether cancellation at option of insurer is on pro-
rata basis?
Whether cancellation at option of insurer for
fraudulent cases is on ‘no refunds’ basis
Whether Free Look period option is provided under
the policy?
Others

C.h. Sum Insured and Rate Structure for Primary Member:

Chart given below applicable for primary member alone: Y/N

If No, Chart applicable for: _____________

Different Sums Sum Premiums applicable at different ages

Insured (in Rs) Insured (Rs. per annum)
(Rs) For 25 For 30 For 40 For 50 For 60 For 65 For 70
years years years years years years years
Minimum sum
insured available
Premium charged 200,000
for Rs. 2 lakhs
sum insured
where applicable
Premium charged 300,000

6
 Annexure - VI

for Rs. 3 lakhs

sum insured
where applicable
Maximum sum
insured available

C.i. Reinsurance Details:

Reinsurance Details Y/N Details
Any reinsurance other than obligatory cession
If yes, whether pricing is linked to reinsurance rates

C.j. Critical Illness Coverage:

C.j.1. Critical Illness Covered If yes, details

(Y/N) thereof
If Critical Illness is an additional component of a wider
health cover, whether sum insured for Critical Illness
is different from that for the primary component

C.j.2. Critical Illness Covered If yes, survival period

(Y/N) required in number of days
Survival Period required

C.j.3. Critical Illness Covered Period If modified from

(Y/N) Standard
Definitions, details
Stroke resulting in permanent symptoms
Cancer of specified severity
Kidney Failure requiring regular dialysis
Open Chest Coronary Artery Bypass Graft
Major Organ/ Bone Marrow Transplant
Coma of specified severity
Multiple Sclerosis with persisting symptoms
First Heart Attack of specified severity
Open Heart repair or replacement of heart
valves
Motor Neuron Disease with permanent
symptoms
Permanent Paralysis of Limbs
Major Injuries
Major Burns
Others
If any other critical illness cover is applicable, details of the same.

7
 Annexure - VI

C.k. Hospital Cash Coverage:

C.k.1. Hospital Cash Covered If yes, details
(Y/N) thereof
If Hospital Cash is an additional component of a wider
health cover, whether the amount of hospital cash
cover is linked to sum insured

C.k.2. Minimum Deductib Maximum Minimum Maximum

Hospital Stay le if any Period Daily Daily
Cash required (days) Covered Payout Payout
(days) (days) option (Rs) option (Rs)
Room
ICU
Accidental
Any other
C.l. High Deductible Coverage:
High Deductible Coverage Amount (Rs.)
Minimum Deductible Option
Minimum Sum Insured above the minimum deductible
Maximum Deductible Option
Maximum Sum Insured above the maximum deductible
C.m. Outpatient Coverage:

C.m.1. Outpatient Coverage Y/N If yes, Fixed

Premium (Rs.)
Is the policy modeled as fixed total premium and variable
OPD sum insured? I I
C.m.2. Outpatient Coverage Y/N Period (MM/YY)
Is there any restriction on period?
If yes, the period till which IRDA approval was given for
this component I I
C.m.3. Sum OPD Premiums applicable for different ages
Outpatient Insured (Rs. per annum)
Coverage (Rs) For 25 For 30 For 40 For 50 For 60 For 65 For 70
years years years years years years years
Minimum OPD
Cover offered
Maximum OPD
cover offered

8
 Annexure - VI

C.n. Travel Coverage:

C.n.1. Travel Coverage Applicable If yes, Condition
(Y/N) days s/ Details
Minimum duration of travel specified
Maximum duration of travel specified
Coverage for emergency evacuation-ground
Coverage for emergency evacuation-air
ambulance
Coverage for emergency hospitalization
Coverage for emergency OPD expenses
Coverage for emergency repatriation
Coverage for repatriation of mortal remains
Coverage for attendant travel
Coverage for loss of baggage
Coverage for loss of passport
Coverage for emergency stabilization in case
of pre-existing diseases
Coverage beyond emergency stabilization in
cases with pre-existing diseases
TPA used for servicing policies
Any Other Coverage

C.n.2. Travel Coverage Applicable If yes, Details

(Y/N) Code
Geographical zones where policy covers
travel (Refer Travel Code Master for codes)
If any other zone is applicable, give details of
the zone.
C.o. Pricing and Underwriting Details:
C.o.1. Pricing Criteria Applicable Rank by Priority/
(Y/N) Weightage
Age
Sum Insured
Gender
Size of Group
Geographical location of insured
Deductible or Co-pay opted
Occupation
Policy period
Discount for number of sections/ components
covered
Extension or reduction in geographical
jurisdiction of coverage
Any other pricing criteria

9
 Annexure - VI

C.o.2. Expected Claim Ratio Percentage

Expected incurred claim ratio in first completed year
Expected incurred claim ratio in second completed year
Expected incurred claim ratio in third completed year

C.o.3. Underwriting Details Applicable If yes, Age

(Y/N) after which
required
Whether entirely pre-underwritten
Pre Insurance Medical Examination requirement
Whether required at an earlier age based on
proposal form details

C.o.4. Underwriting Details Applicable Criteria filed Maximum

(Y/N) with IRDA loading/
(Y/N) discount (%)
Health-status based loading
applicable on new policies
Health status based loading
applicable on renewals
Claim history based loading
applicable on renewals
Maximum loading for all variables
taken together
Maximum discount for all variables
taken together.
Any other underwriting criteria

If any other underwriting criteria are applicable, details of the same.

Addl. Comments/ Remarks/ Notes:

10
 Annexure - VI

INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY

DETAILS FOR FILE AND USE APPROVAL OF HEALTH INSURANCE PRODUCTS

1 A & B. PRODUCT INDEX & PROCESSING HISTORY

C. PRODUCT DETAILS
2
C.a. Hospitalization : Contingencies covered
3 C.b. Waiting periods and sub limits for specified diseases
4 C.c. Exclusions
5 C.d. Age Limits & C.e. Cost sharing
6 C.f. Loyalty Benefits & C.g. Other Terms and Conditions
7 C.h. Sum Insured and Rate Structure for Primary Member & C.i. Reinsurance Details
8 C.j. Critical Illness Coverage & C.k. Hospital Cash Coverage
9 C.l. High Deductible Coverage & C.m. Outpatient Coverage
10 C.n. Travel Coverage
11 C.o. Pricing Criteria, Expected Claim Ratio & Underwriting Details

11
 Annexure - VII

Customer Information Sheet

Description is illustrative and not exhaustive
S. TITLE DESCRIPTION REFER TO
NO POLICY
CLAUSE
NUMBER
1 Product • Approved Brand Name
Name
2 What am • Hospital admission longer than xx hrs
I covered • Related medical expenses incurred xx days prior to hospitalisation / amounting to x%
for: of claim
• Related medical expenses incurred within xx days from date of discharge / amounting
to x% of claim
• Specified / Listed procedures requiring less than 24 hours hospitalisation (day care)
• Cover for xx critical illnesses on undergoing specified procedure or on diagnosis of an
illness of specified severity
• Hospital daily cash benefit of Rs__ per day
• OPD / Dental / Maternity coverage
• Emergency or Travel Medical Assistance etc
3 What • Any hospital admission primarily for investigation / diagnostic purpose
are the • Pregnancy, infertility, congenital/genetic conditions,
major • Non-allopathic medicine,
exclusion • Domiciliary treatment, treatment outside India.
s in the • Circumcision, sex change surgery ,cosmetic surgery & plastic surgery,
policy: • refractive error correction, hearing impairment correction, corrective & cosmetic
dental surgeries,
• Organ donor expenses,
• Substance abuse, self-inflicted injuries, STDs and HIV / AIDS,
• Hazardous sports, war, terrorism, civil war or breach of law,
• Any kind of service charge, surcharge, admission fees, registration fees levied by the
hospital.
(Note: the above is a partial listing of the policy exclusions. Please refer to the policy
clauses for the full listing).
4 Waiting • Initial waiting period: 30 days for all illnesses (not applicable on renewal or for
period accidents)
• Specific waiting periods :
o 12 months for xx diseases (clauses aa to bb)
o 24 months for yy diseases (clauses cc to dd)
o 36 months for zz diseases (clauses ee to ff)
o 48 months for xx diseases (clauses gg to hh)
• Pre-existing diseases: Covered after __ months/ Not covered
5 Payout • Reimbursement of covered expenses up to specified limits AND / OR
basis • Fixed amount on the occurrence of a covered event
6 Cost • In case of a claim, this policy requires you to share the following costs:
sharing o Expenses exceeding the following Sub-limits
ƒ Room / ICU charges beyond __________
ƒ For the following specified diseases:
ƒ ____________
ƒ _____________
o Deductible of Rs XXX per claim / per year / both
o xx% of each claim as Co-payment (yy % in a non-network hospital)
7 Renewal • Your policy is ordinarily renewable (OR Guaranteed) up to age x (OR for x years)
Conditio • After you attain the age of x years, the following features of your policy change:
ns o -------------------------------------
o -------------------------------------
• Other terms and conditions of renewal
(LEGAL DISCLAIMER) NOTE: The information must be read in conjunction with the product brochure and
policy document. In case of any conflict between the KFD and the policy document the terms and conditions
mentioned in the policy document shall prevail.
 Annexure - VII

S. TITLE DESCRIPTION REFER TO

NO POLICY
CLAUSE
NUMBER
8. Renewal • x% increase in your annual limit for every claim free year (or) x% discount on renewal
Benefits: premium, subject to a maximum of x%.
• In case a claim is made during a policy year, the bonus proportion (or) discount would
reduce by x% in the following year.
• For every block of x claim free policy years, free health check up for the insured
persons subject to maximum x% of sum insured.
9. Cancella • This policy would be cancelled, and no claim or refund would be due to you if:
tion o you have not correctly disclosed details about your current and past health
status OR
o have otherwise encouraged or participated in any fraudulent claims under the
policy.

(LEGAL DISCLAIMER) NOTE: The information must be read in conjunction with the product brochure and
policy document. In case of any conflict between the KFD and the policy document the terms and conditions
mentioned in the policy document shall prevail.
 Annexure - VIII

SERVICE LEVEL AGREEMENT

between:- -
This agreement made and entered into on this ----- day of ------20XX at, _______, India

“_____________________________________________” an insurance company having its

Registered Office at __________________________________________________ and its
Corporate 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) of
the First Part.

AND

I
“___________________________” licensed by the Insurance Regulatory and Development
Authority under the IRDA (Third Party Administrators - Health Services), Regulation 2001,
under License no ______ and having its Registered Office at
(__________________________________________) (hereinafter referred to as the “TPA”,
which expression shall unless repugnant to the context or meaning thereof be deemed to
mean and include its successors and permitted assigns) of the Second Part.

(“The Insurer” and the “TPA” are individually referred to as a “party" and collectively as
“parties")
 Annexure - VIII

WHEREAS

2
-
The Insurer has been registered under Section 3 of the Insurance Act 1938 (Act 4 of
1938) and is, inter-alia, engaged in the business of providing health insurance in
India.

The TPA has obtained a license as a Third Party Administrator under the IRDA (Third
Party Administrator - Health Services) Regulation, 2001 (hereinafter referred to as
“the Regulation”) framed under Sections 14 and 26 of the Insurance Regulatory and
Development Authority Act, 1999 (Act 4 of 1999) read with Section 114 A of the
Insurance Act, 1938 (Act 4 of 1938) and is engaged in making available health
services with regard to Health Insurance business conducted by the insurer.

3 The parties have agreed that the TPA shall provide the insured person of the Insurer,
health services for a fee and on terms and conditions more particularly described in
this Agreement.

4 Whereas the parties are desirous of recording in this Agreement, the terms and
conditions under which the TPA will render the aforesaid services to the insured
person of the Insurer.

NOW THEREFORE IT IS AGREED as follows: -

1 DEFINITIONS & INTERPRETATION

1.1 The following terms and expressions shall have the following meanings for purposes
of this Agreement.

1.1.1 “Agreement” shall mean this agreement and all schedules supplements,
appendices, appendages, annexure and modifications thereof made in
accordance with the terms of this agreement and shall be deemed to be the
Agreement as defined in Section 2(a) of the Regulation.

1.1.2 “Emergency” shall mean a serious medical condition or symptom resulting

from injury or sickness which arises suddenly and requires immediate care
and treatment, generally received within 24 hours of onset to avoid jeopardy
to life or serious damage to the health of Insured Person, until stabilization at
which time this medical condition or symptom is not considered an
Emergency anymore.

1.1.3 “Force Majeure Event” shall have the meaning ascribed to it in clause 20
below.

1.1.4 “Fees” shall mean the agreed fees payable by the Insurer to the TPA for
health services rendered by it as detailed in clause 3 of the Agreement
hereto.
 Annexure - VIII

1.1.5 "Health Services by TPA" means the services to be rendered by a TPA under
an agreement with an insurance company in connection with "health
insurance business" or ‘health cover’ as defined above but does not include
the business of an insurance company or the soliciting either directly or
through an insurance intermediary including an insurance agent, of health
insurance business or claim settlements of health insurance policies or claim
rejections of health insurance policies.

1.1.6 “IRDA” shall mean the Insurance Regulatory and Development Authority
established under the Insurance Regulatory and Development Authority Act
1999.

1.1.7 “I.D. Card or smart card” shall mean the identity card provided by the insurer
or its representative TPA on behalf of the insurer to the Insured Persons and
bearing the details listed in clause 3.1.4 of Annexure A below

1.1.8 “Network Provider” means hospitals or health care providers which have a
valid agreement with the insurer to settle claims through cashless facility.

1.1.9 “Service Area” shall mean the area within which the Insurer has authorized
the TPA to provide services.

1.1.10 “TPA Regional Office” shall mean the offices of the TPA located at various
regional locations throughout India and agreed with the Insurer to be known
as TPA Regional Office.

1.1.11 “Underwriting Offices” shall mean the offices of the Insurer located at
various locations throughout India.

1.2 Any grammatical form of a defined term herein shall have the same meaning
as that of such term.

1.4 Any reference to an Agreement, Memorandum of Understanding, Instrument

or other Document (Including a reference to this agreement) herein shall be
to such Agreement, Instrument or other Document, as amended,
supplemented or notated pursuant to the terms thereof.

1.5 Terms and expressions denoting the singular shall include the plural and vice
versa.
 Annexure - VIII

1.6 The term “including” shall always mean “including, without limitation,” for
purposes of this Agreement.

1.7 The terms “herein”, “hereinafter”, “hereto”, “hereunder” and words of

similar import refer to this agreement as a whole.

1.8 Headings are used for convenience only and shall not affect the
interpretation of this Agreement.

2 THE SERVICES

The TPA hereby agrees to provide the health services, by itself, in due compliance of
the terms and conditions and in the manner more particularly set out in Annexure A
to this Agreement.

3 SERVICE FEES
Subject to the TPA rendering the health services, the Insurer shall pay to the TPA the
Fee as detailed below

Rate of Service Charge

Type of service Rate of service

4 CLAIMS PROCESSING AND PAYMENT (CPP) SERVICES

The procedure of processing of the claims shall be handled by the TPA Regional
Offices. Any intimation of claim and receipt of claim papers by the respective
Underwriting office of the Insurer shall be forwarded to the Regional Processing
Office of the TPA. This service provided by the TPA along with the responsibilities of
the TPA as detailed in Annexure C to this agreement is collectively referred to as the
“CPP Service”.

5 CLAIMS HANDLING

The TPA shall only process the claim to facilitate the insurer to take decision on claim
settlement or claims rejection, as applicable. Only the insurer shall have the right to
settle or repudiate a claim. The TPA may convey the repudiation of a claim to the
insured, on advice by the insurer. Where the TPA sends the intimation about the
repudiation to the claimant, it shall be clearly indicated in the repudiation letter that
“the claim has been repudiated as advised by the insurer” and the specific reasons
thereof for repudiation. Further, the repudiation letter shall also clearly mention that
 Annexure - VIII

the insured may approach the grievance cell of the insurer if he/ she is not satisfied
by the settlement. The contact details of grievance cell shall be provided in the letter.

6 GRIEVANCE RAISED BY INSURED AND REOPENING OF CLAIM

The Insured Person may approach the grievance cell of the Insurer against the
decision of the Insurer. This right of approaching the grievance cell of the Insurer will
be mentioned by the TPA in every repudiation/settlement advice as mentioned in
Clause 5 above. The insurer may advise the TPA to re-open the claim and process
suitably if proper and relevant documents as required for the claim settlement are
submitted.

