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(Stamp Paper 500 rupees)
MoU between The New India Assurance Company Limited and the Hospital
For Bhamashah Swasthya Bima Yojana 2017
Service Agreement
Between
(Insert Name of the Hospital)
(Address of the hospital)
and
New India Assurance Company Limited
(registered Office Address)
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This Agreement (Hereinafter referred to as “Agreement”) made at ________ on this
___________day of ___________Year 2017
BETWEEN
_____________(Hospital), an institution located in _________, having their registered
office at
____________ (here in after referred to as “Hospital”, which expression shall, unless
repugnant to the context or meaning thereof, be deemed to mean and include it's successors
and permitted assigns) as party of the FIRST PART
AND
New India Assurance Company Limited, a Company registered under the provisions of the
Companies Act, 1956 and having its registered office
___________________________________________________ (hereinafter referred to as
“Insurer” which expression shall, unless repugnant to the context or meaning thereof, be
deemed to mean and include it's successors, affiliate and assigns) as party of the SECOND
PART.
The (hospital) and Insurer are individually referred to as a "Party” or “party" and
collectively as "Parties” or “parties")
WHEREAS
1. Hospital is a health care provider duly recognized and authorized by appropriate
authorities to impart heath care services to the public at large.
2. Insurer is registered with Insurance Regulatory and Development Authority to
conduct general insurance business including health insurance services. Insurer has
entered into an agreement with the Government of the State of Rajasthan wherein it
has agreed to provide the health insurance services to identified Beneficiary families
covered under Bhamashah Swasthya Bima Yojana (BSBY).
3. Hospital has expressed its desire to join Insurer's network of hospitals and has
represented that it has requisite facilities to extend medical facilities and treatment to
beneficiaries as covered under Bhamashah Swasthya Bima Yojana Policy on terms
and conditions herein agreed.
4. Insurer has, on the basis of desire expressed by the hospital and on its representation,
agreed to empanel the hospital as empanelled healthcare provider for rendering
complete health services.
5. In this AGREEMENT, unless the context otherwise requires:
a. the masculine gender includes the other two genders and vice versa;
b. the singular includes the plural and vice versa;
c. natural persons include created entities (corporate or incorporate) and vice versa;
d. marginal notes or headings to clauses are for reference purposes only and do not
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bear upon the interpretation of this AGREEMENT.
6. Should any condition contained herein, contain a substantive condition, then such
substantive condition shall be valid and binding on the PARTIES notwithstanding the
fact that it is embodied in the definition clause.
In this AGREEMENT unless inconsistent with, or otherwise indicated by the context, the
following terms shall have the meanings assigned to them hereunder, namely:
Definition
A. Institution shall for all purpose mean a Hospital or other healthcare provider.
B. Health Services shall mean all services necessary or required to be rendered by the
Institution under an agreement with an insurer in connection with “health insurance
business” or “health cover” as defined in regulation 2(f) of the IRDA (Registration of
Indian Insurance Companies) Regulations, 2000 but does not include the business of
an insurer and/or an insurance intermediary or an insurance agent.
C. BSBY shall means Bhamashah Swasthaya Bima Yojana
D. Beneficiaries shall mean the person/s that are covered under the BSBY health
insurance scheme of the state Government of Rajasthan and holds a valid Bhamashah
card issued for BSBY.
E. "Bed Strength" means number of beds for which Pollution Control Board has
granted certificate to private hospital or private hospital has applied for certificate to
be issued by the Pollution Control Board before applying for empanelment under
BSBY. For Government hospital bed strength means number of beds sanctioned by
the Government for that Hospital.
F. "Disease Package/ Procedures" these are the packages listed under General
illnesses, critical illnesses and procedures reserved for Government & private
hospital Institutions category as per Annexure 5 (A) and 5(B) to be treated cashless.
G. "Eligible family" means a family who is covered under National Food Security Act
(NFSA) and any other category of families decided by the Government of Rajasthan
having a Bhamashah ID card
H. "Empanelled Hospital" means any private institution established for inpatient
medical care with sufficient facilities for the disease treatment and surgeries and
empanelled under the Scheme by the Insurer as per the Empanelment Guidelines
I. "Family" includes each and every person whose name is included in Identity Card of
that eligible family and also includes new born child of that family up to the age of
one year without his name in the Identity Card.
J. "Identity card" means Bhamashah Card
K. “Insurer” means the New India Assurance company limited for the implementation
of BSBY in Rajasthan.
L. "Minimum Document Protocols" (MDP) are the necessary documents to be
submitted by the network hospital to the Insurer for processing pre-auth & claims.
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M. "Scheme" means the " Bhamashah Swasthya Bima Yojana "
N. "Sum Assured/ Wallet" means provision of Health Insurance Coverage up to Rs.
30,000/- for general illnesses and Rs 3,00,000 for the critical medical and surgical
procedures per family per year on floater basis.
O. Confidential Information includes all information (whether proprietary or not and
whether or not marked as ‘Confidential’) pertaining to the business of the Company
or any of its subsidiaries, affiliates, employees, Companies, consultants or business
associates to which the Institution or its employees have access to, in any manner
whatsoever.
