Guidelines - Policyholder.gov.in

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Feb 20, 2013 - contracts and with the Providers (Hospitals) for health care services under health .... council of any st
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regulatory and

DEVELOPMENT AUTHORITY

20/02/2013

IR D A / H L T /C IR /03< T /02/2013

A ll C E O S o f L ife In su rers, N on -L ife In surers, S tan d alon e H ealth In su rers and T P A s

Re: G u id elin es on S tan d ard ization in H ealth In su ran ce H ealth insurance ad dresses a m ajo r area o f public concern. A lth o u g h it is rap id ly grow ing, access to health insurance still rem ain s lim ited and ad d to it co m p lain ts esp ecially due to variable interpretations o f key policy term s are enorm ous. In o rd er to ad d ress the expectation o f public m ore effectively, th e A uthority pro p o se to stip u late th e fo llo w in g in resp ect o f all health insurance policies issued by life and general insurers in the country. 1.

S tan d ard D efin ition for 46 co m m o n ly used term s in health in su ra n ce policies:

S tandard term s w ould red u ce am biguity, en ab le all stak eh o ld ers to p ro v id e b etter serv ices and enable cu sto m ers to interact m ore effectively w ith insurers, T P A s and p roviders. A ll insurers shall adhere to the stipulated d efinitions, annexed at A n n ex u re I, w h ile d efin in g th ese 46 core term s in all health insurance policies. 2.

S tan dard N om en clatu re and P roced ures for C ritical Illnesses:

In view o f resolving the d ifferen ces in the defin itio n s o f term s on C ritical Illnesses ado p ted by the different insurers w hich are creatin g confusion in th e m inds o f co n su m ers and th e industry especially at th e tim e w h en insurers and re-insurers have to arriv e at a p o in t w here lum p sum paym ent is m ade, 11 C ritical Illness term s have been stan d ard ized to be adopted uniform ly across industry, if o ffered under the product. A ll p ro d u cts o fferin g the 11 critical illness coverage shall ensure th a t defin itio n s o f the stated 11 term s are in line w ith the stipulated d efinitions an nexed at A n n ex u re II. 3.

S tan dard P re-au th orizatio n and C laim form :

A com m on industry w ide pre-au th o rizatio n and claim form w ill sig n ifican tly stream line p rocesses at all stages. T his w ill en hance the ability o f p ro v id ers to o b tain a tim ely prior authorization. By im plem entin g it in an optical ch aracter reco g n itio n (O C R ) form at, the ability to tran sfe r data from a h an d w ritten p ap er based form to IT sy stem s has been enhanced thus reducing th e d ata entry issues for T PA s and insurers. E v ery co m p an y shall attach set o f claim form s alo n g w ith policy term s and co n d itio n s to th e p o licy h o ld er. T he form s are attached at A n n ex u re III. 4.

S tan dard L ist o f E xclu ded E xp en ses in H osp italization In d em n ity policies:

H ospitalization indem nity pro d u cts are the com m onest p ro d u cts in the Indian m ark et and acco u n t for m ost o f the health insurance sold in the country. T h e stan d ard listing o f 199 ex cluded item s, an area w hich has otherw ise been fairly v ariab le in its interp retatio n and

’item *p=n, cfrFRT cTcT, ^fteFT, |^TRK-500 004. © : 91-040-2338 1100, W : 91-040-6682 3334

Parisharam Bhavan, 3rd Floor, Basheer Bagh, Hyderabad-500 004. India. Ph.: 91-040-2338 1100, Fax: 91-040-6682 3334

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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY

im plem entation, has been finalized. T he sam e is annexed at A n n ex u re IV. H ow ever, Insurers m ay include these exclusions, if the p roduct design allow s for, o r if th e in su rer w an ts to include th ese as part o f hospitalizatio n expenses. 5.

S tan dard File and In form ation Sheet:

U se

A pp lication

F orm ,

D ata b a se

S h eet

and

C u sto m er

T he existing F & U form used by the non-life insurers is d esig n ed keep in g in v iew largely the characteristics o f N on Life pro d u cts other than H ealth. W ith this, th e essen tial inform ation like th e sum insured, the m inim um and m axim um age, term o f the p ro d u ct etc th a t gets captured in th e F& U form is v ery m inim al. In o rd er to cap tu re th e relev an t p ro d u ct design inform ation, th e m odified File and U se A p p licatio n form along w ith the D atab ase sheet and C u sto m er info rm atio n sheet as annexed in the A nn exu re: V , V I and V II resp ectiv ely shall be subm itted u nder File and U se proced u re by the insurers. T his circu lar supersed es all th e ex istin g circulars /g u id elin es on File an d U se P rocedure for health insurance prod u cts offered by life in surers/non-life in su rers/h ealth insurers. All the insurers shall co m p ly w ith the File and U se proced u re specified in th is circular. 6.

S tan d ard a g reem en t betw een T P A & In surer and P rovid er (H o sp ita l) & In su rer:

T he insurers en ter into agreem en ts w ith the T P A s for h ealth serv ices u n d er health insurance contracts and w ith the P roviders (H ospitals) for health care serv ices u n d er health insurance contracts. T he S ervice Level A g reem en t shall include the m in im u m standard clauses as annexed in A n n exu re: V III and IX, as applicable. T his is issued u nder section 14(2) o f IRD A A ct, 1999 and shall be effectiv e from 1st Ju ly 2013 for group prod u cts and l sl O cto b er 2013 for o th er products.

*I^R, cftel

V PLEASE FAX / SCAN RAGE 1 ONLY REQUEST FOR CASHLESS HOSPITALISATION FOR MEDICAL INSURANCE POLICY

(To be filled in block letters)

DETAILS OF THE THIRD PARTYADMINISTRATOR a) Name of TFA/ Insurance company: b) Toll free phone number; c) Toll free FAX:

TO BE FILLED BYTHE INSURED I FATIENT

a) Name of the Patient:

























c)Age:













Q

Male

CD Female

e) Contact number:





















I ) Insured card ID number: □





g) Policy number I Name of corporate:























h) Currently do you have any other Mediclaim / Health insurance: Give details



Years [~v~| [~v~|



b) Gender:



Yes





Months[~M~| |





Q No









| □

Company Name 0







d) Date of birth: 0

0



0







0





0



0

0





0





0





0

0







□ 0









0

0

0









h) Employee ID:















0

0

0

0

0

0

0

0

0

0

0

[ _ _________________________________________________________________ ___________________________________________________________________ [ ]

i) Do you have a family physician:

[^Y e s

k) Contact number, if any:

0

0

0

QN 0

j) Name of the family physician: [

o

0

0

0

0

0

10

0

[~ 11

]I

1[

11

11 11

10

0

0

0

[

I[

1 0 1

10 1

10

1 11

1

(PLEASE COMPLETE DECLARATION ON THE REVERSE SIDE OF THIS FORM)

0

TO BE FILLED BY THE TREATING DOCTOR / HOSPITAL

a) Name of the treating doctor: 0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

c) Nature of ILLNESS / Disease with presenting complaints

0

0

0

0

0

b) Contact number: [

e) Duration of the present ailment: f H [ I f I Days — — — f) Provisional diagnosis:

i. Date of first consultation: 0 0 — —

0 0 — —

0

0

0

0

0









0

0

0

0

0

iv. FIR No [

||

|f

ii. Past history of present ailment if any:

]

i. ICO 10 Code: □ g) Proposed line of treatment:

Q Medical Management

Q

Surgical Management

[ I ] Intensive care



ED Investigation









[ J Non allopathic treatment

i) Route of drug administration:

h) If Investigation & I or Medical Management provide details i) If Surgical, name of surgery:

i. ICD 10 PCS Code:

j) If other treatments provide details:

k) How did injury occur:

I) In case of accident:

] 0

d )Relevant clinical findings:

i. Is it RTA:

I I Yes I I No

ii. Dale of injury:

0

0

0

0

( 0 0

iii. Reported to Police : ED Yes (” J No

v. Injury/Disease caused due to substance abuse/alcohol consumption: Q Yes Q ] No

vi.Test conducted to establish this :

HD Yes Q No

I) In case of Maternity:

Date of Delivery:

0

Q G

Q P

I IL



a

0

0

0

(If Yes attach reports)

0

0 If yes, since (month / year'

Mandatory: Past History of any chronic illness

Details of the patient admitted a) Date of admission:

b)Time: 0

!

c) Is this an emergency/a planned hospitalization event?: d) Expected no. of days stay in hospital:

j

j|

]j

j

j Emergency

| Days

[

0

: 0

0

] Planned

e) Room Type I

0 Per Day Room Rent + Nursing & Service Charges + Patient's Diet:

I

Rs.

0

0

0

0

O

0

g) Expected cost for investigation + diagnostics.:

Rs.

0

h) ICU Charges:

Rs.

O

i) OT Charges:

Rs.

0

0

0

0

j) Professional fees Surgeon + Anesthetist Fees + consultation Charges

Rs.

0

0

0

0

k) Medicines + Consumables + Cost of Implants (if applicable please specify). Other hospital expenses if any:

Rs.

0

0

O

0

0

0



Diabetes

0

0

0

0



Heart Disease

0

0

0

0



Hypertension

0

0

0

0

0

0



Hyperlipidemias

0

0

0

0

0

0

0

0



Osteoarthritis

0

0

0

0

0

0

0

0



Asthma / COPD / Bronchitis

0

0

0

0

0

0



Cancer

0

0

0

0



Alcohol or drug abuse

0

0

0

0



Any HIV or STD / Related ailments

0

0

0

0

O O

0

O

0

O 0

0

|

Any other Ailment give details: I) All inclusive package charges if any applicable

Rs.

0

m) Sum Total expected cost of hospitalization

Rs.

O

0

0 O

0 0

0 O

O 0

0 0

0

(PLEASE READ VERY CAREFULLY) d e c la r a tio n

mmmmmmmmmmmmmmmmm

We confirm having read understood and agreed to the Declarations on the reverse of this form a) Name of the treating doctor: 0

0

0

0

0

0

b) Qualification:

0

0

0

0

0

0

0

Hospital Seal (Must include Hospital ID)

0

0

0

0

0

c) Registration No. with State Code: 0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

;

Patient I Insured Name & Signature: (IMPORTANT: PLEASE TURN OVER)

PAGE 2: NOT TO BE FAXED/SCANNED

DECLARATION BY THE PATIENT / REPRESENTATIVE

1.1agree to allow the hospital to submit all original documents pertaining to hospitalization to the Insurer/TP.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. 4 .1hereby 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 .1 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 .1hereby 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 with respect to the claim, my right to claim reimbursement of the said expenses shall be absolutely forfeited. 7 .1agree to indemnify the hospital against all expenses incurred on my behalf, which are not reimbursed by the Insurer I TPA.

a) Patient's I Insured’s N a m e :____________________________________________________________________________________________________________________

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 duty countersigned by the insured I 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 I 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 I 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.

CLAIM FORM - PART A TO BE FILLED IN BY THE INSURED The issue of this Form is not to b e taken a s an admission of liability

(To be filled in block letters)

DETAILS OF PRIMARY INSURED:

OPolfcyNo: □



































c) Company/ TPA ID No:







































d)Name:

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

e)Address:

0000000000O0000000000000000000000000000O0

0

0

b) SI. No/ Certificate No: □

0

0

0

0

0

0



0

0



0



0



0



0



0







O

0

0

0

0

0

0

0

□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□DO □ □ □ □ □ □ □ □ □ □ □

Phon.No:

EmaillD:l

I

DETAILS OF INSURANCE HISTORY:____________________________________________________________________________________________ __ __________________________________________

a) Currently covered by any other Mediclaim / Health Insurance: c) If yes, company n a m e Q □



Sum Insured (Rs.) Q

Q

Q













EHYes EH No







□ Q

b) Date of commencement of first Insurance without break: Qj] Q7]







^ N o . □









j □



















[ j [J □



[ ]j j













d) Have you been hospitalized in the last four years since inception of the contract? EH Yes EH NoDate:[ m] [ m]

| f) If yes, Company Name



















[ y] [ y]

e) Previously covered by any other Mediclaim / Health insurance:

EH Yes EH No



DETAILS OF INSURED PERSON HOSPITALIZED:

£ j L±Ll L ill UU LU l_!U LUI_ 11_ 11_ 11_ 11_ I LLl L J liLJ L§J LUI_ I L iil LAJ LMJLeJ I_ 11_ 11_ I biJ I_ I lEJ LD I

a) Name:

Male □

b) Gender:

Female □

c)Age: years [~v~] [~Y~| months |~m] |~M~| d) Date of Birth: [~5~| [~D~|

EH

e) Relationship to Primary insured:

Self

f) Occupation:

Self Employed EH

Service EH

g) Address (if different from above):





EH

Spouse





Child EH

Father

Homemaker^] □





Student









EH EH □

EH

Mother

Retired EH □







EH

Other

[~m] [ m~|

Q

Q

(Please Specify) |

Other EH (Please Specify) □







































□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□ PinC

o d e :0 0 0 0 0 0

PhoneNo: □





















E'maillD:l

(/) m oH O Z o

~ l

DETAILS OF HOSPITALIZATION:________________________________________________________________________________________________ __ _________________________________________

a) Name ol Hospital where Admitted:

0

b) Room Category occupied: c) Hospitalization due to: e) D ate d Admission:

Injury 0

i) If Injury give cause: ii. Reported to police:

0

0

0

0

0

Day care EH

0

EH 0

Self inflicted

Illness 0

EH 0

EH

0

0

Maternity 0

0

0

0

0

0

0

0

Twin sharing

EH

0

0

0

EH

0

0

0

0

0

0

: 0

EH

0

g) Dale ol D is c h a rg e :0 0

Substance Abuse/Alcohol Consumption

Report &Police FIR attached:

EH Yes EHNo

0

0

0

0

0

[

J[

0

0

0

[

j[ J

0

0

0

0

3 or more beds per room EH

d) Date of Injury / Date Disease first detected /Date of Delivery:

I) Time: 0

Road Traffic Accident

EHYes EH No

0

Single occupancy EH

EH

0

[15] [TT]

0

i. If Medico legal:

0

0

]

h) Time: 0

0

:

[^ 1 1 ^ 1

EHYes EH No

(/) m o H O z a

j) System of Medicine: |

DETAILS OF CLAIM:

______________________________

a) Details of the treatment

Claim Documents Submitted- Check List:

j

i. Pre-hospitalization Expenses:

Rs.

iii. Post-hospitalization Expenses:

Rs. : _\

v. Ambulance Charges:

Rs.

i;

|

!.

|__ |___] j__ j [

]

|Q

ii. Hospitalization Expenses: iv. Health-Check up Cost:

0 0 0 0 0 0 0

V i.