7 PROCESSING OF CLAIMS AND TURN AROUND TIME

The TPA will process all the claims applications to the extent possible within 2
working days after receipt of the complete set of claim documents,

8 MANAGEMENT INFORMATION SYSTEMS (MIS) SERVICE

The TPA shall provide management information system reports whereby the Insurer
will be provided information regarding the enrolment, pre
authorization/reauthorization, claims processed and such other information
regarding the services as required by the Insurer. The reports will be submitted by
the TPA to the Insurer on a regular basis as agreed between the Parties. The
Management Information system reports provided by the TPA to the Insurer are
referred to as the “MIS Service” and are detailed in Annexure D to this agreement.

9 AUTHORITY OF TPA

The TPA has declared that it has full capacity and authority to execute deliver and
perform this Agreement and it has taken all necessary action(s) (corporate, statutory
or to otherwise) to execute, deliver, perform and authorize the execution, delivery
and performance of this Agreement and that it is fully empowered to enter into and
execute this Agreement, as well as perform all its obligations hereunder.

10 TPA REPRESENTATIONS WARRANTIES AND RESPONSIBILITES

The TPA representations, warranties and responsibilities are detailed in Annexure E

to this agreement

11 COMPLAINTS BEFORE JUDICIAL AND QUASI-JUDICIAL BODIES

 Annexure - VIII

Any complaint filed before any judicial or quasi-judicial body against the TPA for
claim repudiation by insurer, would be jointly defended by the Insurer and the TPA
(through an advocate in case of judicial bodies). Where an advocate has been
engaged for the purpose, the professional fee will be paid by the Insurer.

Where the case is due to deficiency of health service by the TPA and is not related to
policy terms and conditions, the complaint would be defended by the TPA alone and
all costs to defend the complaint would be borne by the TPA.

12 AUTHORITY OF THE INSURER

The Insurer has full capacity and authority to execute deliver and perform this
Agreement and it has taken all necessary action (corporate, statutory or otherwise)
to execute delivery, perform and authorize the execution delivery and performance
of this Agreement and that it is fully empowered to enter into and execute this
Agreement as well as perform all its obligations hereunder.

13 INSURER REPRESENTATIONS WARRANTIES AND RESPONSIBILITIES

The Insurer representations, warranties and responsibilities are detailed in Annexure

F to this agreement.

14 CONFIDENTIAITY

Maintenance and Confidentiality of information

(i) TPA shall abide by its obligations mentioned under IRDA (Third Party
Administrators - Health Services) Regulations, 2001 with respect to data
maintenance and confidentiality.

(ii) TPA shall, in maintaining the records in terms of Regulation (22) (1), follow
strictly the professional confidentiality between the parties as required.

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

(iv) TPA shall maintain the data under this agreement by taking all reasonable
care and precautions including but not limited to:

(a) The Data must be maintained and updated using information

technology.
 Annexure - VIII

(b) The TPA shall have systems, fireballs and all paraphernalia to avoid
jeopardizing the data.

(c) The TPA shall have a Business Continuity Plan ready, in order to face
any contingency that may arise.

(d) The TPA shall make adequate arrangements for data backup. Data
backup shall be done in electronic data Storage (e.g. Magnetic tape,
used for tertiary and off-line storage) and the data backup shall be
preserved for three years

(e) The entire data related shall be sole proprietary of Insurer

The expression Confidential Information shall, without limitation, include

confidential or proprietary information received by the other party whether directly
from the other party or otherwise. Confidential Information includes without
limitation inventions, innovations, works or intellectual property and any idea, trade
secret, know-how or data of any nature concerning the development, use,
formulation, manufacture or performance of either party or its products or
prospective products or services, and any research and development activities,
process, techniques, inventions, specifications, algorithms, prototypes, designs,
drawings or test data thereof, software programs, computer programs or
documentation, specifications, source code, object code of such software and
computer programs, inventions, processes, engineering products, services, the
Insurer’s markets or the business of either party or that of their respective clients.
Information shall be deemed to be confidential whether the same comes to the
knowledge of the other party orally or is contained in tangible or fungible form and
whether contained in a floppy disc, computer system, brochure, booklet or
otherwise. Unless otherwise specified, all information received by the either party
and pertaining to the other party shall be deemed to be Confidential Information.
The terms of this Agreement are confidential and shall only be disclosed on a need
to know basis.

The TPA shall keep the Insurer informed of any breach of the confidentiality
obligations and shall provide necessary assistance and co-operation to the Insurer as
the Insurer may require in this regard.-

Notwithstanding anything contained herein, the restriction on use and disclosure set
out above shall not apply to any Confidential Information which is required to be
disclosed by way of an action, subpoena or order of a court of competent jurisdiction
or of any requirement of legal process, law or governmental order, decree,
regulation or rule;

15 INDEMNIFICATION
 Annexure - VIII

15.1 TPA shall hereby indemnify and keep the Insurer indemnified from and
against all and any costs, damages or losses (whether consequential, business
or otherwise) arising out of the breach of any representation warrant and or
covenant made by it in this Agreement, breach of the Agreement generally or
for non-fulfillment of its obligations under law or to any third party/parties.

15.2 TPA shall be solely liable for and will indemnify defend and hold harmless the
other party from and against any and all claims, liability damages and/or
costs (including but not limited to legal fees) arising from out of or in
connection with:

15.2.1 The breach of any warranty, representation, covenant or term of this

agreement;

15.2.2 The non-fulfillment of its obligations under law or to any third party /
parties;

15.2.3 The gross negligence and / or willful misconduct by it and/or its

Officers, Directors, Employees, Agents or Affiliates;

15.2.4 The infringement or violation of any third party’s copyright patent,

trade, secret, trademark, intellectual property, intellectual property
right in relation to the services.

16. TERM & TERMINATION

16.1 This Agreement shall take effect on the date of execution hereof by both
Parties, and shall remain in force for an initial period of 1 year subject to
quarterly review at the discretion of the Insurer and also subject to a right to
the Insurer to terminate the Agreement after review of the performance of
the TPA by the Insurer on a monthly basis. The Insurer will review the
performance of the TPA based on factors including but not limited to:-

16.1.1 The facilities set up including quality and reliability of software other
infrastructure based on the volume of business serviced and
arrangement made by the TPA towards servicing the Policy Holders of
the TPA.

16.1.2 The quality of service provided;

16.1.3 The customers satisfaction reports received and

16.1.4 Such other factors as the Insurer deems fit and specifies

16.2 This Agreement may be terminated;

 Annexure - VIII

16.2.1 By both Parties by mutual consent; or

16.2.2 By the non- defaulting Party in the event of a change in the

management or a change in the controlling interest of the other party
without the prior written consent of the non defaulting Party; or

16.2.3 By the non-defaulting Party in the event that the other Party fails a
maintain any license certification or accreditation required to conduct
or perform the business contemplated by such party under this
agreement; or

16.2.4 By the Insurer in the event of breach by the TPA of

(i) This agreement or

(ii) Its representations and warranties in this Agreement; or

(iii) Its covenants, agreements or obligations contained herein;

16.2.5 By the Insurer after a period of three months in pursuance of clause

16.1 above.

16.3 The TPA shall apply in writing for renewal of this agreement at least 15 days
before expiry of one year from the date of execution (if not already cancelled
in terms of clause 16.1). The Insurer may consider continuance of the services
of the TPA and may require them to enter into a fresh agreement.
Continuance of services is not mandatory but it is at the discretion of the
Insurer and the decision of the Insurer shall be binding final in this regard.

16.4 This Agreement may be terminated forthwith by either Party if the other Party
is prevented from performing any of its obligations hereunder due to a Force
Majeure Event and such Force Majeure Event continues for a period of 4
weeks without interruption.

16.5 On termination of this agreement for any reason whatsoever.

16.5.1 The Insurer shall be liable to the TPA for all costs and charges for
services performed in accordance with the terms of this agreement
until the date of termination.

16.5.2 The TPA shall comply with the provisions of IRDA (Health Insurance)
Regulations 2013 in case of terminations of this agreement.

16.5.3 The TPA shall not deny access to Insurer for any records, documents,
evidence, books of all transactions or any related information for a
period of five years from the date of termination of agreement and
shall comply with the extant rules on this.
 Annexure - VIII

17 COSTS

Except as provided to the contrary in this Agreement, each party shall bear their own
costs in relation to complying with the terms and conditions of and performing their
respective obligations under this agreement including without limitation legal fees,
advisory fees and other expenses required for the preparation and execution of this
agreement.

18 FORCE MAJEURE

18.1 Neither Party shall be in breach of any of its obligations under this agreement
to the extent that its performance is prevented, physically hindered or
delayed by an act, event or circumstance (whether of the kind described
herein or otherwise) which is not reasonable within the control of such.

Force Majeure shall include the following:

(a) Fire, flood, atmospheric disturbance, lighting, storm, typhoon,

tornado, earthquake, washout, or other acts of God;

(b) War, riot, blockage, insurrection, acts of public enemies, civil

disturbances, terrorism and sabotage and threats of such actions;

(c) Strikes lock-outs, or other industrial disturbances or labors disputes;

(d) Changes of any applicable Rule, Regulation or Law.

18.2 In the event that any Force Majeure Event continues for a period of 4 (four)
weeks without interruption, the party not affected by such Force Majeure
Event shall be entitled to terminate this Agreement by giving notice to the
other Party pursuant to and in accordance with the provisions of clause 16.4
of this Agreement.

19 ASSIGNMENT

19.1 Neither Party shall be entitled to assign its rights and/or obligations under
this agreement.

19.2 Subject to the foregoing this agreement shall be fully binding to the benefit
of and be enforceable by the Parties hereto and their respective successors
and permitted assigns.
20 GENERAL
 Annexure - VIII

20.1 The Insurer shall have the discretion in entrusting/ allocating the servicing of its
policyholders to the TPA.

20.2 The Insurer may allow the TPA to continue to service the existing clients
irrespective of the service area allocated to the TPA.

20.3 The Insurer shall have discretion at all times, in modifying, adding, deleting or
canceling the areas and / or offices entrusted with the TPA at its sole
discretion.

20.4 The Insurer shall have discretion at all time to induct new TPAs to provide
services to the Policyholders at any place or region or service area.

20.5 The Insurer shall have discretion at all times to inspect the TPAs infrastructure
and activities.

21 ENTIRE AGREEMENT

This Agreement entered into between the Insurer and the TPA represents the entire
agreement between the Parties and shall supersede any previous agreement or
understanding between the Parties in relation to matters covered hereby.

22 RELATIONSHIP

22.1 The parties to this Agreement 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 Agreement 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.

22.2 It is clarified that neither the TPA nor any of its employees shall be deemed to
be the employees of the Insurer for any purpose whatsoever.

23 VARIATION

No variation of this Agreement shall be binding on either Party unless, and to the
extent that such variation is recorded in written document executed by both Parties.
Where any such document is executed by both Parties, neither Party shall allege that
such document is not binding by virtue of an absence of consideration.
 Annexure - VIII

24 SEVERABILITY

If any provision of this Agreement is invalid, unenforceable or prohibited by Law, this

Agreement shall be considered divisible as to such provision and such provision shall
be inoperative and the remainder of this Agreement shall be valid, binding and do
the like effect as though such provision was not included herein.

25 NOTICES

Any notice given under or in connection with this Agreement shall be in writing and
in the English language. Notices may be given by being delivered to the address of
the addressee 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 or by email or by any
other method agreed by the parties(in which case the original shall be sent by
courier services).

________ :
Address :
Tel :
Fax :
Email :

Name of the TPA : _______________________________________

Address of the TPA : _______________________________________,
________ - ____________
Tel : ________________________
Fax : ________________________
Email:_______________________________

26 DISPUTE RESOLUTION

26.1 If any dispute arises between the Parties hereto during the subsistence of this
agreement or thereafter in connection with the validity, interpretation,
implementation or alleged breach of any provision of this agreement, the
Parties will refer such dispute to their respective Head Offices for resolution.
If the dispute is not resolved within 30 days of such reference, either party
may refer the dispute for resolution to a sole arbitrator who shall be jointly
appointed by both parties. Where the parties do not agree upon a sole
arbitrator within 30 days from receipt of a request by one party from the
other party, parties would appoint one arbitrator each, who shall in turn
appoint the presiding arbitrator.

26.2 The law governing the arbitration shall be the Arbitration and Conciliation
Act, 1996 as amended or re-enacted from time to time.
 Annexure - VIII

26.3 The proceedings of arbitration shall be conducted in English language.

26.4 The arbitration shall be held in XXXX, India.

27 GOVERNING LAW AND JURISDICTIONAL COURTS:

-
This agreement shall be governed and construed by the laws of India without regard

-
to the conflict of laws, principles and any dispute in relation to this AGREEMENT.
Disputes not resolved between the parties shall be subject to the exclusive
jurisdiction of the courts at XXXX India

IN WITNESS WHEREOF the Parties have caused this agreement to be executed by their
duly authorized representative in as of the date first hereinabove written.

SIGNED, SEALED AND DELIVERED

BY The Within Named
By

Authorized signatory
For __________________

In the presence of

1.

2.

SIGNED SEALED AND DELIVERED

By the within named
By ………………………., Director
For (___________________________).

In the presence of
1.

2.
Annexure A

1. HEALTH SERVICE BY TPA UNDER HEALTH INSURANCE CONTRACTS

1.1 TPA to provide list of Network Service Providers.

 Annexure - VIII

The TPA shall make available the list of Network Service Providers affiliated by the insurer to
the Insured Person in the Guidebook issued to the Insured People.

1.2 Non-Network Service Providers

The TPA shall also process claims of such Insured who have not opted for Cashless Service
and also Claims of Insured who avail treatment from non-Network Service Providers.

2. CALL CENTER SERVICES

2.1 The TPA shall provide telephone services for the guidance and benefit of the
Insured Persons whereby the Insured Persons shall receive guidance about various
issues by dialing a national Toll free number. These services provided by the TPA
subject to its responsibilities and subject to responsibilities of the Insurer as detailed
in this clause 2.2, are collectively referred to as the Call Centre Service.

2.1.1 Call Centre Information

The TPA shall operate a call center for the benefit of all Insured Persons. The
call center shall function for 24 hours a day 7 days a week around the year. As
part of the call Centre Service the TPA shall provide the following:-

1) Provide instant accessibility to the clients for all information required

about network providers.
2) Provide complete list of network hospitals at all locations of client
operations.
3) Provide Fax confirmation (received, and sending).
4) Provide Claim status (Cashless, Reimbursement, and Payments).
5) Provide information related to E-Card.
6) Provide all assistance related to Cashless Claims.

2.1.2 Language

The TPA undertakes to provide the call centre service to the Insured Persons
in the following languages viz. English, Hindi and local language.

2.1.3 Toll Free Number

The TPA will operate a toll free number, for general queries on cashless,
claims and card statuses, auto mailers, and auto generated SMS facilities for
updating claims statuses and automated email facilities. The cost of operating
of the entire call centre service not limited to provision of toll free voice and
fax number shall be borne solely by the TPA.

2.1.4 Call Centre Analysis

 Annexure - VIII

The TPA will provide general call centre statistics in a format i.e. MIS sheet for
call analysis, as may be mutually agreed to by the Parties, on a monthly basis
including aspects of grievance redressed and pending redressal. Any specific
format, if required will have to be intimated by the Insurer in advance to the
TPA.

2.1.5 Information at Local Offices

The TPA branch offices located across the country will assist the Insured
Person in obtaining the necessary information during working hours of the
TPA. All information required after working hours will be available from the
central call center or processing house only.

2.2 Responsibilities of the Insurer in respect of the Call Centre Service

2.2.1 Insurer to inform Insured Person

The Insurer will intimate the toll free number to all Insured Persons along
with addresses and other telephone numbers of the TPA’s main office and
regional offices.

3. CASHLESS ACCESS SERVICE

3.1 The TPA has to ensure that all the Insured Persons are provided with timely
pre-authorisation to the Policy Holders as covered under the policy. This service
provided by the TPA along with the responsibilities of the TPA and subject to
responsibilities of the Insurer as detailed in this clause 3 is collectively referred to
as the “Cashless Access Service”.

3.1.1 Responsibilities of the TPA in providing the Cashless Access Service

Guidebook and other details

The TPA shall forward a user guidebook/brochure prepared by them to the

Insurer for its approval, upon such approval; the guidebook/brochure shall be
filed along with the agreement.