P. Bhamashah card with proof of relation shall mean Identification Card for
beneficiaries for availing benefits under Bhamashah Swasthya Bima Yojana (BSBY)
as per specifications given by Government of Rajasthan.
NOW IT IS HEREBY AGREED AS FOLLOWS:
Article 1: Term
1.1. Subject to Article 1.2, this Agreement shall be for a period of One year. However, it is
understood and agreed between the Parties that the term of this agreement may be
renewed yearly upon mutual consent of the Parties in writing, either by execution of a
Supplementary Agreement or by exchange of letters.
1.2. The Parties agree and acknowledge that the Hospital, which was empanelled in
previous scheme of BSBY with Insurer and fulfilled the eligibility criteria as per
terms and conditions of new RFP, was deemed to be empanelled under this current
Scheme for a period not exceeding 30 days with effect from 13/12/2017. During this
period, the Hospital may apply afresh for regular empanelment. Such deemed
empanelment stands cancelled on expiry of 30 days or sooner, if the Insurer, upon
verification of the Hospital’s infrastructure, is not satisfied of the fulfilment of the
eligibility criteria by the Hospital, under the current Scheme.
Article 2: Services
2.1 Scope of services
1. The institution contemplates provision of specified treatment procedures to Eligible
Persons inter alia at Package Rates on cashless basis, subject to pre-authorisation (if
any) by Insurance Company
2. The Institution undertakes to provide the service in a precise, reliable and professional
manner to the satisfaction of Insurer and in accordance with additional instructions
issued by Insurer in writing from time to time.
3. The Institution shall treat the beneficiaries of Bhamashah Swasthya Bima Yojana
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according to good business practice.
4. The institution will extend priority admission facilities to the BSBY beneficiaries,
whenever possible.
5. The Institution shall provide packages for specified interventions/ treatment to the
beneficiaries as per the rates mentioned as per Annexures………
6. The charges for medical/ surgical procedures/ interventions under the Benefit package
will be no more than the package charge agreed by the Parties, for that policy year. In
the case of medical conditions, a flat per day rate will be paid depending on whether
the patient is admitted in general or ICU.
7. These package rates in case of surgical or in case of medical will include:
a) Registration Charges
b) Bed charges (General Ward in case of surgical)
c) Nursing and Boarding charges
d) Surgeons, Anaesthetists, Medical Practitioner, Consultants fees etc.
e) Anaesthesia, Oxygen, O.T. Charges, Cost of Surgical Appliances etc.
f) Medicines and Drugs
g) Cost of Prosthetic Devices, implants
h) X-Ray and other Diagnostic Tests etc.
i) Post hospitalization Expenses and medicines for 10 days after discharge from the
hospital.
j) Any other expenses related to the treatment of the patient in the hospital during
hospitalisation.
k) Diagnostic procedures
The diagnostic procedures leading to surgery / medical treatment under BSBY
will be part of the selected package and if any charges/fees collected for
diagnostic procedure by same empanelled hospital before booking of TID for that
selected procedure/ package shall be refunded back to the patient before
discharge through recorded means either NEFT or cheque
8. The Institution shall ensure that under this agreement, medical treatment/facility is
provided with all due care and accepted standards is extended to the beneficiary.
9. Identification of beneficiaries will be done by using AADHAR linked biometrics and
live photo (date & time stamped) at the time of admission & discharge in BSBY
software
10. The Institution shall allow Insurance Company official to visit the beneficiary during
the admission at institution. Insurer shall not interfere with the medical team of the
Institution; however, Insurer reserves the right to discuss the treatment plan with
treating doctor. Further access to medical treatment records and bills prepared in the
Institution will be allowed to Insurer on a case to case basis.
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11. The Institution shall also endeavour to comply with future requirements of the Insurer
to facilitate better services to beneficiaries e.g. providing for standardized billing, ICD
coding, etc. and if mandatory by statutory requirement both parties agree to review
the same.
12. The Institution agrees to have its bills audited on a case to case basis as and when
necessary through the Insurer audit team. This will be done on a pre-agreed date and
time and on a regular basis.
13. The Institution will convey to its medical consultants to keep the beneficiary only for
the required number of days of treatment and carry out only the required investigation
& treatment for the ailment, for which the beneficiary is admitted. Any other
incidental investigation required by the patient is not covered under Insurer policy and
will not be paid by Insurer and the Institution needs to recover it from the patient.
2.2 Hospital warrants that presently and at all times during the term of this Agreement;
1. It satisfies the Eligibility Conditions stated in Annexure 1
2. It does not exclude any specialty service deliberately from the Scheme in spite of
having such facility and agrees to empanel for the specialties for which adequate
infrastructure is available.