Others ( c o d e ) :0 0

0

Total

vii. Pre-hospitalization period:

days

000

viii. Post-hospitalization period:

EH Yes EH No

b) Claim for Domiciliary Hospitalization:

R s-

0000000

Rs- 0 0 0 0 0 O 0 RS- 0 0 O 0 0 0 0 Rs. 0 0 0 0 0 0 0

da»s 0 0 0

(If yes, provide details in annexure)

Rs.

iii. Critical Illness Benefit:

EH Copy of the claim intimation, if any EH Hospital Main Bill □

Hospital Break-up Bill

EH Hospital Bill Payment Receipt EH Hospital Discharge Summary EH Pharmacy Bill

in m o H O

I I Operation Theatre Notes

c) Details of Lump sum / cash benefit claimed: i. Hospital Daily Cash:

EH Claim Form Duly signed

0 0 0 0 0 0 0

Rs. __ ___ ;

v. Pre/Post hospitalization Lump sum benefit: Rs. □



L □



;l 1 □



ii. Surgical Cash: .



Rs- O O 0 0 0 0 0

0000000

iv. Convalescence: vi. Others:







Rs- 0 0 0 0 0 0 0 00O 0000



ECG

I | Doctor's request for investigation r ] Investigation Reports (Including CT _ I MRI / USG / HPE) L J Doctor’s Prescriptions

EH Others

DETAILS OF BILLS ENCLOSED:___________

SI. No

Bill No

1.

Issued by

Date D

D

M

M

Y

Y

Amount (Rs)

Towards

2.

D

D

M

M

Y

Y

Hospital Main Bill Pre-hospitalization Bills:

3.

0

D

M

M

Y

Y

Post-hospitalization Bills:__ Nos Pharmacy Bills

4.

D

D

M

M

V

y

5.

D

0

M

M

Y

y

6.

0

D

M

M

v

Y

7.

D

D

M

M

Y

y

8.

D

0

M

M

Y

r

9.

D

0

M

M

Y

Y

10

D

D

M

M

Y

Y

cm /> o

Nos

DETAILS OF PRIMARY INSURED'S BANK ACCOUNT:

a)PAN:

0000000000 b) Account Number: I I I II II II 1 1 II 1 1 II II II 1 1 II II II II 1 1 II I 00000000000000000000000000000000000000 d) Cheque/ DD Payable details: I e)IFSCCode: 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 c) Bank Name and Branch:

(IMPORTANT: PLEASE TURN OVER)

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 m ade any false or untrue statem ent, suppression or concealm ent of any material fact with resp ect to questions ask ed in relation to this claim, my right to claim reim bursem ent shall b e forfeited. I also consent & authorize TPA / insurance company, to seek necessary medical information / docum ents from any hospital / Medical Practitioner who h a s attended on the person against whom this claim is m ade. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplem entary claim except the pre/post-hospitalization claim, if any.

Date: 0

0

@

0

0

0

I

Signature of the Insured

place: [

GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured) FORMAT

DESCRIPTION

DATA ELEMENT

SECTION A - DETAILS OF PRIMARY INSURED a)

Policy No.

b)

SI. No/ Certificate No.

c)

Com pany TPA ID No.

Enter the policy number Enter the social insurance num ber or the certificate num ber of social health insurance schem e

As allotted by the insurance com pany As allotted by the organization

Enter the TPA ID No

License num ber a s allotted by IRDA and printed in TPA docum ents.

d)

Name

Enter the full nam e of the policyholder

Surnam e, First n am e, Middle nam e

e)

Address

Enter the full postal ad d ress

Include Street, City and Pin Code

SECTION B - DETAILS OF INSURANCE HISTORY Indicate w hether currently covered by another Mediclaim / Health Insurance

Tick Y es or No

b)

Currently covered by any other Mediclaim / Health Insurance? D ate of C om m encem ent of first Insurance without break

Enter the date of com m encem ent of first insurance

Use dd-mm-yy format

c)

Com pany Name

Enter the full nam e of the insurance com pany

Nam e of the organization in full

Policy No.

Enter the policy num ber

As allotted by the insurance com pany

a)

d)

e) f)

Sum Insured

Enter the total sum insured a s per the policy

In ru p ees

Have you been Hospitalized in the last four years since inception of the contract?

Indicate whether hospitalized in the last four years

Tick Y es or No

Date

Enter the date of hospitalization

Use mm-yy format

Diagnosis Previously Covered by any other Mediclaim/ Health Insurance? Company Name

Enter the diagnosis details Indicate w hether previously covered by another Mediclaim / Health Insurance Enter the full n am e of the insurance company

O pen Text Tick Y es or No Nam e of the organization in full

SECTION C - DETAILS OF INSURED PERSON HOSPITALIZED a)

Name

Enter the full n am e of the patient

Surnam e, First nam e, Middle nam e

b)

G ender

Indicate G ender of the patient

Tick Male or Fem ale

c)

Age

Enter a g e of the patient

Number of y ears and m onths

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, p lease specify.

f)

Occupation

Indicate occupation of patient

Tick the right option. If others, p lease specify.

g)

Address

Enter the full postal a d d ress

Include Street, City and Pin Code

h)

Phone No

Enter the phone num ber of patient

Include STD code with telephone num ber

i)

E-mail ID

Enter e-mail ad d ress of patient

Com plete e-mail a d d ress

a)

Name of Hospital where admitted

Enter the n am e of hospital

Name of hospital in full

b)

Room category occupied

Indicate the room category occupied

Tick the right option

c) d)

Hospitalization due to

Indicate reason of hospitalization

Tick the right option

Enter the relevant date

Use dd-mm-yy format

SECTION D - DETAILS OF HOSPITALIZATION

e)

Date of Injury/Date D isease first detected/ Date of Delivery Date of admission

0

Enter d ate of admission

Use dd-mm-yy format

Time

Enter time of admission

Use hh:mm format

g)

Date of discharge

Enter d ate of discharge

Use dd-mm-yy format

h)

Time

Enter time of discharge

U se hh:mm format

■)

If Injury give cau se

Indicate c a u se of injury

Tick the right option

If Medico legal

Indicate whether injury is m edico legal

Tick Y es or No

Reported to Police

Indicate whether police report w as filed

Tick Y es o r No

MLC Report & Police FIR attached

Indicate whether MLC report and Police FIR attached

Tick Y es or No

System of Medicine

Enter the system of medicine followed in treating the patient

O pen Text

j)

SECTION E - DETAILS OF CLAIM a)

Details of Treatm ent E xpenses

Enter the amount claimed a s treatm ent e x p en ses

In ru p ees (Do not en ter p aise values)

b)

Claim for Domiciliary Hospitalization

Indicate whether claim is for domiciliary hospitalization

Tick Yes or No

c)

Details of Lump sum / c ash benefit claimed

Enter the am ount claimed a s lump sum / c ash benefit

In ru p ees (Do not en ter p aise values)

d)

Claim Docum ents Subm itted-Check List

Indicate which supporting docum ents are submitted

Tick the right option

SECTION F - DETAILS OF BILLS ENCLOSED Indicate which bills are enclosed with the am ounts in ru p ees SECTION G - DETAILS OF PRIMARY INSURED’S BANK ACCOUNT a)

PAN

Enter the perm anent account number

As allotted by the Income Tax departm ent

b)

Account Number

Enter the bank account num ber

As allotted by th e bank

c)

Bank Nam e and Branch

Enter the bank nam e along with the branch

Nam e of the Bank in full

d)

C heque/ DD payable details

Enter the nam e of the beneficiary the ch eq u e/ DD should be m ade out to

Nam e of the individual/ organization in full

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 d ate (in dd:mm:yy format), place (open text) and sign.

I

< /) om H O Z

2 - 0 ' O lCLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL The issu e of this Form is not to b e taken a s an adm ission of liability P le ase indude the original preauthorization req u est form in lieu of PART A

ZLO)J2>

(To be filled in block letters)

DETAILS OF HOSPITAL a) Name of the hospital:





















b) Hospital ID:

0

0

0

[[J 0 ] 0

0

(0 0 ]











|







c) Type of Hospital:

d) Name of the treating dodor 0 0 0 0 0 0 0 0 0 0 0 0 0 G e) Qualification:



D

0













Network

EH

H

0 H

0 0 0 O

0

0

0 0 O

| f) Registration No. with State Code: 0



0

0



Non Network

0

0







EH



















(If non network fill section E)

0 0 0 0 0 0 0 0 0 0 0 0 0 0

9) Phone No. |

||

||

||

||

||

||

||

||

||

||

|

DETAILS OF THE PATIENT ADMITTED__________________________________________________________________________________________________________________________________ a) Name of the Patient:

0

0

b) IP Registration Number I

||

f) Date of Admission:

0

j) Type of Admission:

0

0

0

||

||

||

0

0

0 ||

0

0

||

||

0

0

0

0

I

0

0

0

0

c) Gender:

Male □

g)Time: 0

0

Planned

EH

Day Care □

EH

Discharge to another hospital

Maternity

0

0

0

0

0

Female □ : 0

Discharge to home

Emergency □

I) Status at time of discharge:

0

EH

0

0

d) Age: Years 0

0

0

Deceased

0

0

0

0

0

Months0

0

h) Date of Discharge: 0

0

i. Date of Delivery.0

0

k) If Maternity

EH

0

EH

0

0

0

0

0

0

0

0

0

0

0

0

e) Date of b i r t h 0 0

0

0

0

0

i)Time:

0

0

: 0

0

0

0

0

ii. Gravida Status:

0

0

0

0

0

m) Total claimed amount

DETAILS OF AILMENT DIAGNOSED (PRIMARY)__________________________________________________________________________________________________________________________

a)

ICD10 Codes i. Primary Diagnosis:

0

ii. Additional Diagnosis: 0

iii. Co-morbidities:

|

0

0

0

0

0

0

0

0

0

0

0

1

||

||

||

||

b)

Description

||

||

0000000

I

ii. Procedure2:

0000000

|

iii. Procedure3:

0000000

EH Yes EH No

f) If authorization by network hospital not obtained, give reason:

|

EH Yes EH No

g) Hospitalization due to Injury:

e) Pre-authorization Number:

0

0

0

0

0

Self-inflicted EH

i. If Yes, give cause

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0 |

ii. If Injury due to Substance abuse / alcohol consumption, Test Conducted to establish this: 0

C /> m

o H o z

iv. Details of Procedure:

d) Pre-authorization obtained:

0

Description

i. Procedure1:

iv. Co-morbidities:

v. FIR no.0

ICD 10 PCS

vi.

Road Traffic Accident

EH Yes EH No

EH

(If Yes, attach reports)

Substance abuse / alcohol consumption

iii. If Medico legal: EDYes

EHNo

EH

iv. Reported to Police:

EHYes EHNo

If not reported to police give reason:

CLAIM DOCUMENTS SUBMITTED - CHECK LIST



Claim Form duly signed





Original Pre-authorization request



CT/MR/USG/HPE investigation reports



Copy of the Pre-authorization approval letter



Dodor’s reference slip for investigation



Copy of photo ID card of patient verified by hospital



ECG



Hospital Discharge summary



Pharmacy bills



Operation Theatre notes



MLC report & Police FIR



Hospital main bill



Original death summary from hospital where applicable



Hospital break-up bill



Any other, please specify

DETAILS IN CASE OF NON NETWORK HOSPITAL

Investigation reports

C /) m o H O z

(ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of

□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□DD «*□ □ □□ □□ □ □ □ □ □ □ □□ □ □ □ **»□□□□□□□□□□□□□□□□□□□ m Pin C o d e : 0 0 d) Hospital PAN:

I 11

11

11

0 11

0

0

0

11

11

11

b)Phone N o.0

0

0

0

0

0

0

0

0

0

11

c) Registration No. with State C o d e : 0 0

0

0

0

0

0

0 11|e)NumberofInpatientbeds|

iii. Others:

DECLARATION BY THE HOSPITAL

(PLEASE READ VERY CAREFULLY)

We hereby declare that the information furnished in this Claim Form is true &correct to the best of our knowledge and belief. Ifwe have made any false or untrue statement, suppression or concealment of any material fad, our right to claim under this claim shall be forfeited.

^

O

00 00 00 Signature and Seal of the Hospital Authority:

i

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 nam e of hospital

Nam e of hospital in full

b)

Hospital ID

Enter ID num ber of hospital

As allocated by the TPA

c)

Type of Hospital

Indicate whether In network or non network hospital

Tick the right option

d)

Name of treating doctor

Enter the nam e of the treating doctor

Nam e of doctor in full

e)

Qualification

Enter the qualifications of the treating doctor Enter the registration num ber of the doctor along with the state code

Abbreviations of educational qualifications

Enter the phone num ber of doctor

Include STD code with telephone num ber

f)

Registration No. with S tate Code

g)

Phone No.