The TPA shall dispatch the approved Guidebook and related information to
the Insured Person within 7 working days of receipt of information regarding
the issuance of policy to the Insured Person from the Insurer along with the
identity card. The Guidebook will inter-alia contain information regarding the
following:

1) SMS service Details

2) Cashless request form
 Annexure - VIII

3) Specimen Certificate
4) List of Network providers
5) Cashless Hospitalization Process
6) Reimbursement Process
7) List of ________ branch offices and their contact numbers

3.2 Deficiencies in the Required Data

In case the data given to the TPA is not sufficient for the purpose of preparing
the I.D. Card the TPA will intimate to the Head office of the Insurer
immediately. The TPA shall be responsible for dispatch and delivery of the
I.D. Cards to the Insured Person only after the requisite information regarding
the Insured Person is submitted by the Insurer to the TPA.

3.3 I.D. Card production

The issue I.D. Cards will bear a logo of the Insurer and in a size and format
mutually agreed by the Insurer and the TPA.

3.4 The I.D. Card will have:

(i) A unique specific Alpha-numerical Identification Character Set, which

will be generated uniquely for each Insured Person
(ii) Name of the Insured Person and relationship with the Policy Holder
(iii) Age of the Insured Person
(iv) The photograph of the Insured Person
(v) Emergency contact number of the Insurer and the TPA
(vi) Name of the Insurer
(vii) Date of policy issue
(viii) Date of inception of first health insurance policy without break

The cost of manufacturing the I.D. Card shall be borne solely by the TPA. The
Validity period of the cards can be defined by the Insurer, depending upon,
whether long term cards are to be given to the Insured Person.

3.5 Dispatch of I.D. Card and other material

The I.D. card along with the Guidebook and Network Service Provider
directory of the respective city/area etc will be sent directly to the Insured
Person/underwriting Office as per instruction of the Insurer.

3.6 Turn Around Time for enrolment processing and I.D. Card issuance.
 Annexure - VIII

The TPA will complete the issuance of the I.D. Card to the Insured Person
within 7 working days of receipt of complete information either from the
system or the head office of the Insurer.

3.7 Deficient I.D. Cards

In case of error in data/printing mistakes etc. the Insured Person will be

requested to return the I.D. Card to the TPA. TPA will rectify the mistake and
redeliver the I.D. Card within 2 working days of its receipt at its office to the
Insured Person.

3.8 TPA will intimate on a regular basis, the errors, which the TPA would
have come across in the issue of I.D. card etc. to the Insurer.

3.9 Cost of re-issuance of the new cards arising from TPA error will be
borne by TPA. Cost of re-issuance of new cards arising from error in data will
be borne by the insurer/insured, as applicable, at the rate of Rs ___ per card.

3.10 Renewals of the Policy I.D. Card

Upon termination or expiry of the policy period, the cards will then have to
be revalidated by the TPA on confirmation of renewal of the Policy by the
Office of the Insurer without issuing fresh cards.

3.11 Reporting to Insurer Office on the Status of I.D. Card

TPA shall send a weekly report to each underwriting office via E-mail on the
status of enrolment and I.D. Cards related to the particular underwriting
office

3.2 Pre-Authorization for Cashless Access

The TPA shall upon getting the related medical information from the Policy
Holders/ Network Service Provider, verify that the person is eligible under the
policy and after satisfying itself, may recommend to insurer for pre-
authorization. After receiving the recommendation from the insurer, the TPA
shall issue authorization letter/guarantee of payment letter to the Network
Service Provider mentioning the guarantee of the sum, duration of stay and
the ailment for which the person is seeking to be admitted as a patient within
12 hrs of receipt of preauthorization request. All authorization requests
received by the TPA shall have a detailed breakup of the estimated costs.

3.3 Denial of Preauthorization

In case the Provider/policy Holder fails to provide relevant medical details as

required by the TPA, the TPA shall call for all the relevant details within 12
 Annexure - VIII

hours. If the subsequent details are also deficient the TPA shall, on the advice
of the insurer, convey denial of the guarantee of payment to the Network
Service Provider and may not authorize the Insured Person for cashless
access. TPA shall ensure that the data received conclusively shows that the
Policy holder is eligible for insurance coverage within the terms and
conditions of the Policy, before the claim is forwarded to the insurer for
advice.

In case of denial of pre-authorization, the TPA is expected by the Insurer to

communicate to the Policyholder that denial of Cashless Access is in no way
construed to be treated as denial of treatment. The Policyholder is expected
to obtain the treatment as per his/her treating doctor’s advice. The denial of
preauthorization letter shall not be construed to mean that the Policyholder
cannot claim under the terms and conditions of the Policy. The policyholder
can claim for reimbursement, as and when, the Policyholder provides all the
relevant medical details.

3.4 EMERGENCY CASES

In cases of emergency if the TPA is not satisfied with the medical details, it
may call for all the relevant details immediately. However the TPA shall verify
from the Network Service Provider about the nature of ailment and on such
verification if the Policyholder is found to be eligible under the terms of the
Policy, the TPA shall, on the advice of the insurer, convey the guarantee of
payment letter to the Network Service Provider provided the patient is still
admitted in the hospital within 4 hours. The TPA, on advice from the insurer,
convey denial preauthorization within 4 hours, if the information submitted is
deficient.

3.5 Responsibilities of the Insurer in providing the Cashless Access Service

3.5.1 Insurer to provide data to the TPA

The Insurer shall co-ordinate with the TPA by providing the TPA with the
necessary data regarding the Policyholder so as to enable the TPA to process
the applications for allotment of I.D. cards received from the Policyholders.

3.5.2 TPA not to issue I.D. Cards without sanction of Insurer

The Insurer shall ensure that the TPA issues the I.D. cards as per the terms
and condition of the Policies of the Insured Persons. Any I.D. card issued
without the sanction of the Insurer shall be invalid and the TPA hereby
indemnifies the Insurer for any payment made under such I.D. Card not
validated by the Insurer.
 Annexure - VIII

3.5.3 Responsibility of Collection of Data

The responsibility of making available the data to the TPA Regional office lies
with the underwriting office of the Insurer the responsibility of collecting
data lies with the TPA.

4. CUSTOMER RELATIONS AND CONTACT MANAGEMENT (CRCM) SERVICE

The TPA shall provide adequate services to the Policyholders and ensure that
customer grievances are resolved to their satisfaction. This service provided by the
TPA along with the responsibilities of the TPA and subject to responsibilities of the
Insurer as detailed in this clause 4.2.1 is collectively referred to as the “CRCM”
Service.

4.1 Responsibilities of the TPA in providing the CRCM Service

4.1.1 CRCM Cell

The TPA shall have a dedicated CRCM cell for receiving documents and
handling individuals and groups services. The TPA shall also ensure that the
CRCM cell have enough representatives and personnel in all cities/towns
where Insurer has zonal offices.

4.1.2 Customer Grievance

The TPA shall act as a frontline for the redressal of Insured Person’s
grievances. The TPA shall also attempt to solve the grievance at their end.
The grievances so recorded shall be numbered consecutively and the Insured
Person who records the grievance shall be provided with the number
assigned to the grievance. The TPA shall provide the Insured Person with
details of the follow-up action taken as regards the grievance as and when
the Insured Person requires it to do so. The TPA shall provide to the Insurer
Information in pre agreed format of any complaint / grievance received by
oral, written or any other form of communication.

4.1.3 Action Taken Report for Customer Grievance

The TPA shall record in details the action taken to solve the grievance of the
Policyholder in the form of an action taken report [ATR] within ___ days of
the recording of the grievance. The TPA shall provide the Insurer with the
comprehensive action taken report ATR on the grievances reported in pre
agreed format. Any grievance not solved within __ days will be intimated to
the respective underwriting office.

4.1.4 Customer Satisfaction Survey

 Annexure - VIII

The TPA shall on annual basis carry out customer satisfaction survey from a
random sample of the Insured Persons who have obtained and availed the
services provided by the TPA. The TPA shall use the rating card provided in
the Guidebook for the purpose of conducting the survey. The TPA is expected
to provide a synopsis of the findings of the survey along with the Plan of
Action to address the deficiencies, shortcomings in the service provided by
the TPA, if any, or suggestions for improvement at the end of the Insurer, in a
format, that may be mutually arrived at by the Parties. The Insurer reserves
the sole right to carry out a survey of the Insured Persons, on its own accord,
to gather customer feedback and may share the findings of the same with the
TPA, who will be obliged to treat the same at par, with the findings of the
survey carried out by the TPA. Further, the Insurer or agencies appointed by
it or its personnel shall also have access to copies of completed survey cards,
collated by the TPA, for the purposes of the survey for its audit purposes.

4.2 Responsibilities of the Insurer in providing the CRCM Service

4.2.1 Insurer to co-ordinate with TPA

The Insurer shall co-ordinate with the TPA in order to solve the grievance as
and when required by the nature and circumstances of the grievance.
 Annexure - VIII

Annexure B

Responsibilities of the TPA in providing the Billing Service

1 Standardized Billing Pattern

The insurer will provide a standardized billing pattern in an electronic format

to all their Network Service Providers and the billing and settlement shall be
done by the insurer on the basis of these standardized billing patterns.

Annexure C

Responsibilities of the TPA in providing the CPP Service:-

1 Claim Intimation

The TPA shall receive claim intimation from the Insured Person/insurer. The
TPA shall submit all the claim related documents to the insurer through web
based platform for claim settlement/rejection by the insurer.

2 Collection of Claim documents

The TPA shall offer a single window service at the respective TPA Regional
Office to the Insured Persons for receiving the claim documents. In case of
pre-authorization for the Cashless Access Service, the Network Service
Provider will send the claim documents along with the invoice and discharge
voucher, duly signed by the Insured Person directly to the TPA. In the event
that the Insured Person collects the claim documents, the Insured Person will
have to submit the same to the Regional/closest office of the TPA within
seven days of discharge from the medical facility. In the event that the
Insured Person does not opt for a Network Service Provider the Insured
Person may collect the Claim Form from either the Underwriting Office or the
office of the TPA or download the form from the website of the TPA. The
documents for claim will have to be submitted to TPA by the Insured Person.
The TPA office will also submit the pre & post hospitalization claim
documents. TPA shall give due acknowledgement of collected documents.

3 Scrutiny of Claim Documents

The TPA shall scrutinize the claim documents at the initial stage regarding the
medical and eligibility aspect. Deficiency of documents, if any, shall be
intimated to the Insured Person and respective underwriting Office. A
reminder to send the same will again be forwarded to the insured Person
after 5 working days of first intimation of the deficient documents are not
received or are partially received.
 Annexure - VIII

4 Claim Control Number

The TPA shall issue a claim control number to all claims reported for future
reference purposes.

5 Pre and Post hospitalization claims

The TPA shall receive pre and post hospitalization claim documents either
along with the inpatient hospitalization papers or separately and process the
same based on merit of the claim derived on the basis of documents received
and refer the documents to the insurer for advice.

6 Claim Documents
The TPA shall furnish all the claim files, if any, to the insurer in accordance
with the IRDA (Health Insurance) Regulations, 2012

7 Bank reconciliation

The TPA will submit Bank reconciliation Statement to the insurer on monthly
basis.

Annexure D

1 Responsibilities of the TPA in providing the MIS Service:

1.1 The TPA shall ensure that the providers have furnished the
standardized billing form as detail in Annexure B above.

1.2 MIS Reports will be made available to the insurer as and when required
without any pre-condition by the TPA.

2 Export/Import of data through electronic media

The TPA shall arrange for export/import of data as per data formats and
specifications given by the Insurer form time to time in accordance with the IRDA
(Health Insurance) Regulations, 2012.

Annexure E

The TPA represents and warrants to the TPA that:

1.1 Compliance with Memorandum and Articles

 Annexure - VIII

Neither the making of this Agreement nor any due compliance with its terms
will be in conflict with or result in the breach of or constitute a default or
require any consent under:-

(a) Any provision of any Agreement or other Instrument to which the TPA
is a party or by which it is bound
(b) Any judgment, injection, order, decree or award which is binding
upon the TPA and/or
(c) The TPA’s the memorandum and/or articles of association.

1.2 Compliance with Laws

The TPA should comply with all applicable Laws including but not limited to
the Insurance Regulatory and Development Authority (Third Party
Administrator – Health Services) Regulations 2001 and IRDA (Health
Insurance) Regulations, 2012

1.3 Third Party Administrator License

Throughout the term of this Agreement the TPA shall continue to be licensed
with the IRDA as a third party administrator.

1.4 Capability of Service

The TPA should ensure that it is capable of servicing all the health insurance
policies offered by the Insurer and also has sufficient infrastructure, trained
manpower and resources to carry out the activities for servicing these
products and policies.

1.5 Audit of claims processed by TPA

The TPA agrees that the Insurer shall have the right to audit all claims of the
Insurer processed by the TPA. The TPA further agrees to provide access to the
Insurer to their books of accounts and records for the purpose. The
frequency and model of audit will be decided mutually between the TPA and
the Insurer, but at least on a monthly basis.

2 On execution of this Agreement and during the time it is in force the TPA
agrees that it shall be responsible to and shall :

2.1 File Agreement

File a copy of this Agreement and every modification there to within 15 days
of its execution to or modification, as the case may be with the IRDA
 Annexure - VIII

2.2 No other business

Not carry on or conduct any business other than giving third party
administrator services as envisaged in the provision of the Insurance
Regulatory and Development Authority (Third Party Administrator- Health
Services) Regulations [Link] IRDA (Health Insurance) Regulations, 2012

2.3 Control and Management and material change

Disclose to the Insurer the shareholding, control and management of the TPA
and also intimate any material change in the shareholding, control or
management of the TPA to the Insurer. Further, the TPA shall also disclose its
shareholding and/or interest in control and management in any associate
company/sister concern engaged in the health care services.

2.4 Intimation of change

Intimate change in the office of Chief Executive Officer (CEO) / Chief

Administrative Officer (CAO) or any functional director as well as Change of
Address of the Registered Office / Operation office / Regional Offices and
contact details to the Insurer within one week from the date of its
occurrence.

2.5 Code of Conduct

Abide by the code of conduct prescribed by the IRDA or the General

Insurance Council / Life Insurance Council or the Council for Fair Business
Practices, from time to time.

2.6 IRDA Regulation

Abide by the Regulations of IRDA as amended from time to time and any
circular, notification or rule framed by the IRDA, from time to time.

2.7 Annual Report

Furnish to the Insurer an annual report and any other return as may be
required by the IRDA on its activities.

2.8 No Separate Fees

Not charge any separate fees from the Insured Persons, which it serves under
the terms of this Agreement in respect of any health insurance policies that is
being serviced by the TPA on behalf of the Insurer.

2.10 Discounts and Rebates

 Annexure - VIII

TPA shall not demand or accept any benefits in the form of any discounts or
rebates from Providers or insured.
2.11 Business Continuity Plan

Ensure that they have adequate data back up in case of any unforeseen
accident for the purpose of business continuity requirement.

Annexure F

The Insurer represents and warrants to the TPA that:

1.1 Compliance with Memorandum and Articles

Neither the making of this Agreement 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) Any provision of any agreement or other instrument to which the
Insurer is a party or by which it is bound;
(ii) Any judgment injection, order, decree or award which is binding upon
the Insurer; and/or
(iii) The Insurers Memorandum and / or Articles of Association.

1.2 Compliances with Laws

It has complied with all applicable Laws including but not limited to the
Insurance Regulatory and Development Authority (Third Party Administrator
– Health Services) Regulations [Link] IRDA (Health Insurance) Regulations,
2012

1.3 Insurance License

Throughout the term of this agreement the Insurer shall continue to be an

insurance company under Law to carry on the activities contemplated herein.

2 On execution of this Agreement and during the time it is in force the Insurer
agrees that it shall be responsible to the TPA for the following :

2.1 Inform TPA on Insured’s data

Pass on the data to the TPA Regional Office on weekly/fortnightly basis as the
case may be.

2.2 Insured Person to return I.D. Card

 Annexure - VIII

Instruct the Insured Person to return the cards upon non-renewal of the
policy.

2.3 Instruct underwriting Offices

Instruct all their Underwriting Offices to utilize the services of the TPA in
accordance with the agreement.

2.4 Claims Management

Forward all intimation claim documents if received by the Underwriting

Offices to the respective TPA Regional Office.
Annexure - VIII
 Annexure - IX

Exposure Draft MoU Between Insurance Company and the Provider

Service Agreement

Between

________________________________

and

______________________ Insurance Co. Ltd.

____________
___________
__________
This Agreement (Hereinafter referred to as “Agreement”) made at ________ on this ___________
day of ___________ 20__.