3. For providing the Treatments listed in Schedule and generally for the purpose of
this Agreement it has at present and shall continue to maintain throughout the
period of the Agreement on round the clock basis;
a) Fully qualified Doctors in modern medicine besides Casualty/Duty Doctor(s),
Specialists, Nurses, paramedics and support staff round the clock
b) Adequate number of beds in separate Male and Female General Wards not
below the number stated in the application, with adequate spacing and
facilities including toilets, rest rooms and other conveniences
c) Fully equipped with required medical, surgical and diagnostic facilities such
as Pathological tests, X-ray, ECG etc. either in house or under tie up with
nearby Diagnostic Centre, round the clock basic diagnostic facilities for
biochemical, pathological, radiology tests such as Calorimeter/Auto analyser,
Microscope, X-Ray, ECG, USG etc. and manned by qualified
pathologist/technicians
d) It shall be able to facilitate round the clock advanced diagnostic facilities
either In-House or under tie-up with nearby Diagnostic Centre
e) Fully equipped microbiologically certified Operation theatre for performing
surgical operations
f) Post operative ward with required facilities
g) ICU facility with requisite staff and facilities not limited to air conditioning,
De-fibrillator, pulse oximeter, ventilator etc.
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h) Enable Blood Bank facilities either in-house or under tie-up with any nearby
provider
i) Facilitate at all times ambulance services either owned or under tie-up
j) It shall maintain complete record of consultation, treatment, advices, reports
and information on day to day basis and provide the same as and when
required.
k) Hospital should maintain line list of procedures carried out & treatment given
in following Proforma in a separate register maintained for BSBY
Name
of
patient
Age Gender Address Diagnosis
Name of
surgery /
Treatment
Date of
admissio
n
Date of
Surgery
Date of
discharge
l) Update insurer for any change in no. of beds, ICU capacity, ventilators
availability, any addition/deletion of new equipment’s which will have to be
more than 2 in working condition at all times
m) Have tie up with Central Treatment Facility for Bio Medical Waste
Management and be in possession of valid Pollution Control Board
certification at all times.
2.3 Hospital assures
1. That it shall deal with Eligible Persons in a courteous manner and that it shall not
under any circumstances avoid or discriminate in providing treatment under the
Scheme
2. It shall respond and provide on 24-hour basis, best treatment/facility to Eligible
Persons on priority basis and that its response, quality or standard of Treatment
under the Scheme shall in no case be inferior in any respect in comparison with
services provided to any other patient in the normal course of its business
3. To extend admission facilities to the Beneficiary families round the clock.
4. To provide diagnostic tests and medical treatment for beneficiary families
irrespective of surgery / Therapy required according to good business practices.
5. It will ensure that the best and complete diagnostic, therapeutic and follow-up
services based on standard medical practices / recommendations are extended to
the Beneficiary.
6. To provide quality service to the beneficiary by following Standard protocols for
diagnosis and treatment. It is also mandatory for the Provider to assess the
appropriate need and subject the beneficiary for Treatment / Procedure.
7. To provide quality medicines, standard prosthesis, Implants and disposables while
treating the beneficiary families.
2.4 Hospital undertakes that throughout the period of this Agreement
1. It shall nominate and keep appointed one or more dedicated Medical Officers for
the purpose of this Agreement.
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2. Insurer shall be informed of the said appointment and any change promptly in
writing
3. It shall provide all necessary support for efficient and smooth functioning of the
Liaison Officer or representatives of the Insurance Company throughout the
period of this Agreement.
4. It shall maintain in perfect working condition the computer systems along with
necessary peripheral equipment and other infrastructure at all times
5. It shall seek approval for only those procedures for which it has been empanelled
and which are approved to be performed at their facility
6. It undertakes to abide by insurers’ decision to change the approved list of
packages as per Government regulations and directives as they may become
reserved for Government facilities alone in future. The decision of insurer will be
final and binding on the provider as to which packages under the scheme can be
serviced by it.
2.5 Bhamashah Swasthya Marg Darshak:
The institution shall appoint Swasthya Marg Darshak (SMD) at their own expenses
throughout policy plan period. The role and responsibilities of the SMD are as stated
below:
1. Maintain Help Desk at Reception of the Hospital.
2. Receive the patient referred from any hospital and attend various walk in patients
3. Work round the clock in shifts to cater to the needs of Emergencies.
4. Verify the Bhamashah/ NFSS/card/fingerprint authentication of the Patients
5. Facilitate the Patient for consultation and admission. Liaison with coordinator or
administration of the hospital
6. Ensure cashless transaction at hospital.
7. Facilitate discharge of the patient.
8. Obtain feedback from the patient.
9. Send daily MIS
These roles and responsibilities are only indicative and may be revised during the
currency of the policy without prior notice.
The minimum criterion for selection of the Swasthya Mitras would be:
He/ She should be a Graduate
He/ She should be a Native & Resident of the institution area
He/ She should have Good communication skills
He/ She should have functional knowledge of computers
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Article 3: Identification of Beneficiaries
1. Bhamashah Swasthya Marg Darshak/s for Bhamashah Swasthya Bima Yojana
beneficiaries. SMD shall man the hospital help desk for 24 hrs and shall be trained
in operating the hardware and software required for servicing the beneficiaries.