As allocated by the Medical Council of India

SECTION B - DETAILS OF THE PATIENT ADMITTED a)

Name of Patient

Enter the n am e of hospital

Name of hospital in full

b)

IP Registration Number

Enter insurance provider registration number

As allotted by the insurance provider

c)

G ender

Indicate G ender of the patient

Tick Male or Fem ale

d)

Age

Enter a ge of the patient

Number of y ears and m onths

e)

Date of Birth

Enter date of admission

U se dd-mm-yy format

f)

Date of Admission

Enter date of admission

U se dd-mm-yy format

g)

Time

Enter time of admission

Use hh:mm format

h)

Date of D ischarge

Enter d ate of discharge

Use dd-mm-yy format

i)

Time

Enter time of discharge

Use hh:mm format

j)

Type of Admission

Indicate type of adm ission of patient

Tick the right option

Date of Delivery

Enter Date of Delivery if maternity

Use dd-mm-yy format

Gravida Status

Enter G ravida statu s if maternity

U se standard format

1)

Status at time of discharge

Indicate statu s of patient at time of discharge

Tick the right option

m)

Total claimed amount

Indicate the total claimed amount

In ru p ee s (Do not enter p aise values)

k)

If Maternity

SECTION C - DETAILS OF AILMENT DIAGNOSED (PRIMARY) a)

ICD 10 Code Enter the ICD 10 Code and description of the primary diagnosis Enter the ICD 10 Code and description of the additional diagnosis

Primary Diagnosis Additional Diagnosis Co-morbidities b)

Enter the ICD 10 Code and description of the co-morbidities

Standard Format and O pen text Standard Format and O pen text Standard Format and O pen text

ICD 10 PC S Procedure 1

Enter the ICD 10 PC S and description of the first procedure

Standard Format and O pen text

Procedure 2

Enter the ICD 10 PCS and description of the seco n d procedure

Standard Format and O pen text

Procedure 3

Enter the ICD 10 PCS and description of the third procedure

Standard Format and O pen text

Details of P rocedure

Enter the details of the procedure

O pen text

c)

Pre-authorization obtained

Indicate whether pre-authorization obtained

Tick Yes or No

d) e)

Pre-authorization Number If authorization by network hospital not obtained, give reason

Enter pre-authorization num ber

As allotted by TPA

f)

Enter reason for not obtaining pre-authorization num ber

O pen text

Hospitalization due to injury

Indicate if hospitalization is due to injury

Tick Y es o r No

C ause

Indicate ca u se of injury

Tick the right option

If injury due to su b stan ce abuse/alcohol consumption, test conducted to establish this

Indicate whether test conducted

Tick Y es o r No

Medico Legal

Indicate whether injury is m edico legal

Tick Y es o r No

R eported To Police

Indicate whether police report w as filed

Tick Y es or No

FIR No.

Enter first information report num ber

As issued by police authorities

Enter reason for not reporting to police

O pen Text

If not reported to police, give reason

SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST Indicate which supporting docum ents are submitted SECTION E - DETAILS IN CASE OF NON NETWORK HOSPITAL a)

Address

Enter the full postal ad d ress

Include Street, City and Pin Code

b)

Phone No.

c)

Registration No. with S tate Code

As allocated by the Medical Council of India

d)

Hospital PAN

Enter the phone num ber of hospital Enter the registration num ber of the doctor along with the state code Enter the perm anent account num ber

e)

Number of Inpatient b eds

Enter the num ber of inpatient beds

Digits

f)

Facilities available in the hospital

Indicate facilities available in the hospital

Tick the right option. If others, p lea se specify

SECTION F - DECLARATION BY THE HOSPITAL R ead declaration carefully and mention d ate (in dd:mm:yy format), place (open text) and sign and stam p

Include STD co d e with telephone num ber

As allotted by the Income Tax departm ent

a O ' 0 2 ---2 0 1 3

ANNEXURE IV List of G enerally excluded in H ospitalisation Policy SNO

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

32 33 34 35

List of Expenses G enerally Excluded ("N on-M edical") in H ospital Indem nity Policy -

SU G G E ST IO N S

T O IL E T R IE S /C O S M E T IC S / PE R SO N A L C O M F O R T O R C O N V E N IE N C E IT E M S N ot P ay ab le HA IR REM O V A L CREA M N ot P ay ab le BABY CH A RG ES (U N L E SS SPE C IFIED /IN D IC A TED ) N ot P ay ab le BABY FOOD N ot P ay ab le BABY U T ILITES CH A R G ES N ot P ay ab le BABY SET Not P ay ab le BABY BO TTLES N ot P ay ab le BRUSH N ot P ay ab le CO SY TO W EL HAND WASH N ot P ay ab le N ot P ay ab le M 01STUR1SER PA STE BRUSH POW D ER N ot P ay ab le RAZOR P ay ab le N ot P ay ab le SHO E C O V ER N ot P ay ab le BEA U TY SER V IC ES E ssen tial a n d m ay be B ELTS/ BR A CES p aid specifically fo r cases w h o h av e u n d e rg o n e su rg e ry o f th o ra c ic o r lu m b a r spine. N ot P ay ab le BUDS N ot P ay ab le BA RBER CH A RG ES N ot P ay ab le CAPS CO LD PA C K /H O T PACK N ot P ay ab le CA RRY BAGS N ot P ay ab le N ot P ay ab le CR A D LE CH A R G ES N ot P ay ab le COM B D ISPO SA BLES RA ZO RS CH A R G ES ( for site preparations) P ay ab le N ot P ay ab le E A U -D E-C O L O G N E / RO O M FRESH N ERS N ot P ay ab le EYE PAD N ot P ay ab le EYE SHEILD N ot P ay ab le EM AIL / IN T E R N E T C H A RG ES N ot P ay ab le FOOD CH A R G E S (O T H E R TH A N PATIENT'S D IET PRO V ID ED BY H O SPITA L) N ot P ay ab le FO O T C O V ER N ot P ay ab le GOW N E ssen tial in b a r ia tr ic an d LEG G IN G S v a ric o se vein s u rg e ry a n d sh o u ld be co n sid ered fo r th ese co n d itio n s w h ere s u rg e ry itself is p ayable. N ot P ay ab le LA U N D RY CH A R G ES Not P ay ab le M IN ER A L W A TER N ot P ay ab le O IL CH A R G ES SA N ITA RY PAD N ot P ay ab le

36 37 38 39 40 41 42 43 44 45 46

SLIPPERS T E LEPH O N E C H A RG ES TISSU E PAPER TO OTH PA STE TO O TH BRUSH G U EST SER V IC ES BED PAN BED U N D ER PAD CH A R G ES CA M ER A C O V ER C L IN IPL A ST CR EPE B A N D A G E

47 48 49

C U R A PO RE D IA PER OF A N Y TY PE DVD, CD CH A R G ES

50 51 52 53 54 55 56 57 58

E Y EL E T C O LLA R FACE M A SK FLEXI M ASK G A USE SOFT G A UZE HA ND H O LD E R H A N S A P L A S T /A D H E S IV E BA N D A G ES IN FA N T FOOD SLINGS

59

IT E M S S P E C IF IC A L L Y E X C L U D E D IN THE P O LIC IE S W EIG H T C O N TR O L PR O G R A M S/ SU PPLIES/ SERV ICES

62

C O ST OF SPE C T A C L E S/ C O N T A C T LEN SES/ H EA R IN G AIDS ETC., D ENTA L T R E A T M E N T EX PE N SE S TH A T DO N O T REQ U IRE H O SPIT A L ISA TIO N H O RM O N E R E PL A C E M E N T TH ER A PY

63

H O M E V ISIT CH A R G ES

64

66

IN FER T ILIT Y / S U B FE R T IL IT Y / A SSISTED CO N CEPTIO N PRO CED U RE O B ESITY (IN C L U D IN G M O R B ID O BE SIT Y ) TR E A T M E N T IF EX CLU D ED IN PO LICY PSY CH IA TR IC & PSY C H O SO M A T IC D ISORDERS

67

C O R R EC T IV E SU R G ER Y FO R R EFR A C TIV E ERROR

68

T R E A T M E N T OF SEX U A L LY TRA N SM IT T E D D ISEASES

60 61

65

N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P av ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le/ P a y a b le by th e p a tie n t N ot P ay ab le N ot P ay ab le N ot P ay ab le ( H o w ev er if C D is sp ecifically so u g h t by In su re r/T P A th en p ay ab le) N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le R e aso n a b le costs fo r one sling in case o f u p p e r a rm f ra c tu re s sh o u ld be co n sid ered

E xclusion in policy unless o th e rw ise specified E xclusion o th e rw ise E xclusion o th e rw ise E xclu sio n o th e rw ise E xclusion o th e rw ise E x clusion o th e rw ise E xclusion o th e rw ise E xclusion o th e rw ise E x clusion o th e rw ise E xclusion o th e rw ise

in policy specified in policy specified in policy specified in policy specified in policy specified in policy specified in policy specified in policy specified in policy specified

unless unless unless unless unless unless unless unless unless

69

D O N O R SC R EEN IN G CH A R G ES

70

A D M ISSIO N /R E G IST R A T IO N CH A RG ES

71

H O SPITA LISA TIO N FO R EV A L U A T IO N / D IA G N OSTIC PURPO SE EX PEN SES FOR IN V E STIG A TIO N / T R EA TM EN T IRR EL E V A N T T O TH E D ISEA SE FO R W H ICH A D M ITTED OR D IA G N O SED A N Y E X PEN SES W H EN TH E PA TIE N T IS D IA G N OSED W ITH RETRO V IR U S + O R SU FFER IN G FRO M /H IV / AIDS ETC IS D E TE C T ED / D IR EC TLY O R IND IRECTLY STEM CELL IM PL A N T A T IO N / SURGERY and storage

72

73

74

E xclusion in policy unless o th e rw ise specified E xclu sio n in policy unless o th e rw ise specified Exclusion in policy unless o th e rw ise specified N ot P ay ab le - E xclusion in policy u n less o th e rw ise specified N ot p a y a b le as p e r H IV /A ID S exclusion N ot P ay ab le ex cep t Bone M a rro w T ra n s p la n ta tio n w h e re co v ered by policy

ITEMS WHICH FORM PART OF HOSPITAL SERVICES WHERE SEPARA TE CONSUMABLES ARE NOT PA YABLE BUT THE SER VICE IS 75

W ARD A N D T H EA T R E B O O K IN G CH A RG ES

76

A R TH R O SC O PY & EN D O SC O PY IN STRU M EN TS

77

M IC R O SC O PE C O V ER

78

SU R G IC A L B LA D E S,H A R M O N IC SCA LPEL,SH A V ER

79

SU R G ICA L DRILL

80

EYE K IT

81

EYE D RA PE

82

X -R A Y FILM

83

SPU TUM CUP

84

BOYLES A PPA R A T U S CH A R G ES

85

BLOOD G R O U PIN G A N D CR O SS M A TCH IN G OF D O NO RS SAM PLES

86

A n t is e p tic o r d is in fe c t a n t lo t io n s

88

BAND A ID S, B A N D A G ES, STER LILE IN JEC TIO N S, N EED LES, SYRIN G ES CO TTO N

89

CO TT O N B A N D A G E

87

P ay ab le u n d e r O T C h a rg e s, n o t p ay a b le s e p a ra te ly R e n ta l c h a rg e d by th e h o sp ital p ay ab le. P u rc h a se o f In s tru m e n ts n o t p ay ab le. P ay ab le u n d e r O T C h a rg e s , n ot se p arate ly P ay ab le u n d e r O T C h a rg e s, n o t se p a ra te ly P ay ab le u n d e r O T C h a rg e s, n o t se p a ra te ly P ay ab le u n d e r O T C h a rg e s, n o t se p a ra te ly P a y a b le u n d e r O T C h a rg e s, n o t se p arate ly P ay ab le u n d e r R adiology C h a rg e s, n o t as co n su m ab le P ay ab le u n d e r In v estig atio n C h a rg e s, not as co n su m ab le P a r t o f O T C h a rg e s , n ot se p e ra te lv P a r t o f C o st o f Blood, not p ay a b le N ot P a y a b le -P a rt o f D ressin g C h a rg e s N ot P ay ab le - P a rt of D ressin g ch a rg es Not P a y a b le -P a rt o f D ressin g C h a rg e s N ot P ay ab le- P a r t o f D ressin g C h a rg e s

90

M IC R O PO R E / SU R G IC A L TA PE

91 92

BLADE A PRON

93

T O R N IQ U E T

94 95

O R T H O B U N D L E , G Y N A E C BUNDLE U RIN E CO N T A IN E R

96

ELEM ENTS O F RO O M CH ARGE LU X U R Y TA X

97

HVAC

98

H OUSE K E EPIN G CH A R G E S

99 100

SERV ICE CH A R G ES W H ERE N U RSIN G CH A RG E ALSO CH A RG ED TELEV ISIO N & A IR C O N D IT IO N E R CH A RG ES

101

SU R CH A RG ES

102

A T TE N D A N T CH A R G ES

103

IM IV IN JEC T IO N CH A R G ES

104

CLEA N SH E E T

105

EXTRA D IET O F PA T IE N T (O T H E R TH AN TH A T W HICH FORM S PA R T OF BED CH A RG E) B L A N K ET/W A R M E R B L A N K ET

106

107 108 109 110 111 112 113

A D M IN IS T R A T IV E O R N O N -M E D IC A L C H ARG E S A D M ISSIO N K IT B IRTH C E R TIFIC A TE BLOOD R E SE R V A T IO N CH A R G ES A N D A N TE N A TA L BO O K IN G CH A R G ES C E R TIFIC A T E CH A R G ES C O U R IER C H A R G E S C O N V E N Y A N C E CH A R G ES D IA B ETIC C H A R T CH A R G ES

N ot P a y a b le -P a y a b le by th e p a tie n t w hen p re sc rib e d , o th e rw ise in clu d ed as D ressin g C h a rg e s N ot P ay ab le N ot P ay ab le - P a r t o f H o sp ital S erv ices/ D isp o sab le linen to be p a r t o f O T /IC U ch atg es N o t P ay ab le (serv ice is c h a rg e d by h o sp itals, co n su m ab les c a n n o t be se p a ra te ly ch a rg e d ) P a r t o f D ressin g C h a rg e s N ot P ay ab le

A ctu al ta x levied by g o v e rn m e n t is p a y a b le .P a rt o f room c h a rg e fo r su b lim its P a r t o f room c h a rg e not p a y a b le s e p a ra te ly P a r t o f room c h a rg e not p a y a b le se p a ra te ly P a r t o f room c h a rg e n ot p a y a b le se p a ra te ly P ay ab le u n d e r room ch a rg e s n o t if s e p a ra te ly levied P a r t o f R oom C h a rg e , Not p a y a b le s e p a ra te ly N ot P ay ab le - P a r t o f Room C h a rg e s P a r t o f n u rsin g ch a rg es, not p ay a b le ^ P art of L a u n d ry /H o u se k e e p in g n ot p a y a b le se p a ra te ly P a tie n t D iet p ro v id ed by h o sp ital is p ay a b le N ot P ay ab le- p a r t o f room c h a rg e s

N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot N ot N ot N ot

P ay ab le P ay ab le P ay ab le P ay ab le

114 115 116 117 118

119 120

D O C U M E N T A T IO N C H A R G E S / A D M IN IST R A T IV E EX PEN SES D ISCH A RG E PR O C ED U R E CH A RG ES D A ILY C H A R T C H A RG ES EN TR A N C E PASS / V ISITO R S PASS CH A RG ES E X PEN SES RELA TED TO PRESC RIPTIO N ON D ISCH A RG E