BETWEEN
_____________(Provider) an institution located in _________, having their registered office at
____________ (here in after referred to as “Provider”, which expression shall, unless repugnant to
the context or meaning thereof, be deemed to mean and include it's successors and permitted
assigns) as party of the FIRST PART
AND
______________________ Insurance Company Limited, a Company registered under the
provisions of the Companies Act, 1956 and having its registered office
___________________________________________________ (hereinafter referred to as
“Insurer” which expression shall, unless repugnant to the context or meaning thereof, be deemed
to mean and include it's successors, affiliate and assigns) as party of the SECOND PART.
The (Provider) and Insurer are individually referred to as a "Party” or “party" and collectively as
"Parties” or “parties")
WHEREAS
1. Provider means a hospital or nursing home or day care center (herein after referred as
“Provider”) duly recognized and authorized by appropriate authorities to impart heath care
services to the public at large.
2. Insurer is registered with Insurance Regulatory and Development Authority to conduct
insurance business including health insurance business.
3. Provider has expressed its desire to join Insurer's network of Providers and has represented
that it has requisite facilities to extend medical facilities and treatment to beneficiaries as
covered under Health Insurance Policies on terms and conditions herein agreed.
4. Insurer has on the basis of desire expressed by the Provider and on its representation agreed
to empanel the Provider as empanelled provider/network provider for rendering complete
health services.

In this AGREEMENT, unless the context otherwise requires:

1. the masculine gender includes the other two genders and vice versa;
2. the singular includes the plural and vice versa;
3. natural persons include created entities (corporate or incorporate) and vice versa;
4. marginal notes or headings to clauses are for reference purposes only and do not bear upon
the interpretation of this AGREEMENT.
5. Should any condition contained herein, contain a substantive condition, then such
substantive condition shall be valid and binding on the PARTIES notwithstanding the fact that it is
embodied in the definition clause.

In this AGREEMENT unless inconsistent with, or otherwise indicated by the context, the following
terms shall have the meanings assigned to them hereunder, namely:

Definition
A. Health Services shall mean all services necessary or required to be rendered by the
Institution under an agreement with an insurer in connection with “health insurance
business” or “health cover” as defined in regulation 2(f) of the IRDA (Registration of Indian
Insurance Companies) Regulations, 2000 but does not include the business of an insurer
and or an insurance intermediary or an insurance agent.
B. Beneficiaries shall mean the person/s that are covered under the health insurance policy
issued by the [insurance company].
C. Confidential Information includes all information (whether proprietary or not and whether
or not marked as ‘Confidential’) pertaining to the business of the Company or any of its
subsidiaries, affiliates, employees, Companies, consultants or business associates to which
the Institution or its employees have access to, in any manner whatsoever.
D. Smart Card/identification card shall mean Identification Card for health insurance policy
issued by the Insurer or by its representative TPA.

NOW IT IS HEREBY AGREED AS FOLLOWS:

Article 1:
Application of Agreement
1. This Agreement shall be for a period of one year. However, it is understood and agreed
between the Parties that the term of this agreement may be renewed yearly upon mutual
consent of the Parties in writing, either by execution of a Supplementary Agreement or by
exchange of letters on agreed terms and conditions by mutual consent of both Parties. In
case the renewal process is underway and both Parties have in principle agreed
to renew the agreement, all rights and obligations under this MOU may continue
seamlessly.

2. Any new Provider or treatment centre that is or may in future be owned or managed
by the Provider after the date of this Agreement may be added to the list of Providers
by agreement between the Parties in writing.
3. [Insurance Company] reserves the right to de-empanel a Provider from the
Agreement if there is a change of control affecting that Provider. The Provider shall
notify [Insurance Company] in writing within 15 working days of a change of control.
4. [Insurance Company] reserves and shall always have the right to negotiate and enter in
to similar agreements with other Providers and providers of healthcare services.

Article 2:
Warranties
1. By the [Insurance Company]
a. [Insurance Company], holds a valid license from the Authority under the Act and under
the Regulations to act as a Insurance Company and the said license is valid and
subsisting and the same has not been revoked by the Authority under the
Act and the Regulations.
b. [Insurance Company] under this MOU is entitled to pay to the Provider for
the necessary medical treatment given to the Beneficiary provided the Provider has
fulfilled all the necessary conditions as mentioned.
c. This agreement is signed by a person duly authorized by [Insurance
Company] , and all the terms and conditions contained in this agreement are
binding on [Insurance Company]
d. Provider and [Insurance Company] unequivocally warrant that in the process of
rendering services or documentation or billing, no illegal/unethical act/s will be
committed.
2. By the Provider
The Provider warrants and represents that:
a. It is and shall always be in compliance with all laws relating to providing Services to
the Beneficiary and keeping at all times in effect all licenses, registrations, permits
and other governmental approvals which may from time to time be necessary for
that purpose.
b. It has and shall continue to have the doctors, staff and employees with requisite
skills, knowledge and experience to provide Services as required in this Agreement.
c. It has never committed a criminal offence which prevents it from practicing
medicines and no criminal charge has been established or are pending against it by
a court of competent jurisdiction.
d. It has procured and shall always maintain adequate insurances including but not
limited to employers' liability insurance, public liability insurance, professional
indemnity policy and such other insurances as required by law or as specified by
the [Insurance Company].
e. It has full power, capacity and authority to execute, deliver and perform this
Agreement and has taken all necessary actions (corporate, statutory, contractual
or otherwise) to authorize the execution, delivery and performance of this
Agreement.
Article 3:
Scope of Services
1. The Provider shall provide packages for specified interventions/ treatment to the
policyholder/insured as per the rates agreed in schedule-III. It is agreed between the
parties that the package will include:

a. The charges for medical/ surgical procedures/ interventions under the Benefit
package will be no more than the package charge agreed by the Parties, for that
particular year.

b. These package rates (in case of surgical) or flat per day rate (in case of medical) will
include:
i. Registration Charges
ii. Bed charges (General Ward in case of surgical),
iii. Nursing and Boarding charges,
iv. Surgeons, Anesthetists, Medical Practitioner, Consultants fees etc.
v. Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances etc,
vi. Medicines and Drugs,
vii. Cost of Prosthetic Devices, implants,
viii. X-Ray and other Diagnostic Tests etc,
ix. Any other expenses related to the treatment of the patient in the Provider.

2. The Provider shall allow Insurance Company official or its representative TPA to visit the
beneficiary. Insurer shall not interfere with the medical team of the Provider,
however Insurer reserves the right to discuss the treatment plan with treating doctor.
Further access to medical treatment records and bills prepared in the Provider will be
allowed to Insurer or its representative TPA on a case to case basis with prior appointment
from the Provider.

3. The Provider will convey to its medical personnel that they shall keep the beneficiary only
for the required number of days of treatment and carry out only the required investigation
for the particular ailment and treatment for the ailment, which he is admitted. Any other
incidental investigation and consultations required by the patient during hospitalization on
his request needs to be approved separately by Insurer and if it is not covered under
Insurer’s policy will not be paid by Insurer and the Provider needs to recover it from the
patient. In all such cases, Provider will have to inform the patient that he will have to
bear the cost of the same.

4. The Provider provides following services as its main operations (inclusion / exclusion may
vary for each Provider
a. Inpatient / Outpatient treatment to general public
b. Day care procedures
c. Preventive health check-ups
d. Other curative treatments
e. Pharmacy
 f. Other medical or paramedical services.
g. Ambulance Service

5. The Provider hereby agrees to provide medically necessary healthcare services as may be
required by the beneficiary admitted as the patient on Cashless basis in pursuance of
terms and conditions of this MOU and shall follow its standard procedures for
admission of patients and their standard protocols for providing necessary care to the
patients.

6. General Obligations
a. The Provider undertakes to provide the service in a precise, reliable and
professional manner to the satisfaction of [Insurance Company], in
accordance with the applicable legal, regulatory and ethical
obligations and in accordance with additional instructions issued by
[Insurance Company] in writing from time to time.
b. The Provider shall treat the beneficiaries of [Insurance Company] according to good
business practice. It shall equip itself with qualified and experienced doctors,
medical and para - medical staff, nurses, etc., and also all other infrastructure
essential to maintain the desired quality and standard of medication at all times.
c. Provider shall not discriminate any beneficiary of [Insurance Company] in rendering
or providing agreed healthcare services and offers to extend the kind or type of
services, which a beneficiary is entitled as per his / her policy terms and conditions
which will be specified in his letter of authorization.
d. Provider shall not under any circumstances suggest or recommend or inform the
beneficiary approaching the Provider for cashless service, that he/she may opt for
Medical Reimbursement either in lieu of or in addition to cashless facility extended
by the Insurance Company.
e. Provider shall maintain factual medical record documentation as per Indian law and
medical ethics.
f. The Provider shall not inflate rates or indulge in excess billing or unnecessary
Providerisation.
g. The Provider shall inform personnel concerned of the [Insurance Company] of all
the relevant details as and when the patient or any relative requests or asks the
Provider to furnish any information which is false or untrue or fraudulent
for the purpose of procuring pre-authorization or claim reimbursement, or any
other related purpose.
h. The Provider will extend priority admission facilities to the beneficiaries
of the [Insurance Company] ,whenever possible.
i. The Provider shall ensure that medical treatment/facility with all due
care and accepted standards is extended to the beneficiary
j. The Provide shall allow [Insurance Company] officials to visit the beneficiary during
the hospitalization and check the indoor papers/treatment papers. The [Insurance
Company] shall not interfere with the medical treatment of the Provider, however
the [Insurance Company] reserves the right to discuss the treatment plan with
 treating doctor. Access to medical treatment records and bills prepared in the
Provider will be allowed to [Insurance Company] based on a specific request to the
Provider.
Article 4
Tariff

1. The agreement is subject to the detailed schedule of fees submitted by the Provider,
which has to be accepted by [Insurance Company] – included in Schedule III. Tariffs may be
modified only by an amendment to the relevant Schedule executed by both the Parties in
writing.
2. The Provider has to submit the fee schedule in the requisite format (specified in Schedule
III). Provider should also separately list package charges. Such package charges must be
inclusive of stay, medicines, consumables, surgical fees operation theatre etc. No
additional payment would be entertained unless the medical team of [Insurance Company]
agrees with treating consultant for any deviation.
3. Any revision in the fee schedule will be submitted to [Insurance Company] at least 15 days
prior to the effective date. The [Insurance Company] reserves the right to accept or
discontinue the contract after assessing the revised fee schedule.
4. In case the [Insurance Company] is not intimated regarding the revision, [Insurance
Company] will pay for the services only as per the then existing agreed schedule of fees.
5. Provider agrees that the schedule of fee submitted is the lowest and if any other schedule
of fees during the tenure is found lower, provider will refund such additional charges
levied.
6. The Provider agrees to submit clear and unambiguous tariff and related information as well
as details/change in Provider infrastructure, staffing and management changes to the
[Insurance Company].

Package rates
7. Rates are as per attached Schedule III
8. Unless otherwise stated, the above package prices are fully inclusive of all costs, including
(without limitation): accommodation charges, critical care (including ICU, ITU, HDU, CCU,
NICU, PICU etc), laboratory, blood handling and phlebotomy, imaging, theatre fees,
surgeon's fees, anaesthetist's fees, surgeon's follow-up visits in Provider, equipment usage,
recovery, nursing, theatre consumables, prosthesis/implants, theatre drugs (including
anaesthesia), physiotherapy, occupational therapy, hydrotherapy and dietician's fees.
9. The above package prices are valid regardless of the length of the stay in the Provider,
except in exceptional circumstances (where an unexpected medical complication arises
during Treatment which is not due to the mistake or negligence of the Provider and/or
treating doctor). In such circumstances, Pre-Authorisation must be obtained from the
[Insurance Company] for any additional costs above the package price.
 Article 5:
Display of Information
1. For the ease of beneficiary, the Provider shall display the recognition and promotional
material, network status and procedures for admission supplied by the [Insurance
Company] at prominent location, preferably at the reception and admission counter and
Casualty/Emergency departments.
2. A provider also needs to inform their reception and admissions facilities regarding the
procedures of admission and obtaining Pre-authorization and discharge as per the
procedures laid down in Schedule I
3. Provider agrees to the [Insurance Company] displaying the fee schedule on their website
and at the Provider’s reception and admission counter and Casualty/Emergency
departments .
Article 6:
Provider Services- Admission Procedure

1. Identification of Beneficiaries
a. The beneficiaries will be identified by the Provider on the basis of an Smart card/ ID
card issued by the [Insurance Company] – which would bear the logo and wordings
of the [Insurance Company]. The Smart card/ ID card may have the photograph or
signature or thumb impression of the beneficiary.
b. The Provider shall also ask for additional identity proof such as a voter's identity
card, PAN Card, passport or driving license to verify the beneficiary’s identity (in the
event that the beneficiary is a minor, the principal policy holder's proof of identity
will be required).
c. In certain cases where Smart card/ ID cards are not yet issued by [Insurance
Company or its representative TPA], Beneficiary may have only the policy
document issued by [Insurance Company]. In such cases, the Provider would be
required to extend services to the beneficiary.
d. The Provider is required to take a photocopy of the Smart card/ ID card, to be
submitted later with the bill or to keep as proof of the beneficiary being treated.

2. Planned Admission
It is agreed between the parties that on receipt of request for hospitalization on behalf of the
beneficiary the process to be followed by the Provider is prescribed in Schedule I.

3. Emergency admission
a. The Parties agree that the Provider shall admit the Beneficiary in the case of
emergency but pre-authorization request will need to made within 24 hours of the
admission.
b. Provider upon deciding to admit the Beneficiary should inform/ intimate over phone
immediately to the 24 hours Insurer’s helpdesk or the local/ nearest Insurer office or
its representative TPA.
 c. The data regarding admission shall be sent electronically to the server of the insurance
company.
d. On receipt of the preauthorization form for the Provider giving the details of the
ailments for admission and the estimated treatment cost, which is to be forwarded
within 12 hours of admission, Insurer directly or through its representative TPA
undertakes to issue the confirmation letter for the admissible amount within 4 hours
of the receipt of the preauthorization form subject to policy terms & conditions.
e. In case the ailment is not covered or given medical data is not sufficient for the medical
team to confirm the eligibility, Insurer can deny the guarantee of payment, which shall
be addressed, to the Insured under intimation to the Provider. The Provider will have
to follow their normal practice in such cases.
f. Denial of Authorization/ guarantee of payment in no way mean denial of treatment.
The Provider shall deal with each case as per their normal rules and regulations.
g. Pre-Authorization certificate will mention the amount guaranteed class of admission,
eligibility of beneficiaryor various sub limits for rooms and board, surgical fees etc.
wherever applicable. Provider must take care to ensure compliance.
h. The guarantee of payment is given only for the necessary treatment cost of the ailment
covered and mentioned in the request for Providerization. Any investigation carried
out at the request of the patient but not forming the necessary part of the treatment
also must be collected from the patient.
i. In case the sum available is considerably less than the estimated treatment cost,
Provider should follow their normal norms of deposit/ running bills etc., to ensure that
they realize any excess sum payable by the policyholders/insured under the health
insurance policy, not provided for by indemnity.

Article 7:
Checklist for the Provider at the time of Patient Discharge

1. Original discharge summary and billing format as stipulated in Schedule-IV and Schedule-V
respectively, counterfoil generated at the time of discharge, original investigation reports, all
original prescription & pharmacy receipt etc. must not be given to the patient. These are to be
shared on a real time basis to billing department of the insurer or its representative TPA who
will compile and preserve with the insurer.

2. The Discharge card/Summary must mention the duration of ailment and duration of other
disorders like hypertension or diabetes and operative notes in case of surgeries etc as per the
format.

3. Signature or thumb impression of the patient policyholders/insured on final Provider bill must
be obtained.
 Article 8:
Billing & Payment terms

1. The Provider will submit all the original medical bills, discharge summary, investigation reports
along with all the documents of hospitalization and the treatment carried on in the Provider
along with the final preauthorization request.

2. The Provider will submit the final docket to the corporate office or designated local office of
the [Insurance Company].

3. The final docket must contain the following:

a. Preauthorization letter, beneficiary acceptance letter and duly signed claim form,
b. Original final bill with detailed break up of miscellaneous, consumables and other
charges.
c. Original and complete discharge card/ summary mentioning the duration of ailment
and duration of other disorders Like hypertension or diabetes if any.
d. Original investigation reports with corresponding prescription/ request.
e. Pharmacy bill if supplied by Provider with corresponding request.
f. Any other statutory documentary evidence required under law or policy terms and
conditions
g. Status of deposit paid if any by policyholder.

2. All the payments shall be made by direct electronic fund transfer to the extent possible
within 24 hours of submission of completd electronic claim documents in the prescribed
format. However if required, the [Insurance Company or its representative TPA] can:
a. call for further document related to treatment to process the case, in which case the
Provider acknowledges that payment may be delayed.
b. visit Provider to gather further documents related to treatment to process the case.