He/she shall counsel the patient for the required treatment as advised by the
attending doctor.
2. Bhamashah card with proof of relation would be the proof of the eligibility of
beneficiaries for the purpose of the scheme. The beneficiaries will be identified by
the hospital on the basis of bhamashah cards issued to them. Swasthya Marg
Darshak will identify a person by using AADHAR linked biometrics if the finger
prints match with those available at the web portal/ patient is able to provide
sufficient proof of entitlement through production of recognised Government
issued photo ID proofs. In case the patient is not in a position to prove his identity
himself, any other member of the family who is enrolled under the scheme can
verify the patient’s identity by giving his/ her fingerprint/ presentation of the
required documents.
3. Hospital must capture live photograph of the patient along with date and time
stamping in BSBY software for both, at the time of admission & discharge
4. The Institution will set up a Help desk for Bhamashah Swasthya Bima Yojana
beneficiaries. The desk shall be easily accessible and will have all the necessary
hardware and software required to identify the patients.
Article 4: Hospital Services- Admission Procedure
4.1 TID Generation
1. Swasthya Margdarshak will generate TID in real time (within one hour) of
admission for day-care, General ward, ICU
2. Swasthaya Margdarshak will generate TID immediately at the time of admission,
capturing live photograph of the patient along with date & time stamping in
BSBY software immediately after establishing the eligibility of the patient.
Immediate generation of TID means a reasonable time lag, which means
generation of TID on the same day of admission
3. For any medical emergency case where ID card is not available with the patient &
treatment is required to be done immediately & if it does not become possible to
make entry in the BSBY software; a time limit of 72 hours is allowed to generate
the TID. The hospital will report such cases with justification to the Insurer by e-
mail within 24 hours of hospitalisation
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4. Swasthya Margdarshak will block the required packages/procedures in the
software as per prescription of treating doctor
5. If no package is selected with in three days of generation of the TID, then the TID
will automatically stand cancelled
4.2 Claim Processing
Hospital must upload all necessary documents as per MDP and other necessary
documents at the time of admission & discharge
Empanelled hospital shall give a rough estimate to the BSBY patients on the likely
expenditures to the treatment going to be done before treatment of the patient of
eligible family except general ward & ICU procedures. At the time of discharge,
hospital will also provide a final bill for all procedure treating deducted cost of BSBY
package done including general ward & ICU
1. In case of secondary care packages
a. No preauthorisation will be required.
b. Claim will be submitted within next 3 days of discharge of the patient, but live
photograph of the patient with date & time stamping is mandatory to be taken
at the time of discharge in BSBY software which will be automatically
uploaded
c. The hospital will be required to upload necessary documents as per MDP at
the time of submission of the claim.
d. Insurance Company representative may physically check the hospital records
at the hospital end or may advise the hospital to upload the desired documents
for specific cases.
e. Late submission of claim will attract penalty by up to 50% of the package cost
by the insurance company for next 30 days. After expiry of 33 days of
discharge, no payment of the claim will be made to the hospital
2. In case of the Tertiary care packages
a. The empanelled hospital will be required to send the preauthorization request
to the insurance company. In case of any emergencies, the network Hospital
may fill the preauthorization after providing the necessary life-saving
treatment to the beneficiary.
b. The Insurer will ensure that preauthorisation approval is given within 24
hours from its submission after receiving of complete set of documents
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c. The hospital will be required to upload documents as per MDP at the time of
submission of the pre-auth/claim.
d. If pre-authorization confirmation is not provided by the insurer within 24
hours of the intimation received from networked hospital and if there is no
query raised by the Insurer; it will be deemed to be approved
e. Only after pre-authorisation from the Insurer, the treatment will be done on
selected package/s.
f. Claim will be submitted within next 3 days of discharge of the patient, but live
photograph of the patient date & time stamping is mandatory to be taken at the
time of discharge in BSBY software
g. Insurance Company representative may physically check the hospital records
at the hospital end and may advise the hospital to upload the desired
documents for specific cases.
h. Late submission of claim will attract penalty by up to 50% of the package cost
by the insurance company for next 30 days. After expiry of 33 days of
discharge no payment of the claim will be made to the hospital
i. In case the hospital could not treat the patient due to unforeseen circumstances
or does not have the facilities to treat the patient, it should provide the
beneficiary with the first aid/ life-saving treatment before referring the patient
to nearest healthcare institution empanelled under the scheme.
j. Hospital has to maintain minimum mandatory pre & post hospitalization
documents of the patient.
k. Denial of Authorization/ guarantee of payment shall in no way mean denial of
treatment. The hospital shall deal with each case as per their normal rules and
regulations.
l. The guarantee of payment is given only for the necessary treatment cost of the
ailment covered and mentioned in the request for hospitalization. Any
investigation carried out at the request of the patient but not forming the
necessary part of the treatment also must be collected from the patient
m. In case the sum available is considerably less than the estimated treatment
cost, Institution should inform the beneficiary and guide and support the
beneficiary for the process of filing a request for fund enhancement. The
hospital may follow their normal norms of deposit/ running bills etc., to
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ensure that they realize any excess sum payable by the beneficiaries not
provided for by indemnity.