121 122 123 124 125 126 127 128 129

FILE O PEN IN G CH A RG ES IN C ID E N T A L EX PE N SE S / M ISC. C H A RG ES (NOT EX PLA IN ED ) M ED IC A L C E R TIFIC A T E M A IN T E N A N C E C H A R G E S M ED IC A L RECORD S PR EPA R A TIO N CH A RG ES PH O TO C O PIES CH A RG ES PA TIEN T ID EN TIFIC A TIO N BA N D / N A M E TAG W A SH IN G CH A R G ES M ED IC IN E BOX M O RTU A RY CH A R G E S

130

M ED ICO LEG A L C A SE CH A R G ES (M LC CH A RG ES)

131 132 133 134 135 136 137 138 139 140 141 142 143 144

EX TERN A L D U R A B L E D E V IC E S W A LK IN G AID S CH A R G E S BIPA P M A CH IN E CO M M O D E C PA P/ CA PD EQ U IPM EN T S INFU SIO N PU M P - C O ST O X Y G EN C Y L IN D E R (FO R U SAGE O U TSID E THE HOSPITA L) PU L SE O X Y M E TE R CH A R G ES SPA CER SPIRO M ETRE SP02PR O B E N E B U L IZ E R K IT STEAM IN H A LER A RM SLIN G T H ER M O M E TER

145 146 147 148 149 150

CER V ICA L C O LLA R SPLINT D IA B ETIC FO O T W EA R KNEE BRA CES ( L O N G / SH O R T / HIN G ED ) KNEE IM M O B IL IZ E R /SH O U L D E R IM M O BILIZER L U M B O S A C R A L BELT

N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le T o be claim ed by p a tie n t u n d e r P o st H osp w h ere a d m issib le N ot P ay ab le N ot P ay ab le N ot P ay ab le Not P ay ab le Not P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P a y a b le P ay ab le u p to 24 h rs, sh iftin g c h a rg e s not p ay a b le N ot P ay ab le

N ot P ay ab le N ot P ay ab le N ot P ay ab le D evice n o t p ay a b le D evice n o t p ay a b le N ot P ay ab le D evice n ot p ay a b le N ot P ay ab le D evice n o t p ay a b le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le (p aid by p a tie n t) N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le E ssen tial an d sh o u ld be paid specifically fo r cases w h o h av e u n d erg o n e su rg e ry o f lu m b a r spine.

151

N IM BU S BED O R W A TER O R A IR BED CH A RG ES

P a y a b le fo r a n y ICU p a tie n t re q u irin g m o re th a n 3 d ay s in IC U , all p a tie n ts w ith p a ra p le g ia /q u a d rip ie g ia fo r an y reaso n an d a t re a so n a b le cost o f a p p ro x im a te ly R s 200/ d ay

152 153 154 155

A M B U L A N C E C O LLA R A M B U L A N C E E Q U IPM EN T M IC R O SH EILD A B D O M IN A L B IN D ER

N ot P ay ab le N ot P ay ab le N ot P ay ab le E sse n tia l a n d sh o u ld be p aid in p o st s u rg e ry p a tie n ts o f m a jo r a b d o m in a l su rg e ry in c lu d in g T A H , LSCS, in cisio n al h e rn ia re p a ir, e x p lo ra to ry la p a ro to m y fo r in te stin al o b stru c tio n , liv er tr a n s p la n t etc.

156

IT E M S PA YAB LE IF SU P P O R T E D B Y A P R E SC R IP T IO N BETA D IN E \ H Y D R O G EN PER O X ID E \SPIR IT \\ \ D ISIN FEC T A N T S ETC

157

PRIV A TE N U R SES C H A R G E S- SPECIA L N U RSIN G C H A RG ES

158

N U TR IT IO N PLA N N IN G CH A RG ES - D IETICIA N CH A RG ESD IET C H A RG ES SU G A R FREE T ablets

159

161 162

CR EA M S PO W D ER S LO TIO N S (Toileteries are not payable,only prescribed m edical pharm aceuticals payable) D igestion gels ECG E LEC TR O D ES

163

G LO V ES

164

HIV KIT

165

LIST E R IN E / A N TISEPT IC M O U TH W A SH

160

M ay be p a y a b le w hen p re sc rib e d fo r p a tie n t, not p a y a b le fo r h o sp ital use in O T o r w a rd o r fo r d ressin g s in h o sp ital Post h o sp italizatio n n u rsin g c h a rg e s not P ay ab le P a tie n t D iet p ro v id ed by h o sp ital is p ay a b le P ay ab le -S u g a r free v a ria n ts o f ad m issa b le m edicines a r e not ex clu d ed P ay ab le w h en p re sc rib e d P ay ab le w h en p re sc rib e d U pto 5 elec tro d e s a re re q u ire d fo r ev e ry case v isitin g O T o r ICU . F o r lo n g e r sta y in IC U , m ay re q u ire a c h a n g e an d at least on e set ev e ry second d a y m u st be p ay ab le. S terilized G loves p a y a b le / u n ste riliz ed gloves n ot p ay a b le P ay ab le - p a y a b le P re o p e ra tiv e sc re en in g P a y a b le w hen p re sc rib e d

166 167 168

LO ZEN G ES M O U TH PAIN T N EB U LISA TIO N K IT

169 170 171 172

N O V A R A PID V O LIN I G E L / A N A L G E SIC GEL ZY TE E GEL V A C C IN A TIO N CH A R G ES

173

P A R T O F H O S P IT A L 'S O W N C O ST S A N D N O T PA YA B L E A HD

174

A LC O H O L SW A BES

175

SCRUB S O L U T IO N /ST ER IL L IU M

181 182 183 184 185

OTHERS V A CCIN E CH A R G E S FO R BABY A E ST H E TIC T R E A T M E N T / SURGERY TPA CH A R G ES VISCO BELT CH A R G ES A NY K IT W ITH NO D ETA ILS M E N TIO N ED [DELIVERY KIT, O R TH O K IT, R EC O V ER Y KIT, ETC] EX A M IN A TIO N G LO V ES KID N EY TRA Y M A SK O U N C E G LASS O U TST A TIO N C O N SU L T A N T 'S/ SURGEO N 'S FEES

186 187 188

O X Y G EN M A SK PA PER G LO V ES PELV IC T R A C T IO N BELT

189 190

REFERA L D O C TO R 'S FEES A CCU C H EC K ( G lucom etery/ Strips)

191 192 193 194 195

PAN CAN SOFN ET TRO LLY CO V E R U RO M ETER, U R IN E JUG AM BULANCE

176 177 178 179 180

P ay ab le w hen p re sc rib e d P a y a b le w hen p resc rib ed I f used d u rin g h o sp italizatio n is p ay a b le re a so n a b ly P ay ab le w hen p resc rib ed P ay ab le w hen p re sc rib e d P ay ab le w hen p resc rib ed R o u tin e V accin atio n not P ay ab le / P ost Bite V ac cin a tio n P ay ab le

N ot P ay ab le - P a r t H o sp ita l's in te rn a l N ot P ay ab le - P a r t H o sp ita l's in te rn a l N ot P ay ab le - P a r t H o sp ita l's in te rn a l

N ot N ot N ot N ot N ot

of C o st of C o st of C ost

P ay ab le P ay ab le P ay ab le P ay ab le P ay ab le

N o t p ay a b le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot p ay a b le , ex cep t fo r te lem ed icin e c o n su lta tio n s w h e re co v ered by policy N ot P ay ab le N ot P ay ab le S h o u ld be p a y a b le in case o f PI VI) re q u irin g tra c tio n as th is is g e n e ra lly n o t reu sed N ot P ay ab le N ot p a y a b le p re h o sp itila satio n o r post h o sp italisatio n / R e p o rts an d C h a rts re q u ire d / D evice n ot p ay a b le N ot P ay ab le N ot P ay ab le N ot P ay ab le N ot P ay ab le P a y a b le -A m b u la n c e from ho m e to h o sp ital o r in te rh o sp ita l sh ifts is p a y a b le / R T A as specific

r e q u ire m e n t is p ay a b le

196

T EG A D ERM / V A SO FIX SA FETY

197

U RIN E BAG

198 199

SO FTO V A C STO C K IN G S

P ay ab le - m ax im u m o f 3 in 48 h rs a n d th en 1 in 24 h rs P ay ab le w h e re m edicaly n ecessary till a re a so n a b le co st - m ax im u m 1 p e r 24 h rs N ot P ay ab le E ssen tial fo r case like C A B G etc. w h e re it sh o u ld be paid.

Annexure - V

FORM: IRDA-HEALTH INSURANCE PRODUCTS/ RIDERS OFFERED BY LIFE INSURERS AND NON-LIFE INSURERS THIS APPLICATION IS APPLICABLE TO ALL REGISTERED INSURERS CONDUCTING HEALTH INSURANCE BUSINESS IN INDIA, EFFECTIVE FROM DATE OF ISSUE, AND SUPERSEDES THE PREVIOUS CIRCULAR S ISSUED IN THIS REGARD.

1. Application - This is applicable to all insurers carrying on health insurance business in India, registered in accordance with section 3 o f the Insurance Act 1938, in respect of all health insurance products. 2. Description of File and Use Procedure a.

An insurer, who wishes to introduce a new product, shall file an application for such product with the Authority and use the product for sale in the market, subject to the requirements set out in para 3. b. An insurer, who wishes to make changes to any existing product or to withdraw an existing product, shall conform to the requirements set out in para 4 for changes and in para 5 for withdrawals. c. A separate application shall be made in respect of each product and each rider. 3. Procedure to be followed for introduction of new insurance products a. An insurer, wishing to introduce a new product, shall submit an application to the Authority along with Form IRDA- HEALTH INSURANCE PRODUCT/RIDER both for individual as well as group products/riders. b. Within 60days of the receipt of the application referred to in sub-para (1), the Authority may seek additional information with regard to the product, and the insurer shall not commence selling the product in respect of which additional information has been sought by the Authority, until the Authority confirms in writing having noted such information. If no such information is sought by the Authority, the insurer can commence selling the product in the market, as set out in the application after the expiry of the said 60-day period. 4. Procedure to be followed for changes in terms and conditions of existing products - An insurer, wishing to make changes to an existing product, shall submit an application to the Authority setting out the details of the changes in the terms and conditions and giving reasons for the proposed changes, subject to procedure laid down in para 3. 5. Procedure to be followed in case of withdrawal of existing products - An insurer, wishing to withdraw an existing product, shall inform the Authority giving the details of the product and the reasons for withdrawal. 6. GENERAL INSTRUCTIONS a. Insurers shall only use the specified form for filing the products.

Annexure - V

b. If an insurer wishes to offer riders/add-ons along with a basic health insurance product, he must furnish the information in respect of the riders/add-ons separately using the Form: IRDAHEALTH INSURANCE PRODUCTS/RIDERS as the case may be and also the financial projections along with sensitivity analysis for each rider/add-on benefit. It is also clarified that it is not necessary to file the rider details more than once, but it would be necessary to furnish the item financial projections (i.e. item no. 14 o f the Form), when the same rider is offered along with other products.

c.

d.

e. f. g.

h.

i. j.

k.

1.

Note: I f an insurer offers rider A along with product X, product Y or product Z (e.g. Accident Benefit Rider), then the Form has to be furnished afresh along with each o f the products under which the said rider is offered. This is because the financial projections fo r the rider may differ under that product. For instance, the financial projections submitted fo r a rider A under the product X need not be the same when the same rider A is offered along with product Y. As such the financial projections need to be furnished fo r the said rider along with product in the specified Forms. It may be noted that rider details need not be mentioned again but only the financial projections, when the same rider is offered along with the second o f the third product. All items in the Forms with the relevant details must be furnished. For instance, under Item 16 of the Form “Certification” the details such as Name o f Appointed Actuary, Name of the product, Name of Insurer etc. must be furnished. This would avoid unnecessary delays. Forms along with the necessary enclosures such as Specimen Policy Bond, Specimen Proposal Form, Specimen Sales Literature, and the Statement of Financial Projections, etc shall be furnished, but NOT in piecemeal. Insurers shall not alter the contents of the products under the File & Use procedure later without prior approval of the Authority. While submitting the Forms, reference to enclosures shall be avoided. If an insurer wishes to modify materially an existing product which is already in use in the market, then he is required to comply with ‘File & Use’ procedure afresh, depending upon the nature of modification. If an insurer wishes to withdraw an existing product in the market, he may do so. But he shall inform the Authority giving reasons for withdrawal, within 7 days from the date o f withdrawal. If an insurer does not launch the product within a period of 3 months, he will be required to comply with ‘File & Use’ procedure afresh. The Appointed Actuary shall initial on all the pages of the File and Use application form and all the correspondence on products with the Authority shall be made only by the AA. The insurer shall undertake to furnish the premium rates in their web-site so that if any member of public is interested to know the premium rate he can obtain the same by using the web-site. This applies to all products whether individual or group. The insurer shall also furnish the name of the software used in the matter of designing and filing the products (for instance the software can be AXIS,

Annexure - V

PROPHET etc). If the insurer is using his own software he must inform so. This is for the information of the Authority only. II.