3. If payments are not made within 24 hours of such submission, the insurer shall make
payment of all eligible bills within the twenty one days from the date of receipt of such
submission.

4. All payments made by the [Insurance Company] shall be subject to deduction of tax at source
as applicable under the relevant laws.

5. Provided that the [Insurance Company] shall have a right to reject the payment of the claims
that are not in accordance with the terms and conditions of the insurance policy . The
[Insurance Company] shall also not be liable to pay the due bills to the Provider within 24
hours if the sufficient documents and the further information as may be required is not
provided. However, the Provider shall furnish all the required information within 2 working
days of discharge of the patient.
 6. Provider shall approach to the Insurance Company for the recovery of any such denied
payment.

7. The [Insurance Company] shall have a right to deduct such items from the final bills as are not
correlated with corresponding report. However, the Provider may send these reports within
30 days of receiving the payment to get the amount so deducted. Due reason for deductions if
any will be given at the time of settlement of the bills by the insurer

8. The Provider shall be liable to refund any such amounts which has been paid to them due to
concealment of material facts or misleading information, or difference in the information in
the discharge summary/ documents from the Pre authorization.
9. If the Provider submits an invoice for Charges that are not in accordance with Schedule III (on
tariffis) or as set out in this Agreement, such invoices may be rejected or shortfalled by
[Insurance Company].

10. The [Insurance Company] shall not be obliged to pay any invoice issued by the Provider for a
claim for Treatment that was provided more than 6 months prior to the date of issue
of the invoice.

Payment Reconciliation process

11. On a regular basis – but at least quarterly, the [Insurance Company] would provide a list of all
outstanding payments to the Provider.

12. This report would be provided in a standard format as agreed between the parties

13. The parties shall meet regularly, but at least once in two months – to review all such pending
claims to discuss a suitable solution

14. Provider will submit online claim report alongwith the discharge summary in accordance with
the rates as prescribed in the Schedule-III on a daily basis.

Network Rejections
15. A “Network Rejection” is defined as a situation where part or whole of an Authorization Letter
(AL) is revoked by the [Insurance Company] on account of further information which comes to
light when the Provider submits the claims to the [Insurance Company] for payment.

16. Reauthorizations are an essential control to ensure that network rejections – and the
consequent disputes between [Insurance Company] and Providers are minimized.

17. Where the preauthorization / reauthorization was wrongly given by the [Insurance Company]
to the Provider, the Provider would have full recourse upto the amount of the
preauthorization to the [Insurance Company].
18. Where there was a change in the clinical line of treatment after admission, and a
reauthorization was obtained, the reauthorization limits and decision would apply.

19. Where there was a change in the clinical line of treatment after admission, and no
reauthorization was obtained, the Provider would have recourse to the patient only, for the
entire amount of the preauthorization.

20. Where the case papers provided at claims stage show the existence of pre-existing diseases
which are not disclosed under the policy, the [Insurance Company] would not be liable to pay
the claim – and the preauthorization or reauthorization would stand void.
21. Where the case has been investigated by the clinical team of the [Insurance Company] and
found to be fraudulent – the preauthorization / reauthorization would stand void and the
Provider would not have recourse to the [Insurance Company] for the amounts.

22. Where the claim amount includes a secondary or subsequent ailment for which no AL has
been obtained the [Insurance Company] would not be liable to pay for costs linked to the
secondary ailment.

Article 9:
Declarations and Undertakings of a Provider

1. The Provider undertakes that they have obtained all the registrations/ licenses/ approvals
required by law in order to provide the services pursuant to this agreement and that they have
the skills, knowledge and experience required to provide the services as required in this
agreement.

2. The Provider undertakes to uphold all requirement of law in so far as these apply to him and in
accordance to the provisions of the law and the regulations enacted from time to time, by the
local bodies or by the central or the state govt. The Provider declares that it has never
committed a criminal offence which prevents it from practicing medicines and no criminal
charge has been established against it by a court of competent jurisdiction.

Article 10:
General responsibilities & obligations of the Provider

1. Ensure that no confidential information is shared or made available by the Provider or any
person associated with it to any person or entity not related to the Provider without prior
written consent of Insurer.

2. The Provider shall provide cashless facility to the beneficiary in strict adherence to the
provisions of the agreement.
3. The Provider will have this facility covered by proper indemnity policy including errors,
omission and professional indemnity insurance and agrees to keep such policies in force
during entire tenure of the MoU. The cost/ premium of such policy shall be borne solely by the
Provider.

4. The Provider shall provide the best of the available medical facilities to the
policyholders/insured under the health insurance policy.

5. The Provider shall endeavor to have an officer in the administration department assigned for
insurance patient and the officers will eventually learn the various types of medical benefits
offered under the different insurance plans.

6. The Provider shall display their status of preferred service provider at their reception/
admission desks along with the display and other materials supplied by Insurer whenever
possible for the ease of the policyholders/insured.

7. The Provider shall at all times during the course of this agreement maintain a helpdesk to
manage all insurance patients. This helpdesk would contain the following:
a. Facility of telephone
b. Facility of fax machine
c. PC Computer
d. Internet/ Any other connectivity to the Insurance Company Server
e. A person to man the helpdesk at all times.
f. Get Two persons in the Provider trained

8. The above should be installed within 15 days of signing of this agreement. The Provider also
needs to inform and train personnel on the process of obtaining Authorization for conditions
not covered under the list of packages, and have a manned helpdesk at their reception and
admission facilities for aiding in the admission procedures for policyholders/insured under the
health insurance policy.

9. The Provider shall admit, on priority and expeditiously, a beneficiary to the Provider for the
purpose of Treatment without seeking any deposit or advance payment from the Beneficiary
or the [Insurance Company].

10. For Planned and Emergency Admissions, the Provider shall, without any delay, arrange to
secure Pre-Authorization in respect of Services and Treatment to be provided to a beneficiary
and shall comply with the Pre-Authorization Procedure as detailed in Schedule I.

11. The Provider shall ensure that all relevant information in relation to the condition of, and the
Treatment to be received by, the Beneficiary is fully detailed to enable [Insurance Company]
to determine whether the Treatment is covered within the terms of the Beneficiary's Plan and
whether any amounts would be payable by the Beneficiary towards the cost of Treatment.
12. The Provider shall ensure that the proposed cost of treatment in the submitted Pre-
Authorization form against each case is reasonable, appropriate and within the defined
code of conduct under medical terminology.

13. If the [Insurance Company] at any time discovers that the Provider, advertently fraudulently or
negligently provided untrue, incorrect or insufficient information the [Insurance Company]
reserves the right to withdraw the Pre-authorization and refuse payment of the resulting
claim.

14. The Provider shall take Pre-authorization from [Insurance Company] each time the period
covered by the Pre-authorization has expired, or if any aspect of the Treatment has changed.
15. Whenever request is made for additional Authorization (called Re-authorization), the Provider
shall request the [Insurance Company] for such additional preauthorization not less than 8
hours before discharge

16. The [Insurance Company] shall not be responsible for costs or claims in respect of Treatment
not covered by Pre-Authorisation or for which there is no Pre-Authorisation. These costs are to
be recovered by the Provider from the Beneficiary. Typically these include the following:
a. Cost of services not covered by Pre-authorization, including the list of non-medical
items specified in Schedule VI
b. Services which are excluded under the Beneficiary’s Plan
c. Level of service or entitlement higher than the Beneficiarys Plan entitlement (E.g.
Room category)
d. Costs in relation to excess / deductible / copays.

17. The Provider will comply with the Case Management Procedure – where this has been agreed
with the [Insurance Company] in advance.

18. Provider warrants that at no point of time will the cashless facility be revoked without
tendering a minimum XX day prior notice in writing, signed and sealed and providing adequate
reasons to the Chief Operating Officer of the [Insurance Company]. Further the [Insurance
Company] shall be given a minimum of 15 days time to response to the notice/ resolve the
problem or accept the decision of provider. During this period, beneficiarys would continue to
be provided cashless facility for treatment.

19. The Provider shall also Endeavour to comply with future requirement of the [Insurance
Company] to provide for standardized billing, /ICD coding etc and if mandated by industry
standards or by by statutory requirement both parties agree to review the same.

Article 11:
General responsibilities of Insurer

1. Insurer has a right to avail similar services as contemplated herein from other institution
for the Health services covered under this agreement.
 2. Turn around times
Preauthorization / Reauthorizations

Preauthorizations
Planned Admissions
Emergency Admissions
Road Traffic Accidents / Medico Legal Cases
Outpatient services
Reauthorization

3. Any cost with respect to the non-medical items listed in Schedule VI shall not be payable to
the Provider by the [Insurance Company] , and Payment for Medical Benefits shall only be
as per the Schedule III and the terms of this Agreement.

Product coverage and Tariffs

4. The [Insurance Company] shall intimate the Provider regarding modification
of the terms of Policies and also regarding new packages made available by
the [Insurance Company] for its policyholders/insured and provides sufficient
notice to the Provider to adopt the same.

Article 12:
Relationship of the Parties

Nothing contained herein shall be deemed to create between the Parties any partnership, joint
venture or relationship of principal and agent or master and servant or employer and employee or
any affiliate or subsidiaries thereof. Each of the Parties hereto agree not to hold itself or allow its
directors employees/agents/representatives to hold out to be a principal or an agent, employee
or any subsidiary or affiliate of the other.

Article 13:
Reporting

In the first week of each month, beginning from the first month of the commencement of this
Agreement, the Provider and Insurer shall exchange information on their experiences during the
month and review the functioning of the process and make suitable changes whenever required.
However, all such changes have to be in writing and by way of suitable supplementary
agreements or by way of exchange of letters.

All official correspondence, reporting, etc pertaining to this Agreement shall be conducted with
Insurer at its corporate office/regional office at the address _______________________________.
 Article 14:
Termination

1. Insurer reserves the right to terminate this agreement as per the guidelines as given in
Scheduel-II

2. This Agreement may be terminated by either party by giving three month’s prior written
notice by means of registered letter or a letter delivered at the office and duly acknowledged
by the other, provided that this Agreement shall remain effective thereafter with respect to all
rights and obligations incurred or committed by the parties hereto prior to such termination.

3. Either party reserves the right to inform public at large along with the reasons of termination
of the agreement by the method which they deem fit.

4. The [Insurance Company] shall have a right to terminate this Agreement, with a
prior notice of three months; the [Insurance Company] shall however ensure
that the payments due in respect of medical treatment already provided or
being provided shall be made as per Schedule-III.

5. The [Insurance Company] reserves the right not to pay any such bill which as
per the understanding of [Insurance Company] is fraudulent and on the basis of
which the termination notice is being served.

6. The Provider shall have the right to terminate the Agreement with the
[Insurance Company] with prior notice of three months. However in such
instances the Provider shall ensure, that all admitted patients under going
treatment at the time of termination are treated completely and discharged.

7. The provider shall be obliged to provide cashless authorization to the

beneficiaries during the period of notice.

Article 15:
Confidentiality

1. This clause shall survive the termination/expiry of this Agreement.

2. Each party shall maintain confidentiality relating to all matters and issues dealt with by the
parties in the course of the business contemplated by and relating to this agreement. The
Provider shall not disclose to any third party, and shall use its best efforts to ensure that its,
officers, employees, keep secret all information disclosed, including without limitation,
document marked confidential, medical reports, personal information relating to insured, and
other unpublished information except as maybe authorized in writing by Insurer. Insurer shall
not disclose to any third party and shall use its best efforts to ensure that its directors,
 officers, employees, sub-contractors and affiliates keep secret all information relating to the
Provider including without limitation to the Provider’s proprietary information, process flows,
and other required details.

3. In Particular the Provider agrees to:

a. Maintain confidentiality and endeavour to maintain confidentiality of any persons
directly employed or associated with health services under this agreement of all
information received by the Provider or such other medical practitioner or such other
person by virtue of this agreement or otherwise, including Insurer’s proprietary
information, confidential information relating to insured, medicals test reports
whether created/ handled/ delivered by the Provider. Any personal information
relating to a Insured received by the Provider shall be used only for the purpose of
inclusion/preparation/finalization of medical reports/ test reports for transmission to
Insurer only and shall not give or make available such information/ any documents to
any third party whatsoever.
b. Keep confidential and endeavour to maintain confidentiality by its medical officer,
employees, medical staff, or such other persons, of medical reports relating to Insured,
and that the information contained in these reports remains confidential and the
reports or any part of report is not disclosed/ informed to the Insurance Agent /
Advisor under any circumstances.
c. Keep confidential and endeavour to maintain confidentiality of any information
relating to Insured, and shall not use the said confidential information for research,
creating comparative database, statistical analysis, or any other studies without
appropriate previous authorization from Insurer and through Insurer from the Insured.

Article 16:
Indemnities and other Provisions

INSPECTION, AUDIT AND ACCESS RIGHTS

1. Upon reasonable notice to the Provider and subject to appropriate supervision by the
Provider's staff, [Insurance Company] or its representative TPA shall have the right to
reasonable access during working hours to conduct an inspection of the Provider from
time to time in connection with:
a. quality assuring specific Services;
b. reasonable concerns about the Provider expressed by anyone; and/or
c. audit of the Provider's compliance with the management of care and quality
standards as agreed.
d. Any other matter as required under this agreement

2. If any material issue of quality and/or any issue of safety is identified as a result of any
inspection carried out under Clause 1 , [Insurance Company] shall immediately notify the
Provider of the issue and the remedial action required. The Provider undertakes to take
such remedial action forthwith as may be advised by [Insurance Company].
3. [Insurance Company] may, on reasonable notice to the Provider, conduct an audit of the
Provider's underlying billing or clinical data in order to satisfy itself of the
appropriateness of decisions made or charges billed and/or paid.

4. To the extent permitted by applicable laws, the Provider will allow [Insurance Company]'s
staff to inspect and if requested will provide a copy of medical records of any Beneficiary,
relevant to the respective claims or preauthorization.

5. The Provider shall allow [Insurance Company]'s staff or appointed representatives

access to the Provider to visit any Beneficiary, to facilitate PreAuthorisation,
case management, discuss aspects of the Treatment, discharge management,
disease management, post-operative care and/or post-discharge care, utilisation
management, quality assurance reviews, utilisation reviews, and grievance procedures
with the Beneficiary and treating consultant where appropriate.

6. In the event that any non-compliance with any term of this Agreement (including, without
limitation, any overcharges) is discovered as a result of any such audit, [Insurance Company]
shall have the right to (at its own discretion):
a. recover from the Provider the amount of any monies overcharged;
b. widen the scope of audit and/or size of the audit sample;
c. caution the Provider against carrying on or indulging in such practices and seek
undertaking from the Provider;
d. cause the Provider take corrective action in order to rectify non-compliances within a
reasonable time-frame; and/or
e. terminate the Agreement in accordance with Schedule-II

Adequate communication facilities:

7. The Provider shall ensure that it has adequate facsimile and communication facilities. It shall
also nominate one person on its staff to serve as a central point of contact for all insured
Beneficiarys.

Display and Advertisement

8. The Provider shall have no objection to [Insurance Company] using the Providers name, as a
preferred Provider to [Insurance Company] and also list the Provider in the communication
with Beneficiarys, etc. The provider may display a signboard stating "[Insurance Company]
Approved Network Provider". But no other signage indicating any association with group
companies' entities of the [Insurance Company] shall be displayed. Excepting the preceding,
the Provider has not been granted any other rights or license to use the trademark, trade
name, service mark, service names, copyrights, etc., belonging to the group companies of the
[Insurance Company]
Others:
9. Insurer will not interfere in the treatment and medical care provided to its beneficiaries.
Insurer will not be in any way held responsible for the outcome of treatment or quality of
care provided by the provider.

10. Insurer shall not be liable or responsible for any acts, omission or commission of the Doctors
and other medical staff of the Provider and the Provider shall obtain professional indemnity
policy on its own cost for this purpose. The Provider agrees that it shall be responsible in any
manner whatsoever for the claims, arising from any deficiency in the services or any failure
to provide identified service

11. Notwithstanding anything to the contrary in this agreement neither Party shall be liable by
reason of failure or delay in the performance of its duties and obligations under this
agreement if such failure or delay is caused by acts of God, Strikes, lock-outs, embargoes,
war, riots civil commotion, any orders of governmental, quasi-governmental or local
authorities, or any other similar cause beyond its control and without its fault or negligence.

12. The Provider will indemnify, defend and hold harmless the Insurer against any claims,
demands, proceedings, actions, damages, costs, and expenses which the company may incur
as a consequence of the negligence of the former in fulfilling obligations under this
Agreement or as a result of the breach of the terms of this Agreement by the Provider or any
of its employees or doctors or medical staff.