4.3 Claims Approval & Payments
1. Hospital will submit online claim report along with the discharge summary
and other required documents in accordance with the rates as prescribed in the
list of packages given by the Health Department, Government of Rajasthan.
2. Insurance company will make online payment to the hospital with in 7days
from claim approval after receipt of complete set of documents
3. Insurer can request the Institution to provide further documents related to
treatment to process the case. The insurer can visit the institution to gather/
verify the documents related to treatment to process the case.
4. All expenses incurred by the institution in providing the documents including
but not limited to postage, photocopying, scanning, printing etc. shall be borne
by the institution
5. In case of query, the insurance company will settle the claim within 5 days of
the last query answered or 14 days of submission of the claim whichever is
late
6. In case of insufficient documents submitted by the hospital, Insurance
company can raise the query for the required documents. If hospital does not
reply the query within 15 days of the last query raised even after two
reminders, then the claim will be settled by insurer on merit basis
7. In case of multiple packages taken for same patient in one hospitalization
highest package will be paid @ 100% to the network hospital and all
subsequent packages will be paid @75% of the package cost. However, in
case of package related to blood transfusion or involve purely
medicine/implants will be paid in full
8. Abscond cases will be rejected
9. In case of LAMA –
a. LAMA– 75% of the package amount
b. All approval subject to the written statement from beneficiary with self-
attestation mentioned reason of LAMA
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Article 5: Checklist for Institution at the time of Patient Discharge
5.1 Original discharge summary, counterfoil generated at the time of discharge, original
investigation reports, all original prescription & pharmacy receipt etc. must be kept
with the hospital and copy of all submitted documents must be given to the patient at
the time of discharge. Live patient photograph with date & time stamped. Any other
relevant document as per prescribed in MDP. These are to be uploaded in the system.
5.2 Signature or thumb impression of the patient/ beneficiary on final hospital bill must
be obtained.
5.3 Satisfactory letter signed by the beneficiaries
Article 6: Declarations and Undertakings of Institution
6.1 The Institution undertakes that they have obtained all the registrations/ licenses/
approvals required by law in order to provide the services pursuant to this agreement
and that they have the skills, knowledge and experience required to provide the
services as required in this agreement.
6.2 The Institution undertakes to uphold all requirement of law in so far as these apply
to them and in accordance to the provisions of the law and the regulations enacted
from time to time, by the local bodies or by the Central or the State Government.
The Institution declares that it has never committed a criminal offence which
prevents it from practicing medicine and no criminal charge has been established
against it by a court of competent jurisdiction.
6.3 Hospital shall follow all the guidelines of Bhamashah Swasthya BimaYojana and
provide cashless services to the beneficiaries. In any case, hospital shall not charge
any additional amount from beneficiaries until and unless Bhamashah card has the
requisite balance amount.
6.4 Hospital shall follow clinical pathways as defined by the State Health Assurance
Agency (SHAA) & Insurer.
Article 7: General responsibilities & obligations of the Institution
7.1 The Institution must ensure the following:
1. No confidential information is shared or made available by the Institution or any
person associated with it to any person or entity not related to the Institution/
insurer without prior written consent of Insurer.
2. The Institution shall provide cashless facility to the beneficiary in strict adherence
to the provisions of the agreement.
3. The services shall be provided as per the package rate of Bhamashah Swasthya
Bima Yojana (BSBY).
4. The Institution will have their facility covered by proper indemnity policy
including errors, omission and professional indemnity insurance and agrees to
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keep such policies in force during entire tenure of the MoU. The cost/ premium of
such policy shall be borne solely by the Institution.
5. The Institution shall provide the best of the available medical facilities to the
beneficiary.
6. The Institution shall endeavour to have an officer in the administration department
assigned for insurance/contractual duties and the officers will eventually learn the
various types of medical benefits offered under the different insurance plans.
7. The Institution must display their status of preferred service provider of BSBY at
their reception/ admission desks along with the display of other materials supplied
by Insurer whenever possible for the ease of the beneficiaries.
8. The Institution shall at all times during the course of this agreement maintain a
helpdesk to manage all BSBY patients
7.2 Infrastructure required for helpdesk manned by Bhamashah Swasthya Marg
Darshak (SMD)
Private hospitals shall ensure the following infrastructure and network:
1. Computer with power backup for at least 8 hours.
2. One biometric scanner for fingerprint compatible with Bhamashah Card capture
as per specification below. The fingerprint scanners used at any of the verification
points should be as per specified for UID.
3. The hospital has to provide the following to enable transactions in the scheme:
Printer, Scanner, Webcam, Stationary, Dedicated 1 mbps broadband connectivity
to be exclusively used by the Swasthya Marg Darshak. Swasthya Marg Darshak to
access the web portal for authentication, online MIS, e-preauthorization etc.
Chair/Table, etc.