File and Use Application form for ‘health insurance products’ offered by Life insurers and non-life insurers:

SN o

Item

1

Name of Life/Health/Non-Life Insurer

1.1

Registration No.alioted by IRDA

2

Name of Appointed Actuary [Please note that his appointment should be in force as on the date of this application] 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.] Unique ID no. (allotted by IRDA, if this application is for modification of an exisitng product) 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 60 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.] Date of modificiation/withdrawal (proposed in case of existing products, but not applicable for

3

3.1

4

5

Particulars (to be filled in by insurer)

Annexure - V

6 6.1

new products): [(a)This must be filled as “Not Applicable” for all the new products, (b) Proposed date o f modification of the features o f 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. ] General Terms and Conditions [All the items should be filled in properly and carefully. No item must be left blank.] Whether the health product is offered to/through: [Answer YES/NO] 6.1.1 6.1.2

Individuals Family Floater

Y E S / NO Y E S/ NO

6.1.3 6.1.4

Y E S / NO Y E S/ NO

6.1.6

Groups Specific geographic locations in India [if YES, specify the locations.] All geographic locations in India Rural population

6.1.7

Micro Insurance

Y E S/ NO

6.1.8

Government Schemes

Y E S/ NO

6.1.9

Indemnity basis

Y E S / NO

6.1.10

Benefit basis

Y E S / NO

6.1.5

6.1.11

6.2

Indemnity and benefit based both inclusive 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

Y E S/ NO Y E S / NO

Y E S/ NO

Annexure - V

for renewal of the contract-minimum grace period shall be 30 days. 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) Maximum Group Size (state the maximum membership of the group) Basic Sum Insured (for groups, per member details to be furnished): 6.2.5.1 Minimum offered 6.2.5.2 Maximum offered 6.2.5.3 Sum insured rebates /discounts offered, if any (please provide objective and transparent criteria to offer rebates and financial justifications by AA-no discretion allowed to the insurer in offering such rebates/discount s) Policy Period: 6.2.6.1 Minimum

6.2.5

6.2.5

6.2.6

Annexure - V

Policy period offered

6.2.7

6.2.6.2

Maximum Policy period offered

6.2.6.3

Premium paying terms, if different from policy term

Modes of Premium Payment Offered: 6.2.7.1 State the modes o f premium payment allowed- (Single premium /annual/ halfyyearly, etc.) 6.2.12

6.2.8

Rebates/charges for different modes offered, with justifications from A A:

Annualised Premium (for group give the details per member) 6.2.8.1 Minimum: 6.2.8.2

Maximum:

6.2.8.3

Premium rebates /discounts offered, if any (please provide objective and transparent criteria to offer rebates and financial justifications by AA-no discretion allowed to the insurer in

Annexure - V

6.2.9

offering such rebates/discount s) Entry Age: 6.2.9.1 Minimum: 6.2.9.2 Maximum:

6.2.10

Maximum renewal Age, for age specific products

6.2.11

Restrictions on travel outside India (If YES, specify the conditions]

YES/NO

6.2.12

Any other restrictions [If there is restriction proposed, the same should be furnished, e.g. future occupation]

YES/NO

6.2.13

Deductibles allowed Co-pay allowed Staff rebates or any other Rebates offered— ( please provide objective and transparent criteria to offer rebates and financial justifications by AA-no discretion allowed to the insurer in offering such rebates/discounts) Any other discounts offered— ( please provide objective and transparent criteria to offer rebates and financial justifications by AA-no discretion allowed to the insurer in offering such rebates/discounts) Any loadings proposed— ( please provide objective and transparent criteria to offer rebates and financial justifications by AA-no discretion allowed to the insurer in offering such rebates/discounts)

i 6.2.14 6.2.15

6.2.16

i 6.2.17

Annexure - V

6.2.18 6.3

Subrogation, if any

Product details: 6.3.1 Is the Product filed for Yes/No the first time? 6.3..1. If no, furnish the date of first filing of the product. I f yes, please go to item no 7 directly.____________________________________ 6.3.1.2 Please give the proposed modifications in tab u lar form S.no Existing Features / Proposed Justification Any assumptions/premi modification for such supporting urns rates -w hich s modification data for are proposed to such modify___________ modification

6.3.2

Whether the product Yes/No features/assumptions/pre mium rates have been modified from the date of clearance? 6.3.2.1 If Yes, Please give the information of all the modifications carried out till date in tab u lar form :-H istory of modifications carried out till date: SN o Date of Exisitng Features/Ass Date of modificati Features/A of um ptions/pre clearance on filed ssumpitons/ mium rates the with the premium modified modification Authority rates as on from the from the date of first/subsequ A uthority and clearance ent filing i.e. the unique the identification of the after product i.e. clearance of num ber before the the allotted modificatio modification n

Benefit Structure of the Product. [This section should describe the various contingencies under which 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 Insured: 7.1

On Hospitalization

Annexure - V

7.2

On events other than (7.1) (please furnish the complete details seperately for each benefit offered)

7.3 7.4

On cancellation by the insured: On cancellation by the insureronly allowed on grounds of misrepresentation, fraud, non­

7.7

disclosure or non-cooperation of the insured Specify Non-forfeiture conditions [When the contract would be not null and void] 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 product.The charges, if any, towards the cost of the option shall also be specified. 1 Procedure for renewal

7.8

Riders / ADD-ons

7.5 7.6

7.8.1

7.8.2

8

8.1 8.2

Riders / Add-ons attached to the product

S.No

Rider/Add­ on Name

UIN alloted by IRDA

Date of clearance

Any other features that may be relevant for the product. 7.8.3 How the rider will benefit the insured if taken along with this product 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.) Specify Non-medical Limit [No medical examination asked fori Specify when and what classes of lives would be subject to medical examination

Annexure - V

8.3

9

Specify the minimum participation of membership for groups. Exclusions: please specify time bound exclusions have been proposed for payment of benefits Exclusions: please specify permanent exclusions have been proposed for payment of benefits Other Terms:

9.1

Nomination

9.2

Conditions for revival of the contract, in case of installment/regular premiums: Distribution Channels & New Business Strain. Distribution channels: 10.1.1 Specify the various 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] 10.1.2 Commission scales to distribution channels— specify the rates which are to be paid-[reply shall be specific and can not refer to the replies like “as per the “Act”] Expected proportions of business Distributio to be procured by each channel n shall be indicated for the next 5 Channel years. l.Individua 1 Agents 2. Corporate Agents 3. Brokers 4. Othersspecify

8.4 8.5

10 10.1

10.2

10.3

New Business Strain, if any

Yea r1

5. Total Year 1 Year 2

Year 2

Year 3

Yea r3

Yea r4

Year 4

Yea r5

Year 5

Annexure - V

11 11.1 11..2 11.3 11.4 11.5 11.6

Reinsurance arrangements: Retention limit Name of the reinsurer (s) Terms of reinsurance(type of reinsurance, commissions, etc.). Any recapture provisions shall be described. Reinsurance rates provided Whether a copy of the reinsurance program and a copy of the Treaty is sumbitted to the Authority. 11.6.1

12 12.1

12.2 12.3

12.4

12.5

12.6

Yes/NO

Whether reinsurance Yes/No program and a copy of the treaty enclosed (required only if these are not filed with the Authority previously) Pricing: The pricing assumptions and the methodology may vary depending on the nature of product. Give details of the following Give the actuarial formulae, if any, used; if not, state how premiums are arrived at giving briefly the methodology and details): Source of data (internal/industry/ reinsurance) Rate of morbidity [The tables whereever relevant shall be the prescribed one.] Rates of policy terminations, if any. [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 .] Rate of interest, if any. [The rate or rates must be consistent with the investment policy of the insurer.] Commission scales [Give rates of commission. These are explicit items.]

Annexure - V

12.7

12.8

12.9

12.10 12.11 12.12 12.13 12.14

12.15

12.16

12.17

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.] 12.7.1 First year expenses by : sum assured related, premium related, per policy related 12.7.2 Renewal expenses, where relevant (including overhead expenses) by : sum assured related, premium related, per policy related 12.7.3 Claim expenses 12.7.4 Future inflationary increases, if any allowed in pricing Allowance for transfers to shareholder, if any: [Please see section 49 of the Insurance Act, 1938] Taxation. [Please see the relevant sections of the Income Tax Act, 1961] Any other parameter relevant to pricing o f product -please specify Reserving assumptions (please specify all the relevant details) Base rate (risk premium)-fumish the rate table, if any Gross premium- furnish the rate table. Expected loss ratio (for the product) -to be furnished for each plans offered within the product separately Age-wise loss ratio- to be S.No Age Loss ratio furnished for each plans offered within the product separately Sum insured-wise- loss ratio to be S.No SA Loss ratio furnished each plans offered within the product separately Age and sum insured wise loss Table given below (SI band and age bands ratio - to be furnished for each shall be increased depending on the minimum plans offered within the product and maximum SI offered) separately

Annexure - V

S.NO

12.18

12.19 12.20

12.21

SI/Age 25000 50000 100000 150000 200000 bands 1 >=0=3=16=26=31=36=41=46=51=56=61=66 Expected combined ratio (for the product) -to be furnished for each plan separately Age-wise combined ratio- to be furnished for each plan separately Sum insured-wise- combined ratio to be furnished for each plan separately Age and sum insured wise Table given below (SI band and age bands combined ratio - to be furnished shall be increased depending on the minimum for each plan separately and maximum SI offered) S.NO SI/Age 25000 50000 100000 150000 200000 bands 1 >-0=3=16=26=31=36=41=46=51=56=61=66 Expected cross-subsidy between age/sum insured/ plans etc Experience of similar products, if any S.No Expos Premi Numb ure um - er of claim Rs. s 7

12.22 12.23

13 13.1 13.2

Incur red claim s-Rs.

Claim frequ ency

Aver age cost per claim

Burni ng costRs.

Loss ratio

Comb ined ratio

200809 200708 200607 200506 200405 1. Exposure: earned life year (no of life earned during a p articu lar financial year); 2. Prem ium : premium earned during the financial year; 3.Num ber of claims: claims occurred during the financial year; 4. Incurred claims: Incurred am ount 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; Revision in pricing for existing products Justification for change/ modification in premium Experience of the product across In addition to the experience of sim ilar plans / sum insured / age bands products in Item 12.23, these tables to be furnished for the product for which revision

Annexure - V

in pricing is requested 13.3

14

14.1 14.2 14.3 14.4 14.4

How the pricing methodology differs between sum insured options, if any 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.j Risk discount rate used in the profit margin Average Sum Insured Assumed Assumptions made under pessimistic scenario Assumptions made under optimistic scenario Age [PM: Profit Margin/Loss PM (base PM (pessimistic Ratio] scenario) scenario) >=0=3=16=26=31=36=41=46=51=56=61=66 15

The following specimen documents shall be enclosed:

15.1 15.2

Proposal Form: 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). Policy Document along with policy schedule

15.3

Annexure - V

15.4 15.5

Underwriting Manual Claims Manual

15.6 15.7 15.8 15.9

Premium Table Certificates -Form A, Form B and Form C Customer information sheet Database sheet

16. Certification. The Insurer shall enclose a certificate from the Appointed Actuary, countersigned by the 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 Date:

Signature of the Appointed Actuary.

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

Annexure-V Form A

FILING OF GENERAL INSURANCE PRODUCT Name of insurer: Date of filing: Class of insurance: Name of product:

Certificate by Principal Officer Or Designated Officer This is to confirm that: 1. The rates, term s and conditions of the above-m entioned product filed with this certificate have been determ ined in compliance with the IRDA Act, 1999, Insurance Act, 1938, and th e Regulations and guidelines issued thereunder, including the File and Use guidelines. 2. The prospectus, sales literature, policy and endorsem ent docum ents, and the rates, term s and conditions of the product have been prepared on a technically sound basis and on term s that are fair betw een the insurer and the client and are set out in language that is clear and unambiguous. 3. These docum ents are also fully in com pliance with the underwriting and rating policy approved by the Board of Directors of the insurer. 4. The statem ents m ade in the filing Form A are true and correct. 5. The requirem ents of th e revised File and Use guidelines have been fully com plied with in respect of this product.

Date: Place:

Signature of Principal Officer or Designated Officer Name and designation

Annexure-V Form B

FILING OF GENERAL INSURANCE PRODUCT Name of insurer: Date of filing: Class of insurance: Name of product:

Certificate by Appointed Actuary This is to confirm that: 1. I have carefully studied th e requirements of the File and Use Guidelines in relation to th e design and rating of insurance products. 2. The rates, term s and conditions of the above-m entioned product are determ ined on a technically sound basis and are sustainable on the basis of information and claims experience available in the records of the insurer. 3. An adequate system has been put in place for collection of data on premiums and claims based on every rating factor that will enable review of the rates and term s of cover from tim e to tim e. It is planned to review the rates, terms and conditions o f cover based on emerging experience (enter periodicity o f review).

4.

Date: Place:

The requirem ents of th e revised File and Use guidelines have been fully complied with in respect of this product.

Signature of Appointed Actuary Name and designation

Annexure-V Form C

FILING OF GENERAL INSURANCE PRODUCT Name of insurer: Date of filing: Class of insurance: Name of product:

Certificate by th e Lawyer of the insurer This is to confirm that: 1.

2.

3.

Date: Place:

I have carefully studied the prospectus, sales literature, policy wordings and en dorsem ent wordings relating to the above-m entioned product in the light of the IRDA (Protection of Policyholders' Interests) Regulations 2002, and the File and Use Guidelines. The above m entioned docum ents are written in clear unambiguous language, and properly explain the nature and scope of cover, the exceptions and limitations, the duties and obligations of the insured and the effect of non-disclosure of material facts. These docum ents are in compliance with the Policyholders' Protection Regulations and Insurance Advertisem ents and Disclosure Regulations.

Signature of Lawyer Name and address

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 o f Categorization is provided at Appendix 1. Accordingly, insurers have to provide the Categorization in the order o f 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: (Autom atically generated field after product approval by Authority)

..................

B. PROCESSING HISTO RY (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 com m unicated on (DDMMYY): Text of any M ajor Policy Stand/ Observation by Chairm an/M em ber on this product file:

Annexure-VI

C. PRODUCT DETAILS C.a. Hospitalization : Contingencies covered: Contingency

Covered (Y/N)

Sub-Lim its in % of SI, if applicable

Sub limits in fixed rupee terms, if applicable

Room charges Boarding charges for patient Nursing charges for patient ICU charges Medical Practitioners Fees Operation Theatre charges Surgical Consum ables Prescribed drugs Diagnostic tests Cost of blood Cost of transplantation Hospitalization expenses of donor Cost of artificial limbs Cost of pacemakers Parenteral Chem otherapy Radiotherapy Haemodialysis Domiciliary Hospitalization Am bulance charges Maternity expenses Neonatal expenses Funeral expenses Pre-hospitalization expenses Post-hospitalization expenses Cost of periodic health check­ up for policies w ithout claims Cost of periodic health check­ up for policies with claims Day Care procedures covered Dental Procedures Hearing Aids Spectacles/ contact lens A ny other contingency covered W hether any waiver of sub-lim its is available in different plans or at different terms: Y/N If yes, details of sub-lim its which can be waived and term s for the sam e : __

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

Any sub­ Period in months Any sub­ limits in % (Mention 'O' if no limits in of S.l. terms rupee terms waiting period)

General waiting period for new covers (except accidents) Pre-existing diseases Cataract Hernia or Hydrocele Benign Prostate Hypertrophy Hysterectom y (non-m alignant) Fistula in Anus, Anal Fissure, Piles Sinusitis Gall Bladder Stones Joint replacem ent 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) H eart Disease (old product) Cancer (old product) Hypertension (old product) Diabetes (old product) A ny other waiting p e rio d / sub-limit. If any other waiting period/ sub-lim its are applicable, details of the same.

C.c. Exclusions: Type of exclusion Pre-existing disease for non-indem nity or non­ domestic policies War, invasion, war like operation Circumcision unless m edically necessary

Applicable Special (Y/N) conditions, if any

Annexure - VI

Vaccination/inoculation except post-bite Venereal diseases and HIV/AIDS Pregnancy/ Maternity except ectopicjDregnancy Voluntary term ination of pregnancy Fertility or assisted conception Treatm ent of obesity Cosmetic or aesthetic procedures except for burns/ injuries etc. Change of life/ sex-change Spectacles or contact lens Hearing Aids Dental treatm ent except requiring hospitalization Convalescence/ debility Intentional self-injury/ suicide attem pt Influence of intoxicating drugs or alcohol Expenses unlinked to active treatm ent in hospital Nuclear w eapons/m aterial OPD expenses except pre and post­ hospitalization as covered under Scope Naturopathy or Yoga Ayurvedic M edicine Hom eopathic M edicine Unani Medicine Unrecognized system s of m edicine Speed contest, racing, adventure sports Durable or external medical equipm ent required post-operatively Personal com fort and convenience items Hormone replacem ent therapy Mental Illness Any other If any other exclusion applies, details of the same.

C.d. Age Limits Minimum Age at Entry -A d u lt (Years) Maximum Age at Entry -A d u lt (Years)^ Maximum Age till which renewal is available -A d u lt (Years) Minimum Age at Entry -C h ild (Months) Maximum age up to which dependent children who are unmarried and unemployed can be covered (Years)

Annexure - VI

C.e. Cost sharing: Cost Sharing Details

Applicable (Y/N)

Details

Applicable (Y/N)

Percentage

Does the policy have com pulsory deductibles Does the policy have voluntary deductibles Cost Sharing Details Does the policy require any com pulsory co-pay in network hospitals Does the policy have option for voluntary co-pay in network hospitals Does the policy require any com pulsory co-pay in non-network hospitals Does the policy require any com pulsory co-pay in hospitals outside a specified geographical area? Does the policy require any com pulsory co-pay for pre-existing diseases? Does the policy require any com pulsory co-pay for ‘packaged’ charges by hospitals? Any other sub-lim its? If any other cost sharing applies, details of the same.

C.f. Loyalty Benefits Offered At first (Y/N) renewal 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.

At second renewal (cum ulative)

Maxim um

Annexure-

C.g. Other Term s and Conditions Applicable (Y/N)

Term s/Conditions

Details as applicable

W hether the policy is only available to a restricted group (e.g. custom ers of a bank) W hether the policy is only intended for claims arising in a specified and limited network of medical providers? W hether change in risk is to be intimated on renewal W hether TPA being used for the product W hether there is a Premium Installment option W hether increase in sum insured permissible at renewal W hether change of options/plans within same product permissible at renewal W hether inward migration allowed from other products of same insurer W hether inward migration allowed from other/ similar products of any insurer W hether there are any restrictions on renewal of specific sections/ com ponents before the maximum renewal age fo r the product W hether parents are covered under the policy? W hether cancellation at option of insurer is on pro­ rata basis? W hether cancellation at option of insurer for fraudulent cases is on ‘no refunds’ basis W hether 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 Insured (in Rs)

Minimum sum insured available Premium charged for Rs. 2 lakhs sum insured where applicable Premium charged

Sum Insured (Rs)

2 00 ,00 0

300,000

Premiums applicable at different ages (Rs. per annum) For 25 For 30 For 40 For 50 For 60 For 65 For 70 years years years years years years years

Annexure -

for Rs. 3 lakhs sum insured where applicable Maximum sum insured available

C.i. Reinsurance Details: Y/N

Reinsurance Details Any reinsurance other than obligatory cession If yes, w hether pricing is linked to reinsurance rates

Details

C.j. Critical Illness Coverage: Covered (Y/N)

C.j.1. Critical Illness

If yes, details thereof

If Critical Illness is an additional com ponent of a wider health cover, w hether sum insured for Critical Illness is different from that for the primary com ponent C.j.2. Critical Illness

Covered (Y/N)

If yes, survival period required in num ber of days

Survival Period required C.j.3. Critical Illness

Covered (Y/N)

Period

Stroke resulting in perm anent sym ptom s 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 replacem ent of heart valves Motor Neuron Disease with permanent symptoms Permanent Paralysis of Limbs Major Injuries Major Burns Others f any other critical illness cover is applicable, details of the same.

If modified from Standard Definitions, details

Annexure-

C.k. Hospital Cash Coverage: If yes, details thereof

Covered (Y/N)

C.k.1. Hospital Cash If Hospital Cash is an additional com ponent of a wider health cover, w hether the am ount of hospital cash cover is linked to sum insured C.k.2. Hospital Cash

Minimum Stay required (days)

Deductib le if any (days)

Maximum Period Covered (days)

Minimum Daily Payout option (Rs)

Maximum Daily Payout option (Rs)

Room ICU Accidental A ny other C.l. High Deductible Coverage: A m ount (Rs.)

High Deductible Coverage 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. O utpatient Coverage

Y/N

If yes, Fixed Prem ium (Rs.)

Y/N

Period (MM/YY)

Is the policy modeled as fixed total premium and variable OPD sum insured? C .m .2. O utpatient Coverage Is there any restriction on period? If yes, the period till which IRDA approval was given for this com ponent C .m .3. Outpatient Coverage Minimum OPD Cover offered Maximum OPD cover offered

OPD Premiums applicable for different ages Sum (Rs. per annum) Insured (Rs) For 25 For 30 For 40 For 50 For 60 For 65 For 70 years years years years years years years

Annexure -

C.n. Travel Coverage: C.n.1. Travel Coverage

Applicable (Y/N)

If yes, days

Condition s i Details

Minimum duration of travel specified Maximum duration of travel specified Coverage for em ergency evacuation-ground Coverage for em ergency evacuation-air ambulance Coverage for em ergency hospitalization Coverage for em ergency OPD expenses Coverage for em ergency repatriation Coverage for repatriation of mortal remains Coverage for attendant travel Coverage for loss of baggage Coverage for loss of passport Coverage for em ergency stabilization in case of pre-existing diseases Coverage beyond em ergency stabilization in cases with pre-existing diseases TPA used for servicing policies Any Other Coverage C .n.2. Travel Coverage

Applicable (Y/N)

If yes, Code

Details

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

Applicable (Y/N)

Rank by Priority/ W eightage

Annexure - VI

C.o.2. Expected Claim Ratio Expected incurred claim ratio in first completed year Expected incurred claim ratio in second completed year Expected incurred claim ratio in third completed year Applicable (Y/N)

C.o.3. Underwriting Details

Percentage

If yes, Age after which required

W hether entirely pre-underwritten Pre Insurance Medical Examination requirement W hether required at an earlier age based on proposal form details C.o.4. Underwriting Details

Applicable (Y/N)

Criteria filed with IRDA (Y/N)

Maximum loading/ 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. A ny other underw riting criteria If any other underwriting criteria are applicable, details of the same.

Addl. Com m ents/ Rem arks/ Notes:

10

Annexure-VI

INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY DETAILS FOR FILE AND USE APPROVAL OF HEALTH INSURANCE PRODUCTS

1 2

A & B. P R O D U C T IN D E X & P R O C E S S IN G H IS T O R Y C. P R O D U C T D E T A IL S C .a. H o s p ita liz a tio n : C o n tin g e n c ie s co vered

3 4 5 6 7 8 9 10 11

C .b. W a itin g p erio d s an d s u b lim its fo r s p ecified d is e a s e s C .c. E x c lu s io n s C .d. A ge L im its & C .e. C o s t sh arin g C.f. L o yalty B e n e fits & C .g. O th e r T e rm s and C o n d itio n s C .h. S um In s u re d an d R ate S tru c tu re fo r P rim ary M e m b e r & C.i. R e in s u ra n c e D etails C .j. C ritic a l Illn e s s C o v e ra g e & C .k. H o sp ital C ash C o v e ra g e C .I. H igh D e d u c tib le C o v e ra g e & C .m . O u tp a tie n t C o v e ra g e C .n. T ra ve l C o v e ra g e C .o. P ricin g C rite ria , E x p e c te d C laim R atio & U n d e rw ritin g D etails

2- O

■2



2 -0

12

Annexure - VII

Customer Information Sheet Description is illustrative and not exhaustive s.

DESCRIPTION

TITLE

NO

1 2

Product Name What am I covered for:

3

What are the major exclusion s in the policy:

4

Waiting period

5

Payout basis Cost sharing

6



Approved Brand Name

• •

Hospital admission longer than xx hrs Related medical expenses incurred xx days prior to hospitalisation / amounting to x% o f claim • Related medical expenses incurred within xx days from date o f discharge / amounting to x% o f claim • Specified / Listed procedures requiring less than 24 hours hospitalisation (day care) • Cover for xx critical illnesses on undergoing specified procedure or on diagnosis o f an illness o f specified severity • Hospital daily cash benefit o f Rs__per day • OPD / Dental / M aternity coverage • Emergency or Travel Medical Assistance etc • Any hospital admission primarily for investigation / diagnostic purpose • Pregnancy, infertility, congenital/genetic conditions, • Non-allopathic medicine, • Domiciliary treatment, treatment outside India. • Circumcision, sex change surgery ,cosmetic surgery & plastic surgery, • 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 o f law, • Any kind o f service charge, surcharge, admission fees, registration fees levied by the hospital. (Note: the above is a partial listing o f the policy exclusions. Please refer to the policy clauses for the full listing). • Initial waiting period: 30 days for all illnesses (not applicable on renewal or for 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 fif) o 48 months for xx diseases (clauses gg to hh) • Pre-existing diseases: Covered after m onths/N ot covered • Reimbursement o f covered expenses up to specified limits AND / OR • Fixed amount on the occurrence o f a covered event • In case o f a claim, this policy requires you to share the following costs: o Expenses exceeding the following Sub-limits ■ Room / ICU charges beyond ■ For the following specified diseases: ■ ■ o

Deductible o f Rs XXX per claim /p e r year / both xx% o f each claim as Co-payment (yy % in a non-network hospital) Your policy is ordinarily renewable (OR Guaranteed) up to age x (OR for x years) After you attain the age o f x years, the following features o f your policy change:

o

7

Renewal Conditio ns

• •

o o •

....................

-----------------------------------

Other terms and conditions o f renewal

(L E G A L D IS C L A IM E R ) N O TE : The information must be read in conjunction with the product brochure and policy document. In case o f any conflict between the KFD and the policy docum ent the terms and conditions mentioned in the policy docum ent shall prevail.

REFER TO POLICY CLAUSE NUMBER

A n n ex ure - VII

S. NO

8.

DESCRIPTION

TITLE

Renewal Benefits:

• • •

9.

Cancella tion



x% increase in your annual limit for every claim free year (or) x% discount on renewal premium, subject to a maximum o f 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 o f x claim free policy years, free health check up for the insured persons subject to maximum x% o f sum insured. This policy would be cancelled, and no claim or refund would be due to you if: 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 DISCLAIM ER) NOTE: The information must be read in conjunction with the product brochure and policy document. In case o f any conflict between the KFD and the policy document the terms and conditions mentioned in the policy docum ent shall prevail.

REFER TO POLICY CLAUSE NUMBER

^v[ox Annexure: VIII Minimum Standard Clauses necessarily to be included in the Service Level Agreement between Insurer and the Third Party Administrator: The services rendered by the TPA to the insurer shall be in accordance with the provisions of the Insurance Act, 1938, extant regulations, guidelines in this regard. The Authority may, from time to time, prescribe clauses to be included in the agreements which shall be entered into between insurers and TPAs and such agreements shall cover the following amongst others: 1. The specific services to be rendered by the TPA, the procedure, as prescribed by the insurer, to be followed by the TPA for providing each o f such services as agreed to. 2. The fee payable to the TPA for each o f the services rendered by the TPA as detailed below. The complete details on the basis on which payment becomes payable shall be documented. Rate of Service Fee Service Provided

Fee payable

3. Turnaround times for each o f the services rendered by the TPA, the course o f action in case o f default o f services. 4. The TPA / insurer responsibilities in enforcing the agreement. 5. Confidentiality requirements 6. Termination notice 7. Inspection, Audit and Access rights o f the TPAs on regular and ad-hoc basis 8. Arbitration and Dispute resolution 9. The minimum details on the id-cards including photograph o f the insured, name o f the insurer, emergency contact number, logo o f the insurer 10. Issue of ID cards, cost o f issuing the ID cards and the course o f action in case of default 11. Procedure for cashless facility as in Schedule-I 12. Procedure for de-empanelment o f network providers as in Schedule-II 13. Customer services and relations 14. Services rendered by the TPA shall compliance with the extant laws. 15. Intimation o f changes in the key positions in the office o f the TPA. 16. Code o f conduct.

Schedule-I

Provider Services- Cashless Facility Admission Procedure The insured shall be provided treatment free of cost for all such ailments covered under the policy within the limits / sub-limits and the sum insured, i.e., not specifically excluded under the policy. The Provider shall be reimbursed as per the tariff agreed under the service level agreement for different treatments or procedures. The procedure to be followed for providing cashless facility shall be:

I.

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 preauthorization form prescribed by the Authority i.e. “request for authorization letter” (RAL). The RAL shall 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 insured. The insurer’s or its representative TPA’s medical team may consult the treating physician or the insured, if necessary. 2. If the treating physician of the provider identifies any disease or ailment as pre-existing, the treating physician shall record it and also inform the insured immeidately. 3. In the cases w here the symptoms appear vague / no effective diagnosis is arrived at, the medical team o f the insurer or its representative TPA may consult with treating physician /insured, if necessary. 4. The RAL shall reach the authorization department of insurer or its representative TPA 7 days prior to the expected date of admission, in case of planned admission. 5. If “clause 3”above is not follwed, the clarification for the delay needs to be forwarded along with the request for authorization. 6. The RAL form shall be dully filled with clearly mentioning Yes or No and/or the details as required. The form shall not be sent with nil or blanks replies. 7. The guarantee o f payment shall be given only for the medically necessary treatment cost o f the ailment covered and mentioned in the request for hospitalization. Non covered items i.e. non-medical items which are specifically excluded in the policy, like Telephone usage, food provided to relatives/attendants, Provider registration fees etc shall be collected directly from the insured. 8. T he auth o rizatio n letter by the insurer o r its rep resen tativ e T P A shall clearly indicate th e am o u n t agreed fo r p ro v id in g cashless facility fo r hospitalization. 9. In event of the cost of treatment increasing, the the provider may check the availability of further limit with the insurer or its representative TPA. 10. When the cost o f treatment exceeds the authorized limit, request for enhancement o f authorization limit shall be made immediately during hospitalization using the same format as for the initial preauthorization. The request for enhancement shall be evaluated based on the availability of further limits and may require to provide valid reasons for the same. No enhancement o f limit is possible after discharge of insured. 11. Further the insurer shall accept or decline such additional expenses within a maximum of 24 hours of receiving the request for enhancement. Absence o f receiving the reply from the insurer within 24 hours shall be construed as denial of the additional amount.

12. In case the insured has opted for a higher accommodation / facility than the one eligible under the polciy, the provider shall explain orally the effect o f such option and also take a written consent from the insured at the time of admission as regard to owing the responsibility o f such expenses by the insured including the proportionate e x p en se s w h ich h av e a d ire c t b e arin g d u e to up g ra d a tio n o f room accommodation/facility. In all such cases the insuer shall pay for the expenses which are based on the eligibility limits o f the insured. H ow ever provider may charge any advance amount/security deposit from the insured only in such cases where the insured has opted for an upgraded facility to the extent of the amounts to be collected from the insured. 13. Insurance company guarantees payment only after receipt of RAL and the necessary medical details. The Authorization Letter (AL) shall be issued within 48hours of receiving the RAL. 14. 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 or its representative TPA shall seek further clarification/ information immeidately. 15. Authorisation letter [AL] shall mention the authorization number and the amount guaranteed for the procedure. 16. In case the balance sum available is considerably less than the cost of treatment, provider shall follow their norms of deposit/running bills etc. However, provider shall only charge the balance amount over and above the amount authorized under the health insurance policy against the package or treatment from the insured. 17. Once the insured is to be discharged, the provider shall make a final request for the pre­ authorization for any residual amount along with the standard discharge summary and the standar billing format. Once the provider receives final pre-authorization for a specific amount, the insured shall be allowed to get discharged by paying the difference between the pre-authorised amount and actual bill, if any. Insurer, upon receipt of the complete bills and documents, shall make payments of the guaranteed amount to the provider directly. 18. Due to any reason if the insured does not avail treatment at the Provider after the pre­ authorization is released the Provider shall return the amount to the insurer immediately. 19. All the payments in respect of pre-authorised amounts shall be made electronically by the insurer to the provider as early as possible but not later than a week, provided all the necessary electronic claim documents are received by the insurer. 20. Denial of authorization (DAL) for cashless is by no means denial of treatment by the health facility. The provider shall deal with such case as per their normal rules and regulations. 21. Insurer shall not be liable for payments to the providers 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. 22. Provider, Insurer and its representative TPA shall ensure that the procedure specified in this Schedule is strictly complied in all respects. II.

Preauthorization Procedure - Emergency Admissions:

1. In case o f emergencies also, the procedure specified in I (1), (2) and (3) shall be followed. 2. The insurer or its representative TPA may continue to discuss with treating doctor till conclusion of eligibility o f coverage is arrived at. However, any life saving, limb saving, sight saving, emergency medical attention cannot be withheld or delayed for the purpose

Schedule-I

o f 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 shall refund the deposit amount to the insured if taken barring a token amount to take care o f non covered expenses. III.

Preauthorization Procedure - RTA / MLCs:

1. If requesting a pre-authorisation for any potential medico-legal case including Road Traffic Accidents, the Provider shall indicate the same in the relevant section of the standard form. 2. 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 insurer or its representative TPA. IV.

Authorization letter (AL):

1. Authorization leter shall 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, if any. The Provider shall see that these rules are strictly followed; else the AL will be considered null and void. 3. In the event the room category, if any, is not available the same shall be informed to the insurer or its representative TPA and the insured. For such cases, if the insured is admitted to a class o f accommodation higher than what he is eligible for, the provider shall collect the necessary difference, if any, in charges from the insured. 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. V.

Reauthorization:

1. Where there is a change in the line of treatment - a fresh authorization shall be obtained from the insurer immediately - this is called a reauthorization. 2. The same pre-authorisation form shall be used for the reauthorization, and the same turnaround times as specified shall apply. VI.

Discharge:

1. The following documents shall be included in the list o f documents to be sent along with the claim form to the insurer or its representative TPA. These shall not be given to the insured. a. Original pre authorization request form, b. Original authorization letter, c. Original investigation repots,

Schedule-I

d. All original prescription & pharmacy receipt etc 2. Where the insured requires the discharge card/reports 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 insurer". 3. The discharge card/Summary shall mention the duration of ailment and duration of other disorders like hypertension or diabetes and operative notes in case o f surgeries. The clinical detail shall be sufficiently and justifiably informative. In addition, the Provider shall provide all the relevant details pertaining to past treatment availed by the insured in the Provider. 4. Signature o f the insured on final Provider bill shall be obtained. 5. In the event of death or incapacitation of the insured, the signature of the nominee or any of insured’s of the family who represents the insured as such subject to reasonable satisfaction of Provider shall be sufficient for the insurer to consider the claim. 6. Standard Claim form duly filled in shall be presented to the insured for signing and identity of the insured shall be confirmed by the provider. Billing: 1. The Provider shall submit original invoices directly to insurer or its representative TPA and such invoices shall contain, at the minimum, following information: a. the insured's full name and date of birth; b. the policy number; c. the insured'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 or any other code as specified by the Authority from time to time; g. the diagnosis at the time treatment and diagnosis code according to ICD-10 or any other code as specified by the Authority from time to time; h. whether this is an interim or final bill/account; i. the description o f 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 insured's signature (in original). 2. 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 insured and the treating consultant for the treatment performed; c. original and complete discharge summary in standard form and billing form in the standard form, 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 insured's policy; and g. photocopy o f the insured's photo identification (eg voter's Smart card/ ID card, passport or driving licence etc). 3. The Provider shall submit the final invoice and all supporting documentation required within 2 days of the discharge date.

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 o f a Provider, the Insurance Company can put that Provider on the watch list. 2. The data o f such Provider shall be analysed very closely on a daily basis by the Insurance Company for patterns, trends and anomalies. Step 2 - Suspension of the Provider 3. 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. 4. 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 5. 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 6. The detailed investigation may include field visits to the Providers, examination of case papers, talking with the policyholders/insured (if needed), examination o f Provider records etc. 7. 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). 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 8. 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. b. After receipt of the explanation and its examination, the charges may be dropped or an action can be taken.

Schedule-II c. The action could entail one of the following based on the seriousness o f the issue and other factors involved: i. A warning to the concerned Provider, ii. De-empanelment o f the Provider. 9.

The entire process should be completed within 30 days from the date o f suspension.

Step 5 - Actions to be taken after De-empanelment 10. 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. 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 deempanelment 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 deempanelment, 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, the aforementioned actions shall be subject to the dispute resolution process agreed in the service level agreement.

/ . -ZL_

A nnexure - IX

Agreement between Insurers, Network Providers and/or TPAs

Insurance companies may offer policies providing cashless services to the policyholders provided the services are offered in network providers who have been enlisted to provide medical services either directly under an agreem ent with the insurer or by an agreem ent between health services provider, the TPA and the insurer. The provider em panelm ent shall be made based on the information furnished in th e standard em panelm ent form as in Schedule-V. The Authority may, from time to time, prescribe clauses to be included in such agreem ents as stipulated in the Agreements which shall be entered into betw een insurers, network providers/TPAs and shall cover the following amongst others: 1. Scope of services provided by the network provider 2. the tariff applicable with respect to various kinds of healthcare services being provided by the network provider. 3. a clause empowering the insurer to cancel or otherwise modify the agreem ent in case of any fraud, misrepresentation, inadequacy of service or other non-compliance or default on the part of TPA or network provider; provided no such cancellation or modification shall be done by the insurer unless the concerned TPA/ network provider is given an opportunity of being heard. 4. a standard clause providing for continuance of services by a network provider to the insurance company if the TPA is changed or the agreem ent with TPA is term inated. 5. a clause providing for opting out of network provider from a given TPA for reasons of inadequacy of service rendered by the TPA to the network provider. 6. a clause specifically requiring only the insurance company the power to deny a claim. 7. a clause enabling insurer to inspect the premises of the network provider at any time without prior intimation.

Annexure - IX

8. Turnaround times for each of the services rendered by the parties, the course of action in case of default of services. 9. The responsibilities and obligations o f each o f the parties to the agreement in enforcing the agreement. 10. Display o f information by the network provider at prominent location, preferably at the reception and admission counter and Casualty/Emergency departments. 11. Confidentiality requirements 12. Termination notice 13. Inspection, Audit and Access rights o f the network providers and the TPAs involved on regular and ad-hoc basis 14. Arbitration and Dispute resolution 15. Procedure for cashless facility as in Schedule-I 16. Procedure for de-empanelment o f network providers as in Schedule-II 17. Procedure to furnish the standard Discharge summary as in Schedule-Ill 18. Procedure to furnish the standard Billing Format as in Schedule-IV 19. Payments to be m ade through direct electronic fund tran sfer subject to deduction of tax at source as applicable under the relevant laws. 20. Payment Reconciliation process on a regular basis. 21. Customer services and relations 22. Services rendered by the TPA shall compliance with the extant laws. 23. Code o f conduct.

Schedule-Ill

STANDARD DISCHARGE SUMMARY: 1. Components o f standardization: a. List o f standard contents in the discharge summary b. Standard guidelines for preparing a discharge summary so that the interpretation o f the terms in the document and the information provided is uniform. 2. Standard Contents o f Discharge Summary Format: a. Patient’s Name*: b. Telephone No / Mobile No*: c. IPDNo: d. Admission No: e. Treating Consultant/s Name, contact numbers and Department/Specialty : f. Date o f Admission with Time : g. Date o f Discharge with Time : h. MLC N o /F IR N o * : i. Provisional Diagnosis at the time o f Admission: j. Final Diagnosis at the time o f Discharge: k. ICD-10 code(s) or any other codes, as recommended by the Authority, for Final diagnosis*: 1. Presenting Complaints with Duration and Reason for Admission: m. Summary o f Presenting Illness: n. Key findings, on physical examination at the time o f admission: o. History o f alcoholism, tobacco or substance abuse, if any: p. Significant Past Medical and Surgical History, if any*: q. Family History if significant/relevant to diagnosis or treatm ent: r. Summary of key investigations during Hospitalization*: s. Course in the Hospital including complications if any*: t. Advice on Discharge*: u. Name & Signature of treating Consultant/ Authorized Team Doctor: v. Name & Signature of Patient / Attendant*: * refer to guide notes below: 3. GUIDE NOTES FOR FILLING DISCHARGE SUMMARY FORMAT: a. The patient’s name shall be the official name as appearing in the insurance policy document and the attendants should be made aware that it cannot be changed subsequently, because in some cases the attendants give the nick names which are different from documented names. As a matter o f abundant precaution, all personal information should be shown to the patient/attendant and validated with their signatures. b. The contact numbers shall be specifically those o f the patient and if pertaining to attendant, the same should be mentioned. c. Where applicable, copy o f MLC/FIR needs to be attached d. Desirable not mandatory e. Significant past medical and surgical history shall be relevant to present ailment and shall provide the summary of treatment previously taken, reports of relevant tests conducted during that period. In case history is not given by patient, it should be specified as to who provided the same.

Schedule-lll

f.

Summary o f key investigations shall appear chronologically consolidated for each type o f investigation. If an investigation does not seem to be a logical requirement for the main disease/line o f treatment, the admitting consultant should justify the reason for carrying out such test/investigation. g. The course in the hospital shall specify the line o f treatment, medications administered, operative procedure carried out and if any complications arise during course in the hospital, the same should be specified. If opinion from another doctor from outside hospital is obtained, reason for same should be mentioned and also who decided to take opinion i.e.whether the admitting and treating consultant wanted the opinion as additional expertise or the patient relatives wanted the opinion for their reassurance. h. Discharge medication, precautions, diet regime, follow up consultation etc should be specified. If patient suffers from any allergy, the same shall be mentioned. i. The signatures/Thumb impression in the Discharge Summary shall be that o f the patient because generally the patient is discharged after having improved. In other cases like Death summary or transfer notes in case o f terminal illness, the attendant can sign, the inability o f the patient to sign should be recorded by the attending doctor.

20 01- 2 0 )3,

Schedule-IV

STANDARD FORM AT FOR PROVIDER BILLS

1. Components of standardization: Standardization involves three components: i. Bill Format ii. Codes for billing items and nomenclature iii. Standard guidelines for preparing the bills. 2. Format Specified: The bill is expected to be in two formats. i. The summary bill and ii. The detailed breakup o f the bills. 3. Explanation and Guidelines - Summary Bill i. The summary format is annexed in the Schedule-IV A ii. The Bill shall be generated on the letter head o f the provider andin A4 size to aid scanning. iii. The summary bill shall not have any additional items (only 9) iv. The provider has to mention the service tax number in case they charge service tax to the insurance company. v. The payer mentioned in the bill has to be necessarily the insurance company and not the TPA. vi. In case o f package charged for any procedure/treatment, the provider is expected to mention the amount in serial no 9 only. Itemsbeyond the package are to be mentioned in serial numbers 1 to 8. vii. The patient/attendant signature is mandatory on the summary bill viii. The additional guidelines to fill the summary format shall be as below: Field Name

Remarks

Provider Name

Legal entity name and not the trade name

Provider Registration Number

Registration number o f the provider with local authorities, once the clinical establishments (registration and regulation) bill, 2007 is passed, then registration number under this act

Address

Address o f the Facility where member is admitted. A provider can have more than one facility.

IP No

Unique number identifying the particular hospitalization o f the member

Patient Name

Full name o f the patient

rxi

Schedule-IV

Payer Name

Name o f 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 o f insurance company needs to be mentioned and not the TPA.

Member address

Full address o f the member

Bill Number

Bill number o f the provider

Bill Date

Date on which the bill is generated.

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 o f admission o f the member in case o f IPD cases. In case o f Day care procedures, this is the date o f procedure

Date of discharge

Date o f discharge o f the member in case o f IPD cases. In case o f Day care procedures, this is the date of procedure(same as date o f 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 Rs. ‘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 Rs.‘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

Schedule-IV

mentioned here. SL No 3 o f billing Summary

All items under the primary head Rs. ‘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 o f billing Summary

All items under the primary head Rs.‘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 o f billing Summary

All items under the primary head Rs.‘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 to be mentioned here.

SL No 6 o f billing Summary

All items under the primary head Rs.‘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 o f billing Summary

All items under the primary head Rs.‘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 Rs.‘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 Rs.‘900000’ in the detailed bill have to be

Schedule-IV

summarized into this. If more than one procedure is done, the total amount o f the two procedures needs to be summarized Total Bill amount

Sum total o f all items 1 to 9 in the bill

Amount paid by the member

Amount o f 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 insurance company

Service tax

Service Tax company

chargeable to

insurance

Amount Payable

Total amount payable by company including service tax

insurance

Amount in words

Above amount in words for the sake of clarity

Patients signature

Signature o f the patient or the attendant of the patient needs to be mandatorily taken

Authorized signatory

The signature o f the authorized signatory at the provider

discount

to

the

4. Explanation and Guidelines - Detailed Breakup of the Bill i. The summary format is annexed in Schedule-IV-B ii. The Bill shall be generated on the letter head o f the provider and in A4 size paper to aid scanning. iii. The billing has to be done at level 2 or 3 iv. In case o f medicines/consumables, the relevant level code has to be mentioned (40100, 401002) and the text should indicate the actual medicine used v. If providers have outsourced the pharmacy to external vendors, in such cases the providers can attach the original bills separately. However, the summary o f this original bill has to be mentioned in the summary bill. vi. In case o f pharmacy returns the same code originally used is to be used with a negative sign in the units. vii. In case o f cancellation o f any service the same code originally used is to be used with a negative sign indicating reversal.

Schedule-IV

viii. The date on which the service is rendered is to be mentioned in the bill. This would be a. the date o f requisition in case of investigations b. date o f consultation for professional fees c. date o f requisition in case o f pharmacy/consumables irrespective o f when they were used d. date o f return of pharmacy items for pharmacy returns ix. The additional guidelines to fill the summary format shall be as below, except that the first section o f the bill is same as the bill summary referred in 3 above. Field Name

Remarks

Date

Date on which service is rendered. For example, this is the date o f investigation, date o f procedure etc.

Code

Level 2 or 3 code o f the billing item as per the codes( Part I I }

Particulars

Text explanation o f 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)

Schedule-IV

. Schedules:

Schedule-IV A SUMMARY BILL FORMAT

Bill Number

Provider Name Provider registration No. Address IP No Patient Name Payer Name Member Address

XXXX Insurance Company Ltd

Bill Date PAN Number Service Tax Regn No Date of admission Date of Discharge Bed Number

Billing Summary SI No 1 2 3 4 5 6 7 8 9

Primary Code 100000 200000 300000 400000 500000 600000 700000 800000 900000

Total Bill Amount Amount paid by member Amount charged to Payer Discount Amount Service Tax Amount Payable Amount in Words

Patients Signature

Amount

Particulars Room & Nursing Charges ICU Charges OT Charges Medicine & Consumables Professional Fees' Investigation Charges Ambulance Charges Miscellaneous Charges Package Charges

0 ............. 0

0 0 0 0 Rupees Zero Only

Authorized Signatory

Schedule-IV

Schedule-IV B DETAILED BREAKUP FORMAT PART-I

Bill Number

Provider Name Provider registration No. Address

Bill Date PAN Number Service Tax Regn No Date of admission Date of Discharge Bed Number

IP No Patient Name Payer Name Member Address

Billing Details 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

SI No

Date

^8

Schedule-IV

PART-II: Level 1

Level 1

Code

100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000 100000

Level 2 Code

Level 2

101000 101000 101000 101000 101000 101000 101000 101000 101000 101000 101000 101000

Room Charges Room Charges Room Charges Room Charges Room Charges Room Charges Room Charges Room Charges Room Charges Room Charges Room Charges Room Charges

100000 100000

Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges Room & Nursing Charges

101000 102000 102000 102000 102000 102000 102000 102000 102000 103000 103000 103000 104000 104000

Room Charges Nursing charges Nursing charges Nursing charges Nursing charges Nursing charges Nursing charges Nursing charges Nursing charges Duty Doctor fee Duty Doctor fee Duty Doctor fee Monitor charges Monitor charges

200000 200000 200000 200000 200000 200000 200000 200000

ICU Charges ICU Charges ICU Charges ICU Charges ICU Charges ICU Charges ICU Charges ICU Charges

201000 201000 201000 201000 201000 201000 201000

ICU Charges ICU Charges ICU Charges ICU Charges ICU Charges ICU Charges ICU Charges

200000 200000 200000 200000

ICU Charges ICU Charges ICU Charges ICU Charges

201000 201000 201000 202000

ICU Charges ICU Charges ICU Charges ICU Nursing charges

Level 3 Code

Level 3

101001 101002 101003 101004 101005 101006 101007 101008 101009 101010 101011 101012

General Ward charges Semi-private room charges Single Room charges Single Deluxe room charges Deluxe room charges Suite charges

102001 102002 102003 102004 102005 102006 102007

Nursing fees Dressing Nebulization Injection charges Infusion pump charges Aya Charges Blood Transfusion Charges

103001 103002

Duty Doctor fee RMO Fees

104001

Pulse Oxymeter charges

201001 201002 201003 201004 201005 201006

Burns Ward HDU charges ICCU charges Isolation ward charges Neuro ICU charges Pediatric/neonatal ICU charges Post Operative ICU Recovery Room Surgical ICU

201007 201008 201009

Remarks

Electricity charges Bed sheet charges Hot water charges Establishment Charges Alpha/Water Bed Charges Attendant Bed Charges

If used in normal Room

If ICU nursing charged seperatel

y

Schedule-IV

200000

ICU Charges

202000

ICU Nursing charges

202001

Nursing fees

200000

ICU Charges

202000

ICU Nursing charges

202002

Dressing

200000

ICU Charges

202000

ICU Nursing charges

202003

Nebulization

200000

ICU Charges

202000

ICU Nursing charges

202004

Injection charges

200000

ICU Charges

202000

202005

Infusion pump charges

200000 200000 200000

ICU Charges ICU Charges ICU Charges

203000 203000 203000

ICU Nursing charges Monitor charges Monitor charges Monitor charges

203001 203002

Monitor charges Pulse Oxymeter charges

200000 200000 200000 200000

ICU Charges ICU Charges ICU Charges ICU Charges

203000 204000 204000 204000

Monitor charges Monitor charges Monitor charges

203003 203004 203005

Cardiac Monitor charges IABP charges Phototherapy Charges

200000

ICU Charges

204000

ICU Supplies & equipment

204001

Oxygen charges

200000

ICU Charges

204000

204002

Ventilator charges

200000

ICU Charges

204000

ICU Supplies & equipment 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

If ICU nursing charged seperatel

y If ICU nursing charged seperatel Y If ICU nursing charged seperatel

y If ICU nursing charged seperatel

y

If used in ICU

ICU Supplies & equipment

Tempora

ry Pacemak er

200000

ICU Charges

204000

ICU Supplies & equipment

300000 300000 300000 300000 300000 300000 300000 300000

OT Charges OT Charges OT Charges OT Charges OT Charges OT Charges OT Charges OT Charges

301000 301000 301000 301000 301000 301000 302000

OT rent OT rent OT rent OT rent OT rent OT rent OT Equipment charges

204006

Defibrillator Charges

301001 301002 301003 301004 301005

Major OT charge Minor OT Charge Cath Lab Charges Theatre charges Labour Room Charges

Schedule-IV

302001

C-arm charges

302002

Endoscopy charges

302003

Laproscope charges

302004

Equipment charges

If not specified

OT Equipment charges

302005

Monitor charges

for OT monitori

302000

OT Equipment charges

302006

Instrument charges

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

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 300000 400000

OT Charges OT Charges Medicine & Consumables charges Medicine & Consumables charges

304000 304000

OT Sterlization OT Sterlization

304001

CSSD Charges

401000

400000

Medicine & Consumables charges

401000

Medicine & Consumables charges Medicine & Consumables charges

401001

Ward Medicines

400000

Medicine & Consumables charges

401000

401002

Ward Consumables

400000

Medicine & Consumables charges

401000

401003

Ward disposables

400000

Medicine & Consumables charges

401000

401004

Ward Materials

400000

Medicine & Consumables charges

401000

401005

Vaccination drugs

500000 500000

Professional fees charges Professional fees charges

300000

OT Charges

302000

300000

OT Charges

302000

300000

OT Charges

302000

300000

OT Charges

302000

300000

OT Charges

302000

300000

OT Charges

300000

400000

501000

OT Equipment charges OT Equipment charges OT Equipment charges OT Equipment charges

Medicine & Consumables charges Medicine & Consumables charges Medicine & Consumables charges Medicine & Consumables charges Visit charges

ng forOT instrume nts

includes guidewir es, catheter etc

OT drugs under OT charges

Schedule-IV

Consultation Charges

500000 500000

Professional fees charges Professional fees charges

501000 501000

Visit charges Visit charges

501001 501002

500000 500000 500000 500000

Professional Professional Professional Professional

charges charges charges charges

501000 502000 502000 502000

Visit charges Surgery Charges Surgery Charges Surgery Charges

501003

Medical Supervision Charges Professional fees

502001 502002

Surgeons Charges Assisstant Surgeons Fee

500000

Professional fees charges

503000

500000

Professional fees charges

503000

503001

Anaesthetists fee

500000

Professional fees charges

503000

Anaesthetists fee Anaesthetists fee Anaesthetists fee

503002

OT standby charges

500000

Professional fees charges

504000

500000

Professional fees charges

505000

500000 500000

Professional fees charges Professional fees charges

505000 504000

500000

Professional fees charges

504000

500000

Professional fees charges

600000 600000

fees fees fees fees

Would also include Standby Surgeon

Providers charge for standby anaesthe tist

Intensivist Charges Technician Charges Physiotherapy Procedure charges Procedure charges

504000

504000

Procedure charges

Investigation Charges Investigation Charges

601000

Bio Chemistry

Serum Sodium, Ueres etc

600000

Investigation Charges

602000

Cardiology charges

600000

Investigation Charges

603000

Haemotology charges

for procedur es like echo, ECG etc cross matching etc

600000

Investigation Charges

604000

Microbiology charges

blood culture, C&S

600000

Investigation Charges

605000

Neurology

for EMG, EEG etc

505000

OT /Cath Lab Technician

504001

Bedside procedures

504002

Suture charges

Catheteri zation, Central IV Line, Tracheos tomy, Venesect ion

Schedule-IV

600000

Investigation Charges

606000

Nuclear medicine

600000

Investigation Charges

607000

600000

Investigation Charges

608000

Pathology charges Radiology services

600000

Investigation Charges

609000

600000

Investigation Charges

610000

600000

Investigation Charges

611000

Profiles

700000 700000

Ambulance Charges Ambulance Charges

701000

Ambulance Charges

800000 800000

Miscellaneous charges Miscellaneous charges

801000

800000

Miscellaneous charges

802000

800000

Miscellaneous charges

803000

800000

Miscellaneous charges

804000

800000 800000

Miscellaneous charges Miscellaneous charges

805000 806000

800000

Miscellaneous charges

807000

800000

Miscellaneous charges

808000

Admission charges Attendant food charges Patient food charges Registration charges MRD Charges Documentation charges Telephone charges Bio Medical Waste Charges

800000

Miscellaneous charges

809000

Taxes

900000

Package Charges

900000

Package Charges

901000

Cardiac Surgery

PET CT, Bone scan etc

X-ra, CT, MRI etc

Serology charges Medical Genetics

Chrosom al Analysis etc Profiles instead of individua 1tests (Lipid profile, LFT etc)

Luxury Tax/Surcharge/Service Charge

ICD-10PCS

CABG

Excluding VAT & Service Tax To be used only in case of packages To be used only in case of packages

Schedule-IV

900000

Package Charges

902000

CardiologyPacka ges

ICD-10PCS

PTCA

900000

Package Charges

903000

Cath Lab

ICD-10PCS

CAG

900000

Package Charges

904000

Dental Procedures

ICD-10PCS

Root Canal Treatment

900000

Package Charges

905000

ENT

ICD-10PCS

FESS

900000

Package Charges

906000

Gastroenterolog

ICD-10PCS

Gastrectomy - Partial

y

900000

Package Charges

907000

General Surgery

ICD-10PCS

Inguinal hernia

900000

Package Charges

908000

Gynaecology

ICD-10PCS

LSCS

900000

Package Charges

909000

Nephrology

ICD-10PCS

Nephrectomy

900000

Package Charges

910000

Neuro Surgery

ICD-10PCS

Craniotomy

900000

Package Charges

911000

Oncology Procedures

ICD-10PCS

IMRT

900000

Package Charges

912000

Opthalmology procedures

ICD-10PCS

Cataract

To be used only in case of packages To be used only in case of packages To be used only in case of packages To be used only in case of packages To be used only in case of packages To be used only in case of packages To be used only in case of packages To be used only in case of packages To be used only in case of packages To be used only in case of packages To be used only in case of packages

Schedule-IV

900000

Package Charges

913000

Orthopaedic Surgery

ICD-10PCS

Bilateral TKR

900000

Package Charges

914000

Plastic Surgery

ICD-10PCS

Skin Grafting

900000

Package Charges

915000

Pulmonology Packages

ICD-10PCS

Pleural Tapping

900000

Package Charges

916000

Urology

ICD-10PCS

ERCP

900000

Package Charges

917000

Vascular Surgery

ICD-10PCS

Embolectomy

To be used only in case of packages To be used only in case of packages To be used only in case of packages To be used only in case of packages To be used only in case of packages