Article 17:
Notices

1. All notices, demands or other communications to be given or delivered under or by reason of

the provisions of this Agreement will be in writing and delivered to the other Party:
a. By registered mail;
b. By courier;
c. By facsimile;

2. In the absence of evidence of earlier receipt, a demand or other communication to the other
Party is deemed given

a. If sent by registered mail, seven working days after posting it; and
b. If sent by courier, seven working days after posting it; and
c. If sent by facsimile, two working days after transmission. In this case, further confirmation
has to be done via telephone and e-mail.

3. The notices shall be sent to the other Party to the above addresses (or to the addresses which
may be provided by way of notices made in the above said manner):
 a. -if to the Provider:
Attn: …………………
Tel : …………….
Fax: ……………

b. -if to ______________________
______________________ insurance Company Limited
______________________
______________________
______________________

Supersession
4. It is agreed between the parties that by execution of this agreement all the prior
correspondence, negotiations, minutes, MOU, Agreement and other documents shall be
superseded. The terms of this agreement shall supersede all the terms and conditions of the
earlier agreement executed between the parties.

Severability
5. If any provision of this MOU is held by any court or other competent authority to be invalid
or unenforceable in whole or in pan. this MOU shall continue to be valid as to its other
provisions and the remainder of the affected provision.

6. The invalidity or unenforceability of any provisions of this Agreement in any jurisdiction shall
not effect the validity, legality or enforceability of the remainder of this Agreement in such
jurisdiction or the validity, legality or enforceability of this Agreement, including any such
provision, in any other jurisdiction, it being intended that all rights and obligations of the
Parties hereunder shall be enforceable to the fullest extent permitted by law.

Waiver
7. No waiver by any Party of any default with respect to any provision, condition or
requirement hereof shall be deemed to be waiver of any other provision, condition or
requirement hereof nor act as waiver of any remedy available for breach of that very
provision, condition or requirement in the future.

8. No delay or omission of any Party to exercise any right hereunder on one occasion in any
manner shall impair the exercise of any such right or any other occasion

Non-solicitation
9. The [Insurance Company] and Provider , both Parties hereby agrees that they shall not
solicit each other's clients, business partners, business prospects duing the validity
peiod of this MOU and for a period of ive (2) years ater the expiry/termination
(howsoever caused) of this MOU.
 Article 18
Miscellaneous

1. This Agreement together with any Annexure attached hereto constitutes the entire
Agreement between the parties and supersedes, with respect to the matters regulated
herein, and all other mutual understandings, accord and agreements, irrespective of their
form between the parties. Any annexure shall constitute an integral part of the Agreement.

a. Except as otherwise provided herein, no modification, amendment or waiver of any

provision of this Agreement will be effective unless such modification, amendment or
waiver is approved in writing by the parties hereto.

b. Should specific provision of this Agreement be wholly or partially not legally effective
or unenforceable or later lose their legal effectiveness or enforceability, the validity of
the remaining provisions of this Agreement shall not be affected thereby.

c. The Provider may not assign, transfer, encumber or otherwise dispose of this
Agreement or any interest herein without the prior written consent of Insurer,
provided whereas that the Insurer may assign this Agreement or any rights, title or
interest herein to an Affiliate without requiring the consent of the Provider.

d. The failure of any of the parties to insist, in any one or more instances, upon a strict
performance of any of the provisions of this Agreement or to exercise any option
herein contained, shall not be construed as a waiver or relinquishment of such
provision, but the same shall continue and remain in full force and effect.

e. The Provider will indemnify, defend and hold harmless the Insurer against any claims,
demands, proceedings, actions, damages, costs, and expenses which the latter may
incur as a consequence of the negligence of the former in fulfilling obligations under
this Agreement or as a result of the breach of the terms of this Agreement by the
Provider or any of its employees/doctors/other medical staff.

f. Law and Arbitration

i. The provisions of this Agreement shall be governed by, and construed in

accordance with Indian law.

ii. Any dispute, controversy or claims arising out of or relation to this Agreement or
the breach, termination or invalidity thereof, shall be settled by arbitration in
accordance with the provisions of the (Indian) Arbitration and Conciliation Act,
1996.
 iii. The arbitral tribunal shall be composed of three arbitrators, one arbitrator
appointed by each Party and one another arbitrator appointed by the mutual
consent of the arbitrators so appointed.

iv. The place of arbitration shall be ________ and any award whether interim or final,
shall be made, and shall be deemed for all purposes between the parties to be
made, in _________.

v. The arbitral procedure shall be conducted in the English language and any award
or awards shall be rendered in English. The procedural law of the arbitration shall
be Indian law.

vi. The award of the arbitrator shall be final and conclusive and binding upon the
Parties, and the Parties shall be entitled (but not obliged) to enter judgement
thereon in any one or more of the highest courts having jurisdiction.

vii. The rights and obligations of the Parties under, or pursuant to, this Clause
including the arbitration agreement in this Clause, shall be governed by and
subject to Indian law.

viii. The cost of the arbitration proceeding would be born by the parties on equal
sharing basis.

NON – EXCLUSIVITY
2. Insurer reserves the right to appoint any other provider for implementing the packages
envisaged herein and the provider shall have no objection for the same.

Declaration
3. Provider hereby declares that:
a. Information provided to [Insurance Company] is true and authentic to the best of its
knowledge and belief.
b. In the event that the furnished information is either false or turns out to be false
[Insurance Company] is entitled to dis-empanel this Provider from the list of Network
Providers.
c. [Insurance Company] has a right to comprehend that this ground i.e., act of furnishing
information by Provider which is false or turns out to be false, is in addition to other
grounds envisaged elsewhere in this agreement.

Representative TPA:
4. The insurer may appoint a TPA who may represent the insurer in order to assist the insurer
with respect to claims processing and related matters within the scope of the Health Services
to be renedered by the TPA. The insurer may change the TPA any time without giving notice to
 the Provider and inform the Provider immediately. The Provider shall not get into any
agreement with the TPA on this matter.

SIGNED AND DELIVERED BY the Provider.- the within named_________, by the Hand of
_____________________ its Authorised Signatory

In the presence of:

SIGNED AND DELIVERED BY ______________________ INSURANCE COMPLAY LIMITED, the within

named ______________________, by the hand of ___________ it’s Authorised Signatory

In the presence of:

 Schedule-I
Provider Services- Admission Procedure

The beneficiaries shall be provided treatment free of cost for all such ailments covered under the
policy within the limits / sub-limits and sum insured, i.e., not specifically excluded under the
policy. The Provider shall be reimbursed as per the Schedule-III for different treatments or
procedures.

Preauthorization Procedure – Planned Admissions

1. Request for hospitalization shall be forwarded by the provider immediately after obtaining
due details from the treating doctor in the prescribed format by the Authority i.e. “request
for authorization letter” (RAL). The RAL needs to be sent electronically along with all the
relevant details in the electronic form to the 24-hour authorization /cashless department
of the insurer or its representative TPA along with contact details of treating physician and
the beneficiary. The insurer’s or its representative TPA’s medical team may consult the
treating physician or the beneficiary, if necessary.
2. In the cases where the symptoms are vague / no effective diagnosis is arrived at, the
medical team of [Insurance Company] would get in touch with treating physician
/beneficiary if necessary.
3. The RAL should reach the authorization department of insurer or its representative TPA 7
days prior to the expected date of admission, in case of planned admission.
4. In failure of the above “clause 3”, the clarification for the delay needs to be forwarded
with the request for authorization.
5. The RAL form should be dully filled with clearly mentioning Yes or No and/or the details as
required. There should be no nil, or blanks.
6. The guarantee of payment is given only for the medically necessary treatment cost of
the ailment covered and mentioned in the request for hospitalization. Non covered
items like Telephone usage, food provided to relatives/attendants, Provider
registration fees etc must be collected directly from the insured (These are
specifically and fully listed in Schedule VI). Any Investigation carried out at the
request of the patient but not forming the necessary part of the treatment also must be
collected from the patient.
7. The authorization letter by the insurer or its representative TPA normally
mentions the amount agreed for providing cashless facility for hospitalization.
Therefore in event of the cost of treatment increasing, the the provider may check the
availability of further limit with [Insurance Company] by again following the process of
requesting for pre-authorization for the enhanced amount.
8. In case the Beneficiary has opted for a higher accommodation / facility than the one
under his plan, the Provider shall take a written consent from the beneficiary at the
time of admission as regard to owing the responsibility of such expenses by the
beneficiary including the proportionate expenses which have a direct bearing
due to up gradation of room accommodation/facility. In all such cases the
 [Insurance Company] shall pay for the expenses which are based on the eligibility
limits of the beneficiary. However provider may charge any advance amount/security
deposit from the beneficiary only in such cases where the beneficiary has opted for an
upgraded facility to the extent of the amounts to be collected from the beneficiary.
9. Insurance company guarantees payment only after receipt of RAL and the necessary
medical details. The Authorization Letter (AL) shall be issued within 12 hours of receiving
the RAL
10. In case the ailment is not covered or given medical data is not sufficient for the medical
team of authorization department to confirm the eligibility, insurer shall seek further
clarification/ information immeidately.
11. The cash less facility is given only for the necessary treatment cost of the ailment covered
and mentioned in the request for Authorisation for hospitalization.
12. Authorisation letter [AL] will mention the authorization number and the amount
guaranteed for the procedure. Provider must see that these rules are strictly followed.
13. In case the balance sum available is considerably less than the cost of treatment, provider
should follow their norms of deposit/running bills etc. However provider shall only charge
the balance amount against the package or treatment from the policyholders/insured
under the health insurance policy. Insurer upon receipt of the bills and documents would
release the guaranteed amount.
14. When the cost of treatment exceeds the authorized limit, request for enhancement
of authorization limit shall be made immediately during hospitalization using the same
format as for the initial preauthorization. The request for enhancement would be
evaluated based on the availability of further limits and would need to provide valid
reasons for the same. No enhancement of limit is possible after discharge of beneficiary.
15. Further the [Insurance Company] shall accept or decline such additional expenses within a
maximum of 24 hours of receiving the request for enhancement. Absence of receiving the
reply from the [Insurance Company] within 24 hours shall be construed as denial of the
additional amount.
16. Thereafter, once the beneficiary is to be discharged, the Provider shall make a final
request for the pre-authorization for any residual amount along with the discharge
summary.
17. Due to any reason if the beneficiary does not avail treatment at the Provider after the pre
authorization is released the Provider would need to return the amount to the insurer.
18. All the payments shall be made electronically by the insurer to the provider within the
same day of receipt of all the documents, to the extent possible, provided all the necessary
documents are received by the insurer; however, if not paid on same day, reasons shall be
recorded and the payment shall be paid within two days of the receipt of electronic claim
documents as required.
19. Denial of authorization (DAL) for cashless is by no means denial of treatment by the health
facility. The health care provider shall deal with such case as per their normal rules and
regulations.
20. Insurer will not be liable for payments in case the information provided in the “request for
authorization letter” and subsequent documents during the course of authorization, is
found incorrect or not disclosed.
Preauthorization Procedure – Emergency Admissions
1. In case of emergencies the provider should initiate the procedure for preauthorization
using the format provided in Section XX.
2. The [Insurance Company] may continue to discuss with treating doctor till conclusion of
eligibility of coverage is arrived at. Any life saving, limb saving, sight saving, emergency
medical attention cannot be withheld or delayed for the purpose of waiting for pre-
authorisation. Provider meanwhile may consider treating him by taking a token deposit
or as per their norms.
3. Once a pre-authorisation is issued after ascertaining the coverage, Provider should refund
the deposit amount to the beneficiary if taken barring a token amount to take care of
non covered expenses. Once the patient is medically stable, he must be transferred to
the room which he is eligible for as per his health plan, which would be mentioned in
the pre-authorisation certificate.

Preauthorization Procedure – RTA / MLCs

5. If requesting a pre-authorisation for any potential medico-legal case including Road Traffic
Accidents, the Provider must indicate the same in the relevant section of the standard
format.
6. In case of a road traffic accident and or a medico legal case if the victim was under the
influence of alcohol or inebriating drugs or any other addictive substance or does
intentional self injury, it is mandatory for the Provider to inform this circumstance of
emergency to the [Insurance Company.

Authorization letter (AL)

1. Authorization leter will mention the amount, guaranteed class of admission, eligibility, of
the patient or various sub limits for rooms and board, surgical fees etc. wherever
applicable, as per the benefit plan for the patient.
2. The Authorization letter will also mention Validity of dates for admission and number of
days allowed for hospitalization. The Provider must see that these rules are strictly
followed; else the AL will be considered null and void.
3. In the event the room category is not available the same will be informed to the [Insurance
Company] and the patient. For such cases if the patient is admitted to a class of
accommodation higher than what he is eligible for, the provider shall collect the necessary
difference in charges from the patient himself.
4. The AL has a limited period of validity – which is 15 days from the date of sending the
authorization.
5. AL is not an unconditional guarantee of payment. It is conditional on facts presented –
when the facts change the guarantee changes.

Reauthorization
1. Where there is a change in the line of treatment – a fresh authorization has to be obtained
from the [Insurance Company] – this is called a reauthorization.
 2. The same format is to be used for the reauthorization, and the same TATs as specified in
section XX would apply.
3. In case of any change after the preauthorization – the Provider is required to obtain a
reauthorization 12 hours prior to discharge.

Discharge:
1. The following documents are to be included in the list of documents to be sent along
with the claim form to the [Insurance Company]. These must not be given to the
Beneficiary.
a. Original pre authorization request form,
b. original authorization letter,
c. Original discharge card,
d. original investigation repots,
e. all original prescription & pharmacy receipt etc
2. Where the patient requires the discharge card/repots he or she can be asked to take
photocopies of the same at his or her own expenses and these have to be clearly stamped
as "Duplicate & originals are submitted to [Insurance Company]".
3. The discharge card/Summary must mention the duration of ailment and duration of other
disorders like hypertension or diabetes and operative notes in case of surgeries. The
clinical detail should be sufficiently and justifiably informative. In addition, the Provider
shall provide all the relevant details pertaining to past treatment availed by the Patient in
the Provider.
4. Signature of the patient / beneficiary on final Provider bill must be obtained.
5. In the event of death or incapacitation of the beneficiary, the signature of the nominee or
any of beneficiary’s of the family who represents the beneficiary as such subject to
reasonable satisfaction of Provider shall be sufficient for the [Insurance Company] to
consider the claim.
6. Claim form of the [Insurance Company] must be presented to the beneficiary for signing
and identity of the patient/ beneficiary again confirmed.
Billing
7. The Provider shall submit original invoices directly to [Insurance Company] and such
invoices shall contain the following information:
 a. the patient's full name and date of birth;
b. the patient's [Insurance Company] beneficiary ship number or policy number as
appropriate;
c. the patient's address;
d. the admitting consultant;
e. the date of admission and discharge;
f. the procedure performed and procedure code according to ICD-10 PCS;
g. the diagnosis at the time treatment and diagnosis code according to ICD-10;
h. whether this is an interim or final bill/account;
i. the description of each Service performed, together with associated Charges,
j. the agreed standard billing codes associated with each Service performed and dates
on which items of Service were provide; and.
k. the patient's signature (in original).
8. The Provider shall submit the following documents with the final invoice:
a. copy of Pre-Authorisation letter;
b. fully completed claim form (or the relevant claim section of the Pre-
Authorisation letter), signed by the Beneficiary and the treating consultant for the
Treatment performed;
c. original and complete discharge summary, including the treating Consultant's
operative notes;
d. original investigation reports with corresponding prescription/request;
e. pharmacy bill with corresponding prescription/request:
f. any other statutory documentary evidence required under law or by the Beneficiary's
Plan; and
g. photocopy of the Beneficiary's photo identification (eg voter's Smart card/ ID card,
passport or driving licence etc).
9. The Provider must not give original discharge summaries, investigation repots, or
prescriptions to the Beneficiary.
10. The Provider shall submit the final invoice and all supporting documentation required
within 2 days of the discharge date.

Note: In the cases where the beneficiary is admitted in a Provider during the current policy period
but is discharged after the end of the policy period, the claim has to be paid by the insurance
company under the policy which is operating during the period in which beneficiary was
admitted.
 Schedule-II
PROCESS NOTE FOR DE-EMPANELMENT OF PROVIDERS

Process To Be Followed For De-Empanelment of Providers:

Step 1 – Putting the Provider on “Watch-list”

1. Based on the claims data analysis and/ or the Provider visits, if there is any doubt on the
performance of a Provider, the Insurance Company can put that Provider in the watch list.
2. The data of such Provider shall be analysed very closely on a daily basis by the Insurance
Company for patterns, trends and anomalies.
3. The Insurance Company will immediately inform the Health Insurance Forum about the
Provider which have been put in the watch list within 24 hours of this action.