The above should be installed within 15 days of signing of this agreement. The Institution
also needs to inform and train personnel on the handling of above machine and also on the
process of obtaining pre-authorization for critical illness under the list of packages, and
have a manned helpdesk at their reception and admission facilities for aiding in the
admission procedures for beneficiaries of BSBY.
Article 8: General responsibilities of Insurer
8.1 Insurer has a right to avail similar services as contemplated herein from other
institution(s) for the Health services covered under this agreement.
Article 9: Relationship of the Parties
9.1 Nothing contained herein shall be deemed to create between the Parties any partnership,
joint venture or relationship of principal and agent or master and servant or employer and
employee or any affiliate or subsidiaries thereof. Each of the Parties hereto agrees not to
hold itself or allow its directors employees/agents/representatives to hold out to be a
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principal or an agent, employee or any subsidiary or affiliate of the other.
Article 10: Reporting
10.1 In the first week of each month, beginning from the first month of the commencement
of this Agreement, the Institution and Insurer shall exchange information on their
experiences during the month and review the functioning of the process and make
suitable changes whenever required. However, all such changes have to be in writing and
by way of suitable supplementary agreements or by way of exchange of letters.
10.2 All official correspondence, reporting, etc. pertaining to this Agreement shall be
conducted with Insurer at its corporate office
Article 11: Termination/De-empanelment of hospital & penalties
11.1 This Agreement may be terminated by either party by giving one month’s prior
written notice by means of registered letter or a letter delivered at the office and duly
acknowledged by the other or email, provided that this Agreement shall remain effective
thereafter with respect to all rights and obligations incurred or committed by the parties
hereto prior to such termination.
11.2 Hospital is not willing to continue its services under the scheme
11.3 The insurer reserves the right to terminate the services of the hospital with immediate
effect if the latter is found to be involved in;
Malpractices/ fraud/ misrepresentation
If at any point of time during agreement it is found that hospital does not fulfil the
criteria of agreement and empanelment guidelines
Charging money from the beneficiaries
Equipment deficiencies
Man-power deficiencies
Violation of MOU
Resorting to Unwanted / Unwarranted Medical/Surgical Procedures
Hospital does not comply with the order of DGRC/SGRC/Appellate
authority/scheme guidelines
Any such activity against the spirit and benefit of the scheme
Any other as decided by authority
11.4 The insurer reserves the right to terminate the agreement with immediate effect in the
event of breach of this agreement or failure to comply with any stipulations hereof by the
hospital.
11.5 Either party reserves the right to inform public at large along with the reasons of
termination of the agreement by the method which they deem fit.
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11.6 Actions to be taken post De-empanelment
Once a healthcare provider has been de-empanelled from BSBY, following steps shall be
taken:
1. A letter shall be sent to the healthcare provider thereby conveying the De-
empanelment
2. Details of de-empanelled healthcare provider to be sent to SHAA so that it can be
published on BSBY/ Bhamashah website.
3. An FIR against the healthcare provider to be lodged by SHAA at the earliest in
case the de-empanelment is on account of fraud or a fraudulent activity.
4. The Insurance Company which had de-empanelled the healthcare provider shall
be advised to notify the same in the local media thereby informing all
beneficiaries about the de-empanelment, so that the beneficiaries of the scheme do
not utilize the services of that particular healthcare provider.
5. If the healthcare provider appeals against the decision of the insurance company,
all the aforementioned actions shall be subject to the decision of the concerned
Committee decision with a copy to the SHAA
11.7 Penalties -
1. For Private Hospital:If private hospital is found guilty on detailed investigation then-
a. 1st Incidence: Show Cause Notice but no suspension and after giving opportunity
of personal hearing if found guilty, the rejection of said claim and penalty of 5
times of specific claim amount/package.
b. 2nd Incidence: Suspension of the hospital with issue of notice.After giving the
opportunity of personal hearing, if the hospital is found guilty, rejection of said
claims and penalty of 10 times of specific claim amount may be imposed on the
hospital. The suspension of the hospital will be revoked immedictaely after penalty
amount is deposited by the said hospital to the Insurer.
c. 3rd Incidence: Show cause notice with suspension of hospital. After giving the
opportunity of personal hearing, if the hospital is found guilty, rejection of said
claims and de-empanelment along with penalty of 20 times of specific claim
amount.
2. For Govt hospitals:
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a. 1st Incidence: Show Cause Notice but no suspension and after giving opportunity
of personal hearing if found guilty, rejection of said claims and penalty of 5 times
of specific claim amount/package.
b. 2nd Incidence: Show cause notice with suspension of hospital. In inquiry if found
guilty, rejection of said claims and penalty of 10 times of specific claim amount.
Aggrieved party under clause 1.25.8 of the RFP may appeal as per clause 1.23.3 of the
RFP.
Article 12: Confidentiality
This article shall survive the termination/expiry of this Agreement.
12.1 Each party shall maintain confidentiality relating to all matters and issues dealt with by
the parties in the course of the business contemplated by and relating to this agreement.