Step 2 – Suspension of the Provider

4. A Provider can be temporarily suspended in the following cases:
a. For the Providers which are in the “Watch-list” if the Insurance Company observes
continuous patterns or strong evidence of irregularity based on either claims data or
field visit of Providers, the Provider shall be suspended from providing services to
policyholders/insured patients and a formal investigation shall be instituted.
b. If a Provider is not in the “Watch-list”, but the insurance company observes at any stage
that it has data/ evidence that suggests that the Provider is involved in any unethical
practice/ is not adhering to the major clauses of the contract with the Insurance
Company involved in financial fraud related to health insurance patients, it may
immediately suspend the Provider from providing services to policyholders/insured
patients and a formal investigation shall be instituted.
5. The Health Insurance Forum should be informed of the decision of suspension of Provider
within 24 hours of this action.
6. A formal letter shall be send to the Provider regarding its suspension with mentioning the
timeframe within which the formal investigation will be completed.

Step 3 – Detailed Investigation

7. The Insurance Company can launch a detailed investigation into the activities of a Provider in
the following conditions:
a. For the Providers which have been suspended.
b. Receipt of complaint of a serious nature from any of the stakeholders
8. The detailed investigation may include field visits to the Providers, examination of case
papers, talking with the policyholders/insured (if needed), examination of Provider records
etc.
9. If the investigation reveals that the report/ complaint/ allegation against the Provider is not
substantiated, the Insurance Company would immediately revoke the suspension (in case it
is suspended) and inform the same to the Health Insurance Forum.
a. A letter regarding revocation of suspension shall be sent to the Provider within 24 hours
of that decision.
Step 4 – Action by the Insurance Company
10. If the investigation reveals that the complaint/allegation against the Provider is correct then
following procedure shall be followed:
a. The Provider must be issued a “show-cause” notice seeking an explanation for the
aberration and a copy of the show cause notice is sent to the Health Insurance Forum.
b. After receipt of the explanation and its examination, the charges may be dropped or an
action can be taken.
c. The action could entail one of the following based on the seriousness of the issue and
other factors involved:
i. A warning to the concerned Provider,
ii. De-empanelment of the Provider.

11. The entire process should be completed within 30 days from the date of suspension.

Step 5 – Actions to be taken after De-empanelment

12. Once a Provider has been de-empanelled by insurer, following steps shall be taken:
a. A letter shall be sent to the Provider regarding this decision with a copy to the Health
Insurance Forum
b. This information shall be sent to all the other Insurance Companies which are doing
health insurance business.
c. An FIR shall be lodged against the Provider by the insurer at the earliest in case the de-
empanelment is on account of fraud or a fraudulent activity.
d. The Insurance Company which had de-empanelled the Provider, may be advised to
notify the same in the local media, informing all policyholders/insured about the de-
empanelment, so that the beneficiaries do not utilize the services of that particular
Provider.
e. If the Provider appeals against the decision of the Insurance Company, all the
aforementioned actions shall be subject to the decision of the concerned Committee of
the Health Insurance Forum.

Grievance by the Provider

13. The Provider can approach the Grievance Redressaal Committee constituted by the Health
Insurance Forum for the redressal. The Grievance Redressal Committee will take a final view
within 30 days of the receipt of representation. However, the Provider will continue to be
de-empanelled till the time a final view is taken by the Grievance Redressal Committee.

Special Cases for De-empanelment

In the case where at the end of the Insurance Policy if an Insurance Company does not want to
continue with a particular Provider in a district it can de-empanel that particular Provider.
However, it should be ensured that adequate number of Providers are available in that area
for the policyholders/insured.
 Schedule III:
Tariffs and fees
Explanatory notes
1. Tariff rates are attached in the tables below. The following serve to provide explanations
for the same

Accommodation charges The above accommodation charges are inclusive of: room, bed, all
in-room furniture, equipment and facilities, ward equipment
usage, nursing, resident medical oficers, ward
dressings/consumables, ward drugs, patient meals, laundry, linen,
housekeeping, cleaning, and removal of sutures.
Theatre charges, The charges are inclusive of: operating room costs including all
surgeon's and equipment and facilities, nursing and support staf,
anaesthetist fees instrumentation, theatre dressings and consumables
(excluding drugs, prosthesis / implants unless stated).
Where more than one procedure is performed at the same time
the Provider may charge 100% of the charge for the most complex
procedure and 75% of the charge for any other procedure
performed.-the surgeries will be billed as per the tarif approved
separately and not as per the % mentioned above if it is 2 diferent
incisions

2. Accommodation
Beneficiarys are entitled to stay in accommodation up to a cetain standard, depending
on their scale of cover, as notified by [Insurance Company] to the Provider from time-to-
time.

If a Beneficiary is accommodated in a room categorized and charged at a higher rate

than that Beneficiary's entitlement the Provider will only be reimbursed by the [Insurance
Company] for the room for which the Beneficiary is entitled to.
The Provider may only recover any additional Charge for a higher standard room from the
Beneficiary if the Beneficiary's entitled room standard is available but the Beneficiary
chooses to be accommodated in a higher standard room and the Provider has obtained
the prior written consent of the Beneficiary.
In the event that the Beneficiary is accommodated in a higher standard room due to
lack of room availability, then neither the [Insurance Company] nor the Beneficiary shall
be obliged to pay for any additional Charges.

Schedule-IV and Scheduel-V attached separately.

 Schedule VI
List of Non Medical Items
List of non-medical items not covered under [Insurance Company] insurance Policies,as prescribed
by the Authority.
SUGGESTED STANDARD FORMAT FOR PROVIDER BILLS

Contents
1. Objective ......................................................................................................................................... 2
2. Components of standardization ..................................................................................................... 2
3. Background ..................................................................................................................................... 2
5. Format Suggested ........................................................................................................................... 4
6. Standard guidelines ........................................................................................................................ 8
8. Annexures ....................................................................................................................................... 9
1. Objective

• Standardizing billing formats and enabling mapping of hospital information systems to

specific data requirements of the Insurance companies for faster claim processing and
enhanced analysis of data

2. Components of standardization

Standardization involves three components:

• Bill Format
• Codes for billing items and nomenclature
• Standard guidelines for preparing the bills so that the interpretations of the headings in
the bill are uniform.

3. Background

There is a huge variation in the billing formats and understanding of various items in a
provider bill. Each provider provides a format specific to their organization which often has
insufficient or redundant information. In many cases the same information may have been
interpreted differently by the hospital and provider. This creates inefficiencies in the claim
processing resulting in higher costs of healthcare and lower quality for the patients.
Standardisation of Billing Procedures in the hospitals promotes transparency and removes
the friction between the insured, providers and payers.

FICCI constituted a committee with the purpose of looking at “standardizing the billing
procedures in various hospitals to avoid any ambiguity between the health insurance
stakeholders”. The Objective of the working group was to look at how billing items and
formats could be standardized with integration into the standard suggested claim form. The
group would also look at how hospitals can map their existing information system to a
particular requirement of the Insurance companies. This exercise was aimed at
standardization of formats rather than fixing tariffs and rates.

The ultimate objective of this exercise is to facilitate electronic transmission of provider bills
to the payers for processing and payment. The standardized format would be shared with
providers for implementation and could be included as part of the standard contract
between insurers/TPA’s and the providers.

The committee had representatives from all stakeholders including insurers, TPA’s, providers
and consultancy companies and was headed by Shri. S L Mohan, Secretary General, General
Insurance Council.
4. Methodology

1) Collecting various bill formats from multiple hospitals of different sizes and also take into
cognizance the existing bill processing systems of the TPA’s and Insurance companies as also
the HIS of hospitals.
2) Defining and listing the above into main components and various sub-components of the
bill. The first level components were mapped to the Standardized Claims Form which was
developed by IRDA last year.
3) Discussing each component of the bill in detail with the multi-stakeholder group ensuring
that the data in the format is not reported in any other document and is sufficient for claim
processing without being too difficult for the hospital to report.
4) Developing a coding system for each component. The group has evaluated procedure codes
to be used in the bill and have agreed on using ICD-10-PCS level 5 codes in line with
requirement of Tariff Advisory Committee’s Health data requirements. Codifying the billing
components will be useful for enabling faster and accurate processing of the bills TPA’s and
also aid electronic transmission of bills.. The codes were discussed with the representatives
from providers and also IT companies.
5) Testing the evolving the Bill Format from both IT and hospital perspective to check its
adaptability electronically. Any feedback would be incorporated.
6) Providing guidance notes in the format for the reference of Doctor’s and patients detailing
and defining the components.
7) Disseminating this format with the large advisory group for review and feedback. Finalizing
the format based on the feedback from the working group.
 FICCI

5. Format Suggested

The bill is expected to be in two formats.

• The summary bill and

• The detailed breakup of the bills.

Explanation of headings – Summary Bill

The suggested summary format is annexed in the report (Annexure I)

The Bill is expected to be generated on the letter head of the provider and in A4 size to aid
scanning.

Field Name Remarks

Provider Name Legal entity name and not the trade name

Provider Registration Number Registration number of the provider with

local authorities. once the clinical
establishments (registration and regulation)
bill, 2007 is passed, then registration number
under this act

Address Address of the Facility where member is

admitted. A provider can have more than
one facility.

IP No Unique number identifying the particular

hospitalization of the member

Patient Name Full name of the patient

Payer Name Name of the Insurance company with whom

the member is insured. In case of cash
patient then the field is to be left blank. If the
bill is raised to more than one insurer then
the primary insurer who has given cashless is
to be mentioned. The name of insurance
company needs to be mentioned and not the
TPA.

Member address Full address of the member

Bill Number Bill number of the provider

Bill Date Date on which the bill is generated.

 FICCI

PAN Number PAN Number – Mandatory

Service Tax Regn No Registration number from service tax

authorities. Mandatory in case service tax is
charged in the bill

Date of admission Date of admission of the member in case of

IPD cases. In case of Day care procedures,
this is the date of procedure

Date of discharge Date of discharge of the member in case of

IPD cases. In case of Day care procedures,
this is the date of procedure(same as date of
admission)

Bed Number Bed number in which the patient is admitted.

In case the member is admitted under more
than one bed number, all the numbers have
to be mentioned.

SL No 1 of billing Summary All items under the primary head ‘100000’ in

the detailed bill have to be summarized into
this. In case the procedure is packages, then
only bills amount beyond the package needs
to be mentioned here.

SL No 2 of billing Summary All items under the primary head ‘200000’ in

the detailed bill have to be summarized into
this. In case the procedure is packages, then
only bills amount beyond the package needs
to be mentioned here.

SL No 3 of billing Summary All items under the primary head ‘300000’ in

the detailed bill have to be summarized into
this. In case the procedure is packages, then
only bills amount beyond the package needs
to be mentioned here.

SL No 4 of billing Summary All items under the primary head ‘400000’ in

the detailed bill have to be summarized into
this. In case the procedure is packages, then
only bills amount beyond the package needs
to be mentioned here.

SL No 5 of billing Summary All items under the primary head ‘500000’ in

the detailed bill have to be summarized into
this. In case the procedure is packages, then
only bills amount beyond the package needs
 FICCI

to be mentioned here.

SL No 6 of billing Summary All items under the primary head ‘600000’ in

the detailed bill have to be summarized into
this. In case the procedure is packages, then
only bills amount beyond the package needs
to be mentioned here.

SL No 7 of billing Summary All items under the primary head ‘700000’ in

the detailed bill have to be summarized into
this. In case the procedure is packages, then
only bills amount beyond the package needs
to be mentioned here.

SL No 8 of billing Summary All items under the primary head ‘800000’ in

the detailed bill have to be summarized into
this. In case the procedure is packages, then
only bills amount beyond the package needs
to be mentioned here.

SL No 9 of billing Summary All items under the primary head ‘900000’ in

the detailed bill have to be summarized into
this. If more than one procedure is done, the
total amount of the two procedures needs to
be summarized

Total Bill amount Sum total of all items 1 to 9 in the bill

Amount paid by the member Amount of bill paid by the member including
co-pay, deductible, non-medical items etc
incl discount offered to member, if any.

Amount charged to Payer Amount payable by Insurance company

Discount Amount Amount offered as discount to the insurance

company

Service tax Service Tax chargeable to insurance company

Amount Payable Total amount payable by insurance com[any

including service tax

Amount in words Above mount in words for the sake of clarity

Patients signature Signature of the patient or the attendant of

the patient needs to be mandatorily taken

Authorized signatory The signature of the authorized signatory at

 FICCI

the provider

Explanation of headings – Detailed Breakup of the Bill

The suggested summary format is annexed in the report (Annexure II)

The Bill is expected to be generated on the letter head of the provider and in A4 size to aid
scanning.

The first section of the bill is same as the bill summary.

Field Name Remarks

Date Date on which service is rendered. For

example, this is the date of investigation,
date of procedure etc.

Code Level 2 or 3 code of the billing item as per

the codes(annex III)

Particulars Text explanation of the item charged

Rate Per unit price (per day room rent, per

consultation charge)

Unit No of units charged(hours, days, number as

appropriate)

Amount Rate*unit(s)
 6. Standard guidelines

Summary Bill

- The summary bill should not have any additional items (only 9)
- The provide has to mention the service tax number in case they charge service tax to the
insurance company/TPA
- The payer mentioned in the bill has to be necessarily the insurance company and not the
TPA.
- In case of package charged for any procedure/treatment, the provider is expected to
mention the amount in serial no 9. Only items beyond the package are to be mentioned in sl
nos 1 to 8.
- The patient/attendant signature is mandatory on the summary bill

Detailed breakup

- The billing has to be done at level 2 or 3

- In case of medicines/consumables , the relevant level code three has to be mentioned
(40100, 401002) and the text should indicate the actual medicine used
- Some providers have outsourced the pharmacy to external vendors. In such cases the
providers can attach the original bills separately. However, the summary of this has to be
mentioned in the summary bill.
- In case of pharmacy returns the same code originally used is to be used with a negative sign
in the units
- In case of cancellation of any service the same code originally used is to be used with a
negative sign indicating reversal

- The date on which the service is rendered is to be mentioned in the bill. This would be
o the date of requisition in case of investigations
o date of consultation for professional fees
o date of requisition in case of pharmacy/consumables irrespective of when they
were used
o Date of return of pharmacy items for pharmacy returns

Implementation Plan

Post final adoption of this plan by all stakeholders the plan for implementation
would ,inter alia, need to incorporate the following steps:

• Central body for maintenance, dissemination and addition of billing codes

• Integrating it as a standard format with provider HIS and as part of EDI
mechanism for electronic data transfer between insurers and providers
• Publicity plan to create user awareness to promote usage before making it
mandatory as part of provider empanelment norms
 FICCI

8. Annexures
Annexure I

SUMMARY BILL FORMAT

Provider Name …………………….……… Bill Number …….……………..…………

Provider registration
No. Bill Date
Address PAN Number
Service Tax Regn
IP No No
Patient Name Date of admission
XXXX Insurance Company
Payer Name Ltd Date of Discharge
Member Address Bed Number

Billing Summary

Sl No Primary Code Particulars Amount

1 100000 Room & Nursing Charges
2 200000 ICU Charges
3 300000 OT Charges
4 400000 Medicine & Consumables
5 500000 Professional Fees'
6 600000 Investigation Charges
7 700000 Ambulance Charges
8 800000 Miscellaneous Charges
9 900000 Package Charges

Total Bill Amount 0

Amount paid by ………………………………
member 0
Amount charged to
Payer 0
Discount Amount 0
Service Tax 0
Amount Payable 0
Amount in Words Rupees Zero Only

Patients Signature Authorized Signatory

 FICCI

Annexure II

DETAILED BREAKUP FORMAT

Provider Name …………………….……… Bill Number …….……………..…………

Provider registration No. Bill Date
Address PAN Number
IP No Service Tax Regn No
Patient Name Date of admission
Payer Name Date of Discharge
Member Address Bed Number

Billing Details

Sl No Date Code Particulars Rate Nos(Unit) Amount

1 101001 General Ward Charges 500 1 500.00

2 401001 XXX medicine 50 2 100.00

3 401001 XXX Medicine – return 50 -1 -50.00

 Annexure III

Annexed in excel sheet

Level 1 Code Level 1 Level 2 Code Level 2 Level 3 Code Level 3 Remarks
100000 Room & Nursing Charges
100000 Room & Nursing Charges 101000 Room Charges
100000 Room & Nursing Charges 101000 Room Charges 101001 General Ward charges
100000 Room & Nursing Charges 101000 Room Charges 101002 Semi-private room charges
100000 Room & Nursing Charges 101000 Room Charges 101003 Single Room charges
100000 Room & Nursing Charges 101000 Room Charges 101004 Single Deluxe room charges
100000 Room & Nursing Charges 101000 Room Charges 101005 Deluxe room charges
100000 Room & Nursing Charges 101000 Room Charges 101006 Suite charges
100000 Room & Nursing Charges 101000 Room Charges 101007 Electricity charges
100000 Room & Nursing Charges 101000 Room Charges 101008 Bed sheet charges
100000 Room & Nursing Charges 101000 Room Charges 101009 Hot water charges
100000 Room & Nursing Charges 101000 Room Charges 101010 Establishment Charges
100000 Room & Nursing Charges 101000 Room Charges 101011 Alpha/Water Bed Charges
100000 Room & Nursing Charges 101000 Room Charges 101012 Attendant Bed Charges
100000 Room & Nursing Charges 102000 Nursing charges
100000 Room & Nursing Charges 102000 Nursing charges 102001 Nursing fees
100000 Room & Nursing Charges 102000 Nursing charges 102002 Dressing
100000 Room & Nursing Charges 102000 Nursing charges 102003 Nebulization
100000 Room & Nursing Charges 102000 Nursing charges 102004 Injection charges
100000 Room & Nursing Charges 102000 Nursing charges 102005 Infusion pump charges
100000 Room & Nursing Charges 102000 Nursing charges 102006 Aya Charges
100000 Room & Nursing Charges 102000 Nursing charges 102007 Blood Transfusion Charges
100000 Room & Nursing Charges 103000 Duty Doctor fee
100000 Room & Nursing Charges 103000 Duty Doctor fee 103001 Duty Doctor fee
100000 Room & Nursing Charges 103000 Duty Doctor fee 103002 RMO Fees
100000 Room & Nursing Charges 104000 Monitor charges
100000 Room & Nursing Charges 104000 Monitor charges 104001 Pulse Oxymeter charges If used in
normal Room
200000 ICU Charges
200000 ICU Charges 201000 ICU Charges
200000 ICU Charges 201000 ICU Charges 201001 Burns Ward
200000 ICU Charges 201000 ICU Charges 201002 HDU charges
200000 ICU Charges 201000 ICU Charges 201003 ICCU charges
200000 ICU Charges 201000 ICU Charges 201004 Isolation ward charges
200000 ICU Charges 201000 ICU Charges 201005 Neuro ICU charges
200000 ICU Charges 201000 ICU Charges 201006 Pediatric/neonatal ICU charges
200000 ICU Charges 201000 ICU Charges 201007 Post Operative ICU
200000 ICU Charges 201000 ICU Charges 201008 Recovery Room
200000 ICU Charges 201000 ICU Charges 201009 Surgical ICU
200000 ICU Charges 202000 ICU Nursing charges If ICU nursing
charged
seperately

200000 ICU Charges 202000 ICU Nursing charges 202001 Nursing fees If ICU nursing
charged
seperately

200000 ICU Charges 202000 ICU Nursing charges 202002 Dressing If ICU nursing
charged
seperately

200000 ICU Charges 202000 ICU Nursing charges 202003 Nebulization If ICU nursing
charged
seperately

200000 ICU Charges 202000 ICU Nursing charges 202004 Injection charges If ICU nursing
charged
seperately

200000 ICU Charges 202000 ICU Nursing charges 202005 Infusion pump charges
200000 ICU Charges 203000 Monitor charges
200000 ICU Charges 203000 Monitor charges 203001 Monitor charges
200000 ICU Charges 203000 Monitor charges 203002 Pulse Oxymeter charges If used in ICU

200000 ICU Charges 203000 Monitor charges 203003 Cardiac Monitor charges
200000 ICU Charges 204000 Monitor charges 203004 IABP charges
200000 ICU Charges 204000 Monitor charges 203005 Phototherapy Charges
200000 ICU Charges 204000 ICU Supplies & equipment

200000 ICU Charges 204000 ICU Supplies & equipment 204001 Oxygen charges

200000 ICU Charges 204000 ICU Supplies & equipment 204002 Ventilator charges

200000 ICU Charges 204000 ICU Supplies & equipment 204003 Suction pump charges

200000 ICU Charges 204000 ICU Supplies & equipment 204004 Bipap charges

200000 ICU Charges 204000 ICU Supplies & equipment 204005 Pacing Charges Temporary
Pacemaker
200000 ICU Charges 204000 ICU Supplies & equipment 204006 Defibrillator Charges

300000 OT Charges
300000 OT Charges 301000 OT rent
300000 OT Charges 301000 OT rent 301001 Major OT charge
300000 OT Charges 301000 OT rent 301002 Minor OT Charge
300000 OT Charges 301000 OT rent 301003 Cath Lab Charges
300000 OT Charges 301000 OT rent 301004 Theatre charges
300000 OT Charges 301000 OT rent 301005 Labour Room Charges
300000 OT Charges 302000 OT Equipment charges
300000 OT Charges 302000 OT Equipment charges 302001 C-arm charges
300000 OT Charges 302000 OT Equipment charges 302002 Endoscopy charges
300000 OT Charges 302000 OT Equipment charges 302003 Laproscope charges
300000 OT Charges 302000 OT Equipment charges 302004 Equipment charges If not
specified
300000 OT Charges 302000 OT Equipment charges 302005 Monitor charges for OT
monitoring
300000 OT Charges 302000 OT Equipment charges 302006 Instrument charges for OT
instruments
300000 OT Charges 303000 OT Drugs & Consumables

300000 OT Charges 303000 OT Drugs & Consumables 303001 OT Drugs

300000 OT Charges 303000 OT Drugs & Consumables 303002 Implants

300000 OT Charges 303000 OT Drugs & Consumables 303003 OT Consumables includes

guidewires,
catheter etc
300000 OT Charges 303000 OT Drugs & Consumables 303004 OT Materials

300000 OT Charges 303000 OT Drugs & Consumables 303005 OT Gases

300000 OT Charges 303000 OT Drugs & Consumables 303006 Anaesthetic drugs

300000 OT Charges 304000 OT Sterlization

300000 OT Charges 304000 OT Sterlization 304001 CSSD Charges
400000 Medicine & Consumables charges

400000 Medicine & Consumables charges 401000 Medicine & Consumables

charges
400000 Medicine & Consumables charges 401000 Medicine & Consumables 401001 Ward Medicines OT drugs
charges under OT
charges
400000 Medicine & Consumables charges 401000 Medicine & Consumables 401002 Ward Consumables
charges
400000 Medicine & Consumables charges 401000 Medicine & Consumables 401003 Ward disposables
charges
400000 Medicine & Consumables charges 401000 Medicine & Consumables 401004 Ward Materials
charges
400000 Medicine & Consumables charges 401000 Medicine & Consumables 401005 Vaccination drugs
charges
500000 Professional fees charges
500000 Professional fees charges 501000 Visit charges
500000 Professional fees charges 501000 Visit charges 501001 Consultation Charges
500000 Professional fees charges 501000 Visit charges 501002 Medical Supervision Charges
500000 Professional fees charges 501000 Visit charges 501003 Professional fees
500000 Professional fees charges 502000 Surgery Charges
500000 Professional fees charges 502000 Surgery Charges 502001 Surgeons Charges
500000 Professional fees charges 502000 Surgery Charges 502002 Assisstant Surgeons Fee Would also
include
Standby
Surgeon
500000 Professional fees charges 503000 Anaesthetists fee
500000 Professional fees charges 503000 Anaesthetists fee 503001 Anaesthetists fee
500000 Professional fees charges 503000 Anaesthetists fee 503002 OT standby charges Providers
charge for
standby
anaesthetist
500000 Professional fees charges 504000 Intensivist Charges 504000
500000 Professional fees charges 505000 Technician Charges 505000 OT /Cath Lab Technician
500000 Professional fees charges 505000 Physiotherapy
500000 Professional fees charges 504000 Procedure charges
500000 Professional fees charges 504000 Procedure charges 504001 Bedside procedures Catheterizati
on, Central IV
Line,
Tracheostom
y,
Venesection
500000 Professional fees charges 504000 Procedure charges 504002 Suture charges
600000 Investigation Charges
600000 Investigation Charges 601000 Bio Chemistry Serum
Sodium,
Ueres etc
600000 Investigation Charges 602000 Cardiology charges for
procedures
like echo,
ECG etc
600000 Investigation Charges 603000 Haemotology charges cross
matching etc

600000 Investigation Charges 604000 Microbiology charges blood culture,

C&S

600000 Investigation Charges 605000 Neurology for EMG, EEG

etc
600000 Investigation Charges 606000 Nuclear medicine PET CT, Bone
scan etc
600000 Investigation Charges 607000 Pathology charges
600000 Investigation Charges 608000 Radiology services X-ra, CT, MRI
etc
600000 Investigation Charges 609000 Serology charges
600000 Investigation Charges 610000 Medical Genetics Chrosomal
Analysis etc
600000 Investigation Charges 611000 Profiles Profiles
instead of
individual
tests (Lipid
profile, LFT
etc)
700000 Ambulance Charges
700000 Ambulance Charges 701000 Ambulance Charges
800000 Miscellaneous charges
800000 Miscellaneous charges 801000 Admission charges
800000 Miscellaneous charges 802000 Attendant food charges
800000 Miscellaneous charges 803000 Patient food charges
800000 Miscellaneous charges 804000 Registration charges
800000 Miscellaneous charges 805000 MRD Charges
800000 Miscellaneous charges 806000 Documentation charges
800000 Miscellaneous charges 807000 Telephone charges
800000 Miscellaneous charges 808000 Bio Medical Waste
Charges
800000 Miscellaneous charges 809000 Taxes Luxury Tax/Surcharge/Service Charge Excluding
VAT & Service
Tax
900000 Package Charges To be used
only in case
of packages
900000 Package Charges 901000 Cardiac Surgery ICD-10-PCS CABG To be used
only in case
of packages
900000 Package Charges 902000 CardiologyPackages ICD-10-PCS PTCA To be used
only in case
of packages
900000 Package Charges 903000 Cath Lab ICD-10-PCS CAG To be used
only in case
of packages
900000 Package Charges 904000 Dental Procedures ICD-10-PCS Root Canal Treatment To be used
only in case
of packages
900000 Package Charges 905000 ENT ICD-10-PCS FESS To be used
only in case
of packages
900000 Package Charges 906000 Gastroenterology ICD-10-PCS Gastrectomy - Partial To be used
only in case
of packages
900000 Package Charges 907000 General Surgery ICD-10-PCS Inguinal hernia To be used
only in case
of packages
900000 Package Charges 908000 Gynaecology ICD-10-PCS LSCS To be used
only in case
of packages
900000 Package Charges 909000 Nephrology ICD-10-PCS Nephrectomy To be used
only in case
of packages
900000 Package Charges 910000 Neuro Surgery ICD-10-PCS Craniotomy To be used
only in case
of packages
900000 Package Charges 911000 Oncology Procedures ICD-10-PCS IMRT To be used
only in case
of packages
900000 Package Charges 912000 Opthalmology procedures ICD-10-PCS Cataract To be used
only in case
of packages
900000 Package Charges 913000 Orthopaedic Surgery ICD-10-PCS Bilateral TKR To be used
only in case
of packages
900000 Package Charges 914000 Plastic Surgery ICD-10-PCS Skin Grafting To be used
only in case
of packages
900000 Package Charges 915000 Pulmonology Packages ICD-10-PCS Pleural Tapping To be used
only in case
of packages
900000 Package Charges 916000 Urology ICD-10-PCS ERCP To be used
only in case
of packages
900000 Package Charges 917000 Vascular Surgery ICD-10-PCS Embolectomy To be used
only in case
of packages
 Company Logo

Company Name

Company Address

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.

Page 1
 Company Logo

Company Name

Company Address

APPLICATION FORM FOR NETWORK SERVICE PROVIDER

(To be filled in block letters)

HOSPITAL INFORMATION

a) Name of the hospital:

□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ 1
□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□
b) Address:
□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□

SECTION A
□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□
City:
□□□□□□□□□□□□□□□□□ State: □□□□□□□□□□□□□□□□□□□
c) Phone number:
□□□□□□□□□□□ d) Fax no. □□□□□□□□□□□ e) PAN no. □□□□□□□□□□□
f) Registration number:
□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□
g) Email address:

h) Website:

CONTACT DETAILS

a) Chief executive of hospital:

i) Name:
□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□
ii) Phone number:
□□□□□□□□□□□ iii) Email address:
b) Main point of contact for TPA / Insurance company:

□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□

SECTION B
i) Name:

ii) Designation:
□□□□□□□□□□□□□□□□□□□□□□ iii) Phone number:
□□□□□□□□□□□
iv) Email address:

c) Insurance / TPA coordinator:

i) Name:
□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□
ii) Designation:
□□□□□□□□□□□□□□□□□□□□□□ iii) Phone number:
□□□□□□□□□□□
iv) Email address:

BANK DETAILS

a) Bank name and branch:

□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ 1
□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□
b) Address:
SECTION C

□□□□□□□□□□□□□□□□□ State: □□□□□□□□□□□□□□□□□□□

City:

□□□□□□□□□□□□□□□□□□ d) Do you prefer payment by ECR / Cheque? □ □

c) Account number: Yes No

□□□□□□□□□□□ f) IFSC code: □□□□□□□□□□□□□□□□□

e) 9 Digit code number appearing on the MICR cheque:

g) Payee name
nnn□□□□□□□□□□□□□□□□□□□□□□□□□□□□nnnnnnnn l
TAX DETAILS
■
SECTION D

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 Page 2
 Company Logo

Company Name

Company Address

APPLICATION FORM FOR NETWORK SERVICE PROVIDER

OWNERSHIP
■

SECTION E
a) Type (Only tick one)

□ i) Government
□ ii) Non profit
□ iii) Private

TOTAL NUMBER BEDS

------------------------------■
a) Room category wise
I

SECTION F
□□□ □□□ □□□ □□□ □□□
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 speciality

□ ii) Secondary + Multi speciality
□ iii) Tertiary + Single speciality
□ iv) Tertiary + Multiple speciality

b) List of specialties (Tick ALL that apply)

□ i) Internal medicine
□ ii) Cardiology
□ iii) Nephrology
□ iv) Paediatrics
□ v) Pulmonology

SECTION G
□ vi) Gastro-enterology
□ vii) General surgery
□ viiii) Orthopaedics
□ ix) Gynaecology
□ x) Obstetrics

□ xi) Oncology
□ xii) Urology
□ xiii) Obstetrics

c) Nurse bed ratio

□□□ □□□ □□□ □□□ □□□

i) General ii) Twin sharing iii) Single iv) Single AC 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 center

b) Outpatient services

□□□ □□ □□ □□ □□
i) Number of consulting rooms ii) OPD working hours : am / pm to : am / pm

c) Diagnostic facilities
SECTION H

Investigations: (Tick ALL that apply)

□ i) Blood biochemistry
□ ii) Haemotology
□ iii) Microbiology
□ iv) Cytology
□ v) Immunology
□ vi) Blood bank

Radiology

□ i) X-ray
□ ii) USG
□ iii) CT Scan
□ iv) MRI
□
v) Nuclear medicine

Inpatient facilities

□□□ □□□ □□□

i) Number of major operating rooms ii) Number of minor operating rooms iii) Cath lab facility

Pharmacy

□□ □□ □□ □□
i) Day / Night : am / pm to : am / pm

Page 3
 Company Logo

Company Name

Company Address

APPLICATION FORM FOR NETWORK SERVICE PROVIDER

INFRASTRUCTURE AND SUPPORT SERVICE (Tick ALL that apply)

■

SECTION I
□ 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)

■
■

SECTION J
□ 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)

■
■

SECTION K
□ 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

SECTION L
□ i) Inpatient mortality
□ ii) Neonatal mortality
□
iii) Perioperative mortality
□ iv) Surgical site infections

□ v) Hospital acquired infections

□ vi) Unplanned return to theatre
□ vii) Unplanned readmissions
□ viii) Transfers to other hospitals

□ ix) Complications of anaesthesia

□ x) Transfusion reactions

CHECK LIST FOR ENCLOSURES I

□ Tariff Iist I

SECTION M
□ Hospital brochure

□ Copy of the hospital registration certificate with the local government authority

□ Copy of certification (ISO / NABL / JCI / Others)

DETAILS OF OFFICIAL WHO COMPLETED THIS FORM I

Name of person Mobile number

Designation Email address

SECTION N

Authorised Signatory Seal of Hospital

Page 4