The Institution shall not disclose to any third party, and shall use its best efforts to ensure
that its, officers, employees, keep secret all information disclosed, including without
limitation, documents marked confidential, medical reports, personal information
relating to insured, and other unpublished information except as maybe authorized in
writing by Insurer. Insurer shall not disclose to any third party and shall use its best
efforts to ensure that its directors, officers, employees, sub-contractors and affiliates keep
secret all information relating to the Institution including without limitation to the
Institution’s proprietary information, process flows, and other required details.
12.2 In Particular the Institution agrees to:
1. Maintain confidentiality and endeavour to maintain confidentiality of any persons
directly employed or associated with health services under this agreement of all
information received by the Institution or such other medical practitioner or such
other persons by virtue of this agreement or otherwise, including Insurer’s proprietary
information, confidential information relating to insured, medicals test reports
whether created/ handled/ delivered by the Institution. Any personal information
relating to a Insured received by the Institution shall be used only for the purpose of
inclusion/preparation/finalization of medical reports/ test reports for transmission to
Insurer only and shall not give or make available such information/ any documents to
any third party whatsoever.
2. Keep confidential and endeavour to maintain confidentiality by its medical officer,
employees, medical staff, or such other persons, of medical reports relating to
Insured, and that the information contained in these reports remains confidential and
the reports or any part of report is not disclosed/ informed to the Insurance Agent /
Advisor under any circumstances.
3. Keep confidential and endeavour to maintain confidentiality of any information
relating to Insured, and shall not use the said confidential information for research,
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creating comparative database, statistical analysis, or any other studies without prior
authorization from the State Nodal Agency..
Article 13: Indemnities and other Provisions
13.1 Insurer will not interfere in the treatment and medical care provided to its beneficiaries.
Insurer will not be in any way held responsible for the outcome of treatment or quality of
care provided by the Institution.
13.2 Insurer shall not be liable or responsible for any acts, omission or commission of the
Doctors and other medical staff of the Institution and the Institution shall obtain
professional indemnity policy on its own cost for this purpose. The Institution agrees that
it shall be responsible in any manner whatsoever for the claims, arising from any
deficiency in the services or any failure to provide identified service
13.3 Notwithstanding anything to the contrary in this agreement neither Party shall be liable
by reason of failure or delay in the performance of its duties and obligations under this
agreement if such failure or delay is caused by acts of God, Strikes, lock-outs,
embargoes, war, riots civil commotion, any orders of governmental, quasi-governmental
or local authorities, or any other similar cause beyond its control and without its fault or
negligence.
13.4 The Institution will indemnify, defend and hold harmless the Insurer against any claims,
demands, proceedings, actions, damages, costs, and expenses which the company may
incur as a consequence of the negligence of the former in fulfilling obligations under this
Agreement or as a result of the breach of the terms of this Agreement by the Institution
or any of its employees or doctors or medical staff.
Article 14: Notices
14.1 All notices, demands or other communications to be given or delivered under or by
reason of the provisions of this Agreement will be in writing and delivered to the other
Party:
1. By registered mail;
2. By courier;
3. By facsimile; followed with a registered mail
4. By email; followed with a registered mail
14.2 In the absence of evidence of earlier receipt, a demand or other communication to the
other Party is deemed given
1. If sent by registered mail, seven working days after posting it; and
2. If sent by courier, seven working days after posting it; and
3. If sent by facsimile/ email, two working days after transmission. In this case,
further confirmation has to be done via telephone and e-mail.
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14.3 The notices shall be sent to the other Party to the above addresses (or to the addresses
which may be provided by way of notices made in the above said manner):
-if to the hospital:
Attn: …………………
Tel : …………….
Fax: ……………
-if to ______________________
____________The New India Assurance Company Limited
______________________
______________________
______________________
Article 15: Miscellaneous
15.1 This Agreement together with any Annexure attached hereto constitutes the entire
Agreement between the parties and supersedes, with respect to the matters regulated
herein, and all other mutual understandings, accord and agreements, irrespective of their
form between the parties. Any annexure shall constitute an integral part of the
Agreement.
15.2 Except as otherwise provided herein, no modification, amendment or waiver of any
provision of this Agreement will be effective unless such modification, amendment or
waiver is approved in writing by the parties hereto.
15.3 Should specific provision of this Agreement be wholly or partially not legally effective
or unenforceable or later lose their legal effectiveness or enforceability, the validity of
the remaining provisions of this Agreement shall not be affected thereby.
15.4 The Institution may not assign, transfer, encumber or otherwise dispose of this
Agreement or any interest herein without the prior written consent of Insurer, provided
whereas that the Insurer may assign this Agreement or any rights, title or interest herein
to an Affiliate without requiring the consent of the Institution.
15.5 The failure of any of the parties to insist, in any one or more instances, upon a strict
performance of any of the provisions of this Agreement or to exercise any option herein
contained, shall not be construed as a waiver or relinquishment of such provision, but the
same shall continue and remain in full force and effect.
15.6 The Institution will indemnify, defend and hold harmless the Insurer against any claims,
demands, proceedings, actions, damages, costs, and expenses which the latter may incur
as a consequence of the negligence of the former in fulfilling obligations under this
Agreement or as a result of the breach of the terms of this Agreement by the Institution
or any of its employees/doctors/other medical staff.
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Article 16: Law and Arbitration
The provisions of this Agreement shall be governed by, and construed in accordance with
Indian law.
16.1 Any dispute, controversy or claims arising out of or relation to this Agreement or the
breach, termination or invalidity thereof, shall be settled by arbitration in accordance
with the provisions of the (Indian) Arbitration and Conciliation Act, 1996.
16.2 The arbitral tribunal shall be composed of three arbitrators, one arbitrator appointed by
each Party and one another arbitrator appointed by the mutual consent of the arbitrators
so appointed.
16.3 The place of arbitration shall be ________ and any award whether interim or final, shall
be made, and shall be deemed for all purposes between the parties to be made, in
_________.
16.4 The arbitration procedure shall be conducted in the English language and any award or
awards shall be rendered in English. The procedural law of the arbitration shall be Indian
law.
16.5 The award of the arbitrator shall be final and conclusive and binding upon the Parties,
and the Parties shall be entitled (but not obliged) to enter judgement thereon in any one
or more of the highest courts having jurisdiction.
16.6 The rights and obligations of the Parties under, or pursuant to, this Clause including the
arbitration agreement in this Clause, shall be governed by and subject to Indian law.
16.7 The cost of the arbitration proceeding would be borne by the loser of the arbitration
procedure, as determined by the award of the arbitrator. In case there is no winner of the
arbitration proceeding, as determined by the award of the arbitrator, the cost shall be
borne by the parties on equal sharing basis.
Article 17: Non–Exclusivity
Insurer reserves the right to appoint any other Institution for implementing the packages
envisaged herein and the Institution shall have no objection for the same.
Article 18: Severability
The invalidity or unenforceability of any provisions of this Agreement in any jurisdiction
shall not affect the validity, legality or enforceability of the remainder of this Agreement in
such jurisdiction or the validity, legality or enforceability of this Agreement, including any
such provision, in any other jurisdiction, it being intended that all rights and obligations of
the Parties hereund er shall be enforceable to the fullest extent permitted by law.
Article 19: Captions
The captions herein are included for convenience of reference only and shall be ignored in
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the construction or interpretation hereof.
SIGNED AND DELIVERED BY the hospital. –- the within named_________, by the
Hand of
_____________________ its Authorised Signatory
In the presence of:
SIGNED AND DELIVERED BY The New India Assurance Company Limited, the within
named ______________________, by the hand of ___________ it’s Authorised Signatory
In the presence of:
Article 20: Grievance Redressal Mechanism
20.1 Any Complaint regarding clause 2.1(6) will be enquired and heard by DGRC. Any party
aggrieved with the decision of DGRC can appeal to SGRC within 30 days from the date
of decision communicated in writing. In case of no appeal to SGRC within givin time
limit decision of DGRC shall stand final.
20.2 Grievance Redressal :- There will be three tier system for Grievance Redressal
i. District Grievance Redresal Committee,
ii. State Grievance Redresal Committee,
iii Appellate Authority.
a. District Grievenace Redressal Committee - Any complaints against the network
hospital about any difficulty in availing treatments/denial of treatment/non availability of
facilities/ charging money for the opted procedures/packages under BSBY etc., shall be
submitted to the District Collector or CMHO for necessary action or to the call centre at State
level.
i. The complaints received shall be placed for decision of a District Grievance
Redressal Committee (DGRC) at District level.
ii. DGRC will get it enquired and dispose off the complaint within 30 days of its
receipt.
iii. Appeal against the decision of the District Grievance Redressal Committee
will lie to the State Grievance Redressal Committee within 15 days of the
decision. The decision of the SGRC shall be final and binding upon both the
parties.
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b. State Grievenace redressal Committee - Any grievance of network hospital against the
Insurer or Vice Versa will be addressed to SGRC.
i. Any grievance of hospital for empanelment and de-empanelment will be heard
in appeal by State Grievance Redressal committee.
ii. Appeal against the decision of SGRC shall lie to Appellate Authority.
iii. Decision of Appellate Authority will be final and binding upon the both the
parties.
iv. Appellant is required to submit a DD of Rs. 1000/- in favour of CEO, SHAA
payable at Jaipur as fee while submitting appeal to SGRC. Without this appeal
will not be entertained and no communication will be made to appellant in this
regard.
v. Appellant is required to submit a DD of Rs. 5000/- in favour of CEO, SHAA
payable at Jaipur as fee while submitting appeal to Appellate Authority.
Without this appeal will not be entertained and no communication will be
made to appellant in this regard.
In the presence of:
SIGNED AND DELIVERED BY the hospital. - The within named_________, by
the Hand of
_____________________ its Authorised Signatory
SIGNED AND DELIVERED BY The New India Assurance Company Limited, the within
named ______________________, by the hand of ___________ it’s Authorised Signatory
In the presence of:
Witnesses:
