jeevan day ee

~ 1 ~ Signature & stamp of Insurance Agency

Rs. 3000/-

GOVERNMENT OF MAHARASHTRA

Rajiv Gandhi Jeevandayee Arogya Yojana Society (Proposed)

(Procurement Cell)

Arogya Bhavan 1st Floor,

St.George's Hospital Compound,

Near C.S.T.Station,Mumbai-400 001.

Maharashtra State

Website : http://maha-arogya.gov.in & www.maharashtra.gov.in Email: [email protected]

Phone : 022-22631831/22651026, Fax : 022-22625799

REQUEST FOR PROPOSAL (R F P)

Proposals are invited from General Insurance Companies (Licensed and Registered with

IRDA) dealing with Health Insurance for implementation of Rajiv Gandhi Jeevandayee

Arogya Yojana (RGJAY) in Maharashtra. Technical and Financial Proposal documents can be downloaded from website http://maha-arogya.gov.in or www.maharashtra.gov.in or can also be obtained in person from below

mentioned address on any working day during 2nd June 2011 to 29th June 2011 during office

hours.

Not Transferable

RFP No. 1/DHS/PC/Rajiv Gandhi Jeevandayee Arogya Yojana/RFP/2011-12

R F P SCHEDULE

1. Date of commencement of sale of RFP : 02.06.11 2. Pre Proposal Conference : 17.06.11 (at 15.00 hrs.) 3. Last date for availability of Proposal documents : 29.06.11 (up to 17.00 hrs.) 4. Last date for submission of Proposal documents : 30.06.11 (up to 13.00 hrs.)

5. Opening of technical Proposals : 30.06.11 (at 14.00 hrs.).

Complete RFP documents should be submitted at the address mentioned below not later than

13.00 hrs. on 30th June 2011. Proposals received later than the prescribed deadline date and time will not be accepted for opening & evaluation. Address for communication: Office of the Dr. G. S. Chindhe, Joint Director of Health Services (Procurement Cell) On behalf of Rajiv Gandhi Jeevandayee ArogyaYojana Society

1st Floor, Arogya Bhavan

St. Georges Hospital Compound, Mumbai 400 001 Phone NO : 022-22631831 / 22651026 Telefax : 022-22625799

All correspondence / communications about RFP, RGJAY should be made at the above address.

Issued To

M/s. ___________________________________________________________________


A complete set of RFP documents may be purchased by interested eligible Insurance Agency upon

payment of a non refundable fee of Rs. 3000/- (Rupees Three Thousand only ) in the form of a

Demand Draft issued by Nationalized/Scheduled Bank in favour of "Rajiv Gandhi Jeevandayee

Arogya Yojana Society , Mumbai" payable at Mumbai during office hours from 10.00 hours to 17.00

hours on all working days on or before date & time of closing of sale of RFP document.

In case of RFP which is downloaded from website, the bidder should specifically super scribe "Down

loaded from the website" on the top left corner of the envelope. However RFP cost of Rs.3,000.00 in

the form of Demand draft will have to be submitted along with the RFP document. The proposal shall

be rejected summarily upon failure to follow procedure prescribed in the RFP document. The

conditional proposal is liable to be rejected.

The Joint Director of Health Services (Procurement Cell), Mumbai reserves the right to amend /or to cancel R F P without giving any reason to.

Joint Director of Health Services (Procurement Cell) Mumbai

On behalf of

Rajiv Gandhi Jeevandayee ArogyaYojana Society


REQUEST FOR PROPOSAL (RFP) DOCUMENT (DRAFT)

Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) for BPL / APL population in

Maharashtra (Phase I: 8 districts of state of Maharashtra)

Government of Maharashtra has decided to revamp the existing Jeevandayee Yojana by

making it more comprehensive and inclusive. In pursuance with this, State is launching “Rajiv Gandhi Jeevandayee Arogya Yojana” (RGJAY) in a phased manner in order to improve access of Below Poverty Line (yellow card holders) and Above Poverty Line (APL-orange

card holders) families to quality medical care for identified specialty services requiring hospitalization for surgeries and therapies or consultations through an identified network of

health care providers. The insurance policy/coverage under the RGJAY for the eligible beneficiary families in 8 districts of Phase I will be in force for an initial period of one year from the date of commencement of the policy (From 02.10.2011 Phase-I) .

The RGJAY– Phase-I will cover 30 specialized service categories having 972 procedures and 121 follow up procedures. While implementing the scheme in these 8 Districts the RGJAYS

invites a single Proposal being implemented through the interested Insurance Companies. The scheme has following important features as detailed in the scheme.

The Proposal Document consists of the following Parts.

Part-I :- Details of the Scheme

Part-II :- Submission of Technical and Financial Proposals

Part- III :- Process assignment and General Guidelines

Section A- Submission of Proposals

Section B – Technical Information Section C – Financial Proposal

Part –IV :- MOU (Memorandum of Understanding ) Provisional

Appendix 1: General Guidelines on the Packages. Appendix 1a: Detailed list of specified surgeries and therapies

Appendix 1b: Follow up package Appendix 2: Working Pattern Appendix 3: Aarogyamitras and their role

Appendix 4: Procedure of enrolment of network hospitals Appendix 5: Activity Chart for Insurance Company

Appendix 6: Health camp policy Appendix 7: MOU (provisional) between insurer and network hospital

Rajiv Gandhi Jeevandayee Arogya Yojana Society invites sealed competitive proposals from IRDA (Insurance Regulatory Development Authority) registered General Insurance Companies dealing with Health Insurance and having requisite experience as detailed in

Request for Proposal (RFP). Only the financial proposals of those companies who qualify in the technical proposal scrutiny will be opened. The companies which are in agreement with

the scheme and clauses in MoU (provisional), which is an integral part of the scheme, only need to participate in the Selection and any disagreement in this regard may invite disqualification/rejection of Proposal at technical level. Hence all the companies are requested

to go through the Scheme and MoU carefully and submit their proposal.


TABLE OF CONTENTS SR. NO. DETAILS PAGE

PART – I SECTION-A: DETAILS OF THE SCHEME 8

1 NAME OF THE SCHEME 8

2 OBJECTIVES 8

3 BENEFICIARY FAMILIES 9

4 HEALTH CARD 9

5 FAMILY 9

6 IDENTIFICATION 9

7 PRE EXISTING DISEASES 10

8 SUM INSURED ON FLOATER BASIS 10

9 PAYMENT OF PREMIUM 10

10 PERIOD OF INSURANCE & PERIOD OF

AGREEMENT

10

11 PACKAGE 12

12 CASHLESS TRANSACTION 12

13 ONLINE CLAIM SETTLEMENT 12

14 REFUND 13

15 PROCEDURES FOR ENROLLMWNT OF HOSPITALS 13

16 MOU BETWEEN NETWORK HOSPITAL AND RGJAY

SOCIETY

13

17 STANDARDIZATION OF FORMATS 14

18 IMPLEMENTATION PROCEDURE 14

19 AROGYAMITRA 15

20 WEB PORTAL 16

21 ONLINE MIS AND 24 HOUR E-PREAUTHORIZATION 17

22 MEDICAL AUDITORS 17

23 PUBLICITY 17

24 IN HOUSE SYSTEM 17

25 PROJECT OFFFICE AND STATE LEVEL

COORDINATION

17

26 CAPACITY BUILDING 18

27 RUN OFF PERIOD 18

28 RAJIV GANDHI JEEVANDAI MANUAL 19

29 PREPROPOSAL MEETING 19

30 PROPSAL VALIDITY PERIOD 19

31 FORMATION OF CONSORTIUM 19

PART II SUBMISSION OF TECHNICAL AND FINANCIAL PROPOSALS

20

1 SUBMISSION OF PROPOSALS 20

2 SIGNATURE ON EACH PAGE OF DOCUMENT 20

3 DEADLINE FOR SUBMISSION PROPOSALS / PROPOSALS

20

PART III PROCESS: ASSIGNMENT AND GENERAL GUIDELINES

22

1 PROCEDURES FOR EVALUATION OF PROPOSALS 22

2 AWARD OF CONTRACT 22

3 RIGHT TO NEGOTIATE AT THE TIME OF AWARD 22


SR. NO. DETAILS PAGE

4 RGJAY SOCIETY / GOM‟S RIGHT TO ACCEPT OR REJECT ANY OR ALL PROPOSALS

22

5 NOTIFICATION OF AWARD AND SIGNING OF MOU 22

6 CONFIEDENTIALITY 23

7 CANAVASSING, FRAUD AND CORRUPT

PRACTICES

23

SECTION A: SUBMISSION OF PROPOSALS

24

1 GENERAL INFORMATION 24

2 DECLARATION BY THE INSURANCE AGENCY 24

SECTION B :

TECHNICAL INFORMATION

25

A. QUALIFYING CRITERIA 25

B. OTHERS 25

ANNEXURES

Please submit the following:

Annexure-1 IRDA license 28

Annexure-2 Insurance company should have an experience in conceptualizing, designing and implementing large

healthcare schemes and have at least three years‟ experience

29

Annexure-3 Declaration from the insurer that the Insurance Agency has

not been black listed/debarred

30

Annexure-4 An undertaking as per format expressing their explicit agreement to adhere with the details of the scheme

32

Annexure-5 An undertaking as per format confirming that they have

submitted their Proposal as a single entity only and have not form a Consortium for the scheme.

33

Annexure-6 Tailor made policy of the desired Health Insurance Scheme

in conformity to the benefits.

34

Annexure-7 The details of office infrastructure in the state and in the concerned districts.

35

Annexure-8 Activity Chart 36

Annexure-9 Plan for Health Camps. 37

Annexure-10 Empanelled health facilities with Insurer 38

Annexure-11 Any Other information, if any. 39

SECTION C

FINANCIAL PROPOSAL

40

PART IV MOU (MEMORANDUM OF UNDERSTANDING) 41

1 DEFINITION AMD INTERPRETATION 41

2 BENEFICIARY FAMILIES 43

3 COVERAGE 44

4 SUM ASSURED 45

5 PREEXISTING DISEASE 45

6 PRE AND POST HOSPITALIZATION 45

7 DEFINITION OF FAMILY 46

8 HEALTH CARDS 46



9 WEB PORTAL 46

10 PAYMENT OF INSURANCE PREMIUM 47

11 PERIOD OF INSURANCE & PERIOD OF AGREEMENT

47

12 ADJUSTMENT/ REFUND OF PREMIUM 49

13 PROCEDURE FOR ENROLLMENT OF HOSPITALS 49

14 MOU WITH NETWORK HOSPITAL AND

DISCIPLINARY ACTIONS AGAINST THE HOSPITALS

49

15 CASHLESS SERVICE 50

16 PACKAGES 50

17 IMPLEMENTATION PROCEDURE 50

18 HEALTH CAMPS 51

19 DISTRICT LEVEL CO-ORDINATION 52

20 IN-HOUSE SYSTEM 52

21 PROJECT OFFICE AND STATE LEVEL CO-ORDINATION

52

22 AAROGYAMITRAS 54

23 WEB PORTAL 55

24 ONLINE MIS AND – PREAUTHORISATION 56

25 MEDICAL AUDITORS 56

26 PUBLICITY 56

27 SERVICING OF OTHER SCHEMES 57

28 ACTIVITY CHART 57

29 ASSISTANCE FROM THE GOVERNMENT 57

30 CLAIMS PROCEDURE 57

31 RESPONSE TIME 59

32 INSURER REPRESENTATIONS, WARRANTIES AND RESPONSIBILITIES

59

33 JURISDICTION 60

34 NON PERFORMANCE 60

35 INFORMATION FLOW 60

36 RENEWAL 60

37 THE PRECEDENCE OF MOU 60

38 MODIFICATION OF MOU 61

39 MONITORING MECHANISM 61

40 GRIEVANCE MECHANISM 61

41 TERMS & TERMINATION 62

42 FORCE MAJEURE 63

43 ASSIGNMENT 63

44 ENTIRE AGREEMENT 63

45 RELATIONSHIP 63

46 SEVERABILITY 63

47 NOTICES 63

48 GOVERNING LAW 64

49 DISPUTE RESOLUTION 64 APPENDICES



APPENDIX – I GENERAL GUIDELINES ON THE PACKAGES. 65 APPENDIX-Ia

DETAILED LIST OF SPECIFIED SURGERIES AND THERAPIES AND PACKAGE

67

APPENDIX-Ib FOLLOW UP PACKAGE 143

APPENDIX- II WORKING PATTERN 147

APPENDIX -III AROGYAMITRA AND THEIR ROLE 148

APPENDIX -IV PROCEDURE FOR ENROLLMENT OF NETWORK

HOSPITALS

151

APPENDIX –V ACTIVITY CHART FOR INSURANCE COMPANY 154 APPENDIX- VI HEALTH CAMP POLICY 156

APPENDIX-VII MOU (PROVISIONAL) BETWEEN INSURER AND NETWORK HOSPITAL

159


PART - I Section A: Scheme

Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) would be implemented throughout the state of Maharashtra in phased manner for a period of 3 years. The insurance policy/coverage

under the RGJAY for the eligible beneficiary families in 8 districts of Phase I will be in force for an initial period of one year from the date of commencement of the policy (“Phase I”).

The extension of period of the policy will be subject to review and renewal of the policy on a yearly basis which will be based on the quality of experience and performance as well as annual IRDA renewal. Notwithstanding, anything to the contrary mentioned elsewhere in this

RFP the memorandum of understanding will be co – terminus with the insurance policy/coverage which is for a term of 1 year from (From 00.00 hrs. of 02.10.2011 to

Midnight of 01.10.2012 for Phase-I). Based on the quality of experience and performance of the RGJAY the State Government may at its sole discretion and without any obligation extend the RGJAY to cover the whole state.

1. NAME OF THE SCHEME:

Name of the scheme is Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY).

2. OBJECTIVE :

To improve access of Below Poverty Line (BPL) and Above Poverty Line (APL) families (excluding White Card Holders as defined by Civil Supplies Department) to quality medical

care for identified specialty services requiring hospitalization for surgeries and therapies or consultations through an identified network of health care providers.

2.a. BENEFIT:

The scheme would provide 972 surgeries/therapies/procedures along with121 follow up packages in following 30 identified specialized categories:

1 GENERAL SURGERY

2 ENT SURGERY

3 OPHTHALMOLOGY SURGERY

4 GYNAECOLOGY AND OBSTETRICS SURGERY

5 ORTHOPEDIC SURGERY AND PROCEDURES

6 SURGICAL GASTRO ENTEROLOGY

7 CARDIAC AND CARDIOTHORACIC SURGERY

8 PEDIATRIC SURGERY

9 GENITOURINARY SYSTEM

10 NEUROSURGERY

11 SURGICAL ONCOLOGY

12 MEDICAL ONCOLOGY

13 RADIATION ONCOLOGY

14 PLASTIC SURGERY

15 BURNS

16 POLY TRAUMA

17 PROSTHESES

18 CRITICAL CARE

19 GENERAL MEDICINE

20 INFECTIOUS DISEASES

21 PEDIATRICS MEDICAL MANAGEMENT

22 CARDIOLOGY

23 NEPHROLOGY

24 NEUROLOGY

25 PULMONOLOGY

26 DERMATOLOGY


27 RHEUMATOLOGY

28 ENDOCRINOLOGY

29 GASTROENTEROLOGY

30 INTERVENTIONAL RADIOLOGY

Detailed list of surgeries and therapies falling under above specified categories and their package rates are given at Appendix 1 a and that of follow up package are given at Appendix

1 b of Part-IV of the document. 3. BENEFICIARY FAMILIES:

Families holding yellow ration card, Antyodaya Anna Yojana card (AAY), Annapurna card and orange ration card from eight districts viz. Gadchiroli, Amravati, Nanded, Solapur, Dhule, Raigad, Mumbai city and Suburban Mumbai. The families with white ration card holding

would not be covered under the scheme. The beneficiary families would be identified through the “Rajiv Gandhi Jeevandayee Health Card” issued by the Government of Maharashtra or

based on the Yellow and Orange ration card issued by Civil Supplies Department. The total number of beneficiary families in the state would be around 2,04,30,527; out of which approximately 49 Lakh families in the 8 districts are to be covered under the scheme in first

phase as on the date of publishing of the Request for Proposal (RFP) document. District wise profile of the beneficiary families is given below:

Phase-I

Districts Population *Approximate number of

Beneficiary Families

1 Gadchiroli 970294 182889

2 Amravati 2607160 559473

3 Nanded 2876259 543961

4 Solapur 3849543 830011

5 Dhule 1707947 397674

6 Raigad 2207929 566231

7 Mumbai City 3338031 482073

8 Mumbai Suburban 8640419 1340828

Total 26197582 4903140

* Based on data furnished by Civil Supplies department as on 31.05.2010. The total number of beneficiary families for each District is an indicative estimate and may

vary. The number of the final beneficiary families for each district will be given within one month of signing MOU. The total premium payable would be based on this final figure of

eligible beneficiary families. 4. HEALTH CARDS

All eligible families in these districts shall be provided with Rajiv Gandhi Jeevandayee

Arogya Yojana Health Cards in due course of time. These Health Cards will be used for identification of Beneficiary families in the family under the Scheme. Family Health Cards

will be prepared by using data from valid yellow or orange ration cards coupled with Aadhaar numbers issued by UID authorities. As an interim measure till the issuance of health cards, the valid Orange/Yellow Ration Card with Aadhaar number or in case Aadhaar number not

available, any Photo ID card of beneficiary issued by Govt. agencies (Driving license, Election ID,) to correlate the patient name and photograph would be accepted in lieu of health

card. 5. FAMILY:

Family means members as listed and photographed on the Rajiv Gandhi Jeevandayee Arogya

Yojana Health Cards or holding valid Orange/Yellow Ration Card. 6. IDENTIFICATION:

Health card issued by Govt. of Maharashtra/Rajiv Gandhi Jeevandayee Arogya Yojana Society or valid Orange/Yellow Ration Card with Aadhaar number if Health card is not issued would act as a tool for beneficiary identification for availing the health insurance facility. The


following actions would be undertaken by Network hospitals in case of the possible exceptional situations: No. Exceptional Situation Requirement for benefit

1 No Health Card with beneficiary, but Valid Yellow or Orange Ration Card with name of beneficiary is available

Aadhaar number and in case Aadhaar number not taken any Photo ID card issued by Govt. ( Driving license, election identity card with photograph) to correlate the patient name & photograph (In instance of emergency admission, provisional preauthorization may be given subject to confirmation of it against submission of valid photo identity card issued by Govt. before discharge.)

2

Children born after issue of card i.e. name and photo not available on health card or on valid yellow/Orange ration card

Photograph of child with either parent along with Health card/ valid Yellow or Orange ration card of parent and Birth certificate issued by authorized office.

3

Name is there in Yellow or Orange Ration Card and matches with name in photo identity. But the card is invalid as it does not match with the digitized list.

Not eligible for benefit package (The yellow /Orange ration card is cancelled after verification by department but still the family is holding it)

7. PRE EXISTING DISEASES:

All Diseases under the proposed scheme shall be covered from day one. A person suffering from disease prior to the inception of the policy shall also be covered under approved

procedures for that disease.

8. SUM INSURED ON FLOATER BASIS:

The Scheme shall provide coverage for meeting all expenses relating to hospitalization of beneficiary up to Rs. 1,50,000/- per family per year in any of the Empanelled Hospital subject

to Package Rates on cashless basis through Health cards or valid Orange/Yellow Ration Card. The benefit shall be available to each and every member of the family o n floater basis i.e. the total annual reimbursement of Rs. 1.5 lakh can be availed by one individual or collectively by

all members of the family. In case of renal transplant surgery, the immunosuppressive therapy is required for a period of

1 year. So the upper ceiling for Renal Transplant would be Rs. 2,50,000 per operation as an exceptional package exclusively for this procedure. The cases are likely to be very few and well controlled by Human Organ Transplant Act 1994. The claims related to this have to be

settled by Insurer. 9. PAYMENT OF PREMIUM:

Rajiv Gandhi Jeevandayee Arogya Yojana Society / Government of Maharashtra will pay in

advance the insurance premium in installments on behalf of insured beneficiary families to the Insurance Company as mentioned in clause 10 of Memorandum of Understanding (MOU) or as decided by the Society or GoM.

10. PERIOD OF INSURANCE & PERIOD OF AGREEMENT:

The insurance coverage under the scheme for the beneficiary families in 8 districts of Phase I

shall be in force for an initial period of one year from the date of commencement of the policy (From 00.00 hrs. of 02.10.2011 to Midnight of 01.10.2012 for Phase-I). The period of MOU/agreement shall be for three years with effect from 02.10.2011; subject to

review and renewal of policy on yearly basis based on the quality of experience and performance as well as annual IRDA renewal. Based on the quality of experience and

performance of the scheme, the State Government/ Society may extend the scheme to cover the whole state.

10.a. PERFORMANCE SCURITY:

1) The successful insurer shall furnish the security deposit to the RGJAYS within 7 days from the date of communication of Award of Contract for an amount of 5%

of the contract value, valid up to 90 days after the date of completion o f warranty


obligations and enter into MOU on Rs. 100/- non-judicial stamp paper. The cost of Stamp paper should be borne by the insurer. The Security Deposit should be in the

form of Bank Guarantee in favour of the „Rajiv Gandhi Jeevandayee Arogya Yojana ' payable at Mumbai from any Nationalized or Scheduled bank.

2) The Security Deposit will be discharged by the Purchaser and returned to the successful Insurance Agency not later than 30 days following the date of completion of the Insurer‟s performance obligations by the end of first quarter of

execution of scheme, including the warranty obligation, under the MOU. 3) The security deposit shall be discharged (forfeited) as a compensation for any loss

resulting from the failure to perform the obligations under the MOU or in the event of termination of the MOU or in any event as the Purchaser thinks fit and proper.

4) Security deposit will not carry any interest.

10. b. PERFORMANCE PARAMETERS AND PENALTY CLAUSE:

The Insurer is required to perform multiple activities in performance of its obligations arising

out of the insurance contract to it. Any activity not performed by the insurer within the given time line shall hamper implementation of Rajiv Gandhi Jeevandayee Health Insurance Scheme from the planned date. Such activities have been listed here under which the

successful bidder is required to complete within the specified period from the date of award of the insurance contract to it failing which a penalty as specified percentage on total

premium against each section per week/month shall have to pay to the Society for the period of delay. Sr.

No

Activi ty Time frame from the

date of Signing of

Agreement

Penalty for the

delay in

execution in %

of component

charges

PENALTY PER WEEK

A a) Identifying the Project Officer

b) Setting up of Project Office with infrastructure in

Municipal Corporation of Greater Bombay

7 days

30 Days

1%

1%

B Preparation and Cert ification of software on receiving the

specification from Society.

3 month 1%

C Dedicated Website as per the requirement (envisaging

Empanelment MIS,HR MIS, Publicity and Camp MIS, E-

authorization MIS, Claim MIS,

Follow up monitoring MIS, Field operations Support service

MIS, Grievance MIS, Medical Audit MIS, Key performance

Indicators, Operation maintenance MIS)

3 months 2.0%

D Establishment of 24 Hrs Call Center and Establishment of other

infrastructure in each covered District

3 month 1%

E Establishment of sufficient in frastructure in each covered

District. Installation of kiosk, computer and accessories etc.

3 month 1%

F To identify the Hospital Network Providers and networking

with them.

3 months 0.5%

G To arrange cashless treatment of the insured in the empanelled

hospitals under the scheme and facilitation of proper

networking for quick and error-free processing of pre-

authorizations.

3 months 0.5%

H To provide adequate manpower, so as to ensure free flow of

daily MIS and ensure that progress of scheme is reported to

Society in the desired format on a real-time basis.

3 months 0.5%

I Preparation of various formats used for cashless transactions,

discharge summary, b illing pattern and other reports in

consultation with the Government.

1 months 0.5%

PENALTY PER MONTH

J Processing of claims related to the scheme. Pre-authorization of

requests and approval of preauthorization if all the conditions are

System to be ready in

3 months (Continuing

1%


Sr.

No

Activi ty Time frame from the

date of Signing of

Agreement

Penalty for the

delay in

execution in %

of component

charges

fulfilled, within 12 hours of receiving the preauthorization request

from the network provider if failure % is more than 5%)

activity)

K Scrutinize the b ills from network hosp itals and give

approval for the sanction of the bill and forward payment within 7

working days on receipt of complete claim document from the

Network Hospitals. (Failure % is more than 5% )

System to be ready in

3 months &

(Continuing activity)

1%

L Medical Auditing (by minimum qualification MBBS) for

conducting 20% per month concurrent audits of services and

quality of service provided to the beneficiary families delivered

by Network Hospitals on periodic basis as well as and required.

3rd month


0.5%

M HR

a. Number of network hospitals and number of

Aarogymithras /Medical Coordinators, Camp Coord inators

posted- District wise, month wise, and aggregate

b. Number of Public facilit ies (CHCs/PHCs) and number of

Aarogymitras posted - District wise, month wise, and

aggregate

3rd month

Onwards

0.5%

N Training programme for Network Hospital Providers and other stake

holders ones in a month.

2nd

month onwards


0.5%

11. PACKAGE:

The insurer should ensure that the Network hospitals follow the packages worked out by Rajiv

Gandhi Jeevandayee Society. The package rates will include bed charges in General ward, Nursing and boarding charges, Surgeons, Anesthetists, Medical Practitioner, Consultants fees, Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Medicines and

Drugs, Cost of Prosthetic Devices, implants, X-Ray and Diagnostic Tests, food to inpatient, one time transport cost etc. In other words the package should cover the entire cost of

treatment of patient from date of reporting to his discharge from hospital or 10 days after post surgery discharge including complications if any, making the transaction truly cashless to the patient. In instance of death, the carriage of dead body from network hospital to the

village/township would also be part of package.

12. CASH LESS TRANSACTION:

The Insurer has to ensure that adequate facilities are provided to all beneficiary families so that they do not have to pay any deposits at the commencement of the treatment or at the end

of treatment to the extent the Services as covered under the Rajiv Gandhi Jeevandayee Arogya Yojana. It is envisaged that for each hospitalization the transaction shall be cashless for covered procedures. Enrolled beneficiary will go to hospital and come out without making

payment to the hospital subject to procedure covered under the scheme. The same is the case for diagnostics, if, eventually the patient does not end up in undertaking the surgery or

therapy. The beneficiary has right to select network hospital and services of selected network hospital should be made available (Subject to availability of beds). In instance of non- availability of beds at network hospital, the facility of cross referral to nearest another

Network hospital is to be made available.

13. ONLINE CLAIM SETTLEMENT:

The Insurance Company shall settle the claims of the hospitals online within 7 working days of receipt of the Originals bills, Diagnostics reports, Case sheet, Satisfaction letter from

patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost and other relevant documents to Insurer for settlement of the claim. The online progress of claim settlement will be scrutinized and reviewed by Rajiv Gandhi

Jeevandayee Arogya Yojana Society.


14. REFUND:

If there is a surplus after the pure claims experience on the premium (excluding Services Tax)

at end of the policy period, after providing 20% of the premium paid towards the Company‟s administrative cost, of the balance 80% after providing for claims payment and outstanding

claims, 90% of the left over surplus will be refunded to the Government/ Rajiv Gandhi Jeevandayee Arogya Yojana Society within 30 days after the expiry of the Run-off period. (Refer Para No. 27 related to run off period).

15. PROCEDURE FOR ENROLLMENT OF HOSPITALS:

The Public and Private Hospitals will be jointly empanelled within the State of Maharashtra by Rajiv Gandhi Jeevandayee Arogya Yojana Society and Insurance Company following the

empanelment procedure laid down by Rajiv Gandhi Jeevandayee Arogya Yojana Society. The hospitals having minimum of 50 inpatient hospital beds with adequate facilities and offering

the services as stipulated below shall be empanelled after being scrutinized and recommended by the Empanelment and Disciplinary Committee. Empanelment and Disciplinary Committee will constitute a subcommittee of four doctors for this purpose. Two doctors will be

nominated by Insurance Company and two by Rajiv Gandhi Jeevandayee Arogya Society. The purpose of this empanelment is to ensure capability of the hospital to provide some of the

identified 30 specialized categories and seek agreement to the equal or lower price for these 972 procedures and 121 follow up procedures and take an opportunity to assess the current quality of care therein. It would be the responsibility of the Insurer for enrollment of Network

Hospitals in the State of Maharashtra to give adequate facilities for the treatment of the patients when they present themselves. The number of empanelled hospitals and number of procedures in each hospital to be permitted will be based on the need and at discretion of the

society in the interest of beneficiary. Network hospitals are supposed to extend medical aid to the beneficiary under the scheme. Procedure for enrollment of Hospitals is placed as

Appendix- IV of Part IV. Preference for empanelment could be given to the hospitals accredited under National Board of Accreditation for Hospitals. It is also desired to accredit ate the empaneled hospital under National Board of Accreditation for Hospitals in order to

ensure quality of care.

16. MOU WITH NETWORK HOSPITAL AND RGJAY SOCIETY.

[ A) (i) MOU with Network Hospital:

The Insurer shall sign MOU with all the network hospitals to be empanelled under the scheme. Separate MOU‟s with relevant provisions have to be entered into for Multi-

speciality, Cancer Treatment etc. This MOU is subject to the approval of the Rajiv Gandhi Jeevandayee Arogya Yojana Society. The number of empanelled hospitals and number of procedures in each hospital to be permitted will be based on the need and at discretion of the

society in the interest of beneficiary. Network hospitals are supposed to extend medical aid to the beneficiary under the scheme. A provision will be made in MOU regarding non-

compliance / default clause. Such matter shall be looked in to by the Empanelment and Disciplinary Committee, the decision of which will be binding to all concerned.

(ii) Disciplinary actions against the hospitals:

On recommendation by the Empanelment and Disciplinary Committee the Insurer shall take various disciplinary actions against Network Hospital including De- listing from the

empanelment if it is found that guidelines of the Scheme are not followed by it and services offered are not satisfactory as per laid down standards. Hospital may also be delisted or de-empanelled if infrastructure in the hospital is found below the standards laid down by the

society any time during the policy period. In case of any delisting of empanelled hospitals, the insurer shall find alternative immediately.

B) (i) MoU with Rajiv Gandhi Jeevandayee Aarogya Yojana society


The Insurer shall enter into the MOU with GOM / Rajiv Gandhi Jeevandayee Arogya Yojana Society given in Part IV (Provisional), which is an integral part of the scheme within 24 hours

of award of contract. (ii) Nonperformance by insurer

In the event of non-performance by the Insurer as per the guidelines (refer Clause 10.a) of the scheme, the insurer shall abide by the clause 11, 11.a and 17 as per MOU given in Part IV of the document.

17. STANDARDIZATION OF FORMATS:

The Insurance Company shall standardize various formats used for cashless transactions,

discharges summary, billing pattern and other reports in consultations with Rajiv Gandhi Jeevandayee Society.

18. IMPLEMENTATION PROCEDURE:

The Entire scheme is to be implemented as cashless hospitalization arranged by the Insurance Company. The following represents the process flow of treatment to the beneficiary.

A) Process Flow of the Beneficiary Treatment in the Network Hospital

Step 1

Beneficiary families shall approach nearby PHC/Rural, Sub district, General, Women/District Hospital/Network Hospital. Aarogyamitras placed in the above hospitals shall facilitate the beneficiary. If beneficiary visits Government Health Facility other than the Network Hospital,

he/she will be given a referral card to the Network Hospital with preliminary diagnosis by the doctors. The Beneficiary may also attend the Health Camps being conducted by the Network

Hospital in the Villages and can get that referral card based on the diagnosis. The information on the outpatient and referred cases in the PHC/Rural, Sub district, General, Women/DH and the camps will be collected from all Aarogyamitras/Hospitals on regular basis and captured in

the dedicated database through a well-established call center. Step 2

The Aarogyamitras at the Network Hospital examine the referral card and health card or Yellow/Orange Ration Card, register the patients and facilitate the beneficiary to undergo specialist consultation, preliminary diagnosis, basic tests and admission process. The

information like admission notes, test done will be captured in the ded icated database by the Medical Coordinator of the Network Hospital as per the requirement of the Rajiv Gandhi

Jeevandayee Arogya Yojana Society. Step 3

The Network Hospital, based on the diagnosis, admits the patient and sends E-

preauthorization request to the insurer, same can be reviewed by Rajiv Gandhi Jeevandayee Arogya Yojana Society.

Step 4

Recognized Medical Specialists of the Insurer and Rajiv Gandhi Jeevandayee Arogya Yojana Society examine the preauthorization request and approve preauthorization, if, all the

conditions are satisfied. This will be done within 12 working hours and immediately in case of emergency wherein e-preauthorization is marked as “EM”.

Step 5

The Network Hospital extends cashless treatment and surgery to the beneficiary. The Postoperative notes of the Network Hospitals will be updated on the website by the medical

coordinator of the Network Hospital. Step 6

Network Hospital after performing the covered surgery/ therapy/ procedure forwards the Originals bills, Diagnostics reports, Case sheet, Satisfaction letter from patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost

and other relevant documents to Insurer for settlement of the claim. The Discharge Summary and follow-up details will be part of the Rajiv Gandhi Jeevandayee Arogya Yojana Society

portal.


Step 7

Insurer scrutinizes the bills and gives approval for the sanction of the bill and shall make the

payment within agreed period as per agreed package rates. The claim settlement module along with electronic clearance and payment gateway will be part of the workflow in Rajiv

Gandhi Jeevandayee Arogya Yojana Society portal and will be operated by the Insurer. The reports will be available for scrutiny on the Rajiv Gandhi Jeevandayee Arogya Yojana Society login.

Step 8

The Network Hospital will provide free follow-up consultation, diagnostics, and medicines

under the scheme up to 10 days from the date of discharge. B) Health camps

Health Camps are to be conducted in Taluka Head Quarters, Major Gram Panchayats and

Municipalities. Minimum of one camp per week per empanelled hospital has to be held in the eight districts in the policy year. The insurer shall ensure that at least one free medical camp is conducted by each network hospital per week at the place suggested by Rajiv Gandhi

Jeevandayee Arogya Yojana Society. The Rajiv Gandhi Jeevandayee Medical Camp Coordinator MCCOs of the hospital shall coordinate the entire activity. Network hospital shall

carry necessary screening equipment along with specialists (as suggested by the Rajiv Gandhi Jeevandayee Arogya Yojana Society) and other Para-medical staff. The Insurer shall put in the minimum requirements as regards the health camp in the MOU with the hospitals. The

empaneled hospital shall work in close liaison with district coordinator of the Insurance Company, Civil Surgeon/District Health Officer in consultation with District Collector.

Hospital shall follow the Camp policy of Rajiv Gandhi Jeevandayee Arogya Yojana Society. C) District level co-ordination:

District level offices with necessary infrastructure have to be set-up by the Insurance

Company. The Insurer needs to have district level monitoring staff with District Coordinators, & State Coordinators of the Insurance Company. They should monitor Aarogymitras, co-

ordinate with network hospital, district administration and people‟s representatives for effective implementation of the Scheme. They should ensure that camps are held as per schedule, arrange for canvassing for the camp, mobilize patients and follow up the beneficiary

families. They should work in close liaison with district administration under the supervision of District Collector. They should also ensure proper flow of MIS and report to society on day

to day basis about the progress of the scheme in the district. The Insurance Company should ensure that dedicated staff is made available for the scheme. There shall be at least one doctor to be placed in each district. Further, wherever the concentration of the Network Hospitals is

more additional doctors need to be placed. The Insurance Company shall follow the instructions of Rajiv Gandhi Jeevandayee Arogya Yojana Society in this regard.

19. AAROGYAMITHRAS

a) Aarogyamithras in Primary Health Centers (PHC)/Rural Hospitals (RH)/Sub District Hospitals(SDH)/District Hospitals (DH)/General Hospitals (GH)/Women Hospitals(WH):

The unique nature of the scheme demands the insurance company to appoint Aarogyamithras in consultation with Rajiv Gandhi Jeevandayee Arogya Society in PHCs/RH/SDH/GH/WH and district Hospitals of selected 8 Districts for propagating the scheme, mobilizing people

for health camps, counseling beneficiary families facilitating the referral/treatment of these patients and follow up. For effective and instant Communication all the Aarogyamithras will

have to be provided with cell phone CUG connectivity by the Insurance Company. b) Aarogyamithras in Network Hospitals: The Insurance Company also needs to appoint at least one Aarogyamithra at all network hospitals round the clock to facilitate admission,

treatment and cashless transaction of patient. The Aarogyamithras should also help hospitals in pre-authorization, claim settlement and follow-up. They should also ensure proper

reception and care in the hospitals and send regular MIS to call center. Insurance Company shall provide all Aarogyamithras with cell phone having CUG connectivity with SMS based


reporting framework for effective and instant communication. The Insurance Company shall ensure that prefabricated Aarogyamithras kiosks with all additional requirements as per the

design approved by the society is put up in all hospitals. The role of Aarogyamithras can be modified by Rajiv Gandhi Jeevandayee Arogya Yojana Society from time-to-time.

The Insurer will provide uniform and arrange the workshops/training sessions for the Aarogyamithras as per guidelines specified by Rajiv Gandhi Jeevandayee Society. The detailed note on Aarogyamithras and their role are given at Appendix III of Part-IV of the

document. 20. WEB PORTAL:

All activities related to the scheme shall be done through a dedicated portal of Rajiv Gandhi Jeevandayee Society, the development and maintenance cost of which will be borne by the Insurer. The source code and system design document for the application exclusively

developed by Insurer for Rajiv Gandhi Jeevandayee Arogya Yojana shall be provided in good working condition to Rajiv Gandhi Jeevandayee Arogya Yojana Society. A dedicated data

center in the name of Rajiv Gandhi Jeevandayee Yojana will be maintained by the Insurer. The proprietary rights of software will be with Government of Maharashtra and the Insurance Company shall execute all the necessary documents for assignment/transfer of the software to

the Rajiv Gandhi Jeevandayee Arogya Yojana Society. Patient records will be property of Rajiv Gandhi Jeevandayee Arogya Yojana Society. Confidentiality of patient records shall be

maintained by the Insurer. Insurance Company will develop the Software as per the requirement of the Scheme on the directions & guidelines as mandated by Rajiv Gandhi Jeevandayee Arogya Yojana

Society. The web portal will be a repository of information and will have the following features and

the respective workflows: 1. General Information on the scheme. 2. Details of patients reporting and referrals from the PHC / Rural/ Sub-

district/Women/General/District hospitals on daily basis. 3. E-Health Camps system and daily reporting of health camps.

4. Details of patients reporting and getting referred from the health camps. 5. E-Empanelment system. 6. Emergency approval system.

7. Call centre application. 8. Patient registration by Aarogyamithra in Network Hospitals.

9. Details of in-patients and out patients in the network hospitals. 10. On-bed reporting system. 11. Costing of the Tests done in the network hospitals.

12. E-preauthorization. 13. Surgery details.

14. Discharge details. 15. Real-time reporting, active data warehousing and analysis system. 16. Claim settlement.

17. Electronic clearance of bills with payment gateway. 18. Follow-up of patient after surgery.

19. Distribution of Follow-up medicines. 20. Rajiv Gandhi Jeevandayee Messaging Services. 21. Grievance and Feedback workflow.

22. Back Tracking System. 23. E-Office management.

24. Accounting system. 25. TDS workflow. 26. Death reporting system. [


21. ONLINE MIS AND 24 HOURS E- PREAUTHORIZATION.

The Insurance Company should post enough dedicated staff, so as to ensure free flow of daily

MIS and ensure that progress of scheme is reported to society in the desired format on a real-time basis. The company should establish proper networking for quick and error- free

processing of pre-authorizations. The pre-authorization has to be done round the clock in co-ordination with Rajiv Gandhi Jeevandayee Arogya Yojana Society i.e. by a team of doctors from the Rajiv Gandhi

Jeevandayee Arogya Yojana Society and Insurance Company.

The preauthorization team shall have all the specialists concerned with the procedures covered in the scheme on a permanent basis. Rajiv Gandhi Jeevandayee Arogya Yojana Society will

provide necessary specialists and technical committees to evaluate special cases from time-to-time. Rajiv Gandhi Jeevandayee Arogya Yojana Society will provide necessary specialists to

evaluate special cases. A technical committee consisting of specialist from Government Sector nominated by Rajiv Gandhi Jeevandayee Society in the concerned field, CMO of the

Insurer and the Project Manager of the Insurer will evaluate and recommend to the CEO of Rajiv Gandhi Jeevandayee Society. In instance of dispute, the final decision on preauthorization rest with the CEO of Rajiv Gandhi Jeevandayee Society.

[There should be inbuilt anonymity of name of network hospital and health card number in the

software while giving preauthorization and claim settlement. [ [

22. MEDICAL AUDITORS : The Insurance Company shall appoint enough number of medical auditors, who do pre-authorization in consultation with Rajiv Gandhi Jeevandayee Society. The Insurer shall also

recruit specialized doctors for regular inspection of hospitals, attend to complaints from beneficiary families directly or through Aarogyamithras for any deficiency in services by the

hospitals and also to ensure proper care and counseling for the patient at network hospital by coordinating with Aarogyamitras and hospital authorities.

23. PUBLICITY: The Insurance Company on its part should ensure that proper publicity is given to the scheme

in all possible ways. This will include publicity on electronic and print media, distribution of brochures, banners, display boards etc. in public at appropriate places in consultation with RGJAYS. The annual spending on this activity should be two percent of total premium

amount received annually by the insurer. They shall also effectively use services of Aarogyamitras and district Coordinators for this purpose.

24. IN HOUSE SYSTEM:

The Insurer will establish in-house system to provide all such facilities elaborated under the scheme. The Insurer will submit detailed list of staff appointed for Rajiv Gandhi Jeevandayee

Arogya Yojana with their designations, responsibilities and contact numbers before the commencement of policy to the RGJAYS.

25. PROJECT OFFICE AND STATE LEVEL COORDINATION

The insurer shall nominate within 7 days of signing the MOU responsible officer/officers to properly coordinate above work and ensure proper implementation of scheme up to the

satisfaction of Rajiv Gandhi Jeevandayee Society. They shall review the progress with Rajiv Gandhi Jeevandayee Arogya Yojana Society on day-to-day basis and be responsible to

implement the suggestions of Rajiv Gandhi Jeevandayee Arogya Yojana Society for effectively running the scheme. The Project Office of the Insurance Company shall be separately established at a place desired by Rajiv Gandhi Jeevandayee Arogya Yojana Society

and also provide adequate space for Society for better coordination. The Project office shall report to the Rajiv Gandhi Jeevandayee Arogya Yojana Society on a daily basis in the

prescribed proformas. The following departments shall be established by the Insurance Company in the Project Office:


a. 24 hour call center with toll free help line and online workflow. b. Field Operations Department to coordinate the daily activities of field staff.

c. MIS Department to collect, collate and report data on a real–time basis. This department will also have a subunit with operators who collect hourly information

from the Aarogyamitras, regional co-coordinators, district coordinators etc. Based on this the reverse flow of dissemination of information shall also take place. There shall be subunits for each district. The MIS department shall also follow-up the

cases at all levels. The department shall also generate reports as desired by Rajiv Gandhi Jeevandayee Society.

d. HR Department to manage human resources for the scheme. e. Training Department for capacity building of all stakeholders (those who affect

the outcome and those who are affected by outcome) and staff.

f. IT Department to ensure that the website with e- pre-authorization, claim settlement and real –time follow-up is maintained and updated on a 24 hour basis.

g. Round the clock pre-authorization Department with specialist doctors for each category of diseases shall work round the clock along with Rajiv Gandhi Jeevandayee Arogya Yojana Society doctors to see that the pre-authorization is

given within 12 working hours and immediately in case of emergencies. The doctors shall also undertake inspection of hospitals.

h. Claims settlement Department with electronic clearance facilities. i. Health Camp Department to plan intimate implement and follow-up the camps as

per the directions of Rajiv Gandhi Jeevandayee Society.

j. Publicity and logistics Department to undertake all the publicity and logistics activities as specified by Rajiv Gandhi Jeevandayee Society.

k. Grievance Department to be manned by doctors and other staff to address the grievances as per the instructions of the Rajiv Gandhi Jeevandayee Society.

l. Follow up Department to coordinate the follow-up consultations and distributions

of drugs as per the instructions of Rajiv Gandhi Jeevandayee Society. m. Empanelment Department to empanel the hospitals in the network as per the

guidelines given by the society and monitor the compliance. n. Feedback Department to send feedback formats collect and analyze feedback of

the patients as per the directions of Rajiv Gandhi Jeevandayee Society. The

Department will also document each case and upload the same in the Rajiv Gandhi Jeevandayee Arogya Yojana Society portal.

o. Administration Department for office management. p. Vigilance Department for keeping vigil on all services providers and staff q. Accounts Department

r. Other Departments required for office work. 26. CAPACITY BUILDING

I. The Insurer will arrange the workshops / training sessions for the capacity building of the society personnel, their representatives and other stakeho lders in respect of specific field of insurance at each district on the convenience of the society. Insurer

will ensure that workshops and medical camps are organized in association with the network hospitals.

II. The help of NGOs/SHGs will be taken by the Rajiv Gandhi Jeevandayee Help Desk/Rajiv Gandhi Jeevandayee Assistance Counters to spread awareness and guide the prospective patients to the network hospitals. The Insurer will associate in

this task. 27. RUN OFF PERIOD

A Run off Period of one month will be allowed after the expiry of the policy. This means that pre-authorization can be done till the end of policy period and surgeries for such pre-


authorizations can be done up to one month after the expiry of policy period and all such claims will be honored by the Insurance Company.

28. RAJIV GANDHI JEEVANDAI MANUAL Rajiv Gandhi Jeevandayee Arogya Yojana Society will publish a detailed Manual for the

Scheme titled Rajiv Gandhi Jeevandayee Arogya Yojana Manual consisting of all operational guidelines and details of the scheme. Rajiv Gandhi Jeevandayee Arogya Yojana Society may update and modify these guidelines and operational details as per the requirement of the

scheme. The insurer shall follow the guidelines and instructions given in the manual while implementing the scheme.

29. PRE PROPOSAL MEETING

1. A Pre Proposal meeting of the prospective bidders will be held at 15.00 hrs. on

17.06.2011 in the Conference Hall of Arogya Bhavan, Directorate of Health Services

Mumbai, to clarify any queries the Insurance Agencies may have, and for providing additional information if any. No separate intimation of the Pre Proposal meeting will

be sent to the prospective Insurance Agencies, unless there is a change in the time, date or venue of the Pre Proposal meeting.

2. A copy of the proceedings of the Pre Proposal meeting will be sent to all the

prospective Insurance Agencies. The decisions and clarifications denoted in the Proceedings of the Pre Proposal meeting shall be final and binding to all the Insurance

Agencies & minuted decision of pre proposal meeting will be a part of RFP document. 30. PROPOSAL VALIDITY PERIOD:

1. The Proposal shall remain valid for a maximum period of six calendar months from the

Date of declaration after opening financial proposal. 2. (Technical bid). A bid valid for a shorter period shall be rejected 3.. Prior to the expiration of the bid validity the Purchaser may request the Insurance Agency to extend the bid validity for the period as required by the Purchaser

31. FORMATION OF CONSORTIUM:

Eligible Insurance Agencies shall submit their Proposal as a single entity only. Formation of Consortium is not allowed to Proposal. Such Proposals shall be cancelled and not evaluated.


PART II

SUBMISSION OF TECHNICAL AND FINANCIAL PROPOSALS

Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra seek detailed Proposal documents from insurance companies interested in implementing “Rajiv Gandhi

Jeevandayee Yojana for 30 identified specialized categories envisaging 972 procedures and 121 follow up procedures in all the districts of Maharashtra for approximately 2 crore families for a period of 3 years, with a proviso that initially scheme will be launched in 8 districts of

State of Maharashtra for approximately 49 lakh families for 1 year. Renewal of scheme after initial one year and also extension to other districts of the state will be subject to the review of

quality of experience and also performance of the scheme. 1. SUBMISSION OF PROPOSALS:

The Insurance Agency must submit the proposal as per the details mentioned below:

i. Technical proposal both hard and soft format should be sealed in a separate envelop clearly marked in BOLD “SECTION A & B- “TECHNICAL

PROPOSAL OF RAJIV GANDHI JEEVANDAI YOJANA FOR EIGHT

DISTRICTS” written on the top of the envelope. Under no circumstances shall the financial quote appear anywhere in

Technical Proposal and the technical Proposal shall stand rejected if

quoted”.

ii. Financial proposal in hard format should be sealed in another envelop clearly marked in BOLD “SECTION C- FINANCIAL PROPOSAL FOR RAJIV

GANDHI JEEVANDAI YOJANA FOR EIGHT DISTRICTS” written on

the top of the envelope. iii. Both envelop should have the Insurance Agencies Name and Address clearly

written at the Left Bottom Corner of the envelope. iv. Both envelops should be put in a larger cover / envelop, sealed and clearly

marked in BOLD have

“SECTION A&B – “TECHNICAL PORPOSAL FOR RAJIV GANDHI

JEEVANDAI YOJANA FOR EIGHT DISTRICTS”

“SECTION C – FINANCIAL PROPOSAL FOR RAJIV GANDHI

JEEVANDAI YOJANA FOR EIGHT DISTRICTS”

Written on envelop and have the Insurance Agencies Name and Address clearly

written in BOLD at the Left Bottom Corner. v. The Proposals shall be cancelled and not evaluated if the Insurance Agency

fails to: a. Clearly mention Technical / Financial Proposal on the respective

envelops as mentioned in clause 1.0 –I to IV above under Part III.

b. To seal the envelope properly with sealing tape. c. Submit both envelops i.e. financial proposal and Technical Proposal

together keeping in large envelop. d. Give complete Proposals in all aspects. e. Submit Financial Proposals in the specified proforma (Section C).

f. To submit soft copy of Technical Proposal in respective cover.

2. SIGNATURE ON EACH PAGE OF DOCUMENT:

The competent authority of the Insurance Agency must sign and put official stamp on eac h paper of Proposal. Any document / sheet not signed may lead to rejection of Proposal. 3. DEADLINE FOR SUBMISSION of PROPOSAL / PROPOSALS:

Complete Proposal documents should be received at the address mentioned below not later than 13.00 hrs. on 30 th June 2011. Proposal documents received later than the

prescribed date and time will not be entertained under any circumstances. Late Proposal

documents on any count shall be rejected summarily. Delay due to Post or any other reason will not be condoned.


Complete Proposal documents should be submitted in two envelopes i.e. Technical RFP in envelope no.1& Commercial bid in Envelope no. 2. Both bids i.e. Technical RFP & Commercial RFP should be put in one envelope indicating RFP No. Subject & Date of opening of RFP

Address:

Dr. G. S. Chindhe, Joint Director,

Procurement cell, Directorate of Health Services,

On behalf of Rajiv Gandhi Jeevandayee Arogya Yojana Society

Arogya Bhavan First Floor, Procurement cell,

St. Georges’ Hospital campus, Mumbai 400001Mumbai

Phone: 022-22631831, 022-22651026

Fax: 022-22625799

E-mail: [email protected]


PART-III

PROCESS: ASSIGNMENT AND GENERAL GUIDELINES

1. PROCEDURE FOR EVALUATING PROPOSALS The Proposals received within stipulated period and collected in Proposal Box are opened in the presence of Company Representatives. First the Larger Covers are opened and then

Technical and Financial Proposals will be segregated. Then the Technical Proposals will be opened in the presence of Company Representatives. Technical Committee nominated by

Rajiv Gandhi Jeevandayee Arogya Society / Government of Maharashtra will evaluate the technical proposals. Once the technical Proposals have been evaluated, the successful Insurance Agencies will be informed about the date of opening of financial Proposals.

Financial Proposals of only those Insurance Agencies will be opened who are declared successful in the technical Proposal Evaluation stage. Insurance company which are in full

conformity with RFP requirements and conditions shall be declared as Eligible insurance company for opening Envelope no. 2 and Envelope No. 2 (Commercial bid) of such insurance company shall be opened later, on a given date and time. Financial Proposals will be opened

in presence of the representatives of insurance companies that have been declared successful in the technical Proposal evaluation stage. Then Financial Proposals will be evaluated by

financial committee nominated by Rajiv Gandhi Jeevandayee Arogya Society / Government of Maharashtra. The Technical and Financial proposals should be sealed by the Insurance Agency in separate

covers duly super-scribed and both these sealed covers are to be put in a bigger cover which should also be sealed and duly super-scribed.

The Technical Proposals will be evaluated by the Technical Proposal Evaluation Committee duly constituted by the Government of Maharashtra (“GOM”). Financial Proposals of only the technically acceptable offers shall be opened before the successful Insurance Agencies.

2. AWARD OF CONTRACT

Rajiv Gandhi Jeevandayee Arogya Yojana Society / Government of Maharashtra shall award

the contract to the successful Insurance Agency whose Proposal has been determined to be substantially responsive, lowest evaluated Proposal, provided further that the Insurance Agency has been determined by the Rajiv Gandhi Jeevandayee Arogya Yojana Society/

Government of Maharashtra to be qualified to perform the contract satisfactorily. 3. RIGHT TO NEGOTIATE AT THE TIME OF AWARD

Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra reserve the right to negotiate with lowest Insurance Agency after opening the Financial Proposal. 4. RAJIV GANDHI JEEVANDAI AROGYA YOJANA SOCIETY / GOVERNMENT OF

MAHARASHTRA‟S RIGHT TO ACCEPT OR REJECT ANY OR ALL PROPOSALS: Rajiv Gandhi Jeevandayee Arogya Yojana Society / Government of Maharashtra reserves the

right to accept or reject any Proposal or annul the Selection process and reject all Proposals at any time without assigning any reason prior to award of contract, without thereby incurring any liability to the affected Insurance Agency or Agencies. Rajiv Gandhi Jeevandayee

Arogya Yojana Society / Government of Maharashtra is not bound to accept the lowest or any Proposal. Incomplete Proposals and financial Proposals with extra attachments are liable to be disqualified.

5. NOTIFICATION OF AWARD AND SIGNING OF MOU:

The Notification of Award will be issued with the approval of the Proposal Accepting

Authority. The terms of MOU are non-negotiable and the successful insurance company shall sign the MOU proposed by Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra at part IV of the document in duplicate within 24 hours of

declaration of „award of contract‟, failing which the contract may be offered to the next Insurance Agency in order of merit. Once the MOU is signed, the insurer will have no right to

cancel the MOU signed between Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra and insurer.


6. CONFIDENTIALITY:

Information relating to the examination, clarification, evaluation, and comparison of

proposals, and recommendations for the award of a Contract shall not be disclosed to insurers or any other persons not officially concerned with such process until the notification of

Contract award is made. Any effort by the insurer to influence the Purchaser in the Purchaser's proposal evaluation, proposal comparison, or contract award decisions may result in the rejection of the Insurer's

proposal. 7. CANVASSING, FRAUDULENT AND CORRUPT PRACTICES:

Insurance Agencies are hereby informed that canvassing in any form for influencing the process of notification of award would result in disqualification of the Insurance Agency. Further, they shall observe the highest standard of ethics and will not indulge in any corrupt,

fraudulent, coercive, undesirable or restrictive practices, as the case may be. “Corrupt practice” means the offering, giving, receiving or soliciting of anything of value to

influence the action of the public official “Fraudulent practice” means a misrepresentation of facts in order to influence RFP process or an execution of a contract to the detriment of RGJAY, and includes collusive practice

among Insurers/Authorized Representative (prior to or after Proposal submission) designed to establish Proposal prices at artificial non-competitive levels and to deprive RGJAY free and

open competition; “Collusive practice” means a scheme or arrangement between two or more Insurance Agency, with or without the knowledge of the Purchaser, designed to establish RFP prices at

artificial, noncompetitive level; and “Coercive practice” means harming or threatening to harm, directly or indirectly, persons or their property to influence their participation in the

procurement process or effect the execution of the contract Government of Maharashtra will re ject a proposal for award if it determines that the Insurer/Insurers have engaged in corrupt or fraudulent practices

Government of Maharashtra will declare a firm ineligible, either indefinitely or for a stated period of time, to be awarded a contract if it at any time determines that the Selection

Insurer/Insurers has engaged in corrupt and fraudulent practices in competing for, or in executing, a contract. Amendment/Cancellation of Proposal Documents

a) At any time prior to the deadline for submission of Proposals, the Rajiv Gandhi Jeevandayee Arogya Yojana Society/ Government of Maharashtra may, for any reason

modify the RFP documents, by amendment or cancel the process. b) The amendment will be notified in writing/by e-mail/by fax or through website to all prospective

Insurance Agencies who have taken the RFP documents and amendments will be binding on them.

c) To give prospective Insurance Agencies reasonable time in which to take the amendment into account in preparing their RFP document, the Purchaser shall extend, at its discretion, the deadline

for submission of RFP document, in which case, the Purchaser will notify all Insurance Agencies by placing it on website of the extended deadline and will be binding on them.

d) Any addendum/corrigendum as well as clarification thus issued shall be a part of the RFP documents and it will be assumed that the information contained in the amendment will have been

taken into account by the Insurance Agencies in its RFP.

NOTE: Oral statements made by the Insurance Agency at any time regarding quality

of service or arrangements of any other matter shall not be considered.


SECTION A

GENERAL INFORMATION AND UNDERTAKING BY THE INSURANCE

AGENCY IN THE PRESCRIBED PROFORMA ENCLOSED.

TECHNICAL PROPOSAL

GENERAL INFORMATION

1 Name of the Insurance Company

2 Address of Head Office

3 Name and designation of the person submitting the proposals

4 Status Public Sector / Private Sector

DECLARATION BY THE INSURANCE AGENCY

I, _________________________________ Designated as _______________

at_____________________________ of ___________________________

Insurance Company hereby declare that I have read & the contents of the RFP

document, consisting of Part I to IV and having agreed to the contents here by submit

the Proposal in the desired format with respective proformas duly signed by me , If our

Proposal is found successful, the company is agreeable to execute the MoU as given in

part II with in twenty four hours (excluding public holidays) after the award.

DATE: AUTHORIZED SIGNATORY

Seal


SECTION B

Technical Information (A) Qualifying Criteria:

a. General Insurance Company should be registered with IRDA to undertake

insurance related activities. The Insurer should attach a self-attested recent copy of the license as a proof of its registration (Annexure-1 of Part III). Insurance company should have an experience in conceptualizing, designing and

implementing large health insurance schemes and have at least three years‟ experience in catering to health insurance of 10,00,000 families or more enrolled under each

group health insurance policy in the year 2008-09, 2009-2010 and 2010-2011 (Annexure -2 of Part III). Health insurance policies issued for various districts within a State for specific scheme implemented by state/pan India scheme implemented by

Central Govt. on all India basis will be considered as one policy during the financial year.

b. Insurance Company must submit supporting attested documents of past performance along with RFP. Insurance Agency must furnish their complete business address VAT/TAN. PAN registration documents attested copies and a Certificate from Charted Accountant showing revenue income receipts on said business during last three financial years. Insurance Company shall produce Audited Balance Sheet and Profit and Loss Accounts for last three years i.e. 2007-08, 2008-09 & 2009-10 certified by the Auditor.

c. Declaration from the insurer that the Insurance Agency has not been black listed/debarred by any State Government/Central Government or its agencies or not

qualified in participating the Government schemes as per IRDA guidelines. (Annexure -3 of Part III) Declaration from the insurer that the Insurer will establish in-house system to provide

all such facilities elaborated under the scheme.. (Annexure -3a of Part III) d. The Insurer has to provide an undertaking, as per format expressing their explicit

agreement to adhere with the details of the scheme as mentioned in the Part I of the RFP document. (Annexure -4 of Part III) e. The Insurer has to provide an undertaking, as per format confirming that they have

submitted their Proposal as a single entity only and have not form a Consortium for the scheme. (Annexure– 5 of Part III)

f. Tailor made policy of the desired Health Insurance Scheme in conformity to the benefits available, exclusions, conditions etc. There is no structured format for this. (Annexure– 6 of Part III)

B. Others:

(i) Office Infrastructure

Company shall submit the details of office infrastructure in the state and in the concerned

districts in Annexure 7. A detailed organogram with existing manpower may be attached apart from the annexure if desired. (Annexure –7 of Part III) (ii) Activity Chart

The scheme covering the valid yellow and orange ration card holders needs to be launched within time frame. Hence the Insurance Company shall submit a time bound action plan, not

exceeding the date of launch, in Annexure – 8 to mobilize sufficient infrastructure and manpower as per the requirement. (Annexure-8 of Part III) (iii) Plan of Health Camps

The Insurance Agency shall give a detailed action plan on organizing health camps as prescribed in Para 18 D of part I. There is no structured format for this. (Annexure-9 of Part

III) (iv) Empanelled Health Facility with the Insurance Agency

Fresh empanelment of network hospitals has to be done for this Phase. Hence the number of

specialty hospital already empanelled with the Insurance Company in other schemes in the


State and concerned Districts. Insurer shall enumerate only those hospitals having requisite infrastructure as per the scheme. (Annexure-10 of Part III)

(v) Any Other Information, if any.

Any other information Insurer desires to inform, which is relevant to the scheme. There is no

structured format for this. (Annexure-11 of Part III) NOTE:

Insurance Agency shall give point wise reply of the RFP document for agreement /

disagreement and attach the necessary annexure as mentioned above.


Please submit the following:

1 -Qualifying

Criteria:

Details Annexures of

Part III

a IRDA license Annexure-1

b Insurance company should have an experience in conceptualizing, designing and implementing large

healthcare schemes and have at least three years‟ experience in catering to health insurance of 10,00,000

families across the country or more underwritten under each group health insurance policy in the financial year 2008-2009, 2009-2010 and 2010-2011 on State / Pan India

basis.

Annexure-2

c Declaration from the insurer that the Insurance Agency has not been black listed/debarred by any State

Government/Central Government or its agencies or not disqualified in participating the Government schemes as per IRDA guidelines.

Annexure-3

Declaration from the insurer that the Insurer will establish in-house system to provide all such facilities elaborated under the scheme.

Annexure-3a

d An undertaking as per format expressing their explicit

agreement to adhere with the details of the scheme as mentioned in the Part I of the RFP document.

Annexure-4

e An undertaking as per format confirming that they have

submitted their Proposal as a single entity only and have not form a Consortium for the scheme.

Annexure-5

f Tailor made policy of the desired Health Insurance Scheme in conformity to the benefits available, exclusions,

conditions etc. There is no structured format for this.

Annexure-6

2 - Others

i Company shall submit the details of office infrastructure in the state and in the concerned districts. A detailed

organogram with existing manpower may be attached apart from the annexure if desired.

Annexure-7

ii Activity Chart Annexure-8

iii Plan for Health Camps. There is no structured format for

this.

Annexure-9

iv Empanelled health facilities with Insurer Annexure-10

v Any Other information, if any. There is no structured format for this.

Annexure-11


ANNEXURE-1

ATTACH ATTESTED COPY OF IRDA LICENSE


ANNEXURE-2

EXPERIENCE IN GROUP HEALTH INSURANCE

OF THE COMPANY IN INDIA

a. Experience in conceptualizing, designing and implementing large healthcare schemes and have at least three year experience in catering to health insurance of 10,00,000 families

across the country or more underwritten under each group health insurance policy in the financial year 2008-2009, 2009-2010 and 2010-2011 on State / Pan India basis.

b. Number of beneficiary families‟ means enrolled under Group Health Insurance Scheme.

c. Insurers having Coinsurance for the purpose of risk sharing shall not qualify under the scheme.

Sr.

No.

Name of the

Group

Health

Insurance

Scheme

Name

of the

State

Policy

period

Number

of enrolled

Families

Premium (in Rs.) Claims

Number of

enrolled

beneficiary

families

Per

Family

(Rs.)

Total

Premium

(Rs in

Lakh)

Received

(no.)

Settled/

Under

Process

(Rs in

Lakh)

1 2 3 4 5 6 7 8 9

2008-09

1

2

3

2009-10

1

2

3

2010-11

1

2

3

DATE: AUTHORIZED SIGNATORY

Seal


ANNEXURE – 3 NAME AND ADDRESS OF THE INSURANCE COMPANY

DECLARATION (ON BOND PAPER OF RS. 100)

BY THE INSURANCE AGENCY

I, __________________________________________________________ Designated as ___________________________________________at_______________________

_____ of ______________________________________________ Insurance Company hereby declare that Our Insurance Company has not been black

listed/debarred by any State Government/Central Government or its agencies or not disqualified in participating the Government schemes as per IRDA guidelines.

DATE: SIGNATURE

Stamp: Name:

Designation

Address:


ANNEXURE-3A

NAME AND ADDRESS OF THE INSURANCE COMPANY



I, __________________________________________________________

Designated as ________________________________________at__________________________

__ of ______________________________________________ Insurance Company hereby declare that the Insurer will establish in-house system to provide all such facilities elaborated under the scheme.

DATE: SIGNATURE Stamp: Name:

Designation:


ANNEXURE – 4 NAME AND ADDRESS OF THE INSURANCE COMPANY



I, __________________________________________________________ Designated as

________________________________________at____________________________ of ______________________________________________ Insurance Company hereby declare that I have read the contents of the RFP Document consisting of Part

I to IV and having explicit agreement to adhere with the details of the scheme as mentioned in the RFP for implementation of the RGJAY given therein. I hereby

submit the Proposal in the desired format with respective proformas duly signed by me. If our Proposal is found successful, the company is agreeable to execute the MoU within twenty four hours (excluding public holidays) after the award.


Designation:

Address:


ANNEXURE – 5

NAME AND ADDRESS OF THE INSURANCE COMPANY

UNDERTAKING (ON BOND PAPER OF RS. 100)


I,________________________________________________________designated

as ________________________________at_________________________________

_____ of ___________________________________ Insurance Company __________ hereby give an undertaking that the Proposal has been submitted as a single entity and has not formed any consortium with other Insurance Agencies

under RGJAY scheme.


Designation:

Address:


ANNEXURE – 6

TAILOR MADE POLICY OF THE DESIRED

HEALTH INSURANCE SCHEME IN CONFORMITY

TO THE BENEFITS AVAILABLE, EXCLUSIONS, CONDITIONS ETC.

DATE: SIGNATURE

Stamp: Name:

Designation:

Address:


ANNEXURE-7

OFFICE INFRASTRUCTURE IN THE STATE AND

IN THE CONCERNED DISTRICTS.

Office Number of Branches

All India

(Numbers)

State (

Numbers) Number of Branches

Gad

chir

oli

Am

ravati

Nan

ded

Sola

pu

r

Dh

ule

Raig

ad

Mu

mb

ai C

ity

Mu

mb

ai

Su

bu

rban

Head Office

Zonal Offices

Operating Offices

DATE: SIGNATURE

Stamp: Name:

Designation:

Address:


ANNEXURE-8

ACTIVITY CHART

Activity Number of days required to

complete the activity from the

award date

Remarks

Identifying the Project Officer

Setting up of Project Office with infrastructure

in the area of Municipal Corporation of Greater Bombay

Appointment of Medical Officers

Establishment of other staff

Preparatory meeting with hospitals

Inspection of hospitals vis-à-vis scheme

requirements, identification of Rajiv Gandhi Jeevandayee Medical Co-ordinator (MCO), Rajiv Gandhi Jeevandayee Medical camp

Coordinator (MCCO), signing of MoU and Empanelment Of Hospitals

Issue of CUG connections to MCO s and

MCCO s

Installation of kiosk, computer and Accessories and 1mbps connectivity.

Printing and distribution of publicity

Material

Printing and distribution of stationary related to work flow of the scheme.

Appointment of Aarogyamithras

· In PHCs/Govt. Hospitals · In Network Hospitals

Training of Aarogyamithras, distribution of Aprons and CUG mobiles.

Training of Doctors

Training of other staff

IT enabling

Establishment of 24 Hrs Call Center

Establishment of other infrastructure

Establishment of infrastructure in the districts

Preparatory meetings and trainings at district level for inaugural mega camps.


Designation:

Address:


ANNEXURE-9

PLAN FOR HEALTH CAMPS


Designation:

Address:


ANNEXURE-10

DETAILS OF EMPANELLED HEALTH FACILITIES WITH INSURERS


Designation:

Address:

Dsitrict Name of

Hospital

Tertiary/

General

Private/

Govt.

No. of

Beds

Empanelled

for

specialized

category/ies

and

procedures

(Number/s)

1 Gadchiroli

2 Amravati,

3 Nanded,

4 Solapur,

5 Dhule,

6 Raigad,

7 Mumbai Urban

8 Mumbai Suburban

Other Districts

within Maharashtra


ANNEXURE -11

ANY OTHER INFORMATION


Designation:

Address:


SECTION C – FINANCIAL PROPOSAL

A) Premium quote for a sum insured of Rs. 1.50 Lakh per family per annum on floater

basis. (For renal implant the ceiling is Rs. 2.5 lakh):

SR. NO. PREMIUM PER

FAMILY WITHOUT S.T. PREMIUM PER

FAMILY WITH S.T .

1 Rs.

Rs.

(Rs. in words)

(Rs. in words)

B) Details of Add on cover without any additional premium:

Sr. No. Benefits Details

1

2

3

4

Note: No other documents or attachments are permissible along with Section C. Any

deviation will attract disqualification.

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


Designation:

Address:


Part –IV:

M o U (Memorandum of Understanding)

RAJIV GANDHI JEEVANDAYEE AROGYA YOJANA IN MAHARASHTRA. THE

FIRST PHASE in 8 DISTRICTS OF GADCHIROLI, , AMRAVATI , NANDED,

SOLAPUR, DHULE, , RAIGAD, MUMBAI CITY, MUMBAI SUBURBA DISTRICTS

MEMORANDUM OF UNDERSTANDING

This Memorandum of Understanding (hereinafter called the MoU) is executed at

_________on this ____ day of ________ between the Government of Maharashtra/ Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) Society (the society is proposed to be

incorporated prior to award of the contract) having its office at First Floor of Arogya Bhavan, St. Georges‟ Hospital campus, Mumbai 400001 (hereinafter referred to as the “Insured” and Party of the first part) represented by Chief Executive Officer, Rajiv Gandhi Jeevandayee

Arogya Yojana Society, which expression shall, unless repugnant to the context or meaning thereof, be deemed to mean and include its successors and permitted assigns;

AND

(Name of Insurance Company), an Insurance Company having its registered and Head

Office at_______________________ Mumbai (hereinafter referred to as the “Insurer” and the Party of the second part) represented by Chairman cum Managing Director which expression, shall unless repugnant to the context or meaning thereof, be deemed to

mean and include its successors and permitted assigns. WHEREAS:

1. The Government of Maharashtra / Rajiv Gandhi Jeevandayee Arogya Yojana Society, a Nodal

Agency has, after a due Selection process involving Technical and Financial Evaluation, awarded the Contract of Insurance under the “Rajiv Gandhi Jeevandayee Arogya Yojana in 8 districts of Mumbai city, Mumbai Suburban District, Dhule, Raigad, Solapur, Nanded,

Amravati, and Gadchiroli, of the State of Maharashtra for 30 identified specialized categories envisaging 972 identified procedures, to the Insurer and the Party of the second part.

2. The Insurer has agreed that they shall provide the health insurance services to the families of BPL(yellow ration card holders), Antyodaya, Annapurna and APL (orange ration

card holders) belonging to eight Districts of Maharashtra under Phase -1 covered under Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) on the terms and conditions of the policy

and more particularly described in this Agreement within the state of Maharashtra. 3. The commencement of Rajiv Gandhi Jeevandayee Arogya Yojana (RGJAY) through the

Insurer under this agreement shall be effective from 2 October 2011 [Date, Month and Year],

for one year and shall expire on 1 October 2012 [Date, Month and Year]. 4. The Insurer has been registered under Section 3 of the Insurance Act 1938 (Act 4 of 1938)

having its Registration No. ____ And is inter alia engaged in the business of providing General Insurance in India.

5. The Insurer has agreed to issue the Policy to the satisfaction and in favour of the Insured

covering the Beneficiary families in the manner agreed herein.

NOW THEREFORE IT IS AGREED as follows:

1. DEFINITIONS & INTERPRETATION

1.1 The following terms and expressions shall have the following meanings for

purposes of this Agreement: i. “Agreement” shall mean this agreement and all Schedules, supplements,

appendices, appendages and modifications thereof made in accordance with the terms of this agreement.

ii. “Benefit(s)” shall mean the health services that the beneficiary families

are entitled to receive based on the contract between the Government of Maharashtra and the Insurer under Rajiv Gandhi Jeevandayee Arogya


Yojana (RGJAY) subject to the terms, conditions, limitations and exclusions of the Policy.

iii. “Beneficiary (ies)” shall mean those existing families of BPL, Antyodaya, Annapurna and APL (except white ration card holders) belonging to Eight

Districts of Maharashtra covered under Rajiv Gandhi Jeevandayee Arogya

Yojana and enrolled under RGJAY. iv. “Business Day” shall mean days on which commercial banks are open for

business in India. v. “Government of Maharashtra” shall mean either, Government of

Maharashtra or Rajiv Gandhi Jeevandayee Arogya Society nominated by the Govt. of Maharashtra.

vi. “RGJAY” shall mean Rajiv Gandhi Jeevandayee Arogya Yojana

vii. “RGJAS” shall mean Rajiv Gandhi Jeevandayee Arogya Yojana Society

viii. “Claim Payment” shall mean the payment of claim to the Empanelled

Hospitals/Nursing Homes under the RGJAY based on the invoice/ Health

card or yellow/Orange ration card transaction received by the insurer from

the health providers and also it would include the payments made for reimbursement claims.

ix. “De-Listing of Empanelled Hospitals/Nursing homes” shall mean delisting

the empanelled hospital by the Insurer based on the criteria defined. x. “Empanelled Hospitals/Nursing Homes” shall mean the Hospital/ Nursing

Home as has been empanelled by the Insurer as per parameters defined in this agreement to provide health care services under Rajiv Gandhi Jeevandayee

Arogya Yojana.

xi. “Family” mean members as listed on the Rajiv Gandhi Jeevandayee Arogya Yojana Health Cards or holding valid Orange/Yellow Ration Card. The details in the Health Card will be taken as the proof for determining the eligibility of

the beneficiary. For those beneficiary families whom the health cards are not distributed, the beneficiary families will be identified based on names

displayed on their valid Orange/Yellow Ration Card distributed by Department of Food and Civil Supplies coupled with Aadhar number or photo identity card issued by Govt. agency (driving license, election card) till he/she

gets Aadhaar number.

xii. “Force Majeure Event” shall include: (i) Fire, flood, atmospheric disturbance, lightning, storm, typhoon, tornado, earthquake, washout, or other

acts of God; (ii) War, riot, blockade, insurrection, acts of public enemies, civil disturbances, terrorism and sabotage and threats of such actions; (iii) Strikes, lock-outs, or other industrial disturbances or Labour disputes

xiii. “IRDA” shall mean the Insurance Regulatory and Development Authority established under the Insurance Regulatory and Development Authority

Act 1999. xiv. “Insured” shall mean the Government of Maharashtra /Rajiv Gandhi

Jeevandayee Arogya Society (RGJAS) / Nodal Agency who has paid the

premium on behalf of their beneficiary families to Insurer for availing the health insurance services under RGJAY.

xv. “Insurer” shall mean an Insurance Company selected by the Government of Maharashtra to provide all such services to the RGJAY beneficiary families as outlined in the agreement under RGJAY.

xvi. “Law” includes all Statutes, Enactments, Acts of Legislature, Laws, Ordinances, Rules, Bye Laws, Clauses, Regulations, Notifications,

Guidelines, Policies, and orders of any Statutory Authority constituted under the provisions of Constitution of India or Courts in India.


xvii. “Party” shall mean either the Insurer or the Government of Maharashtra and “Parties” shall mean both the Insurer and the Government of Maharashtra.

xviii. “Period of Agreement” shall mean that the agreement will be for three year

from the effective date,

xix. “Period of Insurance policy” shall mean the period of one year from the inception date as notified during which the Insurance Policy shall be operative to provide the benefit to the RGJAY beneficiary families.

xx. “Project Office” shall mean the office of the Insurer located at Mumbai to

coordinates the provision of RGJAY under this Agreement.

xxi. “Policy” shall mean the Health Insurance Policy of the Insurer issued to the Insured on behalf of the families of Below Poverty Line Population (yellow

card holders), Antyodaya, Annapurna and Above Poverty Line Population (APL-orange ration card holders) belonging to eight Districts of Maharashtra under RGJAY.

xxii. “Policy Holder” shall mean the Insured who has paid the premium on behalf

of their beneficiary families to Insurer for availing the health insurance services under RGJAY.

xxiii. “Premium” shall mean an amount agreed by both Parties charged per family on an annual basis as consideration for providing health insurance services

under this Agreement.

xxiv. “Package Charges” shall mean the indicative maximum charges per ailment/procedure for benefits including follow up package covered by this Agreement as fixed under Rajiv Gandhi Jeevandayee Arogya Yojana

society.

xxv. “Provider” shall mean empanelled Hospitals / Nursing homes under the

scheme. xxvi. “Scheme” shall mean the Rajiv Gandhi Jeevandayee Arogya Yojana as

operational and as otherwise outlined in this Agreement.

” Health Card shall mean Health Photo Card for RGJAY beneficiary families issued under RGJAY by the Insurer as per specifications given by Government of

Maharashtra. xxvii. “Service Area” shall mean within state of Maharashtra basis within which the

Government of Maharashtra has authorized the Insurer to provide health

insurance service under RGJAY.

1.2 OTHERS

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

ii. “Headings” are used for convenience only and shall not affect the

interpretation of this Agreement.

iii. Any reference to an agreement, contract, instrument or other document (including a reference to this Agreement) herein shall be to such agreement, instrument or other document as amended, supplemented or pursuant to the

terms thereof. iv. Terms and expressions denoting the singular shall include the plural and vice versa.

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

vi. The term “herein”, “hereof”, “hereinafter”, “hereto”, “hereunder” and words of

similar import refer to this Agreement as a whole.

2. BENEFICIARY FAMILIES:

Families holding yellow ration card, Antyodaya Anna Yojana card (AAY), Annapurna card and orange ration card from eight districts viz. Gadchiroli, Amravati, Nanded, Solapur, Dhule,


Raigad, Mumbai city and Suburban Mumbai. The families with white ration card holding would not be covered under the scheme. The total number of beneficiary families in the state

would be around 2,04,30, 527; out of which approximately 49 Lakh families in the 8 districts are to be covered under the scheme in first phase as on the date of publishing of the Request

for Proposal (RFP) document. District wise profile of the beneficiary families is given below:

Phase-I Districts Population *Approximate number of

Beneficiary Families 1 Gadchiroli 970294 182889

2 Amravati 2607160 559473 3 Nanded 2876259 543961

4 Solapur 3849543 830011

5 Dhule 1707947 397674

6 Raigad 2207929 566231

7 Mumbai City 3338031 482073

8 Mumbai Suburban 8640419 1340828

Total 26197582 4903140

* Based on data furnished by Civil Supplies department as on 31.05.2010.

The beneficiary families would be identified through the Rajiv Gandhi Jeevandayee Health Card issued by the Government of Maharashtra or based on the Yellow and Orange ration card issued by Civil Supplies Department.

The following actions would be undertaken by Network hospitals in case of the possible exceptional situations: No Exceptional Situation Requirement for benefit

1 No Health Card with beneficiary, but Valid Yellow or Orange Ration Card with name of beneficiary is available

Aadhaar number and in case Aadhaar number not taken any Photo ID card issued by Govt. ( Driving license, election identity card with photograph) to correlate the patient name & photograph (In instance of emergency admission, provisional preauthorization may be given subject to confirmation of it against submission of valid photo identity card issued by Govt. before discharge.)

2

Children born after issue of card i.e. name and photo not available on health card or on valid yellow/Orange ration card

Photograph of child with either parent along with Health card/ valid Yellow or Orange ration card of either parent and Birth certificate issued by authorized officer.

3

Name is there in Yellow or Orange Ration Card and matches with name in photo identity. But the card is invalid as it does not match with the digitized list.

Not eligible for benefit package (The yellow /Orange ration card is cancelled after verification by department but still the family is holding it)

3. COVERAGE: This is a package medical insurance scheme to cover hospitalization for surgeries and therapies through cashless treatment in respect of the following 30 identified specialized

categories having 972 procedures and 121 follow up procedures along with follow up packages.

1 GENERAL SURGERY

2 ENT SURGERY

3 OPTHALMOLOGY SURGERY

4 GYNAECOLOGY AND OBSTETRICS SURGERY

5 ORTHOPEDIC SURGERY AND PROCEDURES

6 SURGICAL GASTRO ENTEROLOGY

7 CARDIAC AND CARDIOTHORACIC SURGERY


8 PEDIATRIC SURGERIES

9 GENITOURINARY SYSTEM

10 NEUROSURGERY

11 SURGICAL ONCOLOGY

12 MEDICAL ONCOLOGY

13 RADIATION ONCOLOGY

14 PLASTIC SURGERY

15 BURNS

16 POLY TRAUMA

17 PROSTHESES

18 CRITICAL CARE

19 GENERAL MEDICINE

20 INFECTIOUS DISEASES

21 PEDIATRICS

22 CARDIOLOGY

23 NEPHROLOGY

24 NEUROLOGY

25 PULMONOLOGY

26 DERMATOLOGY

27 RHEUMATOLOGY

28 ENDOCRINOLOGY

29 GASTROENTEROLOGY

30 INTERVENTIONAL RADIOLOGY

Detailed list of specified surgeries and therapies falling in the identified groups and packages is given Appendix – I (a) and the follow up package is given Appendix – 1 (b) of Part IV.

The scheme would provide for cashless treatment to patients in the Network Hospitals in case of covered surgical procedures, interventions and therapies connected with the diseases

/conditions mentioned above. 4. SUM ASSURED:

The Scheme shall provide coverage for meeting all expenses relating to hospitalization of

beneficiary up to Rs. 1,50,000/- per family per year in any of the Empanelled Hospital/Nursing Home subject to Package Rates on cashless basis through Health cards. The

benefit shall be available to each and every member of the family on floater basis i.e. the total reimbursement of Rs. 1.5 lakh can be availed by one individual or collectively by all members of the family.

In case of renal transplant surgery, the immunosuppressive therapy is required for a period of 1 year. So the upper price ceiling for Renal Transplant would be Rs. 2, 50,000 per operation

as an exceptional package exclusively for this procedure. The cases are likely to be very few and well controlled by Human Organ Transplant Act 1994. This would also be part of the coverage. 5. PRE EXISTING DISEASES: All diseases under the proposed scheme will be covered from day one. A person suffering

from any disease prior to the inception of the policy shall also be covered under approved procedures for that disease. 6. PRE AND POST HOSPITALIZATION:

6.1 From date of reporting to hospital up to 10 days from the date of discharge from the hospital shall be part of the package.


6.2 Network Hospital will provide follow-up free consultation, diagnostics and medicines when patient is called for follow-up within 10 days of discharge being

part of the package. 7. DEFINITION OF FAMILY:

Family means members as enlisted and photographed on the Rajiv Gandhi Jeevandayee Arogya Yojana Health Cards or holding valid Orange/Yellow Ration Card.

8. HEALTH CARDS

All eligible families in these districts shall be provided with Rajiv Gandhi Jeevandayee Arogya Yojana Health Cards in due course of time. These Health Cards will be used for identification of Beneficiary families in the family under the Scheme. Family Health Cards

will be prepared by using data of valid ration cards (yellow and orange) issued by Food and Civil supplies department coupled with Aadhaar numbers issued by UID authorities, although

the latter is individual card. As an interim measure till the health card is issued, the valid Orange/Yellow Ration Card with Aadhaar number or in case Aadhaar number not available, any Photo ID card of patient issued by Govt. agencies (Driving license, Election ID) would be

required to correlate the patient name and photograph for identification of beneficiary. 9. WEB PORTAL:

All activities related to the scheme shall be done through a dedicated portal of Rajiv Gandhi Jeevandayee Society, the development and maintenance cost of which will be borne by the Insurer. The source code and system design document for the application exclusively

developed by Insurer for Rajiv Gandhi Jeevandayee Arogya Yojana shall be provided in good working condition to Rajiv Gandhi Jeevandayee Society. A dedicated data center in the name

of Rajiv Gandhi Jeevandayee Yojana will be maintained by the Insurer. The proprietary rights of software will be with Government of Maharashtra .Patient records will be property of Rajiv Gandhi Jeevandayee Society. Confidentiality of patient records

should be maintained. The web portal will be a repository of information and will have the following features and the respective workflows:

1. General Information on the scheme. 2. Details of patients reporting and referrals from the PHC / Rural/ Sub-

district/Women/General/District hospitals on daily basis.

3. E-Health Camps system and daily reporting of health camps. 4. Details of patients reporting and getting referred from the health camps.

5. E-Empanelment system. 6. Emergency approval system. 7. Call centre application.

8. Patient registration by Aarogyamithra in Network Hospitals. 9. Details of in-patients and out patients in the network hospitals.

10. On-bed reporting system. 11. Costing of the Tests done in the network hospitals. 12. E-preauthorization.

13. Surgery details. 14. Discharge details.

15. Real-time reporting, active data warehousing and analysis system. 16. Claim settlement. 17. Electronic clearance of bills with payment gateway.

18. Follow-up of patient after surgery. 19. Distribution of Follow-up medicines.

20. Rajiv Gandhi Jeevandayee Messaging Services. 21. Grievance and Feedback workflow. 22. Back Tracking System.

23. E-Office management. 24. Accounting system.


25. TDS workflow. 26. Death reporting system.

10. PAYMENT OF INSURANCE PREMIUM:

It is agreed that Government shall pay to the Insurer an amount of Rs. ---------- Plus Service

Tax as applicable, towards the entire annual premium etc. The payment shall be made in four installments of Rs. ------------------- Plus services tax each as under:.

First Installment: Before the commencement of the scheme

Second installment: Before the start of second quarter of year

Third installment: Before the start of third quarter of year

Fourth installment: Before the start of fourth quarter of year

The total number of beneficiary families for each District is an indicative estimate and may vary. The number of the final beneficiary families for each district will be given within one month of signing MOU. The total premium payable would be based on this final figure of

eligible beneficiary families. Following activities should be completed before inception of scheme within three months of

award of contract before release of the first installment of the premium. 1) The successful insurer shall furnish the security deposit to the RGJAYS within 7

days from the date of communication of Award of Contract for an amount of 5%

of the contract value, valid up to 90 days after the date of completion of warranty obligations and enter into MOU on Rs. 100/- non-judicial stamp paper. The cost of

Stamp paper should be borne by the insurer. The Security Deposit should be in the form of Bank Guarantee in favour of the „Rajiv Gandhi Jeevandayee Arogya Society' payable at Mumbai from any Nationalized or Scheduled bank. The

Security Deposit will be discharged by the Purchaser and returned to the Supplier not later than 30 days following the date of completion of the Insurer‟s

performance obligations by the end of first quarter of execution of scheme, including the warranty obligation, under the MOU. The security deposit shall be discharged (forfeited) as a compensation for any loss resulting from the failure to

perform the obligations under the MOU or in the event of termination of the MOU or in any event as the Purchaser thinks fit and proper.

2) The Insurance Company has to empanel minimum 100 network hospitals in the state and it should be ensured that all procedures should be covered cumulatively in empanelled hospitals.

3) The Insurance Company has to start call center with all requisite staff, departments and appointment of field staff with staff at network hospital. An adequate area

should be reserved for office of Rajiv Gandhi Jeevandayee Arogya Yojana Society office. Software (if so specifications and certifying authority) and Connectivity should be established in order to start the scheme.

11. PERIOD OF INSURANCE & PERIOD OF AGREEMENT:

The insurance coverage under the scheme for the beneficiary families shall be in force for a

period of one year from the date of commencement of the policy (From 0.00 hrs of 02.10.2011 to Midnight of 01.10.2012 for Phase-I). The period of agreement shall be for three years with effect from 02.10.2011; subject to

annual review and renewal of policy based on performance parameters as below. 1. Percentage of health camps in a month (One health camp per week)

2. Claim ratio 3. Number and Percentage of complaints redressed against total complaints received. 4. Minimum number hospitals to be empanelled at start of scheme 100.

5. Time required for preauthorization 12 hours ordinarily and immediately in cases of emergency.

6. Time required for claim settlement. 7. IEC Activities according to norms fixed.


8. Any new issue coming up in fulfillment of objective of RGJAY Society / GOM. 11.a. PERFORMANCE PARAMETERS AND PENALTY CLAUSE:

The Insurer is required to perform multiple activities in performance of its obligations arising out of the insurance contract to it. Any activity not performed by the insurer within the given time line shall hamper implementation of Rajiv Gandhi Jeevandayee Health Insurance

Scheme from the planned date. Such activities have been listed here under which the successful bidder is required to complete within the specified period from the date of award of

the insurance contract to it failing which a penalty as specified percentage on total

premium against each section per week/month shall have to pay to the RGJAY society for the period of delay. Sr.

No

Activity Time frame from

the date of Signing

of Agreement

Penalty for the delay

in execution in % of

component charges

PENALTY PER WEEK

A a. Identifying the Project Officer

b. Setting up of Project Office with in frastructure

Municipal Corporation of Greater Bombay

7 days

30 Days

1%

1%

B Preparation and Certificat ion of software on receiving the

specification from Society.

3 month 1%

C Dedicated Website as per the requirement (envisaging

Empanelment MIS,HR MIS, Publicity and Camp MIS, E-

authorization MIS, Claim MIS,

Follow up monitoring MIS, Field operations Support

service MIS, Grievance MIS, Medical Audit MIS, Key

performance Indicators and variable salary, Operat ion

maintenance MIS)

3 months 2.0%

D Establishment of 24 Hrs. Call Center and Establishment of

other infrastructure

3 month 1%

E Establishment of sufficient infrastructure in each district.

Installation of kiosk, computer and accessories etc.

3 month 1%

F To identify the Hospital Network Providers and networking

with them.

3 months 0.5%

G To arrange cashless treatment of the insured in the

empanelled hospitals under the scheme and facilitation of

proper networking for quick and error-free processing of

pre-authorizat ions.

3 months 0.5%

H To provide adequate manpower, so as to ensure free flow of

daily MIS and ensure that progress of scheme is reported to

Society in the desired format on a real-time basis.

3 months 0.5%

I Preparation of various formats used for cashless

transactions, discharge summary, billing pattern and other

reports in consultation with the Government.

1 months 0.5%

PENALTY PER MONTH

J Processing of claims related to the scheme. Pre-authorization of

requests and approval of preauthorization if all the conditions are

fulfilled, within 12 hours of receiving the preauthorization

request from the network provider if failure % is more than

5%)

System to be ready

in 3 months

(Continuing

activity)

1%

K Scrutinize the b ills from network hosp itals and give

approval for the sanction of the bill and forward payment

within 7 working days on receipt of complete claim document

from the Network Hospitals. (Failure % is more than 5%)

System to be ready

in 3 months &

(Continuing

activity)

1%

L Medical Auditing (by minimum qualificat ion MBBS) fo r

conducting 20% per month concurrent audits of services

and quality of service provided to the beneficiary families

delivered by Network Hospitals on periodic basis as well as

and required.

3rd month

(Continuing

activity)

0.5%


Sr.

No

Activity Time frame from

the date of Signing

of Agreement

Penalty for the delay

in execution in % of

component charges

M HR

Number of network hospitals and number of

Aarogymitras /Medical Coordinators, Camp

Coordinators posted- District wise, month wise, and

aggregate

Number of Public facilit ies (CHCs/PHCs) and number

of Aarogymitras posted - District wise, month wise,

and aggregate

3rd month

onwards

0.5%

N Training programme for Network Hospital Providers and other

stake holders ones in a month.

2nd

month onwards (Continuing activity)

0.5%

12. ADJUSTMENT/ REFUND OF PREMIUM: If there is a surplus after the claims experience on the premium (excluding Service Tax) at the end of the policy period, after providing 20% of the premium paid towards the Company‟s

administrative cost, of the balance 80% after providing for claims payment and outstanding claims, 90% of the left over surplus will be refunded to the Government of Maharashtra / Rajiv Gandhi Jeevandayee Arogya Yojana Society within 30 days after the expiry of the Run-

off period. 13. PROCEDURE FOR ENROLLMENT OF HOSPITALS:

The Public and Private Hospitals will be jointly empanelled within the State of Maharashtra by Rajiv Gandhi Jeevandayee Arogya Yojana Society and Insurance Company following the empanelment procedure laid down by Rajiv Gandhi Jeevandayee Arogya Yojana Society. The

hospitals having minimum of 50 inpatient hospital beds with adequate facilities and offering the services as stipulated below shall be empanelled after being scrutinized and recommended

by the Empanelment and Disciplinary Committee. Empanelment and Disciplinary Committee will constitute a subcommittee of four doctors for this purpose. Two doctors will be nominated by Insurance Company and two by Rajiv Gandhi Jeevandayee Arogya Society.

The purpose of this empanelment is to ensure capability of the hospital to provide some of the identified 30 specialized categories and seek agreement to the equal or lower price for these

972 procedures and 121 follow up procedures and take an opportunity to assess the current quality of care therein. It would be the responsibility of the Insurer for enrollment of Network Hospitals in the State of Maharashtra to give adequate facilities for the treatment of the

patients when they present themselves. The number of empanelled hospitals and number of procedures in each hospital to be permitted will be based on the need and at discretion of the

society in the interest of beneficiary. Network hospitals are supposed to extend medical aid to the beneficiary under the scheme. Procedure for enrollment of Hospitals is placed as Appendix- IV of Part IV. Preference for empanelment could be given to the hospitals

accredited under National Board of Accreditation for Hospitals. It is also desired to accreditate the empaneled hospital under National Board of Accreditation for Hospitals in order to ensure

quality of care.

14. MOU with Network Hospital and Disciplinary actions against the hospitals:

(i) MOU with Network Hospital:

The Insurer shall sign MOU with all the network hospitals to be empanelled under the scheme. Separate MOU‟s with relevant provisions have to be entered into for Multi-

speciality, Cancer Treatment etc. This MOU is subject to the approval of the Rajiv Gandhi Jeevandayee Society. Number of empaneled hospitals and specializations will depend on the benefit the beneficiary. Network hospitals are supposed to extend medical aid to the

beneficiary under the scheme. A provision will be made in MOU regarding non-compliance / default clause. Such matter shall be looked in to by the Empanelment and

Disciplinary Committee, the decision of which will be binding to all concerned. The sample MOU is attached as appendix 7 of Part IV.


(ii) Disciplinary actions against the hospitals: On recommendation by the Empanelment and Disciplinary Committee the Insurer shall

take various disciplinary actions against Network Hospital including De-listing from the empanelment if it is found that guidelines of the Scheme are not followed by it and

services offered are not satisfactory as per laid down standards. Hospital may also be delisted or de-empanelled if infrastructure in the hospital is found below the standards laid down by society any time during the policy period. The Insurer is also liable for any

deficiency in the service provided by the network hospital / service provider other than medical services and in case of any delisting the Insurer shall find alternative

immediately. 15. CASHLESS SERVICE: The Insurer has to ensure that adequate facilities are provided to all beneficiary families so

that they do not have to pay any deposits at the commencement of the treatment or at the end of treatment to the extent the Services as covered under the Rajiv Gandhi Jeevandayee Arogya

Yojana. It is envisaged that for each hospitalization the transaction shall be cashless for covered procedures. Enrolled/Eligible beneficiary along with health card/ orange or yellow ration card will go to hospital and come out without making payment to the hospital subject to

procedure covered under the scheme. The same is the case for diagnostics if eventually the patient does not end up in undertaking the surgery or therapy. The beneficiary has right to

select network hospital and services of selected network hospital should be made available. (Subject to availability of beds) In instance of non – availability of beds in network hospital, cross referral to another network hospital may be accepted.

16. PACKAGES: The insurer should ensure that the Network hospitals follow the packages worked out by Rajiv

Gandhi Jeevandayee Society. The package rates will include bed charges in General ward, Nursing and boarding charges, Surgeons, Anesthetists, Medical Practitioner, Consultants fees, Anesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances, Med icines and

Drugs, Cost of Prosthetic Devices, implants, X-Ray and Diagnostic Tests, food to impatient, one time transport cost etc. In other words the package should cover the entire cost of

treatment of patient from date of reporting to his discharge from hospital and 10 days after discharge after surgery including complications if any, making the transaction truly cashless to the patient. In instance of death, the carriage of dead body from network hospital to the

village/township would also be part of package. 17. IMPLEMENTATION PROCEDURE:

The entire scheme is to be implemented as cashless hospitalization arranged by the insurer. The following table steps represent the process flow of treatment to the beneficiary in the Network hospital.

The Entire scheme is to be implemented as cashless hospitalization arranged by the Insurance Company. The following table represents the process flow of treatment to the beneficiary

A) Process Flow of the Beneficiary Treatment in the Network Hospital

Step I

Beneficiary families shall approach nearby PHC/Rural, Sub district, General, Women/District

Hospital/Network Hospital. Aarogyamitras placed in the above hospitals shall facilitate the beneficiary. If beneficiary visits Government Health Facility other than the Network Hospital,

he/she will be given a referral card to the Network Hospital with preliminary diagnosis by the doctors. The Beneficiary may also attend the Health Camps being conducted by the Network Hospital in the Villages and can get that referral card based on the diagnosis. The information

on the outpatient and referred cases in the PHC/Rural, Sub district, General, Women/DH and the camps will be collected from all Aarogyamitras/Hospitals on regular basis and captured in

the dedicated database through a well-established call center.


Step 2

The Aarogyamitras at the Network Hospital examine the referral card and health card or

Yellow/Orange Ration Card, register the patients and facilitate the beneficiary to undergo specialist consultation, preliminary diagnosis, basic tests and admission process. The

information like admission notes, test done will be captured in the dedicated database by the Medical Coordinator of the Network Hospital as per the requirement of the Rajiv Gandhi Jeevandayee Arogya Yojana Society.

Step 3

The Network Hospital, based on the diagnosis, admits the patient and sends E-

preauthorization request to the insurer, same can be reviewed by Rajiv Gandhi Jeevandayee Arogya Yojana Society.

Step 4

Recognized Medical Specialists of the Insurer and Rajiv Gandhi Jeevandayee Arogya Yojana Society examine the preauthorization request and approve preauthorization, if, all the

conditions are satisfied. This will be done within 12 working hours and immediately in case of emergency wherein e-preauthorization is marked as “EM”.

Step 5

The Network Hospital extends cashless treatment and surgery to the beneficiary. The Postoperative notes of the Network Hospitals will be updated on the website by the medical

coordinator. Step 6

Network Hospital after performing the covered surgery/ therapy/ procedure forwards the

Originals bills, Diagnostics reports, Case sheet, Satisfaction letter from patient, Discharge Summary duly signed by the doctor, acknowledgement of payments of transportation cost and

other relevant documents to Insurer for settlement of the claim. The Discharge Summary and follow-up details will be part of the Rajiv Gandhi Jeevandayee Arogya Yojana Society portal.

Step 7

Insurer scrutinizes the bills and gives approval for the sanction of the bill and shall make the payment within agreed period. The claim settlement module along with electronic clearance

and payment gateway will be part of the workflow in Rajiv Gandhi Jeevandayee Arogya Yojana Society portal and will be operated by the Insurer. The reports will be available for scrutiny on the Rajiv Gandhi Jeevandayee Arogya Yojana Society login.

Step 8

The Network Hospital will provide free follow-up consultation, diagnostics, and medicines

under the scheme up to 10 days from the date of discharge. 18. HEALTH CAMPS: Health Camps are to be conducted in Taluka Head Quarters, Major Gram Panchayats and

Municipalities. Minimum of one camp per week per empanelled hospital has to be held in the eight districts in the policy year. The insurer shall ensure that at least one free medical camp is

conducted by each network hospital per week at the place suggested by Rajiv Gandhi Jeevandayee Society. The Rajiv Gandhi Jeevandayee Medical Camp Coordinator (MCCO) of the hospital shall coordinate the entire activity. Network hospital shall carry necessary

screening equipment along with specialists (as suggested by the Rajiv Gandhi Jeevandayee Society) and other para-medical staff. The Insurer shall put in the minimum requirements as

regards the health camp in the MOU with the hospitals. They shall work in close liaison with district coordinator of the Insurance Company, Civil Surgeon/DHO in consultation with District Collector. Hospital shall follow the Camp policy of Rajiv Gandhi Jeevandayee

Society The Insurer shall in consultation with Rajiv Gandhi Jeevandayee Arogya Yojana Society plan,

prepare and inform the schedule of Health Camps well in advance to Rajiv Gandhi Jeevandayee Arogya Yojana Society as per the guidelines and also inform the same to the


District Collectors, Civil Surgeons/DHO, Public Representatives, Empanelled hospitals and other stakeholders.

The Insurer shall ensure that Network Hospital conducts the Camp as per schedule with all necessary equipment and professionals in the concerned fields. They should also submit to

Rajiv Gandhi Jeevandayee Arogya Yojana Society the confirmation of participation in the camps from the Network Hospital. The Network hospital shall enter the details of the patients screened and referred in the camps in the assigned login of the workflow of Rajiv Gandhi

Jeevandayee Arogya Yojana Society Portal. 19. DISTRICT LEVEL CO-ORDINATION:

District level offices with necessary infrastructure have to be set-up by the Insurance Company. The Insurer needs to have district level monitoring staff with District Coordinators, GM‟s/DGM‟s /Area Managers /Assistant Area Managers /District level doctors / Regional

Coordinators of the Insurance Company ( When scheme) is implemented in whole state) should monitor Aarogymitras, co-ordinate with network hospital, district administration and

people‟s representatives for effective implementation of programme. They should ensure that camps are held as per schedule, arrange for canvassing for the camp, mobilize patients and follow up the beneficiary families. He/she should work in close liaison with district

administration under the supervision of District Collector. He should also ensure proper flow of MIS and report to society on day to day basis about the progress of the scheme in the

district. The Insurance Company should ensure that dedicated staff is made available for the scheme. There shall be at least one doctor to be placed in each district. Further wherever the concentration of the Network Hospitals is more additional doctors need to be placed. The

Insurance Company shall follow the instructions of Rajiv Gandhi Jeevandayee Arogya Yojana Society in this regard.

20. IN-HOUSE SYSTEM: The Insurer will establish in-house system to provide all such facilities elaborated under the scheme. The Insurer will submit detailed list of staff appointed to Rajiv Gandhi Jeevandayee

Arogya Yojana Society with their designations, responsibilities and contact numbers before the commencement of policy.

21. PROJECT OFFICE AND STATE LEVEL CO-ORDINATION: The Project Office of the Insurer shall be separately established in the jurisdiction of Municipal Corporation for Greater Bombay for better coordination with the Rajiv Gandhi

Jeevandayee Society and would also provide adequate space for society. The project office shall report to the Rajiv Gandhi Jeevandayee Arogya Yojana Society on a daily basis in the

prescribed proformas. The following departments shall be established by the Insurer in the Project Office.

i. 24 Hour call centre with toll free help line : The Insurer should nominate within 5 days

of award of MOU responsible officer / officers to properly coordinate work and ensure proper implementation of scheme up to the satisfaction of Rajiv Gandhi Jeevandayee

Society. It should review the progress with Rajiv Gandhi Jeevandayee Arogya Yojana Society on day to day basis and be responsible to implement the suggestions of Rajiv Gandhi Jeevandayee Arogya Yojana Society for effectively running the scheme. The

Insurer shall provide telephone services for the guidance and benefit of the beneficiary families whereby the Insured Persons shall receive guidance about various issues by

dialing a State Toll free number. Call Centre Information: The Insurer shall operate a call centre for the benefit of all Insured Persons and for real-time reporting. The Call Centre shall function for 24 hours a day, 7 days a week and round the year. The Insurer

undertakes to provide services to the Insured Persons in Marathi, English and Hindi. The Insurer will operate a state toll free number with a facility of a minimum of 10 lines. The

cost of operating of the Toll free telephone number shall be borne solely by the Insurer. The Insurer will intimate the state toll free number to all beneficiary families along with addresses and other telephone numbers of the Insurer‟s Project Office. The action taken on


every call will be routed through an escalation matrix which ends at the level of CEO of the Rajiv Gandhi Jeevandayee Society. As a part of the Call Centre service the Insurer

shall provide the following: a. Answers to queries related to Coverage and Benefits under the Policy.

b. Information on Insurer‟s office, procedures and products related to health. c. General guidance on the Services. d. For cash-less treatment subject to the availability of medical details required

by the medical team of the Insurer. e. Information on Network Providers and contact numbers.

f. Benefit details under the policy and the balance available with the Beneficiary families.

g. Claim status information.

h. Advising the hospital regarding the deficiencies in the documents for a full claim.

i. Medical and health related queries to be addressed by medical officer in the call center.

j. Any other relevant information to the Beneficiary families including

grievances. k. Any information required from the field for the Insurer.

l. Any related service to the beneficiary families. m. Detailed MIS from Aarogyamithras in Government Hospitals / Network

Hospitals and Camps.

n. Any related Service as directed by Rajiv Gandhi Jeevandayee Arogya Yojana Society from time to time.

ii) MIS Department to collect, collate and report data on a real-time basis. This department will also have to submit with operators who collect hourly information from the Aarogyamthras, regional coordinators, district

coordinators etc. Based on this the reverse flow of dissemination of information shall also take place. There shall be reports for each district. The MIS

department shall also follow-up the cases at all levels. The department shall also generate reports as desired by Rajiv Gandhi Jeevandayee Society.

iii) Field Operations Department to coordinate the daily activities of field staff.

The operations of the field department shall be monitored online. iv) HR Department to manage human resources for the scheme and maintain

online database of staff and their management details. v) Training Department for capacity building of all stakeholders and staff. vi) Publicity and logistics Department to undertake all the publicity and logistics

activities as specified by Rajiv Gandhi Jeevandayee Society. vii) IT Department to ensure that the website with e-preauthorization, claim

settlement and real-time follow-up is maintained and updated on a 24-hour basis. There should be inbuilt anonymity of name of network hospital and health card number in the software while giving preauthorization and claim settlement.

The proprietary rights of software will be with Government of Maharashtra after three years. Patient records will be property of Rajiv Gandhi Jeevandayee

Society. Confidentiality of patient records should be maintained. viii) Round-the-clock Pre-authorization Department with specialist doctors for

each category of diseases shall work round the clock along with Rajiv Gandhi

Jeevandayee Arogya Yojana Society doctors to process the preauthorization within 12 working hours and immediately in cases of emergency.

ix) Claims settlement Department with electronic clearance facilities. x) Health Camp Department to plan, inform, implement and follow-up the

camps as per the directions of Rajiv Gandhi Jeevandayee Society.


xi) Grievance Department to be manned by doctors and other staff to address the grievances from time to time as per the instructions of Rajiv Gandhi

Jeevandayee Society. The insurer shall act as a frontline for the redressal of Beneficiary families / Network Hospital grievances. The Insurer shall also

attempt to solve the grievance at their end. The grievances so recorded shall be numbered consecutively and the Beneficiary families / Network Hospital shall be provided with the number assigned to the grievance. The Insurer shall

provide the Beneficiary families / Network Hospital with details of the follow-up action taken as regards the grievance as and when the Beneficiary families

require it to do so. The Insurer shall also record the information in pre-agreed format of any complaint / grievance received by oral, written or any other form of communication.

Action Taken Report for Customer Grievance: The INSURER shall record in detail the action taken to solve the grievance of the Beneficiary families /

Provider in the form of an Action Taken Report (ATR) within 2 working days

of the recording of the grievance and immediately in case of emergencies . The Insurer shall provide the society / Government with the comprehensive

action taken report (ATR) on the grievances reported in pre-agreed format. The entire process will be done through the call center and Rajiv Gandhi

Jeevandayee Arogya Yojana Society portal. The Insurer shall co-ordinate with Provider / Rajiv Gandhi Jeevandayee Arogya Yojana Society in order to solve the grievance as and when required by the nature and circumstances of the

grievance. xii) Follow-up Department to coordinate the follow-up consultation and

distribution of drugs as per the instructions of Rajiv Gandhi Jeevandayee Society.

xiii) Empanelment Department to empanel the hospitals in the network as per the

guidelines given by Rajiv Gandhi Jeevandayee Arogya Yojana Society and monitor the compliance.

xiv) Feedback department to send feedback formats, collect and analyses feedback of the patients as per the directions of Rajiv Gandhi Jeevandayee Society. The department will also document each case and upload the same in the society

portal. The INSURER shall also collect the satisfaction slip from the Beneficiary families at the time of discharge who had obtained the cashless

services. The Beneficiary families shall submit the Satisfaction slip issued by the INSURER at the time of discharge through Provider. The INSURER shall also carry out the Customer Satisfaction Survey regularly by using the rating

card for the purpose. xv) Administration Department for office management.

xvi) Vigilance Department for keeping vigil on all service providers and staff. xvii) Legal Department exclusively for the project. xviii) Accounts Department.

xix) Other departments required for office work.

22. AAROGYAMITRAS:

i) Aarogyamithras in Rural / Sub district / Women Hospitals / Government Hospitals

etc. The unique nature of the scheme demands the Insurer to appoint Aarogyamithras in consultation with Rajiv Gandhi Jeevandayee Arogya Yojana Society in all Rural / Sub

district / Women Hospitals / Government Hospitals for propagating the scheme, mobilizing people for health camps, counseling beneficiary families, facilitating the

referral / treatment of these patients and follow-up. For effective and instant communication all the Aarogyamithras will have to be provided with cell phone CUG


connectivity by the Insurer. The Insurer will provide uniform (White apron with scheme logo) to all the Aarogyamithras and ensure that they wear it when on duty.

ii) Aarogyamithras in Network Hospitals: The Insurer also needs to appoint minimum three Aarogyamithras at all network hospitals to facilitate admission, treatment and

cashless transaction of patient. The Aarogyamithras should also help hospitals in pre-authorization and claim settlement. They should also ensure proper reception and care in the hospital and send regular MIS. The Aarogyamithras will also ensure cashless follow-

up consultation and facilitate collection, stock maintenance and distribution of follow-up medicine in coordination with pharmacist. For effective and instant communication all

the Aarogyamithras will have to be provided with cell phone CUG connectivity by the Insurer. The Insurer will provide with uniform (White apron with scheme logo) to all the Aarogyamithras and ensure that they wear it when on duty. The Insurer shall ensure that

prefabricated Aarogyamithra kiosks with all additional requirements as per the design approved by Rajiv Gandhi Jeevandayee Arogya Yojana Society is put up in all hospitals.

The role of Aarogyamithra can be modified by the society from time-to-time. The Insurer will provide uniform and arrange the workshops / training sessions for the Aarogyamitras on the guidelines specified by Rajiv Gandhi Jeevandayee Society.

The detailed note on Aarogyamitras and their role is enclosed at Appendix –III of Part IV.

23. WEB PORTAL:

All activities related to the scheme shall be done through a dedicated portal of Rajiv Gandhi Jeevandayee Society, the development and maintenance cost of which will be borne by the

Insurer. The source code and system design document for the application exclusively developed by Insurer for Rajiv Gandhi Jeevandayee Arogya Yojana shall be provided in good

working condition to Rajiv Gandhi Jeevandayee Society. A dedicated data center in the name of Rajiv Gandhi Jeevandayee Yojana will be maintained by the Insurer. The web portal will be a repository of information and will have the following features and

the respective workflows: (Who will prepare) 1. General Information on the scheme.

2. Details of patients reporting and referrals from the PHC / Rural/ Sub-district/Women/General/District hospitals on daily basis.

3. E-Health Camps system and daily reporting of health camps.

4. Details of patients reporting and getting referred from the health camps. 5. E-Empanelment system.

6. Emergency approval system. 7. Call centre application. 8. Patient registration by Aarogyamithra in Network Hospitals.

9. Details of in-patients and out patients in the network hospitals. 10. On-bed reporting system.

11. Costing of the Tests done in the network hospitals. 12. E-preauthorization. 13. Surgery details.

14. Discharge details. 15. Real-time reporting, active data warehousing and analysis system.

16. Claim settlement. 17. Electronic clearance of bills with payment gateway. 18. Follow-up of patient after surgery.

19. Distribution of Follow-up medicines. 20. Rajiv Gandhi Jeevandayee Messaging Services.

21. Grievance and Feedback workflow. 22. Back Tracking System. 23. E-Office management.


24. Accounting system. 25. TDS workflow.

26. Death reporting system. 24. ONLINE MIS AND E-PREAUTHORISATION:

The Insurance Company should post enough dedicated staff, so as to ensure free flow of daily MIS and ensure that progress of scheme is reported to society in the desired format on a real-time basis. The company should establish proper networking for quick and error- free

processing of pre-authorizations. The pre-authorization has to be done round the clock in co-ordination with Rajiv Gandhi

Jeevandayee Arogya Yojana Societies. By a team of doctors from the Rajiv Gandhi Jeevandayee Arogya Yojana Society and Insurance Company. The preauthorization team shall have all the specialists concerned with the procedures covered

in the scheme on a permanent basis. Rajiv Gandhi Jeevandayee Arogya Yojana Society will provide necessary specialists and technical committees to evaluate special cases from time-to-

time. Rajiv Gandhi Jeevandayee Arogya Yojana Society will provide necessary specialists to evaluate special cases. A technical committee consisting of specialist from Government

Sector nominated by Rajiv Gandhi Jeevandayee Society in the concerned field, CMO of the Insurer and the Project Manager of the Insurer will evaluate and recommend to the CEO of

Rajiv Gandhi Jeevandayee Society. The final decision on all the preauthorization would rest with the CEO of Rajiv Gandhi Jeevandayee Arogya Society. There should be inbuilt anonymity of name of network hospital and health card number in the

software while giving preauthorization and claim settlement. 25. MEDICAL AUDITORS:

The Insurer Company shall appoint enough number of medical auditors who does pre-authorization in consultation with Rajiv Gandhi Jeevandayee Society. The Insurer shall also recruit specialized doctors for regular inspection of hospitals, attend to complaints from

beneficiary families directly or through Aarogyamithras for any deficiency in services by the hospitals and also to ensure proper care and counseling for the patient at network hospital by

coordinating with Aarogyamithras and hospital authorities. 26. PUBLICITY: The Insurance Company on its part should ensure that proper publicity is given to the scheme

in all possible ways. This will include publicity on electronic and print media, distribution of brochures, banners, display boards etc. in public at appropriate places in consultation with

RGJAYS. The spending on this activity should be two percent of premium amount. They shall also effectively use services of Aarogyamitras and district Coordinators for this purpose.

They shall effectively use services of Aarogyamitras and district Coordinators for this purpose. Insurer will give wide publicity through and shall submit time bound programme:

i. Guidebook: The Insurer shall handover the guidebook and related information to the Beneficiary families through the district administration in regional language- Marathi. The Guidebook will inter-alia contains

information regarding the following: Information regarding the Insurer and its address, fax number, website

address and other contact information. Toll free number of the Call Centre Service. List of Network Providers.

Information on symptoms of the diseases / systems covered along with diagrammatic representations.

Information on follow-up required. Information on possible preventive and curative measures.


Procedure to be followed by the Beneficiary families for availing the Hospitalization Service as Cashless Access Service.

Information regarding the Policy and Benefits. ii. Theatre Sliders

iii. Publicity by Rajiv Gandhi Jeevandayee Help Desk at the PHCs / Rajiv Gandhi Jeevandayee Assistance Counters at Network hospitals.

CAPACITY BUILDING:

I. The Insurer will arrange the workshops / training sessions for the capacity building of the society personnel, their representatives and other stakeholders in respect of

specific field of insurance at each district on the convenience of the society. Insurer will ensure that workshops and medical camps are organized in association with the network hospitals.

II. The help of NGOs/SHGs will be taken by the Rajiv Gandhi Jeevandayee Help Desk / Rajiv Gandhi Jeevandayee Assistance Counters to spread awareness and guide the

prospective patients to the network hospitals. The Insurer will associate in this task. RAJIV GANDHI JEEVANDAYEE MANUAL Rajiv Gandhi Jeevandayee Arogya Yojana Society will publish a detailed Manual for the

Scheme titled Rajiv Gandhi Jeevandayee Arogya Yojana Manual consisting of all operational guidelines and details of the scheme. Rajiv Gandhi Jeevandayee Arogya Yojana Society may

update and modify these guidelines and operational details as per the requirement of the scheme. The insurer has to follow the guidelines and instructions given in the manual while implementing the scheme.

27. SERVICING OF OTHER SCHEMES: Rajiv Gandhi Jeevandayee Arogya Yojana Society reserve the right to request the Insurer to

extend services for processing of claims generated through any other scheme implemented by Rajiv Gandhi Jeevandayee Society. 28. ACTIVITY CHART:

The activity chart submitted by the Insurer as part of the Proposal document and accepted by Rajiv Gandhi Jeevandayee Arogya Society (Appendix-IV) will be followed by the Insurer to

take up the activities as narrated in the scheme and MOU. (In appendix time frame to be given instead of mentioning before commencement of scheme. This will help in monitoring the process)

29. ASSISTANCE FROM THE GOVERNMENT:

The Government will on their part render all possible assistance viz.

i. To give all necessary support for organizing sensitization programmes for the PHCs and Government Hospitals.

ii. To provide financial assistance for health camps by network hospitals (@ Rs.

5000 per camp) ii. To extend necessary support in providing space and other support for locating

Rajiv Gandhi Jeevandayee Help Desks at PHCs / other Government Hospitals. iii. To provide necessary professionals for technical committee.

30. CLAIMS PROCEDURE:

The beneficiary families would be identified by the Rajiv Gandhi Jeevandayee Health card/ at the PHC / Government Hospital level/ Rajiv Gandhi Jeevandayee Assistance Counters in the

network hospital. A self-declaration by the beneficiary /patient prior to hospitalization for the covered treatment that he does not belong to any of the excluded categories may be required. The family member having Health card will be referred to Network Hospital on

recommendation of the Doctors at these centers. The insurer will make payment of the claims directly to the hospital. Payments will be made to the hospitals within 07 days after the receipt

of all documents. The cost of various tests conducted on health card holders for covered procedures who ultimately do not undergo surgery, will be included in the insurance cost. Insurer will ensure that such test are done free of cost to the patient. The claims procedure


will be carried in the electronic platform of Rajiv Gandhi Jeevandayee Arogya Yojana Society portal. The payment to the Network Hospital will be made online through electronic

clearance. The procedure of processing of the claims will be handled by the project office of the insurer.

The claims procedure will be under taken as detailed below:

i) Claim Intimation

The INSURER shall receive claim intimation from the Network hospital online in the

form as agreed under the scheme. Rajiv Gandhi Jeevandayee Society portal will have reports indicating claim intimations received.

ii) Collection of Claim documents

The INSURER shall offer single window service at the respective Project office to the Network hospital for receiving the claim documents. In case of pre-authorization for

the Cashless Service, the Network hospital will send the claim documents along with the invoice to the INSURER. This also follows an electronic route.

iii) Scrutiny of Claim Documents

The INSURER shall scrutinize the claim documents at the initial stage regarding the medical and eligibility aspect. Deficiency of any documents, if any, shall be

communicated to the Network hospital within 7 working days. A reminder for the same will again be forwarded to the Network hospital once every 3 days of first

intimation of the deficient documents are not received or are partially received. iv) Claim Control Number

The INSURER will settle all eligible claims and pay the sum to the Network hospital

within seven working days of receipt of the claim. A separate Claim Control Number

is to be provided by insurer for every claim made by Network hospital.

v) Payment of Claims and Claim Turn Around Time The INSURER will settle all eligible claims and pay the sum to the Provider within seven working days of receipt of the claim.

vi) Repudiation of claims

The INSURER on repudiation of the claim not covered under the policy, shall mention

the reasons for repudiation on writing and online to the Network hospital. The INSURER shall also intimate the same to Rajiv Gandhi Jeevandayee Arogya Yojana Society online.

vii) Right of Appeal and reopening of claim

Network Hospital shall have a right of appeal to approach the Insurer if the Provider

feels that the claim is payable. If Network Hospital is not agreed with the Insurers‟ decision in this regard, can appeal to the Central Committee and the decision of the Central Committee will be final and binding on the INSURER and Network Hospital.

This right of appeal will be mentioned by the INSURER in every repudiation advice as mentioned in above. The Central Committee can re-open the claim if proper and

relevant documents as required are submitted. viii) Review of paid claims

The Central committee will have the right to reopen a settled claim and to direct the

Insurer to settle for an appropriate amount within a period of 3 months of payment of the claim. The Insurer further agrees to provide access to the Central Committee their

records for this purpose. All the claims settled by the insurer to the network hospitals based on the bills received from the hospitals in conformity with the package rate arrived at and also based on the pre-authorization given by the reopening by the

Insurance company will be reckoned as final and will not be subject to any reopening by any authority except the Central Committee for grievances.

ix) Claim float and Bank Account The Insurer will have a separate Bank account to pay the Network hospital making a valid claim and all payments will be electronically cleared. Detailed reports will be


electronically cleared. Detailed reports will be made available online on a real-times basis.

x) Co-Ordination Committee A committee shall be constituted under the chairmanship of Chief Executive officer

Rajiv Gandhi Jeevandayee Arogya Yojana Society including representative of Insurer and Network Hospital (nominated by Rajiv Gandhi Jeevandayee Society) to review smooth running and functioning of the identified activities.

31. RESPONSE TIME:

Authorization will be decided within12 Working Hours and the Insurer shall do the settling of

claims within 7 working days after receipt of documents. In case of life threatening emergencies, the preauthorization should be given immediately. To facilitate this, the e preauthorization would carry a sign of “EM” to seek priority attention of authorizers. Insurer‟s

response to the Rajiv Gandhi Jeevandayee Scheme will be immediate through: i. 24 hour call centre

ii. Toll free line, exclusively for this Scheme. iii. Aarogyamithras in Rajiv Gandhi Jeevandayee Help Desks / Rajiv Gandhi

Jeevandayee Assistance Counters

iv. District Coordinators/ Regional Coordinators who are nominated exclusively for this purpose.

32. INSURER REPRESENTATIONS, WARRANTIES AND RESPONSIBILITIES a. Power, Capacity and Authority It has full power, capacity and authority to execute, deliver and perform this

Agreement and it has taken all necessary action (corporate , statutory or otherwise), to execute, deliver, perform and authorize the execution, delivery and per formance

of this Agreement and that it is fully empowered to enter into execute this Agreement, as well as perform all is obligations hereunder.

b. Compliance with Memorandum and Articles

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

I. Any provision of any agreement or other instrument to which such party is a party or by which it is bound;

II. Any judgment, injunction, order, decree or award which is binding upon

such party: and / or III. Such party‟s the Memorandum and/ or Articles of Association.

c. Compliance with Laws

It has complied with all applicable Laws including but not limited to the Insurance Regulatory and Development Authority Regulation.

d. Risk Bearing

Society as the buyer of insurance selected sold insurer i.e. xx Ltd as 100% risk

bearer or carrier and no other insurer is allowed to participate in this direct insurance arrangement.

e. Insurance License

Throughout the term of this Agreement, the Insurer shall continue to be an Insurer under Law and licensed under IRDA regulations to carry on the activities

contemplated herein f. Capability of Service

It is capable of servicing all the products and policies and offered and also have

sufficient infrastructure, trained manpower and resources to carry out the activities for servicing these products and policies.

g. Updating the list of Network Provider


The empanelment of Network Providers will be a continuous process and the Insurer will abide by the instructions of Rajiv Gandhi Jeevandayee Arogya Yojana Society

in this regard. h. Disclose INSURER- Network Provider agreement

The INSURER agrees that it shall disclose to the society all agreements entered into by the INSURER with any Network Provider

i. Steering Committee

The INSURER shall have interrelated arrangements for common activities like empanelment of hospitals, planning for camps etc. Under the scheme with the

society and other Insurers. A Steering Committee under the chairmanship of the CEO of Rajiv Gandhi Jeevandayee Arogya Yojana Society will oversee these arrangements.

j. Code of conduct Abide by the code of conduct prescribed by the IRDA or any other governmental

body from time to time. k. Discounts and Rebates

Disclose and pass on to the Government/ Rajiv Gandhi Jeevandayee Arogya

Yojana Society the benefit of any discount or rebates provided by the Network provider to the INSURER.

l. Indemnity: The Insurer agrees to defend, indemnify and hold harmless the Insured, its employees, representatives and agents against all claims, demands, judgments, liabilities, damages, costs, expenses, proceedings or prosecutions arising from or

relating to breach of any of the aforesaid representations, warranties, covenants and responsibilities.

RUN-OFF PERIOD

A “Run Off period” of one month will be allowed after the expiry of the policy period i.e. till the midnight of 1 November 2012 for 8 districts Phase-I. This means that pre-authorizations

can be done till the end of policy period and surgeries for such pre-authorizations can be done up to one month after the expiry of policy period and such claim will be honored by the

Insurance Company. 33. JURISDICTION:

Any dispute arising out of this MOU shall be subject to the jurisdictio n of State of

Maharashtra and Mumbai. 34. NON PERFORMANCE:

Failure to perform and abide with the terms will attract the following in the event of termination:

i) The Insurer will pay back to Rajiv Gandhi Jeevandayee Arogya Yojana Society

within one week the unutilized amount of premium after settlement plus service tax ii) In addition to above, the Insurer will pay the total package amount for all the cases

for which preauthorization has been given, but not claimed. iii) In addition to above, the Insurer shall pay interests at the rate of 12% per annum on

the amount refundable as determined by clauses 18(i) and (ii) above for the period

extending from the date of premium paid till the date of date receipt of refund. 35. INFORMATION FLOW:

The Insurer will ensure that the information flow takes place on a real- time basis. The Insurer will use a state of the art dedicated Internet based network for this purpose. 36. RENEWAL:

The policy may be renewed under the mutual consent of both the parties. The premium for renewal shall be agreed upon prior to the expiry of the existing policy.

37. THE PRECEDENCE OF MOU:

The MOU has precedence over statements.


38. MODIFICATION OF MOU:

The MOU may be modified as and when the need arises in mutual agreement between Rajiv

Gandhi Jeevandayee Arogya Yojana Society and Insurer. 39. MONITORING MECHANISM:

Regular review meetings on the performance/ administration of the Scheme would be held between the Government of Maharashtra / Rajiv Gandhi Jeevandayee Arogya Yojana Society and the Insurer at the Insurer at the District level and at the State Level. The composition of

the monitoring committees shall be as follows: District level:

Chairman: District Collector Co-chairman: Chief Executive Officer Zillah Parishad. Members:

1. District Health Officer. 2. District Supply Officer.

3. District Coordinator of Insurer. 4. Civil Surgeon – Member Secretary

For Mumbai and suburban Mumbai

Chairman: Commissioner, BMC Co-chairman: Additional. Commissioner Health BMC.

Members:

1. District Collector 2. DMER, BMC or Dean of KEM hospital

3. Dean Grant Medical College Mumbai 4. Rationing Controller, Mumbai

5. District Coordinator of Insurer 6. Executive Health Officer BMC - Member Secretary

State Level:

Chairman: Additional Chief Secretary Public Health and Family Welfare Members:

1. Director of Health Services 2. Director Medical Education and Research. 3. Dy. Commissioner Health BMC

3. Project Manager of the Insurer. 4. Member of the Rajiv Gandhi Jeevandayee Society

5. Technical Committee member nominated by Rajiv Gandhi Jeevandayee Society.

6. CEO, Rajiv Gandhi Jeevandayee Arogya Yojana Society– Member

Secretary. The Chairmen of the above committees may invite any non- official member in the project

districts for the meetings. Periodical meetings will be organized at both district and State level. The agenda and issues to be discussed would be mutually decided in advance. The minutes of the meeting at the district and state level will be drawn and a copy will be

forwarded to Rajiv Gandhi Jeevandayee Society. The Insurer shall also put in place a mechanism of their own to monitor the scheme on a real times basis. Detailed reports on the

progress of the scheme and issues if any emerging out of such meetings shall be submitted to Government of Maharashtra / Rajiv Gandhi Jeevandayee Society. 40. GRIEVANCE MECHANISM:

A District level Grievance redressal Committee:

Grievance redressal Committee chaired by District Collector with following members will

form the grievance redressal cell at the district level. The decision by the committee is binding except when an appeal to the central committee at the state level is preferred.


Members of the Committee: 1. District coordinator of Insurer.

2. District Health Officer 3. Member from the Technical Committee (Nominated by Rajiv Gandhi

Jeevandayee Society) 4. Representative from the Insurer. 5. Civil Surgeon cum District Coordinator of the society – Member Secretary.

For Mumbai and suburban Mumbai Chairman: Commissioner, BMC

Co-chairman: Additional. Commissioner Health BMC. Members:

1. District Collector

2. DMER, BMC or Dean of KEM hospital 3. Dean Grant Medical College Mumbai

4. Rationing Controller, Mumbai 5. District Coordinator of Insurer 6. Executive health Officer BMC - Member Secretary

B State Grievance redressal Committee:

Committee Chaired by Chief Executive Officer of Rajiv Gandhi Jeevandayee Arogya Yojana

Society will entertain all the appeals and grievances at the state level. The decision taken by the committee will be final and binding on the both parties. The committee may call the concerned Network Hospital against whom such grievance is reported.

Members of the Committee: 1. Representative of the Rajiv Gandhi Jeevandayee Society

2. Technical Committee Member 3. Representative from the Insurance firm

C. A toll- free number will be made available at Mumbai where any complaint can be

registered. The Insurer will keep track of the complaints and report on the action taken to the Central Committee. The beneficiary families can also send e-mail / fax /letter to CEO of Rajiv

Gandhi Jeevandayee Arogya Yojana Society/ Zonal Office of the Insurer. The details of toll-free Numbers/ addresses will be available with PHCs and other Govt. hospitals. A separate set-up under the supervision of Executive Director of the Insurer at the Corporate Office will

be setup to deal with the grievances. 41. TERMS & TERMINATION:

1. This Agreement shall take effect on the date of signature hereof by both Parties, and shall remain in force till the end of the policy period and the run off period subject to a right to Rajiv Gandhi Jeevandayee Arogya Yojana Society to

terminate the Agreement, on a review of the performance of the INSURER before the same period. Rajiv Gandhi Jeevandayee Arogya Yojana Society will

review the performance of the INSURER based on factors including but not limited to:

The facilities set up arrangements made by the INSURER toward servicing

the beneficiary families.

The extent of Network Hospital;

The quality of service provided;

The beneficiary families satisfaction reports received;

Withholding of any information as sought by Rajiv Gandhi Jeevandayee Arogya Yojana Society at the Selection and implementation stage of the

scheme; and

Such other factors as the Rajiv Gandhi Jeevandayee Arogya Yojana

Society/Government deems fit. 2. This Agreement may be terminated:


a) By Rajiv Gandhi Jeevandayee Arogya Yojana Society before the period mentioned above as provided under clause 41 (1)

b) By both parties by mutual consent; or c) Provided it gives the other party at least 60 days prior written notice; or

In case of termination as given above: i) The Insurer will pay back to Rajiv Gandhi Jeevandayee Arogya Yojana

Society within one week the unutilized amount of premium after

settlement plus service tax ii) In addition to above, the Insurer will pay the total package amount for

all the cases for which preauthorization has been given, but not claimed.

iii) In addition to above, the Insurer shall pay interests at the rate of 12%

per annum on the amount refundable as determined by clauses above for the period extending from the date of premium paid till the date of

date receipt of refund. iv) Rajiv Gandhi Jeevandayee Arogya Yojana Society reserves the right to

re-allot the policy to other insurer as it deems fit for the rest of the

period in the event of termination and the Insurer shall not have any claims to it.

v) Performance security will be forefeited. 42. FORCE MAJEURE: Neither party shall be in breach of any of its performance is

prevented, physically hindered or by an act, event or circumstance (whether of the kind

described herein which is not reasonably within the control of such party (Force Majeure Event).

In the event that any Force Majeure Event continues for a period of 4 (four) weeks without interruption, the Party affected by such Force Majeure Event shall be entitled to terminate this agreement by giving notice to the other party, pursuant to, and in accordance with the

provisions of clause provided it gives the other party at least 60 days prior written notice. 43. ASSIGNMENT:

1. Neither party shall be entitled to assign its rights and/or obligations under this Agreement.

2. Subject to the foregoing, this Agreement shall be fully binding upon Insurer to the benefit of and be enforceable by the parties hereto and the respective successors and

permitted assigns. 44. ENTIRE AGREEMENT:

This Agreement entered into between Rajiv Gandhi Jeevandayee Arogya Yojana Society and the INSURER represents the entire agreement between the parties.

45. RELATIONSHIP: The Parties to this Agreement are independent contractors. Neither Party is an agent, representative or partner of the other Party. Neither party shall have any right, power or authority to enter into any agreement or memorandum of understanding for or on behalf of, or incur any obligation or liability of, or to otherwise bind, the other party. This Agreement shall not be interpreted or construed to create an

association, agency, joint venture, collaboration or partnership to such relationship upon either party.

46. SEVERABILITY:

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

Agreement shall be considered divisible as to such provision shall be inoperative and of the like effect as though such provision was not included herein: 47. NOTICES;

Any notice given under or in connection with this Agreement shall be in writing and in the English language. Notices may be given delivered to the address of the addressee as set out

below (in which case the notice shall be deemed to be served at the time of delivery) by courier services or by fax (in which case the original shall be sent by courier services).


Name of the Insurer: ----------------------------------------. Attn: ------------------------------------.

E-Mai : ----------------------------------. Fax: ------------------------.

48. GOVERNING LAW:

The validity, performance, construction and effect of this Agreement shall be governed by the laws of the Republic of India. Any resolution of any disputes arising from or in connection

with this Agreement, including a breach thereof, shall also be governed by the laws of the Republic of India.

49. DISPUTE RESOLUTION:

1. If any dispute arises between the parties hereto during the subsistence of this Agreement of thereafter, in connection with the validity Interpretatio n

implementation or alleged breach of any provision of this Agreement, the parties shall refer such dispute to their respective chairmen/CEO‟s for

resolution. In the event that the chairmen/CEO‟s are unable to resolve the dispute within 30 days of it being referred to them, then either Party may refer the dispute for resolution to a sole arbitrator who will be Additional Chief

Secretary / Principal Secretary Public Health and Family Welfare Department Government of Maharashtra, or, in the event that the parties are unable to agree

on the person to act as the sole arbitrator within 30 days after any party has claimed for an arbitrators in written form, by three arbitrators, one to be appointed by each party with power to the two arbitrators so appointed, to

appoint a third arbitrator. 2. The law governing the arbitration shall be the Arbitration and Conciliation Act,

1996 as amended or re-enacted from time to time. 3. The proceedings of arbitration shall be conducted in the English language. 4. The arbitration shall be held in Mumbai, India (please refer 5 below).

This deed is executed in two originals, both of which are operative instruments held by both the parties.

For the Government / Rajiv Gandhi For Insurance Company Jeevandayee Society Chief Executive Officer Chairman Managing Director

Witnesses: 1._______________________ 2. ________________________


APPENDIX - I

GENERAL GUIDELINES ON THE PACKAGES.

1. The package includes

Consultation, medicines, diagnostics, specialist services

Implants, grafts, prosthetics

Food to patient

Cost of transportation

Hospital Charges, etc. In other words the packages should cover the entire cost of treatment of the patient from

date of reporting, any complications while in hospital to discharge from hospital and 10 days after discharge, making the transaction truly cashless to the patient. The post-

operative hospital stay in all surgical procedures shall be up to 10 days except in case of day care procedures, Medical interventions and chemotherapy for cancers. Civil & criminal claims arising out of medical negligence while treating beneficiary will be responsibility of

network hospital & will be enforced under prevailing legal framework.

2. Hospital shall conduct all diagnostic tests as per standard protocols free of cost.

3. Hospital shall provide 10 days post discharge free follow up consultation, medicines and diagnostics to the patient within package. However, the extended follow up services are entitled for service elements shown in Appendix 1 –b of Part IV.

4. Hospital shall provide reasonably good food to the patient, and shall make alternate arrangement for food wherever in-house pantry is not available. The hospital shall not give

money as an alternative to food. 5.Hospital shall pay return fare for patient from hospital to place of residence of patient at ST

fare. In instance of death, carriage of dead body from network hospital to village/town of the

beneficiary would also be built in this package. 6.Hospital shall procure compatible blood for the surgeries. The hospital shall provide blood from

their own blood bank if required. In case of non-availability the hospital shall procure from other blood banks, Red Cross, voluntary organizations, etc.

7. Hospital shall make all out efforts to apply and get the accreditation from NABH as soon as

possible.

8.The general guidelines published by Rajiv Gandhi Jeevandayee Arogya Yojana Society separately from time to time shall be followed while implementing the packages.

SPECIAL NOTES ON PACKAGES

1. Renal package:

AV fistula and pre-transplant hemodialysis are approved along with ` surgery only and not separately.

Hospital shall provide post-transplant immunosuppressive therapy for one year.

2. Cancer package:

Chemotherapy and radiotherapy should be administered only by professionals trained in

respective therapies (i.e. Medical Oncologists and Radiation Oncologists) and well versed with dealing with the side-effects the treatment can cause. Hospital should have

qualified and registered oncologist, oncosurgeon and Radiotherapist. Tumour board comprising of qualified and registered oncologist, oncosurgeon and Radiotherapist will decide comprehensive treatment plan of patient. If hospital has no Radiotherapy

equipment and Radiotherapist it should have tie up with nearest Radiotherapy center.

Hospital should have qualified and registered oncologist, oncosurgeon and Radiotherapist. Tumour board comprising of qualified and registered oncologist,

oncosurgeon and Radiotherapist will decide comprehensive treatment plan of patient. If hospital has no Radiotherapy equipment and Radiotherapist it should have tie up

with nearest Radiotherapy center.


Patients with hematological malignancies (leukemia, lymphomas, multiple myeloma) and

pediatric malignancies (Any patient < 14 years of age) should be treated by qualified medical oncologists only.

The advanced radiotherapy packages shall be utilized only for the cases and diseases which

do not respond to conventional radiotherapy package.

Each cycle cost includes

Cost of chemotherapy drugs

Hospital charges

All infusional chemotherapy cancer cases must be treated as inpatients only.

Doctors‟ fees

Supportive care medications (i.e. i.v. fluids, steroids, H2 blockers, anti-emetics)

All investigations

An average of Rs. 2000 to Rs. 5000/- has been added to the above cost, to cover for

treatment of complications. Tumors not included in this list, if have a chemotherapy regimen that is proven to be curative, or provide long term improvements in overall survival will be reviewed on a case by case basis by the technical committee of the

Society. 3. Polytrauma package:

Components of Polytrauma: The components of polytrauma based on the system involved are: 1.Orthopedic trauma, 2. Neuro-Surgical Trauma, 3. Chest Injuries and 4.Abdominal Injuries. The above components may be treated separately or combined as the case warrants. For providing

insurance coverage to polytrauma cases requiring Hospitalization and / or Surgery for Health card holders, management of each of the above can be classified as given below:

Orthopedic trauma 1. Surgical Corrections

Neuro-Surgical Trauma

1. Conservative

2. Surgical Treatment

Chest Injuries

1. Conservative

2. Surgical treatment

Abdominal Injuries

1. Conservative 2. Surgical treatment

I. All cases, which require conservative management with a minimum of one-week hospitalization with evidence of (Imageology based) seriousness of injury to warrant admission, only need to be covered to avoid misuse o f the scheme for

minor / trivial cases. II. In case of Neurosurgical trauma, admission is based on both Imageology evidence

and clinical evidence. III. All surgeries related to polytrauma are covered irrespective of hospitalization

period.

IV. Initial evaluation of all trauma patients has to be free of cost. 4. Prostheses:

i) Cost of prosthesis is inclusive of foot and shoe, wherever required. ii) Prosthesis must have been manufactured with the materials with BIS (Bureau of

Indian Standards) certification.

iii) All prosthesis shall be functional in nature. iv) Manufacturer shall give minimum of 3 years replacement Guarantee.

v) Manufacturer shall provide free replacement of leather parts / straps, etc. during this period apart from replacement guarantee.


APPENDIX: 1A

DETAILED LIST OF SPECIFIED SURGERIES AND THERAPIES

972 procedures

Sr

No

Specialty SYSTEM Indicativ

e Rate &

Upper

ceiling

(Rs.)

1 General surgery

Head and Neck

Brach ial Cyst Excision Inv - Clinical Photograph

Post procedure evidence of Clin ical photograph,

Biopsy

20000

2 General surgery

Head and Neck

Cerv ical Rib excision Inv - Color Doppler , X-

RAY Post procedure evidence of X-Ray/Color

doppler

15000

3 General surgery

Head and Neck

Removal o f Submandibular Salivary gland Inv -

Clin ical Photograph , FNAC Post procedure

evidence of Clin ical photograph, Biopsy

10000

4 General surgery

Head and Neck

Parotid Duct Repair Inv - Silography Post

procedure evidence of Silography

20000

5 General surgery

Head and Neck

Branchial Sinus Excision Inv -Clinical Photograph


Biopsy

20000

6 General surgery

Head and Neck

Hemimandibulectomy Inv - X-Ray Post procedure

evidence of X-Ray

25000

7 General surgery

Head and Neck

Segmental Mandible Excision Inv - X-Ray Post

procedure evidence of X-Ray

25000

8 General surgery

Head and Neck

Carotid Body-tumours Excision Inv - Clinical

Photograph , U S Neck Post procedure evidence of

Clin ical Photograph, Biopsy

30000

9 General surgery

Head and Neck

Partial g lossectomy Inv - Clin ical Photograph,

Biopsy Post procedure evidence of Clinical

Photograph, Biopsy

15000

10 General surgery

Head and Neck

Cystic Hygroma Excision-Extensive Inv - Clin ical

Photograph Post procedure evidence of Clin ical

Photograph, Biopsy

20000

11 General surgery

Head and Neck

Abbe Operation Inv - Clinical Photograph Post

procedure evidence of Clin ical Photograph

15000

12 General surgery

Head and Neck

Vermilionectomy Inv - Clinical Photograph Post


15000

13 General surgery

Head and Neck

Wedge Excision& Vermilionectomy Inv - Clin ical


Photograph, Biopsy

20000

14 General surgery

Head and Neck

Wedge Excision Inv - Clin ical Photograph Post

procedure evidence of Clin ical Photograph,Biopsy

15000

15 General surgery

Head and Neck

Cystic Hygroma Excision-Major Inv - Clin ical


Photograph, Biopsy

20000

16 General surgery

Head and Neck

Thyroid Non

Malignant

Hemithyroidectomy Inv - FNAC , T F T , USG

Post procedure evidence of Clin ical Photograph,

Biopsy

20000

17 General surgery

Head and Neck

Thyroid Non

Malignant

Isthmectomy Inv - FNAC , T F T , USG Post

procedure evidence of Clin ical Photograph,

Biopsy

20000

18 General surgery

Head and Neck

Thyroid Non

Malignant

Partial Thyroidectomy Inv - FNAC , T F T , USG


Biopsy

20000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

19 General surgery

Head and Neck

Thyroid Non

Malignant

Resection Enucleation Inv - FNAC , T F T , USG


Biopsy

20000

20 General surgery

Head and Neck

Thyroid Non

Malignant

Subtotal Thyroidectomy Inv - FNAC , T F T ,

USG Post procedure evidence of Clin ical

Photograph, Biopsy

20000

21 General surgery

Head and Neck

Thyroid Non

Malignant

Total Thyroidectomy Inv - FNAC , T F T , USG


Biopsy

20000

22 General surgery

Head and Neck

Cystic Hygroma Excision-Minor Inv - Clin ical


Photograph, Biopsy

10000

23 General surgery

Head and Neck

Excision of Lingual Thyro id Inv - Clinical

Photograph , Isotope Scan Post procedure

evidence of Clin ical Photograph, Biopsy

25000

24 General surgery

Head and Neck

Parathyroidectomy Inv - USG Post procedure

evidence of Clin ical Photograph, Biopsy

30000

25 General surgery

Head and Neck

Excision of Thyroglossal Cyst Fistula Inv -

Clin ical Photograph , Radionucleide Scan Post

procedure evidence of Clin ical Photograph,

Biopsy

15000

26 General surgery

Breast

Simple Mastectomy(NM) Inv -Mammography


Biopsy

20000

27 General surgery

Abdomen Hernia

Epigastric Hern ia without Mesh Inv - Clin ical


Photograph

15000

28 General surgery

Abdomen Hern ia

Epigastric Hern ia with Mesh Inv - Clin ical


Photograph

30000

29 General surgery

Abdomen Hern ia

Femoral Hernia Inv - Clinical Photograph Post


15000

30 General surgery

Abdomen Hern ia

Hiatus Hern ia Repair Abdominal Inv -U S

Abdomen , UGI Endoscopy Post procedure

evidence of Clin ical Photograph

35000

31 General surgery

Abdomen Hern ia

Rare Hernias (Sp igalion,obuturator,sciatic) Inv -

Clin ical Photograph , USG Post procedure


20000

32 General surgery

Abdomen Hern ia

Umbilical Hernia without mesh Inv - Clinical


Photograph

15000

33 General surgery

Abdomen Hern ia

Umbilical Hernia with mesh Inv - Clinical


Photograph

25000

34 General surgery

Abdomen Hern ia

Ventral and Scar Hernia without mesh Inv -



20000

35 General surgery

Abdomen Hern ia

Ventral and Scar Hernia with mesh Inv - Clin ical

Photograph , USG Post procedure evidence of

Clin ical Photograph

30000

36 General surgery

Abdomen

Lap. Appendectomy Inv - USG Post procedure

evidence of Video, Biopsy, Clin ical Photo

22000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

37 General surgery

Abdomen

Appendicular perforation Inv - USG Post

procedure evidence of Clin ical photograph,

Biopsy

15000

38 General surgery

Abdomen Stomach,

Duodenum, Jejunum

Highly Select ive Vagotomised Inv - Endoscopy

Post procedure evidence of Clin ical photograph

25000

39 General surgery

Abdomen Stomach,

Duodenum, Jejunum

Duodenal perforation Inv - CT-Abdomen , USG ,

X-Ray Post procedure evidence of Clin ical

photograph

20000

40 General surgery

Abdomen Stomach,

Duodenum, Jejunum

Selective Vagotomy Drainage Inv - Endoscopy


40000

41 General surgery

Abdomen Stomach,

Duodenum, Jejunum

Vagotomy Pyloroplasty Inv - Endoscopy Post

procedure evidence of Clin ical photograph

30000

42 General surgery

Abdomen Stomach,

Duodenum, Jejunum

Gastrojejunostomy & Vagotomy Inv - Endoscopy-

Video Photo Post procedure evidence of Clinical

photograph

30000

43 General surgery

Abdomen Stomach,

Duodenum, Jejunum

Operation for bleeding peptic ulcer Inv -

Endoscopy Post procedure evidence of Clinical

photograph

40000

44 General surgery

Abdomen Stomach,

Duodenum, Jejunum

Partial/subtotal Gastrectomy for u lcer Inv -

Endoscopy Post procedure evidence of Clin ical

photograph

40000

45 General surgery

Abdomen Stomach,

Duodenum, Jejunum

Pyloromyotomy Inv - Endoscopy Post procedure

evidence of Clin ical photograph

20000

46 General surgery

Abdomen Stomach,

Duodenum, Jejunum

Gastrostomy Inv - Biopsy , CT , Endoscopy , USG


20000

47 General surgery

Abdomen Stomach,

Duodenum, Jejunum

Gastrostomy Closure Inv -Clin ical Photograph


20000

48 General surgery

Abdomen Small

Intestine

Intussusception Inv - Endoscopy , USG , X-Ray

ABD Post procedure evidence of Clinical

photograph/Biopsy

30000

49 General surgery

Abdomen Small

Intestine

Operation for Acute intestinal obstruction Inv -

Biopsy , Endoscopy , USG , X-Ray ABD Post

procedure evidence of Clin ical photograph/Biopsy

30000

50 General surgery

Abdomen Small

Intestine

Operation for Acute intestinal perforation Inv -

Biopsy , CXR , Endoscopy , USG , X-Ray ABD

Post procedure evidence of Clin ical

photograph/Biopsy

30000

51 General surgery

Abdomen Small

Intestine

Operation for Haemorrhage of the small intestine

Inv - CT W ith Contrast , Endoscopy Post


40000

52 General surgery

Abdomen Small

Intestine

Operations for Recurrent intestinal obstruction

(Noble p licat ion other) Inv - CT-Contrast Post


35000

53 General surgery

Abdomen Small

Intestine

Resection & Anastomosis of small intestine Inv -

CT , X-Ray ABD Post procedure evidence of

Clin ical photograph/Biopsy

35000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

54 General surgery

Abdomen Small

Intestine

Ileostomy Inv - Biopsy , Endoscopy , USG Post


20000

55 General surgery

Abdomen Small

Intestine

Ileostomy Closure Inv - Clinical Photograph Post

procedure evidence of Clin ical photography

20000

56 General surgery

Abdomen Large

Intestine

Mal-rotation & Volvu lus of the midgut Inv - CT ,

X-Ray ABD Post procedure evidence of X-

Ray/Clinical photograph

35000

57 General surgery

Abdomen Large

Intestine

Operation for Volvulus of large bowel Inv - CT-

Contrast , X-Ray Abdomen Post procedure

evidence of X-Ray/Clinical photograph

40000

58 General surgery

Abdomen Large

Intestine

Operation of the Duplication of the intestines Inv -

CT-Contrast Post procedure evidence of Clinical

photograph

40000

59 General surgery

Abdomen Large

Intestine

Left Hemi Colectomy Inv - Barium , CT ,

Endoscopy , USG Post procedure evidence of


30000

60 General surgery

Abdomen Large

Intestine

Right Hemi colectomy Inv - Barium , CT ,



30000

61 General surgery

Abdomen Large

Intestine

Total Colectomy Inv - Barium , CT , Endoscopy ,

USG Post procedure evidence of Clin ical

photograph/Biopsy

40000

62 General surgery

Abdomen Large

Intestine

Colostomy Inv - Barium , CT , Endoscopy , USG


20000

63 General surgery

Abdomen Large

Intestine

Colostomy Closure Inv - Clinical Photograph Post


20000

64 General surgery

Abdomen Rectum

and anus

Pull through abdominal resection Inv - Clinical


photograph

30000

65 General surgery

Abdomen Rectum

and anus

Anterior Resection Inv - Biopsy , Clin ical

Photograph , Colonoscopy Post procedure

evidence of Clin ical photograph/Biopsy

50000

66 General surgery

Liver

Operation for Hydatid cyst of liver Inv - CT , USG

Post procedure evidence of USG

30000

67 General surgery

Liver

Portocaval Anastomosis Inv - MRI , UGI


USG,Endoscopy

80000

68 General surgery Gall

bladder

Cholecystectomy Inv - CT , LFT , USG Post

procedure evidence of Clin ical photograph,USG

20000


bladder

Lap.Cholecystectomy Inv - CT , LFT , USG Post

procedure evidence of Clin ical photograph,USG,

Video

25000


bladder

Cholecystectomy & Exploration CBD Inv - CT ,

LFT , USG Post procedure evidence of Clin ical

photograph,USG, T-Tube, Cholangiogram

25000


bladder

Lap Cholecystostomy with Explorat ion CBD Inv -

CT , LFT , USG Post procedure evidence of

Clin ical photograph,USG

30000


bladder

Cystojejunostomy Inv - CT , LFT , USG Post


40000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


bladder

Cystogastrostomy Inv - CT , LFT , USG Post


40000


bladder

Repair of CBD Inv - CT , LFT , USG Post

procedure evidence of Clin ical photograph,USG,

T-Tube, Cholangiogram

25000

75 General surgery

Adrenals

Operation of Adrenal g lands, bilateral fo r tumour

Inv - Biochemical Investigations , CT , USG Post

procedure evidence of USG,Biopsy

40000

76 General surgery

Adrenals

Operation on Adrenal glands unilateral for tumour

Inv - Biochemical Investigations , CT , USG Post

procedure evidence of USG,Biopsy

25000

77 General surgery

Spleen

Splenectomy for Hypersplenism Inv - CT ,

Peripheral Smear , USG Post procedure evidence

of USG

35000

78 General surgery

Spleen

Splenorenal Anastomosis Inv - MRI , UGI


USG,Endoscopy

60000

79 General surgery

Spleen

Warren shunt Inv - MRI , UGI Endoscopy , USG

Post procedure evidence of USG,Endoscopy

60000

80 ENT surgery Ear Labyrinthectomy Inv - CT-Scan PTI , IA Post


20000

81 ENT surgery Ear Facial Nerve Decompression Inv - CT-Scan Post


20000

82 ENT surgery Ear Temporal Bone Excision Inv - CT-Scan MRI Scan


50000

83 ENT surgery Throat Microlaryngeal Surgery Inv - Nasal Endoscopy


12000

84 ENT surgery Throat Phono Surgery for Vocal cord paralysis Inv - CT-

Scan MRI Scan Post procedure evidence of

Clin ical photograph

25000

85 ENT surgery Throat Laryngo Fissurectomy Inv - CT-Scan Post


20000

86 ENT surgery Throat Excision of Tumours in Pharynx Inv - FNAC Post


Biopsy

20000

87 ENT surgery Throat Parapharyngeal tumour Excision Inv - CT-Scan

MRI Scan , FNAC Post procedure evidence of

Clin ical photograph,Biopsy

20000

88 ENT surgery Throat Adenoidectomy - Gromet insertion Inv -

Impedance Audiometry , X-Ray Nasopharynx


10000

89 ENT surgery Throat Uvulo-palato Pharyngoplasty Inv -

Polysomnography Post procedure evidence of


25000

90 ENT surgery Nose Endoscopic Sinus Surgery Inv - CT PNS , DNE

Photo graph Post procedure evidence of

Endoscopy photo

15000

91 ENT surgery Nose Mastoidectomy Inv - CT Temporal Bone , PTA

Post procedure evidence of X-Ray mastoids

15000

92 ENT surgery Nose Tympanoplasty Inv - PTA , X-Ray Mastoids Post

procedure evidence of PTA,Per OP photo.

15000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

93 ENT surgery Nose Stapedectomy + Veingraft Inv - CT Temporal

Bone , Impedance Audiometry , PTA Post

procedure evidence of Clin ical photo with

piston+vein graft.

15000

94 ENT surgery Nose Excision of benign tumour nose Inv - CT PNS ,

DNE Post procedure evidence of Clin ical

photograph

15000

95 ENT surgery Nose Angiofibroma nose Inv - CT PNS , DNE Post


40000

96 ENT surgery Nose Endoscopic DCR Inv - Clinical Photograph Post

procedure evidence of Endoscopic photo

20000

97 ENT Bronchoscopic foreign body removal Inv -

Relevant X-Ray Post procedure evidence of


20000

98 Ophthalmology

Cornea Sclera

Therapeutic penetrating keratoplasty Inv - B Scan


15000

99 Ophthalmology

Cornea Sclera

Lamellar keratoplasty Inv - B Scan Post procedure


3000

100 Ophthalmology

Cornea Sclera

Corneal patch graft Inv -Clin ical Photograph Post


4000

101 Ophthalmology

Cornea Sclera

Scleral patch graft Inv - Clin ical Photograph Post


6000

102 Ophthalmology

Cornea Sclera

Penetrating keratoplasty Inv - Clinical Photograph


15000

103 Ophthalmology

Cornea Sclera

Double Z plasty Inv - Clin ical Photograph Post


4000

104 Ophthalmology

Cornea Sclera

Amniotic membrane graft Inv - Clinical


photograph

7000

105 Ophthalmology

Vitreo

Vitrectomy Inv - B Scan Post procedure evidence

of Clinical photograph

6000

106 Ophthalmology

Vitreo

Vitrectomy + Membrane peeling+ endolaser Inv -

B.Scan , Fundus Photograph Post procedure

evidence of Fundus photograph

25000

107 Ophthalmology

Vitreo

Monthly Intravitreal Anti-VEGF for macular

degeneration - per in jection (maximum - 6) Inv -


evidence of Fundus photo, Fundus fluorescence

angiography and optical coherence tomography.

7000

108 Ophthalmology

Vitreo

Vitrectomy - Membrane peeling endolaser ,

Silicon oil or gas Inv - B.Scan , Fundus

Photograph Post procedure evidence of Fundus

photograph

30000

109 Ophthalmology

Retina

Scleral buckle for Ret inal detachment Inv -


evidence of Fundus photograph

15000

110 Ophthalmology

Retina

Photocoagulation for diabetic retinopathy per

sitting Inv - B.Scan , Fundus Photograph Post

procedure evidence of Fundus photograph

1500

111 Ophthalmology

Vitreo

Vitrectomy plus silicon oil or gas Inv - B.Scan ,

Fundus Photograph Post procedure evidence of

Fundus photograph

20000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

112 Ophthalmology

Vitreo

Removal Of Silicon Oil Or Gas Inv - B.Scan ,

Fundus Photograph Post procedure evidence of

Fundus photograph

6000

113 Ophthalmology Orb it Socket reconstruction Inv - Clin ical Photograph

Post procedure evidence of Clin ical Photograph

7000

114 Ophthalmology Orb it Dermis fat graft Inv - Clinical Photograph Post


9000

115 Ophthalmology Orb it Orbitotomy Inv - CT Scan Post procedure


10000

116 Ophthalmology Orb it Enuleation with orb ital implant Inv - CT Skull ,

Clin ical Photograph , Orb it Post procedure


20000

117 Ophthalmology

Squint correction

surgery

Rectus muscle surgery single Inv - Clinical


Photograph

6000

118 Ophthalmology

Squint correction

surgery

Rectus muscle surgery Two/Three Inv - Clinical


Photograph

12000

119 Ophthalmology

Squint correction

surgery

Oblique muscle Inv - Clinical Photograph Post


6000

120 Ophthalmology Lid

surgery

Lid reconstruction surgery Inv - Clinical


Photograph

15000

121 Pediatric Ophthalmic

surgery

Photocoagulation for Ret inopathy of prematurity

Inv - Fundus Fluorescence Angiography , Fundus

Photograph , Optical Coherence Tomography Post


showing procedure.

7500


surgery

Pediatric cataract surgery - Phacoemulsification -

IOL Inv - B.Scan , Fundus Photograph Post


15000


surgery

Glaucoma filtering surgery for paediatric

Glaucoma Inv - USG Fundus Fluorescence

Angiography , Fundus Photograph Post procedure


15000

124 Obstetrics Caesarean Hysterectomy with Bladder Repair Inv

- USG Post procedure evidence of Post op

USG/Photograph

30000

125 Obstetrics Rupture Uterus Inv - USG Post procedure

evidence of USG

25000

126 Obstetrics Eclampsia with complication requiring ventilatory

support Inv - ABG , APTT , CUE , Haematocrit ,

LFT , PT , Platelet Count , RFT , S.Fibrinogen

Level Post procedure evidence of Clinical

Photograph, Biochemical investigations

20000

127 Obstetrics Abruptioo placenta with coagulation defect - DIC.

Inv - APTT , Heamatocrit , PT , Platelet Count ,

S.Fibrinogen Level , USG Post procedure

evidence of Clin ical Photograph of retroplacental

clots, USG

20000

128 Gynaecology LAVH Inv - USG Post procedure evidence of Post

op USG,Biopsy,Video.

30000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

129 Gynaecology Vaginal Hysterectomy with pelvic floor repair Inv

- Scan Post procedure evidence of Post op

USG,Biopsy

20000

130 Gynaecology Vaginal Hysterectomy with Mesh repair Inv -

USG Post procedure evidence of Post op

USG,Biopsy

25000

131 Gynaecology Cystocele ,Rectocele & Perineorraphy Inv - USG

Post procedure evidence of Post op USG,Biopsy

20000

132 Gynaecology Pelvic floor Reconstruction with mesh Inv - USG

Post procedure evidence of Post op USG,Biopsy

20000

133 Gynaecology Mc Indo-s repair fo r Vaginal Atresia Inv - Post

procedure evidence of Post op USG,Biopsy

30000

134 Gynaecology Slings with mesh repair for prolapse Inv - USG


40000

135 Gynaecology Vault prolapse abdominal repair Inv - Clinical

Photograph , USG Post procedure evidence of

USG

25000

136 Gynaecology Vault prolapse abdominal repair with mesh Inv -


evidence of USG

25000

137 Gynaecology Laparoscopic Cystectomy Inv - USG Post

procedure evidence of USG,Biopsy,Video.

20000

138 Gynaecology Laparoscopic Ectopic Resection Inv - USG Post


20000

139 Gynaecology Laparoscopic ovarian drilling Inv - USG Post


15000

140 Gynaecology Laparoscopic Myomectomy Inv - USG Post


25000

141 Gynaecology Laparoscopic recanalisation Inv - USG Post


20000

142 Gynaecology Laparoscopic Sling operations Inv - USG Post


25000

143 Gynaecology Laparoscopic adhesolysis Inv - USG Post


25000

144 Gynaecology Vaginal Hysterectomy Inv - Scan Post procedure

evidence of Post op USG AND Biopsy

20000

145 Orthopedics Fracture

Correct ion Surgeries

Bone Grafting as exclusive procedure Inv - X-Ray

Post procedure evidence of Post op X-Ray

20000



Excision or other Operations for Scaphoid

Fractures Inv - X-Ray Post procedure evidence of

Post op X-Ray

15000



Open Reduction & Internal Fixation of Fingers &

Toes @Rs5000 each up to maximum of Rs 15000

Inv - X-Ray Post procedure evidence of Post op

X-Ray

15000



Reduction of Compound Fractures & External

fixation Inv -X-Ray Post procedure evidence of

Post op X-Ray

15000



ILIZAROV Ring Fixator Application Inv - X-Ray

Post procedure evidence of Clin ical photograph,X-

Ray

40000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)



CTEV Neglected . JESS Fixator Inv - Clinical


photograph,X-Ray

30000

151 Orthopedics Open Reduction of Dislocations - Deep Inv - X-

Ray Post procedure evidence of Post op X-Ray

30000

152 Orthopedics Amputations - Forequarter Inv - X-Ray Post

procedure evidence of Clin ical photograph,X-Ray

30000

153 Orthopedics Amputations - Hind Quarter and Hemipelvectomy

Inv - X-Ray Post procedure evidence of Clin ical

photograph,X-Ray

40000

154 Orthopedics Bone

and Joint Surgery

procedures

Arthrodesis of - Major Joints Inv - Flu id Analysis ,

X-Ray Post procedure evidence of Post op X-Ray

30000


and Joint Surgery

procedures

Arthroscopy - Diagnostic Inv - MRI Post

procedure evidence of Arthroscopy picture

20000


and Joint Surgery

procedures

Arthroscopy . Operative Meniscectomy Inv - MRI

Post procedure evidence of Arthroscopy picture

25000


and Joint Surgery

procedures

Arthroscopy - ACL Repair Inv - MRI Post

procedure evidence of Arthroscopy picture

30000


and Joint Surgery

procedures

Avascular Necrosis of Femoral Head (core

decompression) Inv - MRI , X-Ray Post procedure

evidence of Post op X-Ray

15000


and Joint Surgery

procedures

Soft Tissue reconstruction Procedures for

Joints/Osteotomy Inv - Clinical Photograph Post

procedure evidence of Clin ical photograph,X-Ray

30000

160 Orthopedics spine

Surgery

Anterolateral Clearance for Tuberculosis Inv -

MRI Post procedure evidence of Post op X-Ray,

Biopsy

50000

161 Orthopedics Spine

surgery

Costo Transversectomy Inv - MRI Post procedure

evidence of Post op X-Ray

30000

162 Orthopedics Spine

surgery

Spinal Ostectomy and Internal Fixations Inv -

MRI Post procedure evidence of Post op X-Ray

40000

163 Orthopedics Soft

Tissue Surgery

Nerve Repair with Graft ing Inv - Clinical

Photograph Post procedure evidence of Clinical

Photograph

30000


Tissue Surgery

Neurolysis/Nerve Suture Inv - Clin ical


Photograph

25000


Tissue Surgery

Operations for Brachial Plexus & Cerv ical Rib Inv

- MRI Post procedure evidence of Clinical

Photograph,X-Ray

30000


tumours

Excision of Bone Tumours . Deep with re-

construction with conventional prosthes is Inv -

MRI Post procedure evidence of Clin ical

Photograph,X-Ray

40000

167 Surgical

Gastroenterology

Emergency

Surgery for Bleeding Ulcers Inv - Endoscopy Post

procedure evidence of Endoscopy picture

40000

168 Surgical

Gastroenterology

Surgery for Obscure GI Bleed Inv - Endoscopy

Post procedure evidence of Endoscopy picture

60000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

Emergency

169 Surgical

Gastroenterology

Emergency

Diaphragmatic Hernia (Gortex Mesh Repair) Inv -

Ba.Study , CXR , Endoscopy , USG Post


Biopsy

40000

170 Surgical

Gastroenterology

Liver

Rt Hepatectomy Inv - CT , ERClinical Photograph

, USG Post procedure evidence of Clin ical

photograph, USG

75000

171 Surgical

Gastroenterology

Liver

Lt Hepatectomy Inv - CT , ERClinical Photograph


photograph, USG

75000

172 Surgical

Gastroenterology

Liver

Segmentectomy Inv - CT , ERClinical Photograph


photograph, USG

50000

173 Surgical

Gastroenterology

Pancreas

Distal Pancreatectomy Inv - CT , ERCP Post

procedure evidence of Clin ical photograph, USG

100000

174 Surgical

Gastroenterology

Pancreas

Enucleation of cyst Inv - CT Post procedure

evidence of Clin ical photograph, USG

75000

175 Surgical

Gastroenterology

Pancreas

Whipples any type Inv - CT , ERCP Post

procedure evidence of Clin ical photograph, USG

75000

176 Surgical

Gastroenterology

Pancreas

Trip le bypass Inv - CT Post procedure evidence of

Clin ical photograph, USG

25000

177 Surgical

Gastroenterology

Pancreas

Other Bypasses Inv - CT Post procedure evidence

of Clinical photograph, USG

25000

178 Surgical

Gastroenterology

Oesophagus

Colonic Pull up Inv - Biopsy , CT-Scan ,

Endoscopy Post procedure evidence of Clinical

photograph, Biopsy

30000

179 Surgical

Gastroenterology

Oesophagus

Oesophagectomy Inv - Biopsy , CT-Scan ,

Endoscopy Post procedure evidence of Endoscopy

picture, Biopsy

60000

180 Surgical

Gastroenterology

Oesophagus

Oesophago-Gastrectomy Inv - Biopsy , CT-Scan ,


picture, Biopsy

75000

181 Surgical

Gastroenterology

Oesophagus

Lap Heller‟s myotomy Inv - Biopsy , CT-Scan ,


picture, Biopsy

30000

182 Surgical

Gastroenterology

Oesophagus

Lap Fundoplicat ions Inv - Biopsy , CT-Scan ,


picture, Biopsy

45000

183 Surgical

Gastroenterology

Stomach

Partial Gastrectomy Inv - Biopsy , EUS , USG


photograph,Biopsy

40000

184 Surgical

Gastroenterology

Stomach

Total Gastrectomy Inv - Biopsy , CT-Scan ,



40000

185 Surgical

Gastroenterology

Stomach

Truncal vagotomy + Gastro Jejunostomy Inv -

Biopsy , CT-Scan , Endoscopy , USG Post

procedure evidence of Clin ical

photograph,Biopsy

40000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

186 Surgical

Gastroenterology

Stomach

Distal Gastrectomy for Gastric Outlet obstruction

Inv - Biopsy , CT-Scan , Endoscopy , USG Post


photograph,Biopsy

40000

187 Surgical

Gastroenterology

Stomach

Surgery for Corrosive inju ry Stomach Inv -

Biopsy , CT-Scan , Endoscopy , USG Post


photograph,Biopsy

50000

188 Surgical

Gastroenterology

Small Intestine

Volvulus Inv - CT-Scan , X-Ray ABD Post


photograph,Biopsy

40000

189 Surgical

Gastroenterology

Small Intestine

Malrotation Inv - CT-Scan , X-Ray ABD Post


photograph,Biopsy

40000

190 Surgical

Gastroenterology

Small Intestine

Lap Adhesiolysis Inv - CT-Scan , X-Ray ABD

Post procedure evidence of Clinical

photograph,Biopsy

40000

191 Surgical

Gastroenterology

Large Intestine

Right Hemicolectomy Inv - Biopsy , CT-Scan ,

Colonoscopy , Endoscopy Post procedure

evidence of Clinical photograph,Biopsy

30000

192 Surgical

Gastroenterology

Large Intestine

Left Hemicolectomy Inv - Biopsy , CT-Scan ,



30000

193 Surgical

Gastroenterology

Large Intestine

Extended Right Hemico lectomy Inv - Biopsy ,

CT-Scan , Colonoscopy , Endoscopy Post


photograph,Biopsy

35000

194 Surgical

Gastroenterology

Large Intestine

Anterior Resection Inv - Biopsy , CT-Scan ,



40000

195 Surgical

Gastroenterology

Large Intestine

Anterior Resection with Ileostomy Inv - Biopsy ,

CT-Scan , Colonoscopy , Endoscopy Post


photograph,Biopsy

50000

196 Surgical

Gastroenterology

Large Intestine

Abdomino Perineal Resection(Non-Malignant)

Inv - Biopsy , CT-Scan , Colonoscopy ,


photograph,Biopsy

50000

197 Surgical

Gastroenterology

Large Intestine

Hartman.s Procedure with Colostomy Inv - Biopsy

, CT-Scan , Colonoscopy , Endoscopy Post


photograph,Biopsy

45000

198 Surgical

Gastroenterology

Ulcerative colitis III

stage procedure

I Stage-Sub Total Colectomy + Ileostomy Inv -

CT-Scan with Contrast , Colonoscopy ,


photograph,Biopsy

50000

199 Surgical

Gastroenterology


stage procedure

II Stage-J - Pouch Inv - Colonoscopy Post


photograph,Biopsy

30000

200 Surgical

Gastroenterology


stage procedure

III Stage-Ileostomy Closure Inv - Endoscopy Post


photograph,Biopsy

20000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

201 Surgical

Gastroenterology

Ulcerative colitis II

stage procedure

I Stage- Sub Total Colectomy + Ileostomy + J -

Pouch Inv - CT-Scan with Contrast , Co lonoscopy

, Endoscopy Post procedure evidence of Clinical

photograph,Biopsy

80000

202 Surgical

Gastroenterology

Ulcerative colitis II

stage procedure

II Stage- Ileostomy Closure Inv - CT-Scan with

Contrast , Colonoscopy , Endoscopy Post


photograph,Biopsy

20000

203 Surgical

Gastroenterology

Liver

Hepato Cellular Carcinoma(Advanced) Radio

Frequency Ablation Inv - Biopsy , CT-Scan ,

EUSDiagnostic Laparoscopy , Intra operative

Ultrasound Post procedure evidence of Clin ical

photograph/USG

60000

204 Surgical

Gastroenterology

Liver

Haemangioma SOL Liver Hepatectomy + Wedge

Resection Inv - CT-Scan , Endoscopy , USG Post


photograph/Biopsy/USG

75000

205 Surgical

Gastroenterology

Liver

Hydatid cyst-Marsupilisation Inv - Biopsy , CT-

Scan , USG Post procedure evidence of Clinical

photograph/Biopsy/USG

30000

206 Surgical

Gastroenterology

Gall Bladder

Cyst excision + Hepatic Jejunostomy Inv - CT ,

USG Post procedure evidence of Clinical

photograph,Biopsy

45000

207 Surgical

Gastroenterology

Gall Bladder

GB+ Calculi CBD Stones or Dilated CBD Inv -

CBD , ERClinical Photograph , USG Post


photograph,Biopsy

25000

208 Surgical

Gastroenterology

Gall Bladder

Hepatico Jejunostomy Inv - Biopsy , CT-Scan


photograph,Biopsy

45000

209 Surgical

Gastroenterology

Gall Bladder

Choledochoduodenostomy Or Choledocho

jejunostomy Inv - CT , USG Post procedure


35000

210 Surgical

Gastroenterology

Spleen

Splenectomy Inv - CT , USG Post procedure

evidence of Clinical photograph,USG

35000

211 Surgical

Gastroenterology

Spleen

Splenectomy + Devascularisation + Spleno Renal

Shunt Inv - CT , USG Post procedure evidence of


60000

212 Surgical

Gastroenterology

Spleen

Spleenectomy for Space occupying lesion Inv -

CT , USG Post procedure evidence of Clinical

photograph,USG

35000

213 Surgical

Gastroenterology

Pancreas

Lap- Pancreatic Necrosectomy Inv - CT-Scan ,

ERCP , ERClinical Photograph , Endoscopy Post


photograph,Biopsy

100000

214 Surgical

Gastroenterology

Pancreas

Lateral PancreaticoJejunostomy(Non- Malignant)

Inv - CT-Scan , ERCP , ERClinical Photograph ,


photograph,Biopsy

100000

215 Surgical

Gastroenterology

Pancreas

Pancreatic Necrosectomy (open) Inv - CT-Scan ,

ERCP , ERClinical Photograph , Endoscopy Post


photograph,Biopsy

100000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

216 Surgical

Gastroenterology

Pancreas

Distal Pancreatectomy + Splenectomy Inv - CT-

Scan , ERCP , ERClinical Photograph ,


photograph,Biopsy

100000

217 Surgical

Gastroenterology

Pancreas

Central Pancreatectomy Inv - CT-Scan , ERCP ,

ERClin ical Photograph , Endoscopy Post


photograph,Biopsy

100000

218 Surgical

Gastroenterology

Pseudocyst

Cysto Jejunostomy Inv - CT , USG Post procedure


40000

219 Surgical

Gastroenterology

Pseudocyst

Cysto Gastrostomy Inv - CT , USG Post procedure


40000

220 Card iology Coronary ballon Angioplasty Inv - 2 CAD Post


60000

221 Card iology PTCA Addit ional Stent Inv - CAG Post procedure


20000

222 Card iology ASD Device closure Inv - 2D ECHO Post

procedure evidence of Clin ical photograph, 2D

Echo

80000

223 Card iology VSD Device closure Inv - 2D ECHO Post


Echo

80000

224 Card iology PDA Stenting Inv - 2D ECHO Post procedure

evidence of Clin ical photograph, 2D Echo

65000

225 Card iology PDA Device closure Inv - 2D ECHO Post


Echo

60000

226 Card iology Coil Closure Single coil Inv - 2D ECHO Post


Echo

20000

227 Card iology Coil Closure Multiple co ils Inv - 2D ECHO Post


Echo

30000

228 Card iology Balloon

procedures

Balloon Valvotomy Inv - 2D ECHO Post


Echo

20000

229 Card iology Balloon

procedures

Balloon Atrial septostomy Inv - 2D ECHO Post


Echo

30000

230 Card iology

Pacemaker

implantation

Permanent pacemaker implantation Inv - CAG ,

ECG Post procedure evidence of Clin ical

photograph, 2D Echo

75000

231 Card iology

Pacemaker

implantation

Temporary pacemaker implantation Inv - CAG ,

ECG Post procedure evidence of Clin ical

photograph, 2D Echo

10000

232 Card iology

Coarctation of Aorta

repair / Aortoplasty

Coarctation of Aorta Repair With stent Inv - 2D

ECHO , CAG Post procedure evidence of Clin ical

photograph, Doppler

80000

233 Card iology

Coarctation of Aorta

repair / Aortoplasty

Coarctation of Aorta Repair Without stent Inv -

Aortogram Post procedure evidence of Clin ical

photograph, Doppler

30000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

234 Card iology

Angioplasty

Renal Angioplasty Inv - Angiogram Post


Doppler

60000

235 Card iology

Angioplasty

Peripheral Angioplasty Inv - 2D ECHO ,

Angiogram Post procedure evidence of Clinical

photograph, Doppler

60000

236 Card iology

Angioplasty

Vertebral Angioplasty Inv - Angiogram Post


Doppler

75000

237 Card iology

Angioplasty

Angioplasty Additional Stent Inv - Angiogram


Doppler

40000

238 CVTS Surgery fo r

CAD

Coronary bypass Surgery on pump with IABP Inv

- CAG, 2D ECHO Post procedure evidence of


150000

239 CVTS Surgery fo r

CAD

Coronary bypass Surgery off pump with IABP Inv

- 2D ECHO Post procedure evidence of Clinical

photograph.

150000

240 CVTS Vascular

Surgeries

Peripheral embolectomy without graft Inv -

Angiogram , Sp iral CT Angiogram Post procedure

evidence of Color Doppler

25000

241 CVTS Vascular

Surgeries

Excision of AV Malformat ion Large Inv - MRI



75000

242 CVTS Vascular

Surgeries

Excision of AV Malformat ion Small Inv - MRI



40000

243 CVTS Vascular

Surgeries

Arterial embolectomy Inv - Angiogram , Color

Doppler Post procedure evidence of Color

Doppler/SBP/PVR

20000

244 CVTS Vascular

Surgeries

A V Fistula at Wrist Inv - Color Doppler Post

procedure evidence of Color Doppler

10000

245 CVTS Vascular

Surgeries

A V Fistula at Elbow Inv - Color Doppler Post

procedure evidence of Color Doppler

20000

246 CVTS Vascular

Surgeries

D V T - IVC Filter Inv - Color Doppler Post

procedure evidence of Plain X-Ray abdomen,


100000

247 CVTS Vascular

Surgeries

Vascular tumours Inv - Angiogram , Spiral CT

Post procedure evidence of Color Doppler

40000

248 CVTS Vascular

Surgeries

Small arterial aneurysms - Repair Inv -

Angiogram , Sp iral CT Post procedure evidence of

Color Doppler

15000

249 CVTS Vascular

Surgeries

Medium size arterial aneurysms - Repair Inv -


Color Doppler

50000

250 CVTS Vascular

Surgeries

Medium size arterial aneurysms with synthetic

graft Inv - Angiogram , Spiral CT Post procedure


75000

251 CVTS Vascular

Surgeries

Aorto Billac - Bifemoral bypass with synthetic

graft Inv - Angiogram , Spiral CT Post procedure


125000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

252 CVTS Vascular

Surgeries

Axillo Bifemoral Bypass with synthetic graft Inv -


Color Doppler

100000

253 CVTS Vascular

Surgeries

Femorodistal Bypass with vein graft Inv -


Color Doppler

60000

254 CVTS Vascular

Surgeries

Femorodistal Bypass with synthetic graft Inv -


Color Doppler

80000

255 CVTS Vascular

Surgeries

Axillo b rachial bypass using with synthetic graft

Inv - Angiogram , Spiral CT Post procedure


65000

256 CVTS Vascular

Surgeries

Brach ioradial bypass with synthetic graft Inv -


Color Doppler

50000

257 CVTS Vascular

Surgeries

Carotid body tumour Excision Inv - Angiogram ,

Spiral CT Post procedure evidence of Color

Doppler

60000

258 CVTS Vascular

Surgeries

Carotid artery bypass with synthetic graft Inv -


Color Doppler

100000

259 CVTS - Surgery for

Card iac injuries

Surgery without CPB Inv - 2D Echo Post

procedure evidence of 2D Echo

40000

260 CVTS - surgery for

Card iac injuries

Surgery with CPB Inv - 2D Echo Post procedure

evidence of 2D Echo

75000


CAD

CABG on pump without IABP Inv - 2D ECHO ,

CAG Post procedure evidence of Clinical

photograph

125000


CAD

CABG of pump without IABP Inv - 2D ECHO ,

CAG Post procedure evidence of Clinical

photograph

125000


CAD

CABG with aneurysmal repair Inv - CAG Post


110000

264 CVTS Valve

replacement

Mitral valve rep lacement (with valve) Inv - 2D

ECHO Post procedure evidence of 2D Echo

120000

265 CVTS Valve

replacement

Aortic valve replacement (with valve) Inv - 2D


120000

266 CVTS Valve

replacement

Tricuspid valve replacement Inv - 2D ECHO Post


120000

267 CVTS Valve

replacement

Double valve rep lacement (with valve) Inv - 2D


150000

268 CVTS Pericard ium Percardiostomy Inv - 2D ECHO Post procedure

evidence of 2D Echo

10000

269 CVTS Pericard ium Percardectomy Inv - 2D ECHO Post procedure

evidence of 2D Echo

30000

270 CVTS Pericard ium Pericardiocentesis Inv - 2D ECHO Post procedure

evidence of 2D Echo

2000

271 CVTS Coarctation of

Aorta repair

Coarctation of aorta Repair with graft Inv - 2D

ECHO , CAG Post procedure evidence of Doppler

32000

272 CVTS Coarctation of

Aorta repair

Coarctation of aorta Repair without graft Inv - 2D

ECHO , CAG Post procedure evidence of Doppler

25000

273 CVTS Aorta repair Aneurysm resection & grafting Inv - 2D ECHO ,

CAG Post procedure evidence of Doppler

125000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

274 CVTS Aorta repair Intrathoracic Aneurysm-Aneurysm not requiring

bypass (with graft) Inv - CT-Angio , Cath Post

procedure evidence of Doppler

65000

275 CVTS Aorta repair Intrathoracic Aneurysm-Aneurysm requiring

bypass (with graft) Inv - CT-Angio , Cath Post


125000

276 CVTS Aorta repair Dissecting Aneurysms Inv - CT-Angio , Cath Post


75000

277 CVTS Aorta repair Annulus aortic ectasia with valved conduits Inv -

Angio Post procedure evidence of Echo, Doppler

150000

278 CVTS Aorto-aorto bypass with graft Inv - Angio Post


60000

279 CVTS Aorto-aorto bypass without graft Inv - Angio Post


45000

280 CVTS Femoro popliteal bypass with graft Inv - Angio

Post procedure evidence of Doppler

45000

281 CVTS Femoro popliteal bypass without graft Inv - Angio


30000

282 CVTS Femoroileal bypass With Graft Inv - Angio Post


45000

283 CVTS Femoroileal bypass Without Graft Inv - Angio


25000

284 CVTS Femoro-femoral bypass With Graft Inv - Angio


45000

285 CVTS Femoro-femoral bypass Without Graft Inv -

Angio Post procedure evidence of Doppler

25000

286 CVTS TGA Arterial Switch Inv - 2D ECHO , angio Post


150000

287 CVTS TGA Sennings Procedure Inv - 2D ECHO , angio

Post procedure evidence of 2D Echo

120000

288 CVTS Carotid Embolectomy Inv - Angiogram Post


50000

289 CVTS Surgery for Intracardiac tumours Inv - 2D ECHO ,

CAG Post procedure evidence of

Echo/HPE/Clin ical photograph

75000

290 CVTS Ruptured sinus of valsalva correction Inv - CAG

Post procedure evidence of Echo/Clinical

photograph

95000

291 CVTS TAPVC correction Inv - 2D ECHO Post

procedure evidence of Echo/Clin ical photograph

95000

292 CVTS Systemic

Pulmonary shunts

Systemic pulmonary Shunts with graft Inv - 2D

ECHO Post procedure evidence of 2D ECHO

20000

293 CVTS Systemic

Pulmonary shunts

Systemic pulmonary Shunts without graft Inv - 2D

ECHO Post procedure evidence of 2D ECHO

20000

294 CVTS Systemic

Pulmonary shunts

Total correction of Tetralogy of Fallots Inv - 2D

ECHO Post procedure evidence of Clinical

photograph/Echo

95000

295 CVTS Intracardiac Repair of ASD Inv - 2D ECHO Post

procedure evidence of 2D ECHO

75000

296 CVTS Intracardiac Repair of VSD Inv - 2D ECHO Post


75000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

297 CVTS Surgery-PDA Inv - 2D ECHO Post procedure

evidence of 2D ECHO

20000

298 CVTS Ross

procedure -

Intracardiac repair o f

complex congenital

heart diseases

With special conduits Inv - 2D ECHO Post


125000

299 CVTS Ross

procedure -

Intracardiac repair o f

complex congenital

heart diseases

Without special conduits Inv - 2D ECHO Post


95000

300 CVTS Valve repairs With prosthetic ring Inv - 2D ECHO Post


100000

301 CVTS Valve repairs Without prosthetic ring Inv - 2D ECHO Post


85000

302 CVTS Valve repairs Open pulmonary valvotomy Inv - 2D ECHO Post


75000

303 CVTS Valve repairs Closed mit ral valvotomy Inv - 2D ECHO Post


20000

304 CVTS Valve repairs Mitral valvotomy (Open) Inv - 2D ECHO Post


80000

305 CVTS Lungs Pneumonectomy Inv - CT-Chest , X-Ray Post

procedure evidence of Clin ical Photograph/X-Ray

50000

306 CVTS Lungs Lobectomy Inv - CT-Chest , X-Ray Post


50000

307 CVTS Lungs Decortication Inv - CT-Chest , X-Ray Post


50000

308 CVTS Lungs Lung cyst Inv - CT-Chest , X-Ray Post procedure

evidence of Clin ical Photograph/X-Ray

50000

309 CVTS Lungs SOL Mediastinum Inv - CT-Chest , X-Ray Post


50000

310 CVTS Surgical

correction of

Bronchopleural

fistula

Thorocoplasty Inv - CT-Chest , X-Ray Post


50000

311 CVTS Surgical

correction of

Bronchopleural

fistula

Myoplasty Inv - CT-Chest , X-Ray Post procedure

evidence of Clin ical Photograph/X-Ray

50000

312 CVTS Surgical

correction of

Bronchopleural

fistula

Transpleural BPF Closure Inv - CT-Chest , X-Ray


Photograph/X-Ray

50000

313 CVTS Chest Diaphragmatic Eventeration Inv - Barium studies ,

CT-Scan Post procedure evidence of USG

40000

314 CVTS Chest Diaphragmatic Hernia Inv - CT-Scan , USG Post

procedure evidence of USG

40000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

315 CVTS Chest Oesophageal diverticula /Achlasia cardia Inv -

Barium studies , CT-Scan Post procedure evidence

of USG

40000

316 CVTS

Diaphragmatic

injuries

Thoracotomy, Thoraco abdominal approach Inv -

CT-Scan Post procedure evidence of Clin ical

photograph with operative scars

40000

317 CVTS Bronchial

injuries

Foreign body removal with scope Inv -

Bronchoscopy , CT-Scan Post procedure evidence

of Endoscopic picture

20000

318 CVTS Bronchial

injuries

Repair surgery Injuries due to Foreign body Inv -

Bronchoscopy , CT-Scan Post procedure evidence

of Endoscopic picture

40000

319 CVTS Oesophagus

injuries

Gastro study followed by Thoracotomy and

repairs for oesophageal injury fo r Corrosive

Injuries/FB Inv - Gastroscopy Post procedure

evidence of Endoscopic picture

50000

320 CVTS Vascular

Injuries

Surgery without graft for Arterial injuries, venous

injuries Inv - Angiogram , Doppler Post

procedure evidence of Clin ical photograph with

scar

10000

321 CVTS Vascular

Injuries

Vascular In jury in upper limbs -

Axillary,branchial,Radial and Ulnar - Repair with

Vein Graft Inv - Angiogram , Doppler Post

procedure evidence of Color doppler

Up to

40000

322 CVTS Vascular

Injuries

Major Vascular Inju ry -in lower limbs-Repair Inv

- Angiogram , Doppler Post procedure evidence

of Color doppler

Up to

60000

323 CVTS Vascular

Injuries

Minor Vascular Injury Repair- Tibial vessels in

leg Inv - Angiogram , Doppler Post procedure

evidence of Color doppler

Up to

20000

324 CVTS Vascular

Injuries

Minor Vascular Injury Repair -vessels in Foot Inv

- Angiogram , Doppler Post procedure evidence

of Color doppler

Up to

20000

325 CVTS Vascular

Injuries

Surgery with Vein graft Inv - Angiogram ,

Doppler Post procedure evidence of Clinical

photograph with scar Color doppler

15000

326 CVTS Vascular

Injuries

With prosthetic graft Inv - Angiogram , Doppler


with scar

40000

327 CVTS Vascular

Injuries

Neck vascular injury - Carot id vessels Inv -

Angiogram , Doppler Post procedure evidence of

Color Doppler

Up to

100000

328 CVTS Vascular

Injuries

Abdominal vascular injuries - Aorta, Iliac arteries,

IVC, Iliac veins Inv - Angiogram , Doppler Post

procedure evidence of Color doppler

Up to

100000

329 CVTS Vascular

Injuries

Thoracic vascular in juries Inv - Angiogram ,

Doppler Post procedure evidence of Color doppler

Up to

150000

330 Pediatric Surgeries

Congenital

malformations - GI

Tract

Oesophageal atresis Inv - X-Ray, Oesophagoscopy


60000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Congenital

malformations - GI

Tract

Diaphragmatic hernia Inv - USG, CT Post


60000


Congenital

malformations - GI

Tract

Intestinal atresias & Obstructions Inv - x-Ray, CT


50000


Congenital

malformations - GI

Tract

Biliary atresis & Choledocal cyst Inv - CT,

Clin ical Photograph Post procedure evidence of


55000


Congenital

malformations - GI

Tract

Anorectal malformations Stage 1 Inv - Clin ical

Photograph, Proctoscopy Post procedure evidence

of Clinical Photograph

45000


Congenital

malformations - GI

Tract

Anorectal malformations Stage 2 Inv - Clin ical

Photograph, Proctoscopy Post procedure evidence

of Clinical Photograph

60000


Congenital

malformations - GI

Tract

Hirschsprung Disease Stage 1 Inv - Clinical

Photograph, Proctoscopy Biopsy Post procedure


45000


Congenital

malformations - GI

Tract

Hirschsprung Disease Stage 2 Inv - Clinical

Photograph, Proctoscopy Biopsy Post procedure


60000


Congenital

malformations –

Urogenital

Congenital hydronephrosis Inv -

USG/IVP/Renogram Post procedure evidence of

Clin ical Photograph, IVP

50000


Congenital

malformations -

Urogenital

Ureteric reimplantations Inv - Clinical

Photograph/USG Post procedure evidence of

Clin ical Photograph,IVP

65000


Congenital

malformations -

Urogenital

Extrophy bladder Stage 1 Inv - Clin ical



65000


Congenital

malformations -

Urogenital

Extrophy bladder Stage 2 Inv - Clin ical



60000


Congenital

malformations -

Urogenital

Posterior urethral valves Inv - MCU Post

procedure evidence of Clin ical Photograph,IVP

30000


Congenital

malformations -

Urogenital

Hypospadias single stage Inv - Clin ical


Photograph

40000


Congenital

malformations -

Urogenital

Hypospadius stage 2 Inv - Clinical Photograph


35000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Congenital

malformations

Pediatric tumours Inv - CT/Biopsy Post procedure


50000


Congenital

malformations -

Plastic repair

Cleft lip Inv - Clinical Photograph Post procedure


10000


Congenital

malformations -

Plastic repair

Cleft palate Inv - Clin ical Photograph Post


15000


Congenital

malformations -

Plastic repair

Velo-Pharyngial Incompetence Inv - Endoscopy


15000


Congenital

malformations -

Plastic repair

Syndactyly of hand for each hand Inv - Clin ical


Photograph

15000


Congenital

malformations -

Plastic repair

Microtia/ Anotia Inv - Clinical Photograph Post


30000


Congenital

malformations -

Plastic repair

TM joint ankylosis Inv -Clinical Photograph / X-

Ray Post procedure evidence of Clin ical

Photograph

40000


Congenital

malformations –

Urogenital

Hypospadius stage 1 Inv - Clinical Photograph


35000


Congenital

malformations

Hamartoma Excision Inv - CT/ Clinical


Photograph

20000


Congenital

malformations

Hemangioma Excision Inv - Neuro USG+CT Post


25000


Congenital

malformations

Lymphangioma Excision Inv -Neuro USG+CT


40000


Head and neck

Neuroblastoma Inv - CT/USG/FNAC Post


25000


Head and neck

Congenital Dermal Sinus Inv - Neuro USG+CT


Photograph,Biopsy

30000


Head and neck

Cystic Lesions of the Neck Inv -

USG,MRI,CT,Clin ical Photograph Post procedure

evidence of Clin ical Photograph,Biopsy

20000


Head and neck

Encephalocele Inv - Neuro USG+CT Post


20000


Head and neck

Sinuses & Fistula of the Neck Inv - CT,Clinical


Photograph,Biopsy

20000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Chest

Bronchoscopy foreign body removal Inv -

Endoscopic Video Post procedure evidence of


20000


Chest

Paediatric Esophageal obstructions-Surgical

correction Inv -Contrast UGI Post procedure


30000


Chest

Paediatric Esophageal Substitutions Inv - Contrast

study Post procedure evidence of Clinical

Photograph

60000


Chest

Thoracoscopic cysts excision Inv - USG, CT Post

procedure evidence of Clin ical Photograph/Biopsy

40000


Chest

Thoracoscopic decortication Inv - USG, CT Post


40000


Chest

Thoracic Duplications Inv - X-Ray, CT Post


40000


Chest

Thoracic Wall defects- Correction Inv - X-Ray,

CT Post procedure evidence of Clinical

Photograph

50000


Abdomen

Gastric outlet obstructions Inv - Contrast USG, X-


Photograph

30000


Abdomen

Laparoscopic pull through surgeries for HD Inv -

USG,Clin ical Photograph Post procedure evidence

of Clinical Photograph,USG, Video

60000


Abdomen

Paediatric Splenectomy (Non Traumatic) Inv -

USG,Hemogram Post procedure evidence of


35000


Abdomen

Surgeries on adrenal gland in Children Inv - CT,

Hormone assays Post procedure evidence of

Clin ical Photograph,USG

25000


Abdomen

Gastro Esophageal Reflux Correction Inv -

Endoscopy, CT Scan Post procedure evidence of


30000


Abdomen

Hydatid cysts in Paediatric patient Inv - CT,USG


Photograph,USG

40000


Abdomen

Intestinal Polyposis Surgical correct ion Inv -

UG,Endoscopy Post procedure evidence of

Clin ical Photograph,Biopsy

50000


Abdomen

Intussusception Inv - USG,CT Post procedure

evidence of Clin ical Photograph,USG

40000


Abdomen

Paediatric Acute Intestinal Obstruction Inv -

USG,CT Post procedure evidence of Clinical

Photograph,USG

40000


Abdomen

Laparoscopic Appendectomy Inv - USG,Clin ical


Photograph,USG,Video

30000


Abdomen

Laparoscopic Choleycystectomy Inv -


of Clinical Photograph,USG,Video

40000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Abdomen

Laparoscopic pull through for Ano Rectal

Anomalies Inv - USG,Clin ical Photograph Post



60000


Urogenital

Nephrectomy Inv - USG,CT,Clinical Photograph


Photograph,USG

40000


Urogenital

Ep ispadiasis - Correct ion Inv - Clin ical


Photograph

40000


Urogenital

Scrotal transposition repair Inv - USG Post


20000


Urogenital

Undescended Testis Inv - USG,Clinical


Photograph

25000


Urogenital

Torsion Testis Inv - Color doppler, Clin ical


Photograph

25000


Urogenital

Laparoscopic Orch idopexy Inv - USG,Clin ical



25000


Urogenital

Laparoscopic Varicocele ligation Inv -


of Clinical Photograph,USG,Video

25000

387 Urology Renal

Transplantation

A.V. Fistula (Pretransplant procedure only) Inv -

Renal function tests, Serum electro lytes Post


10000

388 Urology Renal

Transplantation

Renal t ransplantation surgery Inv - USG,RFT Post


140000

389 Urology Renal

Transplantation

Post-transplant immunosuppression treatment

From 1st to 6th month after transplantation Inv -

USG,RFT Post procedure evidence of Bills copy

50000

390 Urology Testis,

Testis and Penis

Orchidopexy Bilateral Inv - USG Post procedure


15000

391 Urology Testis,

Testis and Penis

Torsion testis Inv -USG Post procedure evidence


12000

392 Urology Testis,

Testis and Penis

Chordae correction Inv - USG Post procedure


15000

393 Urology Testis,

Testis and Penis

Partial amputation of Pen is(Non-Malignant) Inv -



15000

394 Urology Testis,

Testis and Penis

Total amputation of Penis(Non-Malignant) Inv -



25000

395 Urology Renal

Calculi

Open Pyelolithotomy Inv - USG,KUB,IVP Post

procedure evidence of Clin ical photograph,X-

Ray,USG

10000

396 Urology Renal

Calculi

Open Nephrolithotomy Inv - USG,KUB,IVP Post


Ray,USG

10000

397 Urology Renal

Calculi

Open cystolithotomy Inv - USG,KUB,IVP Post


Ray,USG

10000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

398 Urology Renal

Calculi

Laparoscopic Pyelolithotomy Inv -

USG,KUB,IVP Post procedure evidence of

Clin ical photograph,X-Ray,Video

30000

399 Urology Lithotripsy Cystolithotripsy Inv - USG,KUB Post procedure

evidence of Clin ical photograph,X-Ray,USG

10000

400 Urology Lithotripsy PCNL Inv - USG,KUB,IVP Post procedure

evidence of Clin ical photograph,X-Ray

30000

401 Urology Lithotripsy ESWL Inv - USG,KUB,IVP Post procedure

evidence of Clin ical photograph,X-Ray,IVP

20000

402 Urology Lithotripsy URSL Inv - USG,KUB,IVP Post procedure

evidence of Clin ical photograph,X-Ray

25000

403 Urology Lithotripsy Nephrostomy Inv -USG,IVP Post procedure


2000

404 Urology Lithotripsy DJ Stent (One side) Inv - USG,IVP Post procedure

evidence of X-Ray

5000

405 Urology Correct ive

procedures

Urethroplasty for Stricture Urethra Single stage

Inv - RUG Post procedure evidence of Clinical

photograph

50000


procedures

Urethroplasty for Stricture Urethra Double Stage

Stage-1 Inv - RUG Post procedure evidence of


30000


procedures


Stage-2 Inv - RUG Post procedure evidence of


30000


procedures


Reconstruction Procedure Inv - Clinical

Photograph Post procedure evidence of Photo

50000


procedures

Hypospadius Adult Single Stage Inv - Clin ical


photograph

40000


procedures

Hypospadius Adult Double Stage - Stage-1 Inv -



35000


procedures

Hypospadius Adult Double Stage - Stage-2 Inv -



35000


procedures

Hypospadius Adult Double Stage - TURBT Inv -

CT,USG,Cysoscopy, Biopsy Post procedure

evidence of Clin ical photograph, CT

30000

413 Urology Post-Transplant immunosuppressive Treatment

from 7th to 12 th Month after transplantation Inv -

USG/RFT Post procedure evidence of Bills copy

50000

414 Urology Kidney Nephrostomy Inv - USG,IVP Post procedure

evidence of USG

10000

415 Urology Kidney Nephrectomy Pyonephrosis/XGP Inv - USG,IVP


40000

416 Urology Kidney Simple Nephrectomy Inv - USG,IVP Post


40000

417 Urology Kidney Lap. Nephrectomy Simple Inv - USG,IVP Post


30000

418 Urology Kidney Lap. Nephrectomy Radical Inv - USG,IVP Post


40000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

419 Urology Kidney Lap. Part ial Nephrectomy Inv -USG,IVP Post


35000

420 Urology Kidney Bilateral Nephroureterectomy Inv - USG,IVP Post


25000

421 Urology Kidney Renal Cyst Excision Inv - USG,IVP Post


15000

422 Urology Kidney

Stone

Endoscope Removal of stone in Bladder Inv -

USG, IVP,Scopy. X-Ray. KUB Post procedure

evidence of Endoscopic picture

10000

423 Urology Kidney

Stone

Anatrophic Pyelolithotomy for Staghorn Calculus

Inv - USG,KUB,IVP Post procedure evidence of

Clin ical photograph/X-Ray, USG

50000


procedures

Anderson Hynes Pyeloplasty Inv - X-Ray,

USG,IVP Post procedure evidence of Clin ical

photograph

40000


procedures

Vasico Vaginal Fistula Inv - IVP,Scopy, RGP Post


40000


procedures

Epispadiasis - Correct ion Inv - Clin ical

photograph Post procedure evidence of Clinical

photograph

40000


procedures

Closure of Urethral Fistula Inv - RGU Post


25000


procedures

Optical Urethrotomy Inv - X-Ray, RGU Post

procedure evidence of Endoscopic picture

20000


procedures

Perineal Urethrostomy Inv -X-Ray, RGU Post

procedure evidence of Endoscopic picture

20000


procedures

Ureteric Reimplantation Inv -X Ray,USG,IVP


25000


procedures

Ileal Conduit format ion Inv - X Ray,USG,IVP


20000


procedures

Ureterocele Inv - X Ray,RGU Post procedure


15000

433 Urology Bladder

Prostate

Transurethral resection of prostate (TURP) Inv -

USG,U.Scopy Post procedure evidence of USG

30000

434 Urology Bladder

Prostate

TURP Cyst lithotripsy Inv - X-Ray,USG Post


30000

435 Urology Bladder

Prostate

Open prostatectomy Inv - X-Ray,USG Post


30000

436 Urology Bladder

Prostate

Caecocystoplasty Inv - USG,U.Scopy Post


30000

437 Urology Bladder

Prostate

Total cystectomy Inv -USG,U.Scopy Post


35000

438 Urology Bladder

Prostate

Divert iculectomy Inv -USG,U.Scopy Post


10000

439 Urology Bladder

Prostate

Incontinence Urine (Female) Inv -USG,U.Scopy


20000

440 Urology Bladder

Prostate

Incontinence Urine (male) Inv - USG,U.Scopy


20000

441 Neurosurgery Brain Cran iotomy and evacuation of Hematoma

Subdural Inv - CT Post procedure evidence of


40000

442 Neurosurgery Brain Cran iotomy and evacuation of Hematoma

Extradural Inv - CT Post procedure evidence of

40000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


443 Neurosurgery Brain Evacuation of Brain Abscess - Burr hole Inv - CT


25000

444 Neurosurgery Brain Excision of Lobe (Frontal,Temporal,Cerebellum

etc.) Inv - CT Post procedure evidence of Clin ical

photograph/Biopsy

40000

445 Neurosurgery Brain

Tumours

Parasagittal Inv - CT Post procedure evidence of


50000


Tumours

Basal Inv - CT Post procedure evidence of


60000


Tumours

Brain Stem Inv -CT Post procedure evidence of


70000


Tumours

C P Angle Inv - CT Post procedure evidence of


70000

449 Neurosurgery

Excision of Brain

tumours

Others Inv -CT Post procedure evidence of


40000

450 Neurosurgery

Excision of Brain

Tumours

Excision of b rain tumours Subtentorial Inv - CT


photograph/Biopsy

45000

451 Neurosurgery

Excision of Brain

Tumours

Ventriculo lateral / Ventriculoperitoneal shunt Inv

- CT Post procedure evidence of Clinical

photograph

20000

452 Neurosurgery

Excision of Brain

Tumours

Twist drill craniotomy Inv -CT Post procedure


15000

453 Neurosurgery

Excision of Brain

Tumours

Subdural taping Inv - CT Post procedure evidence


15000

454 Neurosurgery

Excision of Brain

Tumours

Ventricular tapping Inv - CT Post procedure


15000

455 Neurosurgery

Excision of Brain

Tumours

Abscess tapping Inv - CT Post procedure evidence


20000

456 Neurosurgery

Excision of Brain

Tumours

Vascular malformations Inv - MRI,Angio Post


40000

457 Neurosurgery

Excision of Brain

Tumours

Peritoneal shunt Inv - CT Post procedure evidence


20000

458 Neurosurgery

Excision of Brain

Tumours

Atrial shunt Inv - CT Post procedure evidence of


20000


Tumours

Meningoencephalocele Inv - MRI Post procedure


25000


Tumours

Meningomylocele Inv - MRI Post procedure


25000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Tumours

C.S.F. Rhinorrhoea Inv -CT,Clin ical photograph


20000


Tumours

Cran ioplasty Inv - MRI Post procedure evidence


30000


Tumours

Meningocele excision Inv - MRI Post procedure


25000


Tumours

Ventriculoatrial shunt Inv - CT Post procedure


20000


Tumours

Excision of Brain Abscess - Inv -CT Post


60000


Tumours

Aneurysm Clipping Inv -MRI,Angio Post

procedure evidence of Clin ical photograph, X-Ray

100000


Tumours

External Ventricular Drainage (EVD) Inv - CT


40000

468 Neurosurgery Spinal

Surgeries

Surgery on cord tumours Inv - MRI Post


25000


Surgeries

Spinal intramedullary tumours Inv -MRI Post

procedure evidence of Clin ical photograph/X-

Ray/Biopsy

50000


Surgeries

Spina bifida surgery major Inv -MRI Post

procedure evidence of Clin ical photograph/X-Ray

20000


Surgeries

Spina bifida surgery minor Inv - MRI Post


15000


Surgeries

Excision of cervical intervertebral d iscs Inv - MRI


25000


Surgeries

Posterior cervical discectomy Inv - MRI Post


15000


Surgeries

Anterior cervical discectomy Inv - MRI Post


15000


Surgeries

Anterior cervical spine surgery with fusion Inv -

MRI, X-Ray Cervical spine Post procedure

evidence of X-Ray

45000


Surgeries

Anterolateral decompression Inv -MRI Post


30000


Surgeries

Laminectomy Inv - MRI Post procedure evidence

of Clinical photograph/X-Ray

25000


Surgeries

Discectomy Inv - MRI Post procedure evidence of

Clin ical photograph/X-Ray

25000


Surgeries

Spinal fusion procedure Inv - MRI Post procedure


50000

480 Neurosurgery - Other

Surgical Procedures

Stereotactic procedures - Post procedure evidence


20000


Surgical Procedures

Trans sphenoidal surgery Inv - CT Post procedure


20000


Surgical Procedures

Trans oral surgery Inv - CT Post procedure


25000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Surgical Procedures

Combined trans oral surgery and CV Junction

fusion Inv - MRI,X-Ray cerv ical spine Post


30000


Surgical Procedures

C.V. Junction fusion Inv - MRI,X-Ray cerv ical

spine Post procedure evidence of Clinical

photograph

20000

485 Neurosurgery Brain Endoscopy procedures Inv - MRI Post procedure

evidence of Endoscopy picture

65000

486 Neurosurgery Brain De-compressive Cran iotomy(Non Traumatic) Inv

- Post procedure evidence of Clin ical photograph

50000

487 Neurosurgery Brain Intra-Cerebral Hematoma evacuation Inv - MRI


60000

488 Neurosurgery Brain Endoscopic Third Ventriculostomy - Post


30000

489 Neurosurgery Spine Anterior discectomy & bone grafting Inv - MRI

Post procedure evidence of X-Ray

40000

490 Neurosurgery Spine Discectomy with Implants Inv -MRI Post


65000

491 Neurosurgery Spine Corpectomy for Spinal Fixat ion Inv - MRI Post


70000

492 Neurosurgery Spine Spinal Fixat ion Rods and Plates, Artificial d iscs

Inv -MRI Post procedure evidence of X-Ray

85000

493 Neurosurgery Spine Syringomyelia Inv -MRI Post procedure evidence


65000

494 Neurosurgery - Soft

Tissue and Vascular

Injuries

Repair of Brachial plexus injury Inv - MRI Post


60000


Tissue and Vascular

Injuries

Cerv ical Sympathectomy Inv -EMG,Nerve

conduction MRI Post procedure evidence of


50000


Tissue and Vascular

Injuries

Lumbar sympathectomy Inv - EMG,Nerve

conduction MRI Color doppler Post procedure


50000


Tissue and Vascular

Injuries

Decompression/Excision of Optic nerve lesions

Inv - MRI Post procedure evidence of Clinical

photograph

65000


Tissue and Vascular

Injuries

Peripheral nerve injury repair Inv -EMG,Nerve

conduction Post procedure evidence of Clin ical

photograph

50000


Tissue and Vascular

Injuries

Proptosis Inv - MRI Post procedure evidence of


60000

500 Neurosurgery

Epilepsy Surgery

Temporal Lobectomy Inv - MRI,Video EEG,

Psychologic assessment Post procedure evidence


90000

501 Neurosurgery

Epilepsy Surgery

Lesionectomy type 1 Inv -MRI,Video EEG,



150000

502 Neurosurgery

Epilepsy Surgery

Lesionectomy type 2 Inv -MRI,Video EEG,



150000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

503 Neurosurgery

Epilepsy Surgery

Temporal lobectomy plus Depth Electrodes Inv -

MRI,Video EEG, Psychologic assessment Post


140000

504 Neurosurgery -

Trigeminal Neuralgia

Radiofrequency ablation Inv - EMG,Nerve

conduction Post procedure evidence of Clinical

photograph

30000

505 Neurosurgery -

Trigeminal Neuralgia

Micro vascular decompression Inv -EMG,Nerve

conduction Post procedure evidence of Clinical

photograph

60000

506 Neurosurgery -

Management of

Aneurysms

Embolizat ion Inv - MRI,Angiogram Post


50000

507 Neurosurgery -

Management of

Aneurysms

Cost of each coil Inv - MRI,Angiogram Post


30000

508 Surgical Oncology

Head and neck

Composite resection & Reconstruction Inv -

Clin ical photograph, X-Ray,USG,Biopsy Post


Biopsy

60000


Head and neck

Wide excision Inv - Clin ical photograph, X-

Ray,USG,Biopsy Post procedure evidence of

Clin ical photograph, Biopsy

25000


Head and neck

Nech dissection any type Inv - Clin ical

photograph, X-Ray,USG,Biopsy Post procedure


25000


Head and neck

Hemiglossectomy Inv - Clinical photograph, X-

Ray,USG,Biopsy Post procedure evidence of


15000


Head and neck

Maxillectomy any type Inv -Clinical photograph,

X-Ray,USG,Biopsy Post procedure evidence of


25000


Head and neck

Thyroidectomy any type Inv - Clinical



20000


Head and neck

Parotidectomy any type Inv - Clin ical photograph,



20000


Head and neck

Laryngectomy any type Inv - Clin ical photograph,



40000


Head and neck

Laryngo pharyngo oesophagectomy Inv - Clin ical



75000


Head and neck

Hemimandibulectomy Inv - Clinical photograph,



25000


Ca.Eye/ Maxilla

/Para Nasal Sinus

Orbital exenteration Inv - CT Post procedure


25000


Ca.Eye/ Maxilla

/Para Nasal Sinus

Maxillectomy + Orbital exenteration Inv - CT Post


Biopsy

35000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Ca.Eye/ Maxilla

/Para Nasal Sinus

Maxillectomy + In fratemporal Fossa clearance Inv


photograph, Biopsy

40000


Ca.Eye/ Maxilla

/Para Nasal Sinus

Cran io Facial Resection Inv - CT,MRI Post


Biopsy

70000


Nasopharynx

Resection of Nasopharyngeal Tumour Inv -

CT,MRI Post procedure evidence of Clin ical

photograph, Biopsy

50000


Ca.Soft Palate

Palatectomy Any type Inv - CT Post procedure


30000


Ca.ear

Sleeve Resection Inv - CT Post procedure


25000


Ca.ear

Lateral Temporal bone resection Inv - CT,MRI


Biopsy

30000


Ca.ear

Subtotal Temporal bone resection Inv - CT,MRI


Biopsy

50000


Ca.ear

Total Temporal bone resection Inv - CT,MRI Post


Biopsy

60000

528 Surgical Oncology Submandibular Gland Excision Inv - Clinical

photograph, FNAC Post procedure evidence of


20000


Ca.Thyroid

Tracheal Resection Inv - CT,Brochscopy Post


Biopsy

52000


Ca Trachea

Sternotomy + Superior Mediastinal Dissection Inv


photograph, Biopsy

45000


Ca Trachea

Tracheal Resection Inv - CT,Brochoscopy Post


Biopsy

40000


Ca Parathyroid

Parathyroidectomy Inv - CT,Nuclear scan, S.PTH


Biopsy

30000


Ca GIT

Small bowel resection Inv - CT,Barium follow

through Post procedure evidence of Clin ical

photograph, Biopsy

40000


Ca GIT

Closure of Ileostomy Inv - Colonoscopy Post


20000


Ca GIT

Closure of Colostomy Inv -Colonoscopy Post


20000


Ca Rectum

Abdomino Perineal Resection (APR) +

Sacrectomy Inv - CT,BMFT,Colonoscopy,Biopsy


Biopsy

50000


Ca Rectum

Posterior Exenteration Inv -

CT,BMFT,Colonoscopy,Biopsy Post procedure


50000


Ca Rectum

Total Exenteration Inv -

CT,BMFT,Colonoscopy,Biopsy Post procedure


75000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Ca GIT

Oesophagectomy any type Inv -

USG,CTBiopsy,Endoscopy Post procedure

evidence of Clin ical photograph, Biopsy/USG

60000


Ca GIT

Gastrectomy any type Inv -



40000


Ca GIT

Colectomy any type Inv -



40000


Ca GIT

Anterior resection Inv -



50000


Ca GIT

Abdominoperineal resection Inv -



40000


Ca GIT

Whipples any type Inv -



75000


Ca GIT

Tripple bypass Inv -USG,CTBiopsy,Endoscopy


Biopsy/USG

25000


Ca GIT

Other Bypasses-Pancreas Inv -



25000


Ca Gall Bladder

Radical Cholecystectomy Inv -CT Post procedure


60000


Ca Spleen

Splenectomy Inv - CT Post procedure evidence of


35000


Ca Retroperitoneal

Tumors

Resection of Retroperitoneal Tumours Inv -

CT,FNAC Post procedure evidence of Clinical

photograph, Biopsy

45000


Ca Abdominal wall

tumour

Abdominal wall tumour Resection Inv -

CT,FNAC Post procedure evidence of Clinical

photograph, Biopsy

35000


Ca Abdominal wall

tumour

Resection with reconstruction Inv - CT,FNAC


Biopsy

45000


Gynec

Bilateral pelvic lymph Node Dissection(BPLND)

Inv - CT Post procedure evidence of Clinical

photograph, Biopsy

25000


Gynec

Radical Trachelectomy Inv - CT Post procedure


40000


Gynec

Radical vaginectomy Inv - CT,Biopsy Post


Biopsy

40000


Gynec

Radical vaginectomy + Reconstruction Inv -

CT,Biopsy Post procedure evidence of Clinical

photograph, Biopsy

45000


Ca Cerv ix

Radical Hysterectomy +Bilateral Pelvic Lymph

Node Dissection (BPLND) + Bilateral Salpingo

Ophorectomy (BSO) / Ovarian transposition Inv -

PAP Smear, Biopsy, CT Post procedure evidence

of Clinical photograph, Biopsy

45000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Ca Cerv ix

Anterior Exenteration Inv - PAP Smear, Biopsy,


photograph, Biopsy

60000


Ca Cerv ix

Posterior Exenteration Inv -PAP Smear, Biopsy,

CT Post procedure evidence of Clin ical

photograph, Biopsy

50000


Ca Cerv ix

Total Pelvic Exenteration Inv - PAP Smear,

Biopsy, CT Post procedure evidence of Clin ical

photograph, Biopsy

75000


Ca Cerv ix

Supra Levator Exenteration Inv -PAP Smear,

Biopsy, CT Post procedure evidence of Clinical

photograph, Biopsy

70000


Ca Endometrium

Total Abdominal Hysterectomy(TAH) + Bilateral

Salpingo ophorectomy (BSO) + Bilateral pelvic

lymph Node Dissection (BPLND) + Omentectomy

Inv - Endometrial Biopsy, CT Post procedure


35000


Soft tissue /Bone

tumours . Chest wall

Chest wall resection Inv - CT Chest, Bone scan


Biopsy

20000


Soft tissue /Bone

tumours . Chest wall

Chest wall resection + Reconstruction Inv - CT

Chest, Bone scan Post procedure evidence of


30000


Limb Salvage

Surgery

Without prosthesis Inv - CT Local part, CT Chest,

MRI, Bone scan Post procedure evidence of


40000


Limb Salvage

Surgery

With Custom made Prosthesis Inv - CT Local part,

CT Chest, MRI, Bone scan Post procedure


50000


Limb Salvage

Surgery

With Modular Prosthesis Inv - CT Local part, CT

Chest, MRI, Bone scan Post procedure evidence

of Clinical photograph, Biopsy

75000


Limb Salvage

Surgery

Forequarter amputation Inv - CT Chest Post


Biopsy

40000


Limb Salvage

Surgery

Hemipelvectomy Inv - CT,MRI Pelvis, CT Chest


photograph/X-Ray Biopsy

55000


Limb Salvage

Surgery

Internal hemipelvectomy Inv - CT,MRI Pelvis, CT

Chest Post procedure evidence of Clin ical


65000


Limb Salvage

Surgery

Curettage & bone cement Inv - CT,MRI Post


Biopsy

30000


Limb Salvage

Surgery

Bone resection Inv - CT,MRI Post procedure

evidence of Clin ical photograph/X-Ray Biopsy

30000


Limb Salvage

Surgery

Shoulder gird le resection Inv - CT,MRI,Bone scan



40000


Limb Salvage

Surgery

Sacral resection Inv - CT,MRI Post procedure

evidence of Clin ical photograph/X-Ray Biopsy

60000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Genitourinary

Partial Nephrectomy Inv - CT,Isotope renogram


Biopsy

55000


Genitourinary

Nephroureterectomy for Transitional Cell

Carcinima of renal pelvis Inv - CT Post procedure


50000


Genitourinary

Radical nephrectomy Inv -

USG,KUB,IVP,CT,Biopsy Post procedure


40000


Genitourinary

Emasculation Inv - USG,,Biopsy Post procedure


30000


Genitourinary

Radical cystectomy Inv -



60000


Genitourinary

Other cystectomies Inv -



40000


Genitourinary

Total penectomy Inv -Clin ical Photograph Post


Biopsy/USG

25000


Genitourinary

Partial penectomy Inv - Clin ical Photograph Post


Biopsy/USG

15000


Genitourinary

Inguinal block dissection one side Inv - Clinical

Photograph Biopsy Post procedure evidence of

Clin ical photograph, Biopsy/USG

15000


Genitourinary

Radical prostatectomy Inv - USG,KUB,CT Post


Biopsy/USG

60000


Genitourinary

High orchidectomy Inv - USG,Biopsy Post


Biopsy/USG

15000


Genitourinary

Bilateral orch idectomy Inv - USG,Biopsy Post


Biopsy/USG

10000


Testis Cancer

Retro Peritoneal Lymph Node

Dissection(RPLND) (for Residual Disease) Inv -

CT Chest, CT Abdomen pelvis, Tumour markers


photograph,biopsy

60000


Testis Cancer

Adrenalectomy Inv - CT,MRI,Urinary hormones


photograph,biopsy

45000


Testis Cancer

Urinary diversion Inv - Post procedure evidence of

Clin ical photograph,biopsy

40000


Testis Cancer

Retro Peritoneal Lymph Node Dissection RPLND

as part of staging Inv - CT Post procedure

evidence of Clin ical photograph,biopsy

20000


Ca Urinary Bladder

Anterior Exenteration Inv - Cystoscopy, Biopsy,


photograph, Biopsy

60000


Ca Urinary Bladder

Total Exenteration Inv - Cystoscopy, Biopsy, CT


Biopsy

75000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Ca Urinary Bladder

Bilateral pelvic lymph Node Dissection(BPLND)

Inv - CT Post procedure evidence of Clinical

photograph, Biopsy

20000


Thorax, Mediastinum

Mediastinal tumour resection Inv - CT Post


Biopsy

50000


Lung

Lung metastatectomy . Solitary Inv - CT Post

procedure evidence of X-Ray , Biopsy

50000


Lung

Lung metastatectomy . Mult iple Inv - CT Post


60000


Lung

Sleeve resection of Lung cancer.Inv - CT Post


90000


Oesophagus

Oesophagectomy with Two field

Lymphadenectomy Inv - UGI, Endoscopy,


photograph, Biopsy

90000


Oesophagus

Oesophagectomy with Three field

Lymphadenectomy Inv - UGI, Endoscopy,


photograph, Biopsy

100000


Palliat ive Surgeries

Tracheostomy Inv - Clinical Photograph Post


5000



Substernal bypass Inv - Clinical Photograph Post


Biopsy

35000



Gastrostomy Inv - Clinical Photograph Post


20000



Jejunostomy Inv - Clinical Photograph Post


20000



Ileostomy Inv - Clinical Photograph Post


20000



Colostomy Inv - Clinical Photograph Post


20000



Suprapubic Cystostomy Inv - Clin ical Photograph


10000



Intercostal Drainage(ICD) Inv - Clinical


photograph

3000



Gastro Jejunostomy Inv - Clinical Photograph Post


Biopsy

35000



Ileotransverse Colostomy Inv - Clin ical


photograph, Biopsy

50000


Reconstruction

Myocutaneous / cutaneous flap Inv -Clinical


photograph

25000


Reconstruction

Micro vascular reconstruction Inv - Clinical


photograph

45000


Gynecology

Hysterectomy Inv - USG/CT, Biopsy /Endoscopy


photograph,Biopsy/USG

25000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Gynecology

Radical Hysterectomy Inv - USG/CT /Endoscopy,



30000


Gynecology

Surgery for ca Ovary early stage Inv - USG/CT

/Endoscopy, Biopsy Post procedure evidence of

Clin ical photograph,Biopsy/USG

25000


Gynecology

Surgery for ca Ovary Advance stage Inv -

USG/CT /Endoscopy, Biopsy Post procedure

evidence of Clin ical photograph,Biopsy/USG

40000


Gynecology

Vulvectomy Inv - USG/CT /Endoscopy, Biopsy



15000


Gynecology

Salpino oophorectomy Inv - USG/CT /Endoscopy,



25000


Breast

Mastectomy any type Inv - Clin ical photograph,

Mammography, Biopsy Post procedure evidence

of Clinical photograph,Biopsy

25000


Breast

Axillary dissection Inv - Clinical photograph,


photograph,Biopsy

15000


Breast

Wide excision Inv - Clin ical photograph, Biopsy


photograph,Biopsy

5000


Breast

Lumpectomy Inv - Clinical photograph, Biopsy


photograph,Biopsy

3000


Breast

Breast reconstruction Inv - Clin ical photograph,


photograph,Biopsy

25000


Breast

Chest wall resection Inv -Clin ical photograph,


photograph,Biopsy

20000


Skin Tumours

Skin tumours wide excision Inv - Clinical

photograph, Biopsy Post procedure evidence of


10000


Skin Tumours

Skin tumours wide excision + Reconstruction Inv

- Clinical photograph, Biopsy Post procedure


20000


Skin Tumours

Skin tumours amputation Inv - Clin ical



20000


Soft tissue /Bone

tumours .

Wide excision Inv - Clinical photograph, Biopsy


photograph,Biopsy

15000


Soft tissue /Bone

tumours .

Wide excision + reconstruction Inv -Clinical



25000


Soft tissue /Bone

tumours .

Amputation Inv - Clinical photograph, Biopsy


photograph,Biopsy

20000


Lung

Lung cancer pnumenectomy Inv - X-

Ray/CT,Biopsy Post procedure evidence of

Clin ical photograph,Biopsy/X-Ray

50000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Lung

Lung cancer Lobectomy Inv - X-Ray/CT,Biopsy


photograph,Biopsy/X-Ray

50000


Lung

Lung Cancer Decort ication Inv - X-

Ray/CT,Biopsy Post procedure evidence of

Clin ical photograph,Biopsy/X-Ray

50000


bronchoplural fistula

Surgical correct ion of bronchoplural fistula

Thoracoplasty Inv - X-Ray/CT,Biopsy Post



50000



Surgical correct ion of bronchoplural fistula .

Myoplasty Inv -X-Ray/CT,Biopsy Post procedure

evidence of Clin ical photograph,Biopsy/X-Ray

50000



Surgical correct ion of bronchoplural fistula Trans

plural BPF closure Inv - X-Ray/CT,Biopsy Post



50000


Oral cavity

Marginal Mandibulectomy Inv - Orthopantogram


photograph,Biopsy

25000


Oral cavity

Segmental Mandibulectomy Inv -

Orthopantogram/CT Post procedure evidence of


25000


Oral cavity

Total glossectomy + Reconstruction Inv -

CT,Biopsy Post procedure evidence of Clinical

photograph,Biopsy

40000


Oral cavity

Full thickness Buccal mucosal resection &

Reconstruction Inv - Biopsy Post procedure

evidence of Clin ical photograph,Biopsy

50000

639 Medical Oncology

Breast

Adriamycin/Cyclophosphamide (AC) Inv -

Clin ical photograph, Mammography, Biopsy Post


3000


Breast

5- Flurouracil A-C (FAC) Inv - Clinical

photograph, Mammography, Biopsy Post


3100


Breast

AC (AC Then T) Inv - Clinical photograph,



3000


Breast

Paclitaxel Inv - Clin ical photograph,



9500


Breast

Cyclophosphamide / Methotraxate / 5Flurouracil

(CMF) Inv - Clinical photograph, Mammography,


photograph

1500


Breast

Tamoxifen Tabs Inv - Clin ical photograph,



85 per

month


Breast

Aromatase inhibitors Inv - Clinical photograph,



835 per

month


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Urinary Bladder

Bladder cancer weekly Cisplastin Inv -

USG,Biosy Post procedure evidence of Clinical

photograph

2000


Urinary Bladder

Methotraxate Vinblastin Adriamycin

Cyclophosphamide (MVAC) Inv -USG/CT,Biosy


5000


Non small cell Lung

cancer

Cisplastin/Etoposide (IIIB) Inv - X-Ray/CT

Scan,Biopsy Post procedure evidence of Clinical

photograph

7000

649 Medical

OncologyOesophagu

s

Cisplastin- 5FU Inv - Endoscopy/CT Scan, Biopsy


5000


Stomach

5-FU Leucovorin (MCDONALD Regimen) Inv -

Endoscopy/CT Scan, Biopsy Post procedure


5000


Colon Rectum

Monthly 5-FU Inv - Endoscopy/CT Scan, Biopsy


4000


Colon Rectum

5- Flurouracil-Oxaliplastin Leucovorin (Fo lfox)

(Stage III only) Inv - Endoscopy/CT Scan, Biopsy


10000


Bone

tumors/Osteosarcom

a

Cisplastin/Adriamycin Inv - X-Ray/CT Scan,


photograph

20000


Lumphoma,

Hoggkin's

Adriamycin Bleomycin Vinblastin Dacarbazine

(ABVD) Inv - Biopsy Post procedure evidence of


4000


Lumphoma NHL

Cyclophosphamide Adriamycin Vincristin

Prdnisone (CHOP) Inv - Biopsy Post procedure


3500


Multiple Myeloma

Vincristin, Adriamycin,Dexamethasone (VAD)

Inv - Hematology Post procedure evidence of


4000


Multiple Myeloma

Thalidomide+Dexamethasone(oral) Inv -

Hematology Post procedure evidence of Clinical

photograph

3000


Multiple Myeloma

Melphalan Prednisone oral Inv - Hematology Post


1500


Wilm's Tumor

SIOP/NWTS Regimen (Stages I III) Inv -

USG/CT,Biopsy Post procedure evidence of


7000 per

month


Hepatoblastoma -

Operable

Cisplastin Adriamycin Inv - USG/CT,Biopsy Post


15000


Cerv ix

Cerv ical cancer weekly Cisplastin Inv -

USG,Biopsy Post procedure evidence of Clinical

photograph

2000


Childhood B-Cell

Lymphomas

Variabe regimen Inv - Hematology Post procedure


up to

12000


Neuroblastoma Stage

I –III

Variabe reg imen Inv - CT,Biopsy Post procedure


up to

10000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Retinoblastoma

Carbo/Etoposide/Vincristin Inv - Biopsy Post


4000


Histocytosis

Variabe reg imen Inv - Hematology, Biopsy Post


up to

8000 pm


Rhabdomyosarcoma

Vincristin-Actinomycin-Cyclophosphamide

(VACTC) Based chemo Inv -Biopsy Post


9000 per

month


Ewing's Sarcoma

Variabe regimen Inv - X-Ray/CT Scan, Biopsy


up to

9000 per

month


Acute Myeloid

Leukemia

Induction phase Inv - Hematology Post procedure


up to

60000


Acute Myeloid

Leukemia

Comsolidation phase Inv - Hematology Post


up to

40000


Acute Myeloid

Leukemia

Maintenance phase Inv - Hematology Post


3000 per

month


Acute Lymphatic

Leukemia

Induction 1st and 2 nd months Inv - Hematology


up to

50000


Acute Lymphatic

Leukemia

Induction 3RD, 4TH, 5TH Inv - Hematology Post


up to

20000


Acute Lymphatic

Leukemia

Maintenance phase Inv - Hematology Post


3000 per

month


For Unlisted regimen

Palliat ive Chemotherapy Inv - USG/CT,Biopsy


up to

5000per

cycle


Terminally ill

Palliat ive and supportive therapy Inv -



3000 per

month


Vulval cancer

Cisplastin/5-FU Inv - Clinical Photograph, Biopsy


5000


Colo Rectal Cancer

Stage 2 and 3

XELOX along with Adjuvant chemotherapy of

AS-I Inv - CT Abdomen,pelvis, Tissue biopsy,

photograph Post procedure evidence of

USG/CT/Biopsy/Biochemical investigations

4000


Multiple Myeloma

Zoledronic acid along with Adjuvant

Chemotherapy of AS-I Inv - SIEP,Urine fo r Bence

Jones protein, Skeltal survey, Bone marrow

aspiration, Biopsy, S. Electrolytes, 2D ECHO Post

procedure evidence of


3000


Febrile Neutropenia

FN High Risk 1

1ST Line iv antibiot ics And other supportive

therapy ( third generation cephalosporin,

aminoglycoside etc.,) Inv - Blood C.S. Urine C.S.,

Chest X-Ray, Tissue biopsy Post procedure

evidence of USG/CT/Biopsy/Biochemical

investigations

9000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Febrile Neutropenia

FN High Risk 2

2nd line iv antib iotics and other supportive

therapy(Carbapenems, Fourth generation

cephalosporins, Piperacillin, anti-fungal . azo les

etc.,) Inv - Blood C.S. Urine C.S., Chest X-Ray,

Tissue biopsy Post procedure evidence of


30000


Vaginal cancer

Cisplastin/5-FU Inv - Clinical photograph, Biopsy


5000


Ovary

Carboplastin/ Paclitaxel Inv - USG/CT,Biopsy


10500


Ovary Germ Cell

Tumour

Bleomycin-Etoposide-Cisplastin (BEP) Inv -



8000


Gestational

Trophoblast Ds. Low

Risk

Weekly Methotrexate Inv - USG/CT,Biopsy Post


600


Gestational

Trophoblast Ds. Low

Risk

Actinomycin Inv - USG/CT,Biopsy Post


3000


Gestational

Trophoblast High

Risk

Etoposide - Methotrexate -Actinomycin /

Cyclophosphamide Avincristine (EMA-CO) Inv -



6000


Testis

Bleomycin-Etoposide-Cisplastin (BEP) Inv -

USG,Biosy Post procedure evidence of Clinical

photograph

8000


Prostate

Hormonal Therapy Inv - USG,Biosy Post


3000 per

month

689 Radit ion Oncology

Cobalt 60 External

Beam Radiotherapy

Radical Treatment Inv - USG/CT/X-Ray,Biopy


photograph,RT Treatment charts

20000


Cobalt60 External

Beam Radiotherapy

Palliat ive Treatment Inv - USG/CT/X-Ray,Biopy



10000


Cobalt 60 External

Beam Radiotherapy

Adjuvant Treatment Inv -USG/CT/X-Ray,Biopy



15000


External Beam

Radiotherapy (On

Linear Acclerator)

Radical Treatment with photons Inv - USG/CT/X-

Ray,Biopy Post procedure evidence of Clin ical


50000


External Beam

Radiotherapy (On

Linear Acclerator)

Palliat ive Treatment with photons Inv -

USG/CT/X-Ray,Biopy Post procedure evidence

of Clinical photograph,RT Treatment charts

20000


External Beam

Radiotherapy (On

Linear Acclerator)

Adjuvant Treatment with photons/Electrons Inv -

USG/CT/X-Ray,Biopy Post procedure evidence of

Clin ical photograph,RT Treatment charts

35000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Brachytherapy

Intracavity

A) Intracavitary I. LDR per application Inv -


4500


Brachytherapy

Intracavity

A) Intracavitary II. HDR per applicat ion Inv -


2500

697 Radiat ion Oncology

Brachytherapy

Interstitial

B) Interstitial I. LDR per applicat ion Inv -


15000


Brachytherapy

Interstitial

B) Interstitial II. HDR one application and

multip le dose fractions Inv -USG/CT/X-

Ray,Biopy Post procedure evidence of Clin ical

photograph, RT Treatment charts

25000


Specialized

Radiat ion Therapy -

IMRT (Intensity

modulated

radiotherapy)

Up to 40 fractions in 8 weeks Inv - CT with

contrast, Biopsy, MRI Post procedure evidence of

USG/CT/Tumour marker/RT Treatment charts

100000


S Specialized


3DCRT(3-D

conformat ional

radiotherapy)

Up to 30 fractions in 6 weeks Inv -CT with



75000


Specialized


SRS/SRT




75000


Specialized

Radiat ion Therapy

Rapid Ax therapy




150000


Specialized


IMRT With IGRT




150000

704 Plastic Surgery Cleft lip Inv - Clinical Phoptograph Post

procedure evidence of Clin ical Phoptograph

10000

705 Plastic Surgery Cleft Palate Inv - Clin ical Phoptograph Post


15000

706 Plastic Surgery Velo-Pharyngial Incompetence Inv - Endoscopy

Post procedure evidence of Clin ical Phoptograph

15000

707 Plastic Surgery Syndactyly of Hand for each hand Inv - Clin ical

Phoptograph Post procedure evidence of Clinical

Phoptograph

15000

708 Plastic Surgery Microtia/Anotia Inv - Clin ical Phoptograph Post


30000

709 Plastic Surgery TM joint ankylosis Inv - Clinical Phoptograph, X-


Phoptograph

40000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

710 Burns 30% to 50% Up to -40% With scalds ( conservative) Inv -


Clin ical Phoptograph

35000

711 Burns 30% to 50% Upto-40% Mixed Burns( With surgeries) Inv -

Clin ical Phoptograph Post procedure evidence of


50000

712 Burns 30% to 50% Upto-50% with scalds(Conservative) Inv -



60000

713 Burns 30% to 50% Up to -50% Mixed Burns( With surgeries) Inv -



70000

714 Burns Above 50% Up to -60% With scalds ( conservative) Inv -



80000

715 Burns Above 50% Up to -60% Mixed Burns( With surgeries) Inv -



100000

716 Burns Above 50% ABOVE 60% Mixed Burns( With surgeries) Inv -



120000

717 Burns Post Burn

contracture surgeries

for functional

improvement

(Package including

splints pressure

garments and

Physiotherapy)

Mild Inv - Clin ical Phoptograph Post procedure

evidence of Clin ical Phoptograph

20000

718 Burns Post Burn


for functional

improvement

(Package including

splints pressure

garments and

Physiotherapy)

Moderate Inv -Clin ical Phoptograph Post


30000

719 Burns Post Burn


for functional

improvement

(Package including

splints pressure

garments and

Physiotherapy)

Severe Inv - Clinical Phoptograph Post procedure


40000

720 Plastic Surgery Hemifacial Microsmia Inv - 3 D CT, MRI Post


50000

721 Plastic Surgery Leprosy reconstructive surgery Inv - Nerve

conduction study Post procedure evidence of


20000

722 Plastic Surgery Nerve and tendon repair + Vascular repair Inv -

Nerve conduction study, CT Scan Post procedure


30000

723 Plastic Surgery Ptosis Inv -Clinical photograph Post procedure


25000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

724 Plastic Surgery Tumour of mandible and maxilla Inv -

CT/MRI/HPE/Biopsy Post procedure evidence of


40000

725 Plastic Surgery Vaginal atresia Inv - USG Abdomen Post


25000

726 Plastic Surgery Vascular malformations Inv - Angiogram Post


25000

727 Plastic Surgery Correct ive Surgery for Congenital deformity of

hand (per hand) Inv - X-Ray/CT Scan Post


15000

728 Plastic Surgery Correct ive Surgery for Cran iosynostosis Inv - 3D

CT/MRI Post procedure evidence of Clinical

Phoptograph

50000

729 Plastic Surgery Cup and Bat ears Inv - Clinical photograph Post


20000

730 Plastic Surgery Flap cover fo r Electrical burns with vitals exposed

Inv - Clin ical photograph Post procedure evidence

of Clinical Phoptograph

50000

731 Plastic Surgery Reduction surgery for Filarial lymphedema Inv -

Clin ical photograph Post procedure evidence of


20000

732 Plastic Surgery Hemifacial atrophy Inv - 3 D CT, MRI Post


30000

733 Polytrauma

Orthpedic Trauma

Open Reduction and internal fixation of long bone

fractures Inv - X-Ray Post procedure evidence of

X-Ray

15000

734 Polytrauma

Orthpedic Trauma

Amputation Surgery Inv - X-Ray Post procedure


5000

735 Polytrauma

Orthpedic Trauma

Soft tissue injury Inv - Clinical photograph Post


5000

736 Polytrauma

Neurosurgical

trauma consertative

Stay in general ward @RS.500/ Day Inv - X-

Ray/CT Post procedure evidence of Clinical

Phoptograph

6000

737 Polytrauma

Neurosurgical

trauma consertative

Stay in NEURO [email protected]/DAY Inv - X-

Ray/CT Post procedure evidence of Clinical

Phoptograph

28000

738 Polytrauma

Neurosurgical

trauma

Surgical treatment (Up to) Inv - X-Ray/CT Post


150000

739 Polytrauma Chest

consertative

treatment

Chest injuries Conservative stay in General ward

@RS.500/Day Inv -X-Ray/CT Post procedure


3000

740 Polytrauma Chest

consertative

treatment

Stay in Respiratory ICU [email protected]/Day Inv -

X-Ray/CT Post procedure evidence of Clin ical

Phoptograph

20000

741 Polytrauma Chest Surgical treatment Inv - X-Ray/CT Post procedure

evidence of X-Ray

50000

742 Polytrauma

Abdomen

consertative

treatment

Abdominal inju ries Conservative stay in General

ward @RS.500/DAY Inv - X-Ray/USG/CT Post


3000

743 Polytrauma

Abdomen

consertative

treatment

Stay in Surg ical [email protected]/DAY Inv - X-

Ray/USG/CT Post procedure evidence of USG

7000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

744 Polytrauma

Abdomen

Abdominal inju ries surgical treatment Inv - X-

Ray/USG/CT Post procedure evidence of

USG/Clinical photograph

75000

745 Polytrauma

Emergency room

procedures

Tracheostomy Inv - Clinical photograph Post


3000

746 Polytrauma

Emergency room

procedures

Thoracostomy Inv - Clinical photograph Post


3000

747 Orthopedic and facial

trauma wound

management for

compound fractures

Grade I& II Inv - Clin ical photograph,X-Ray Post


10000


trauma wound

management for

compound fractures

Grade -III Inv -Clinical photograph,X-Ray Post


20000


trauma wound

management for

compound fractures

Flap cover surgery for wound in compound

fracture Inv - Clinical photograph,X-Ray Post


20000


trauma other s mall

bone fractures-K-

wiring (to be covered

along with other

injuries only and not

as exclusive

procedure)

Surgery for Patella Fracture (To be covered with

other injuries only and not as exclusive

procedure) Inv -X-Ray Post procedure evidence

of X-Ray

5000


trauma other s mall

bone fractures-K-

wiring (to be covered

along with other

injuries only and not

as exclusive

procedure)

Small bone fractures K-Wiring (To be covered

with other injuries only and not as exclusive

procedure) Inv - X-Ray Post procedure evidence

of X-Ray

5000


trauma Facial

injuries

Facial bone fractures (Faciomaxillary in juries) Inv

-Clinical photograph,X-Ray Post procedure

evidence of Clin ical photograph, X-Ray

15000


trauma Pelv ic bone

fracture

Surgical correct ion of Pelvic Bone fractures. Inv -

X-Ray Post procedure evidence of X-Ray

20000

754 Hearing aid Behind the ear analogue hearing aid. Inv -

Audiometry with post treatment evidence of


10000

755 Prosthesis lower limb

Symes Prostheses

HDP/PP with post treatment evidence of Clin ical

photograph

1000


Symes Prostheses

Fibre with post treatment evidence of Clin ical

photograph

1200


Symes Prostheses

Modular with post treatment evidence of Clinical

photograph

1500

758 Prosthesis Below

Knee(BK/PTB)

Prostheses


photograph

1200


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Knee(BK/PTB)

Prostheses


photograph

1500


Knee(BK/PTB)

Prostheses


photograph

3000

761 Prosthesis Through

Knee Prostheses


photograph

1500


Knee Prostheses


photograph

1800


Knee Prostheses


photograph

3500

764 Prosthesis Above

Knee(AK)

Prostheses


photograph

1500


Knee(AK)

Prostheses


photograph

1800


Knee(AK)

Prostheses


photograph

3500

767 Prosthesis Hip

disarticulation

prosthesis


photograph

2500

768 Prosthesis Hip

disarticulation

prosthesis


photograph

3000

769 Prosthesis Hip

disarticulation

prosthesis


photograph

6000

770 Prosthesis Hip

disarticulation

prosthesis

Partial foot prostheses with post treatment


500

771 Prosthesis Upper

Limb below elbow


photograph

1500


Limb below elbow


photograph

1800


Limb below elbow


photograph

3500


Limb above elbow


photograph

1500


Limb above elbow


photograph

2000


Limb above elbow


photograph

4000


Limb whole upper

limb


photograph

1000


Limb whole upper

limb


photograph

1200


Limb whole upper

limb


photograph

1500


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

Sr

No

Category Disease, stay, Investigations, Post treatment

evidence

Cost Treatment

protocol

780 Critical Care Acute severe asthma with Acute respiratory failure

Inv - ABG , Serum IgE , Spirometry , clinical

photo intubated with ventilator , serum

electrolytes 10 days stay with post treatment

evidence of ABG and other lab investigations

45000 Asthma

Guide lines -

GINA /India,

Ventilatory

Care

781 Critical Care COPD Respiratory Failure (infective

exacerbation) Inv - Blood gases , HRCT Chest ,

ventilator when necessary, clinical photograph,

spirometry, serum electrolytes, 2 D Echo 14 days

stay with post treatment evidence of ABG and

other lab investigations

70000 According to

International

Guide lines,

Ventilatory

Care

782 Critical Care Acute Bronchitis and Pneumonia with Respiratory

failure Inv -clin ical photograph HRCT Chest,

ABG, ventilator 10 days stay with post treatment


50000 IP 10 days,

Inhalers,

LABA,

Ventilatory

Care

783 Critical Care ARDS with ventilatory care Inv - HRCT Chest,

clin ical photograph,ABG 14 days stay with post

treatment evidence of ABG and other lab

investigations

80000 Antimicrobial

s, MICU, O2,

Ventilatory

Care

784 Critical Care ARDS with Mult i Organ failu re with ventilatory

care Inv - HRCT Chest, clinical photograph,ABG,

Sputum CS 14 days stay with post treatment


100000 Antimicrobial

s, MICU, O2,

Ventilatory

Care

785 Critical Care ARDS plus DIC (Blood & Blood products) with

ventilatory care Inv - HRCT Chest, clin ical

photograph,ABG, Sputum CS 14 days stay with

post treatment evidence of ABG and other lab

investigations

120000 Cryo

precipitate,

FFP,

Ventilatory

Care

786 Critical Care OP Poisoning requiring ventilatory assistance

Clin ical photo Inv - Renal chemistry Drug/Poison

level in blood, Blood gases 1 week stay with post

treatment evidence of ABG and other lab

investigations

30000 MICU, O2,

Ventilatory

Care, atropine

787 Critical Care Septic Shock(ICU Management) with ventilatory

assistance Inv - Blood Culture , Blood gases ,

Clin ical photo, Renal Chemistry , USG , Urine

Culture 14 days stay with post treatment evidence

of ABG and other lab investigations

50000 Antimicrobial

s, MICU, O2,

Ventilatory

Care and

other

supportive

measures

788 Critical Care Gen

Medicine

Thrombocytopenia with bleeding d iathesis Inv -

Bone Marrow , Leptospira , PT APTT , Parasite F

/ V , Platelet count , Report and video clip

"online"one week stay with post treatment

evidence of lab investigations

20000 IV fluids,

PRP, SDPIV

- IgIV

antimicrobial

s


Medicine

Haemophilia with Inv - Factor VIII / IX , PT

APTT Report and video clip "online 1 week stay

with post treatment evidence of lab investigations

50000 IV FPP,

Factor VIII /

Cryoprecip ita

te


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Medicine

Other Coagulation disorders with Von willi brands

factor, 1 week stay with with post treatment


50000 IV FPP,

Factor VIII /

Cryoprecipatt

e


Medicine

Chelat ion Therapy for Thalassemia serum Inv -

Ferritin , Heamatocrit , Heamogram , Peripheral

Smear , S.Iron , 5 days stay with post treatment


20000 Chelat ion

Therapy


Medicine

Cerebral Malaria (Falciparum) Inv - CSF

Analysis , Parasite F Test and QBC, 7 days stay

with post treatment evidence of clin ical and lab

investigations

20000 Blood and

Platelet

Transfusion,

IV

antibiotics,

IV fluids,

Mefloquine,

IV quin ine or

IV artesunate,

Paracetamol,

Ventilat iory

Support


Medicine

TB meningit is Inv - ABG , CT Scan Brain CSF

ADA Analysis, 2 weeks stay with post treatment


30000 Anticonvulsa

nts

(Midazolam

or

Lorazepam,

Phenobarbito

ne or

Phenytoin),

Antitubercula

r therapy, IV

Mannitol, IV

antibiotics,

IV

dexamethaso

ne and oral

steroids, IV

flu ids,

Mechanical

Ventilatory

support, Naso

gastric feeds,

Paracetamol


Medicine

Snake bite requiring ventilator support Inv - 8

hourly ABG seven days , CT Scan brain, Blood

sugar 4 hourly 2 weeks stay with post treatment


50000 Antisnake

Venom, IV

flu ids,

Inj.Antibiotic

s ,

Inotropes(Do

butamine,

Dopamine,

Adrenaline,

Noradrenalin

e),

Mechanical

Ventilat ion,

oxygen


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Medicine

Scorpion Sting requiring ventilator support Inv -

Eight hourly ABG for 7days,Blood sugar 8 hourly

ECH, ECG, CVP Monitoring 2 weeks stay with

post treatment evidence of lab investigations

25000 Antiscorption

Venom, IV

flu ids,

Antibiotics,

prazocin,

Mechanical

Ventilat ion,

Oxygen and

other

treatment

such as SNP

drip etc.


Medicine

Metabolic Coma requiring Ventilatory Support

Inv - ABG , Arterial Blood Pressure , Blood Sugar

, Blood Urea , CVP monitoring , ECG , Echo ,

S.Creatin inine , Thyroid Profile, 2 weeks stay


30000 Inotropes IV

antibiotics,

IV fluids,

Inj.Midazo la

m in fusion,

Mechanical

Ventilat ion,

Oxygen,

Sodium

Nitroprusside

797 Infectious diseases Tetanus severe Inv - ABG, swab for culture

sensitivity 3 weeks stay with post treatment

evidence of clinical photograph

20000 Medical,

Ventilator,

tracheostomy

798 Infectious diseases Diphtheria Complicated Inv - ECG-5 times ,

Throat swab for c/s-3 times , Urine for ketone

bodies clinical photograph 4 weeks stay with post

treatment evidence of and lab investigations

25000 Medical,

Tracheostom

y, ventilator

799 Infectious diseases Cryptococcal Meningitis Inv - investigation of

cryprococcal antigen, treatment of 2 weeks stay


20000 Amphotericin

B

+Fluconazole

800 Paediatrics Neonatal Term baby with culture positive sepsis - Non

ventilated Hyperbilirub inemia Inv - Blood culture,

CRP, Serum bilirubin, CSF Analys is, 14 days stay

with post treatment evidence of clinical

improvement and lab investigations

25000 25 %

dextrose,

Calcium

gluconate,

Fluconazole,

IV antib iotics

-Meropenem ,

Maintenance

IV Fluids -

Isolyte P,

Nasogastric

tube feeds,

Phototherapy,

Tobramycin -

80mg


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

801 Pediatrics Neonatal 30 to 32 weeks preterm Severe Hyaline membrane

disease Clin ical sepsis Patent ductus arteriosus -

Medical management Mechanical ventilat ion

Hyperbilirubinemia Inv - 2D ECHO ,

Neurosonogram , Blood culture, CRP, ABG, 8

weeks stay with post treatment evidence of

clin ical improvement and lab investigations

90000 25 %

dextrose,

Calcium

gluconate,

Dobutamine,

Dopamine,

FFP,

Frusemide,

Heparin, IV

antibiotics

(Meropenem

- ,

Tobramycin -

Fluconazole),

Maintenance

IV Fluids ,

Mechanical

ventilation,

Midazolam,

Nasogastric

tube feeds,

PRBC, FFP,

PRP,

Phototherapy-

Umbilical

venous and

arterial lines,

Supplemental

Oxygen,

Surfactant

therapy -

Neosurf,

Vecuronium

802 Pediatrics Neonatal <30 weeks preterm Severe Hyaline membrane

disease Clin ical/Culture positive sepsis Patent

ductus arteriosus - Medical management

Mechanical ventilation Hyperbilirubinemia Inv -

2D ECHO , Neurosonogram, Blood culture,

CRP, ABG 8 weeks stay with post treatment

evidence of clinical improvement and lab

investigations

90000 25 %

dextrose,

Aminoven,

Calcium

gluconate,

Dobutamine,

Dopamine,

FFP,

Frusemide,

Heparin, IV

antibiotics

(Meropenem,

Tobramycin

,Fluconazo le)

, Maintenance

IV Fluids - ,

Mechanical

ventilation,

Midazolam,

Nasogastric

tube feeds,

Normal

saline, PRBC,


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

PRP, FFP,

Phototherapy-

Umbilical

venous and

arterial lines,

Supplemental

Oxygen 7

days,

Surfactant

therapy -

Neosurf,

Vecuronium

803 Paediatrics Neonatal Term baby with persistent pulmonary

hypertension Ventilation-HFO Hyperbilirubinemia

Clin ical sepsis Inv - 2D ECHO , Neurosonogram ,

Blood culture, CRP, ABG, 6 weeks stay with post

treatment evidence of clin ical improvement and

lab investigations

80000 25 %

dextrose,

Aminoven,

Calcium

gluconate,

Dobutamine,

Dopamine,

FFP,

Frusemide,

Heparin, IV

antibiotics

(Meropenem

- ,

Tobramycin -

Fluconazole),

Maintenance

IV Fluids - ,

Mechanical

ventilation,

Midazolam,

Nasogastric

tube feeds,

Normal

saline, PRBC,

PRP, FFP

Phototherapy-

Umbilical

venous and

arterial lines,

Sodium

bicarbonate,

Supplemental

Oxygen,

Surfactant

therapy -

Neosurf,

Vecuronium


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

804 Paediatrics Neonatal Term baby with severe perinatal asphyxia - Non

ventilated Clin ical sepsis Hyperbilirubinemia Inv -

CSF analysis(LP) , CT-Scan , Neurosonogram

,Blood culture, CRP, X-Ray chest 10 days stay



25000 Supplemental

Oxygen 25 %

dextrose,

Calcium

gluconate, IV

Phenobarbito

ne, IV

Phenytoin, IV

antibiotics

(Piperacillin

Tazobactum,

Tobramycin

),

Maintenance

IV Fluids ,

Midazolam,

Nasogastric

tube feeds,

Normal

saline,

Physiotherap

y,

805 Paediatrics Neonatal Term baby with severe perinatal asphyxia -

Ventilated Clin ical sepsis Hyperbilirubinemia, Inv

- Neurosonogram, CT Scan CSF analysis(LP) ,

ABG, Blood culture, CRP, Serum bilirubin, 3



40000 Supplemental

Oxygen,

Mechanical

ventilation,

25 %

dextrose,

Aminoven,

Calcium

gluconate,

Dobutamine,

Dopamine,

FFP, Heparin,

Aminoven,

IV

Phenobarbito

ne, IV

Phenytoin, IV

antibiotics

(Meropenem,

Tobramycin -

Fluconazole),

Maintenance

IV Fluids -

Midazolam,

Nasogastric

tube feeds,

Calcium

gluconate,

Normal

saline, PRBC,

FFP, PRP,

Physiotherap

y,

Phototherapy-


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

Umbilical

venous and

arterial lines,

Vecuronium

806 Paediatrics Neonatal Term baby Severe hyperbilirubinemia Clinical

sepsis Inv - Serum bilirubin, Blood culture, CRP,

X-Ray chest, CSF Analysis, 10 days stay with

post treatment evidence of clinical improvement

and lab investigations

25000 Double

volume

exchange

transfusion,

Double

surface

Phototherapy,

IV antib iotics

(Piperacillin

Tazobactum,

Tobramycin -

)Maintenance

IV Fluids, 25

% dextrose,

Calcium

gluconate,

Nasogastric

tube feeds,

Whole blood,

807 Paediatrics Neonatal Term baby with seizures ventilated Inv -

Neurosonogram, CT-Scan brain, Ultrasound

abdomen, CSF analysis , Blood ammonia ,

Lactate, Metabolilc screening-blood and urine

ABG , Blood culture, 10 days stay with post


lab investigations

25000 Supplemental

Oxygen, IV

antibiotics

(Meropenem

Tobramycin,

Fluconazole),

Maintenance

IV Fluids , 25

% dextrose,

Calcium

gluconate,

Nasogastric

tube feeds, -

Umbilical

venous and

arterial lines,

Aminoven, ,

Dobutamine,

Dopamine,

PRBC, FFP,

PRP,

midazolam,


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

Heparin, IV

Phenobarbito

ne, IV

Phenytoin,

Phototherapy,

Mechanical

ventilation.

808 Paediatrics Neonatal Necrotising enterocolitis, Clin ical sepsis Non

ventilated Hyperbilirub inemia Inv - Blood

culture, Abdomen radiograph and ultrasound ,

LFT , Stool for occult b lood , serum bilirubin, 4



25000 IV antib iotics

(Meropenem

, Tobramycin

Fluconazole),

Maintenance

IV Fluids ,

Metronidazol

e, 25 %

dextrose,

Calcium

gluconate,

Nasogastric

tube feeds,

Albumin,

Aminoven,

Central line,

Heparin,

,Normal

saline,

Phototherapy,

Total

parenteral

nutrition

809 Paediatrics Neonatal Term baby, fu lminant culture positive sepsis,

septic shock, Ventilated, Hyperbilirubinemia

Renal failure, with Inv - Neurosonogram , Ultra

sound of abdomen, 2D ECHO , Abdomen

radiograph, , CSF analysis(LP) ,Blood culture,

ABG, LFT , Stool for occult blood , Renal

function tests, 5 weeks stay with post treatment

evidence of clinical improvement and lab

investigations

40000 Supplemental

Oxygen,

mechanical

ventilation,

IV antib iotics

(Meropenem

, Tobramycin,

Fluconazole),

25 %

dextrose,

Maintenance

IV Fluids ,

Calcium

gluconate,

Nasogastric

tube feeds,

Phototherapy-

Umbilical

venous and

arterial lines,


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

Dobutamine,

Dopamine,

PRBC, PRP,

FFP,

Midazolam,

vecurnium,

Heparin,

Aminoven,

Adrenaline,

Albumin, ,

Frusemide,

Noradrenalin

e, Normal

saline, ,

Peritoneal

dialysis,

Sodium

bicarbonate,

Total

parenteral

nutrition,

810 Paediatrics Neonatal 33 to 34 weeks preterm baby Severe Hyaline

membrane disease Clinical sepsis Bubble CPAP

Hyperbilirubinemia Inv - X-Ray chest, ABG,

Neurosonogram b lood culture, CRP, Serum

bilirubin, 2D ECHO, Neurosonogram, 3 weeks

stay with post treatment evidence of clinical


40000 Supplemental

Oxygen,

CPAP, IV

antibiotics

(Piperacillin

Tazobactum-

1,

Tobramycin

),

Maintenance

IV Fluids , 25

% dextrose,

Aminoven,

Calcium

gluconate,

Heparin,

Midazolam,

Nasogastric

tube feeds,

Phototherapy-

Umbilical

venous and

arterial lines,

811 Paediatrics Neonatal 33 to 34 weeks preterm baby Severe Hyaline

membrane disease with Clinical sepsis,


X-Ray chest, ABG, CRP, Serum bilirubin, Blood

culture, 4 weeks stay with post treatment evidence

of clinical improvement and lab investigations

60000 Supplemental

Oxygen,

Mechanical

ventilation,

25 %

dextrose, IV

antibiotics

(Piperacillin

Tazobactum-

1,

Tobramycin),

Maintenance


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

IV Fluids ,

Calcium

gluconate,

Nasogastric

tube feeds,

Phototherapy-

Umbilical

venous and

arterial lines,

Aminoven,

FFP, Heparin,

Dopamine,

Dobutamine,

Midazolam,

PRBC, FFP,

PRP

812 Paediatrics Neonatal 35 to 36 weeks Preterm Mild Hyaline membrane

disease Culture positive sepsis Nonventilated

Hyperbilirubinemia Inv - X-Ray chest, Blood

culture, CRP, CSF Analysis, Serum bilirubin, 3



35000 Supplemental

Oxygen, 25

% dextrose,

IV antib iotics

-Meropenem ,

Tobramycin,

Fluconazole,

Calcium

gluconate, ,

Maintenance

IV Fluids ,

Nasogastric

tube feeds,

Phototherapy,

813 Paediatrics Neonatal 33 to 34 weeks preterm Mild Hyaline membrane

disease Culture positive sepsis - Nonventilated

Hyperbilirubinemia Inv - Neurosonogram 2D

ECHO , CSF analysis ,Blood culture , CRP,

Serum b ilirubin, X-Ray chest, 4 weeks stay with

post treatment evidence of clinical improvement

and lab investigations

45000 Supplemental

Oxygen, 25

% dextrose,

IV antib iotics

-Meropenem

Tobramycin,

Fluconazole,

Calcium

gluconate,

Maintenance

IV Fluids ,

Nasogastric

tube feeds,

PRBC, PRP,

FFP,

Phototherapy,


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

814 Paediatrics Neonatal 33 to 34 weeks preterm Severe Hyaline membrane

disease Culture positive sepsis Mechanical

ventilation/ Bubble CPAP Hyperbilirubinemia.

Inv - Neurosonogram, 2D ECHO, CSF Analysis,

blood culture, CRP, S.Bilirubin, X-Ray chest,

ABG. 6 weeks stay with post treatment evidence

of clinical improvement and lab investigations

60000

Supplemental

Oxygen,

Mechanical

ventilation,

Surfactant

therapy -

Neosurf, IV

antibiotics -

Meropenem

Tobramycin

Fluconazole,

Maintenance

IV Fluids -

Isolyte P, 25

% dextrose,

Calcium

gluconate,

Nasogastric

tube feeds,

Phototherapy

Umbilical

venous and

arterial lines,

Aminoven,

Dobutamine,

Dopamine,

FFP,

Heparin,

Normal

saline, PRBC,

PRP,

Vecuronium

815 Paediatrics Neonatal 30 to 32 weeks preterm Severe Hyaline membrane

disease Clin ical/ Culture positive sepsis


2D ECHO, Lumbar Puncture CSF analysis ,

Neurosonogram b lood culture, CRP, S. Bilirubin,

X-Ray chest, ABG 8 weeks stay. with post


lab investigations

90000 Supplemental

Oxygen,

Mechanical

ventilation,

Surfactant

therapy -

Neosurf, IV

antibiotics

(Meropenem

Tobramycin -

Fluconazole),

Maintenance

IV Fluids ,25

% dextrose,

Nasogastric

tube feeds,

Phototherapy-

Umbilical

venous and

arterial lines,

Aminoven,

Dobutamine,

Dopamine,


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

FFP, Heparin,

Midazolam,

PRBC, PRP,

Vecuronium

816 Paediatrics Neonatal <30 weeks preterm Severe Hyaline membrane

disease Clin ical/ Culture positive sepsis


2D ECHO , Lumbar Puncture CSF analysis ,

Neurosonogram , b lood culture, CRP,S. Bilirubin,

X-Ray chest, ABG 10 weeks stay, with post


lab investigations

90000 Supplemental

Oxygen,

Mechanical

ventilation,

Surfactant

therapy -

Neosurf, IV

antibiotics

(Meropenem

Tobramycin -

Fluconazole),

IV Fluids - ,

25 %

dextrose,

Nasogastric

tube feeds,

Phototherapy-

Umbilical

venous and

arterial lines,

Aminoven,

Calcium

gluconate,

Dobutamine,

Dopamine,

FFP, Heparin,

Maintenance

Midazolam,

Normal

saline, PRBC,

PRP,

Vecuronium

817 Paediatrics Neonatal 33 to 34 weeks preterm Severe Hyaline Membrane

disease Clin ical/Culture positive sepsis Patent

ductus arteriosus- Medical management

Mechanical ventilation Hyperbilirubinemia, Inv -

2D ECHO , Neurosonogram, blood culture, CRP,

ABG, X-Ray chest Serum bilirubin 6 weeks stay



70000 Supplemental

Oxygen,

Mechanical

ventilation,

Surfactant

therapy -

Neosurf, IV

antibiotics

(Meropenem

Tobramycin -

Fluconazole),


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

IV Fluids - ,

25 %

dextrose,

Nasogastric

tube feeds,

Phototherapy-

Umbilical

venous and

arterial lines,

Aminoven,

Calcium

gluconate,

Dobutamine,

Frusemide,

Dopamine,

FFP, Heparin,

Maintenance

Midazolam,

Normal

saline, PRBC,

PRP,

Vecuronium

818 Pediatric Ic Care

Respiratory

Severe Bronchiolitis (Non Ventilated) Clinical

Photo Inv - ABG OD (ABG -5), X-Ray Chest, 7

days stay

PICU with post treatment evidence of X-Ray and

Pulse

Oxymetry/ABG

15000 Oxygen, I.V

flu ids, Inj.

Ceftriaxone,

Inj.

Hydrocortiso

ne,

Salbutamol,

Budesonide,

nebulisations.


Respiratory

Severe Bronchiolitis

(Ventilated) Inv - CXR ABG 8th hrly

(3/day X 7 days),

Clin ical Photo with 10 days stay

PICU post treatment evidence of X-Ray and

Pulse

Oxymetry/ABG

20000 Oxygen, I.V

flu ids, Inj.

Pipracillin

Tazobactum,

Inj.

Amikacin,

Inj. Methyl

prednisolone,

Salbutamol,

Budesonide,

nebulisations,

Mechanical

Ventilat ion,

Inj.

Midazolam

Infusion


Respiratory

Severe Bronchopneumonia (non Ventilated) Inv -

CXR ABG OD 7 days stay


Pulse

Oxymetry/ABG

15000 Oxygen, I.V

flu ids, Inj.

Ceftriaxone +

Inj.

Amikacin,

Salbutamol,

nebulisations.


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Respiratory

Severe Bronchopneumonia

(Ventilated) Inv - Serial ABG

(3/day X 7 days)

X-Ray Chest

Clin ical Photo 10 days stay in


Pulse

Oxymetry/ABG

30000 Oxygen, IV

flu ids, Inj.

Pipracillin

Tazobactum,

Inj.

Amikacin,

Salbutamol,

nebulisations,

Mechanical

ventilation,

Inj.

Midazolam

Infusion.


Respiratory

Acute Severe Asthma (Ventilated) Inv - Serial

ABG

X-Ray Chest 10 days

PICU stay with post treatment evidence of X-Ray

and

Pulse

Oxymetry/ABG

35000 Oxygen, IV

flu ids, Inj.

Pipracillin

Tazobactum,

Inj.

Amikacin,

Salbutamol,

nebulisations,

Mechanical

ventilation,

Inj.

Midazolam

Infusion.


Respiratory

Severe Aspiration Pneumonia

(Non Ventilated) Inv - Serial ABG

X-Ray Chest 5 days


and

Pulse

Oxymetry/ABG

20000 Oxygen, IV

flu ids, Inj.

Pipracillin

Tazobactum,

Inj.

Amikacin,

Salbutamol,

nebulisations


Respiratory

Severe Aspiration Pneumonia (Ventilated) Inv -

Serial ABG

X-Ray Chest 7 days


and

Pulse

Oxymetry/ABG

25000 Oxygen, IV

flu ids, Inj.

Pipracillin

Tazobactum,

Inj.

Amikacin,

Salbutamol,

nebulisations,

Mechanical

ventilation,

Inj.

Midazolam

Infusion.


Respiratory

ARDS with Mult i-

organ failu re Clin ical Photo, Inv - Blood Culture,

LFT, RFT, ABG, X-Ray Chest 14 days stay with

post treatment evidence of ABG and other Lab

Investigations

100000 MICU, O2,

Antimicrobial

s,

Ventilat iory

Care


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Respiratory

ARDS plus DIC

(Blood & Blood products) Clinical Photo, Inv -

LFT, RFT, Blood Culture, X-Ray Chest, ABG,

Coagulation Profile 14 days stay with post

treatment evidence of ABG and other Lab

Investigations

120000 FFP, Cryo

Precip itate,

Ventilat iory

Care


Card iovascular

Severe Myocarditis Inv - ABG 12 hrly + ECHO +

ECG, CVP monitoring, arterial blood pressure

monitoring 10 days stay with post treatment

evidence of X-Ray and Pulse Oxymetry/ABG

40000 Oxygen, IV

flu ids, Inj.

Pipracillin

Tazobactum,

Inj.

Amikacin,

Salbutamol,

nebulisations,

Mechanical

ventilation,

Inj.

Midazolam

Infusion.


Card iovascular

Congenital heart disease with in fection (non

Ventilated) Inv - Pulse Oxymetry, Echo X-Ray

Chest, CRP 7 days stay in


Pulse Oxymetry/ABG

30000 Oxygen, I.V

flu ids, Inj.

Ceftriaxone,

Inj.

Tobramycin,

Inj.

Dobutamine,

Inj.

Dopamine.


Card iovascular

Congenital heart disease with in fection and

cardiogenic shock (Ventilated) Inv - X-Ray Chest,

Serial ABG, Echo, CVP monitoring, arterial blood

pressure monitoring 10 days


and Pulse Oxymetry/ABG

50000 Oxygen, I.V

flu ids, Inj.

Meropenem,

Inj.

Vancomycin,

Mechanical

ventilation X,

Inj.

Midazolam,

Inotropes,

Dobutamine,

Dopamine,

adrenaline,

noradrenaline

, milirinone.


Card iovascular

Card iogenic shock Inv - ABG X-Ray chest, Echo,

CVP monitoring, arterial b lood pressure

monitoring 10 days



50000 Oxygen, I.V

fluids, Inj.

Meropenem, Inj.

Vancomycin,

Inj.

Midazolam,

Inotropes, (Dobutamine,

Dopamine,

adrenaline,

noradrenaline,

milirinone.


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Card iovascular

Infective Endocarditis Inv - 3 Blood cultures at

half hourly intervals, ABG

X-Ray Chest, Echo 15 days



50000 Oxygen, I.V

fluids, Inj.

Meropenem,

Inj. Vancomycin,

Mechanical

ventilation, Inj.

Midazolam,

Inotropes, (Dobutamine,

Dopamine,

adrenaline,

noradrenaline,

milirinone, Inj. Heparin, low

molecular

weight heparin


CNS

Meningo-encephalitis (Non Ventilated) Inv - CSF

analysis, CT-Scan, EEG 14 days

PICU stay with post treatment evidence for

Clin ical Improvement with lab investigations

40000 Oxygen, I.V

fluids, Inj.

Cefepime, Inj.

Vancomycin,

Inj. Acyclovir, Anticonvulsant

s (Inj.

Lorazepam,

Inj. Phenytoin

(Inj. Phenobarbitone

) Inj.

Midazolam

infusion


CNS

Meningo- encephalitis

(Ventilated) Inv - Serial ABG, CSF analysis , CT

scan, EEG, arterial monitoring 14 days



60000 Oxygen, I.V

fluids, Inj.

Cefepime, Inj.

Vancomycin, Inj. Acyclovir,

Anticonvulsant

s (Inj.

Lorazepam,

Inj. Phenytoin Inj.

Phenobarbitone

), Mechanical

ventilation, Inj.

Midazolam infusion


CNS

Status Epilepticus Inv - Serial ABG, CSF analysis,

CT scan, EEG 14 days



50000 Oxygen, I.V

fluids, Inj. Cefepime, Inj.

Vancomycin,

Inj. Acyclovir,

Anticonvulsant

s (Inj. Lorazepam,

Inj. Phenytoin

Inj.

Phenobarbitone

), Mechanical ventilation, Inj.

Midazolam

infusion

835 Pediatric Ic Care Febrile Seizures (atypical- mechanical ventilated) 25000 Oxygen, I.V


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

CNS Inv - Serial ABG, CSF analysis, CT Scan, EEG 5

days



fluids, Inj.

Cefepime, Inj.

Amikacin, Inj.

Anticonvulsants (Inj.

Lorazepam,

Inj. Phenytoin

Inj.

Phenobarbitone), Mechanical

ventilation, Inj.

Midazolam

infusion


CNS

Intra cranial b leed Inv - Serial ABG, CSF analysis,

CT Scan, EEG 10 days



40000 Oxygen, I.V

fluids,

Antibiotics Inj.

Meropenem, Inj.

Tobramycin,

Mechanical

ventilation, Inj.

Midazolam infusion,

Inotropes

Dobutamine,

Dopamine,

Adrenaline, noradrenaline,

Milrinone,

Anticonvulsant

s (Inj.

Lorazepam, Inj. Phenytoin

Inj.

Phenobarbitone

), Inj. Calcium

837 Pediatric Ic Care GIT Acute Gastro intestinal bleed Inv - ABG/Upper GI

Endoscopy, USG

abdomen 10 days



30000 Oxygen, I.V

fluids,

Antibiotics

(Inj. Ceftriaxone,

Inj. Ofloxacin,

Inj. Amikacin)

Mechanical

ventilation, Inj. Midazolam

infusion,

endoscopic

sclerotherapy,

Inotropes (Dobutamine,

Dopamine)

838 Pediatric Ic Care GIT Acute Pancreatitis Inv - ABG, USG abdomen, CT

Scan Abdomen, serum amylase, lipase, CVP

monitoring, arterial BP monitoring 10 days



50000 Oxygen, I.V fluids,

Antibiotics

(Inj.

Meropenem,

Inj. Vancomycin)

Mechanical

ventilation, Inj.

Midazolam


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

infusion,

Inotropes

(Dobutamine,

Dopamine, Adrenaline,

noradrenaline,

Milrinone,

Insulin, Inj.

Calcium, TPN)

839 Pediatric Ic Care GIT Acute hepatitis with hepatic encephalopathy Inv -

Serial ABG, Bloodsugar 4 hrly, USG abdomen,

CT Scan (brain), Hepatic v iral studies (Hepatitis

B, Hepatit is C, Hepatit is A, LFT, S. Ammonia) 10

days



50000 Oxygen, I.V

fluids, Antibiotics

(Inj.

Meropenem)

Mechanical


infusion,

Inotropes,

Dobutamine,


noradrenaline,

Milrinone, Inj.

Calcium, Inj.

N-Acetyl Cystein, Inj. L-

ornathine, L-

Carnitine,

Anticonvulsant

s (Inj. Lorazepam,

Inj. Phenytoin,

Inj.

Phenobarbitone

)


Renal

Acute Renal Failu re with dialysis Inv - Serial

ABG, X-Ray Chest, Blood Urea cum Serum

Creat inine 4 hrly, USG abdomen, S.Electro lytes

10 days



40000 Oxygen, I.V

fluids,

Antibiotics (Inj.

Meropenem,

Inj. Ofloxacin)

Inotropes,

(Dobutamine, Dopamine)

peritoneal

dialysis, Inj.

Calcium,

Mechanical ventilation, Inj.

Midazolam

infusion.


Endocrine

Diabetic Ketoacidosis Inv - Serial ABG, Blood

sugar 4 hrly, Serum Electro lytes, CVP monitoring

8 days


Clin ical Improvement with biochemical

parameters

30000 Oxygen, I.V

fluids,

Antibiotics

(Inj.

Piperacillin Tazobactum,

Inj.

Tobramycin),

Inotropes

(Dobutamine,


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

Dopamine)

Calcium,

Insulin

infusion.


Infection

Septic shock Inv - Serial ABG, Blood sugar 4

hrly, EEG, USG abdomen, CT scan Brain, Echo,

ECG, Blood culture, X-Ray Chest, CRP 10 days



50000 Oxygen, I.V

fluids, Inj. Meropenem,

Inj.

Vancomycin,

Anticonvulsant

s (Inj. Lorazepam,

Inj. Phenytoin,

Inj.

Phenobarbitone

), Inotropes (Dobutamine,

Dopamine,

Adrenaline,

noradrenaline,

Milrinone). Mechanical

ventilation, Inj.

Midazolam

infusion, TPN.


Toxicology

Snake bite requiring ventilatory assistance Inv -

Serial ABG, S. Electro lytes, Blood sugar 4 hrly,

EEG, CT scan Brain with 10 days



parameters

50000 Oxygen, I.V

fluids, Inj.

Meropenem,

Inj. Vancomycin,

Anticonvulsant

s (Inj.

Lorazepam,

Inj. Phenytoin, Inj.

Phenobarbitone

), Inotropes

(Dobutamine,


noradrenaline,

Milrinone).

Mechanical


infusion,

antisnake

venom


Toxicology

Scorpion sting with myocardit is and cardiogenic

shock requiring ventilatory Assistance Inv - Serial

ABG, Blood sugar 8 hrly, Echo, ECG, CVP

monitoring, arterial blood pressure 10 days



25000 Oxygen, I.V

fluids, Inj.

Meropenem,

Inj. Vancomycin,

Inotropes

(Dobutamine,

Dopamine,

Adrenaline, noradrenaline,

Sodium

nitroprusside),


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

Mechanical

ventilation, Inj.

Midazolam

infusion, antiscorpion

venom


Toxicology

Poison ingestion/ aspiration requiring ventilatory

assistance Inv - Serial ABG, Blood sugar 8 hrly ,

Echo, X-Ray Chest, ECG, CVP monitoring,

arterial blood pressure 7 days



parameters

40000 Oxygen, I.V

fluids, Mechanical

ventilation, Inj.

Midazolam

infusion,

Inotropes (Dobutamine,

Dopamine),

specific

antidote

846 Gen Paediatrics

Respiratory

Acute Broncho/ lobarpneumonia with empyema/

pleural effusion Inv - X-Ray, Pus culture, Blood


of X-Ray Chest

20000 IV fluids,

oxygen, IV

Antibiotics

(Amoxycillin clavulanate or

ceftriaxone,

Amikacin,

vancomycin),

Oral antibiotics,

Nebulisations,

ICD chest

drain, chest

physiotherapy, Mechanical

ventilation if

required and

oral antibiotics/

Anti tubercular drugs after

discharge

847 Gen Paediatrics

Respiratory

Acute Broncho/ lobarpneumonia with pyo

pneumothorax Inv - X-Ray, Pus culture, Blood


of X-Ray Chest

20000 IV fluids, oxygen, IV

Antibiotics,

Nebulisations,

ICD chest

drain, chest physiotherapy,

Mechanical

ventilation if

required and

oral antibiotics/ Anti tubercular

drugs after

discharge

848 Gen Paediatrics CVS Congenital heart disease with congestive cardiac

failure Inv - X-Ray, 2D Echo, ECG, Serial ABG 7

days stay with post treatment evidence of X-Ray

Chest, 2D Echo, ECG

15000 IV fluids, oxygen, IV

Antibiotics

(Ceftriaxone,

Amikacin or

ofloxacin), Nebulisations,

diuretics,


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

Digoxin and

mechanical

ventilation.

849 Gen Paediatrics CVS Acquired heart disease with congestive cardiac

failure Inv - X-Ray, 2D Echo, ECG, Serial ABG 7

days stay with post treatment evidence of X-Ray

Chest, 2D Echo, ECG

15000 IV fluids,

oxygen, IV Antibiotics

(ceftriaxone,

Amikacin or

ofloxacin),

Nebulisations, diuretics, Ace

inhibitors,

Digoxin and

mechanical

ventilation.

850 Gen Paediatrics CVS Viral Myocarditis Inv - X-Ray, 2D Echo, ECG 7

days stay with post treatment evidence of 2D

ECHO , ECG , X-Ray Chest

15000 IV fluids,

oxygen, IV

Antibiotics (ceftriaxone,

Amikacin or

ofloxacin),

diuretics,

inotropes and steroids

851 General Paediatrics

Renal

Steroid Resistant Nephrotic syndrome

Complicated or Resistant Inv - Renal biopsy,

Electrolytes, Urea, creat inine, Urine exam, X-Ray

Chest 2 weeks stay with post treatment evidence

of RFT

25000 Antibiotics

ceftriaxone,

Amikacin or ofloxacin),

Antihypertensi

ve, Diuretics.

Immunosuppressive, pleural

tap/ascitic tap


Renal

Urinary tract infection with complications like

pyelonephritis and renal failure Inv - MCUG

(Micturating cysto urethrogram), Urine fo r Culture

and Sensitivity, Ultrasound 10 days stay with post

treatment evidence of Urine Culture and USG

15000 IV fluids,IV

Antibiotics (Amoxycillin

clavulanate,

ceftriaxone,

Amikacin or

ofloxacin paracetamol,

oral antibiotics

(Amoxycillin

clavulanate,

cefixime). Dialysis.


Renal

Acute Renal Failu re RFT, Serum Electrolytes, C3,

C1, Complement levels, Collagen Vascular profile

10 days stay with post treatment evidence of RFT

10000 Antibiotics,

Antihypertensive, Diuretics

Supportive

Management,

Haemo or

Peritoneal dialysis


Renal

Acute Renal Failu re with dialysis Inv - RFT,

Serum Electrolytes, C3, C1, Complement levels,

Collagen Vascular profile 10 days stay with post

treatment evidence of RFT.

20000 Antibiotics,

Antihypertensive, Diuretics

Supportive

Management,

Haemo or


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

Peritoneal

dialysis


Severe anaemia

Thalassemia Major requiring chelation Therapy

Inv - Hb electrophoresis, Osmotic frag ility test,

Serum Ferrit in 7 days stay with post treatment

evidence of Clin ical and Haematological

Improvements

Up

to 20000

Blood

transfusion., Chelating

Agents (Oral or

Parenteral)


Severe anaemia

Haemophilia including Inv - Von Will brands

Coagulation studies and Factor analysis 7 days

stay with post treatment evidence of Clinical and

Haematological Improvements

20000 Blood and

Blood

products,

Factor concentrate


Severe anaemia

Anaemia o f unknown cause Inv - Hb

electrophoresis, bone marrow examination,

Hierogram 5 days stay with post treatment

evidence of Clin ical and Haematological

Improvements

Up

to 10000

Bloods

transfusion, Haematinics

etc., IV fluids


Infections

Pyogenic meningitis Inv - CSF Analysis & CT-

Scan Brain, Blood Culture, X-Ray Chest with post

10 days stay with post treatment evidence of

Repeat CSF

35000 IV fluids, IV

antibiotics

(Amoxycillin

clavulanate, ceftriaxone,

Amikacin or

ofloxacin,

vancomycin), Paracetamol,

IV

dexamethasone

for below 5 yr.

old children, Anticonvulsant

s (midazolam

or lorazepam,

Phenobarbitone

or Phenytoin), Ventilatory

Support.


Infections

Neuro tuberculosis Inv - CT-Scan Brain CSF

ADA analysis, X-Ray Chest 12 days stay with

post treatment evidence of Clinical and lab

investigation

10000

+ DOTS

Rx free

IV fluids, Naso

gastric feeds, IV antibiotics

anti tubercular

therapy,

Paracetamol,

IV Mannitol, Anticonvulsant

s (midazolam

or lorazepam,

Phenobarbitone

or Phenytoin), IV

dexamethasone

and oral

steroids,

Mechanical Ventilatory

Support.


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)


Infections

Neuro tuberculosis with ventilation Inv - ABG,

CT-Scan Brain CSF ADA analysis 12 days stay

with post treatment evidence of Clinical and lab

investigation

20000

+ DOT

SRx free

IV fluids, Naso

gastric feeds,

IV antibiotics

anti tubercular therapy,

Paracetamol,

IV Mannitol,

Anticonvulsant

s (midazolam or lorazepam,

Phenobarbitone

or Phenytoin),

IV

dexamethasone and oral

steroids,

Mechanical

Ventilatory

Support.


Infections

Suspected Dengue shock syndrome with

thrombocytopenia Inv – Platelet count and

serology with post treatment evidence of platelet

transfusion and clinical photograph

20000 IV fluids,

Inotrpopes,

Platelet transfusion and

supportive

treatment.


Infections

Cerebral Malaria (Falciparum) Inv - CSF analysis,

Parasite F Test and QBC, Electro lytes, ABG 7

days stay with post treatment evidence of Clin ical

and lab investigation

10000 IV fluids, IV

antibiotics

ceftriaxone,

Amikacin,

ofloxacin), Oral

chloroquine or

IV quinine or

IV artesunate,

Paracetamol, mefloquine,

blood and

platelet

transfusion,

mechanical ventilation


Neurology

Convulsive Disorders/Status Epilepticus (Fits) Inv

- EEG, CT Electrolytes, Bl. Sugar, S.calcium,

Phosphorous 7 days stay with post treatment

evidence of clinical and lab investigation

10000 Anticonvulsant

s, IV fluids, Oxygen,

ventilator


Neurology

Stroke Syndrome Inv - CT, Angiogram, EEG, 2D

Echo 14 days stay with post treatment evidence of

clin ical and lab investigation

20000 Oxygen, IV Fluids, Anti

Epieptics, Low

Molecular,

heparin


Neurology

Encephalit is / Encephalopathy Inv - CSF, CT 10

days stay with post treatment evidence of clin ical

and lab investigation

15000 IV fluids,

Mannitol,

Anticonvulsan

ts, Acyclovir, Inj. Ventilator

care


Neurology

Guillian-Barre Syndrome Inv - CSF Analysis,

ENMG Nerve Conduction studies, ABG 15 days

stay with post treatment evidence of clinical and

lab investigation

60000 Immunoglobulin, IV fluids,

ventilary and

supportive

care,


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

Physioherapy

867 Card iology Acute MI (Conservative Management without

Angiogram) Inv - ECG, CPKMB, Troponin, 2D

Echo 1 week stay with post treatment evidence of

ECG, 2D Echo, Lab Investigations

20000 Medical

868 Card iology Acute MI (Conservative Management with

Angiogram) Inv - ECG, CPKMB, Troponin, 2D

Echo, Coronary Angiography 1 week stay with

post treatment evidence of ECG, 2D Echo, Lab

Investigations

30000 Medical

869 Card iology Acute MI with Card iogenic Shock Inv - ECG,

CPKMB, Troponin, 2D Echo, Coronary

Angiography 2 weeks stay with post treatment

evidence of ECG, 2D Echo, Lab Investigations

30000 Medical

870 Card iology Acute MI requiring IABP Pump Inv - ECG,

CPKMB, Troponin, 2D ECHO, Coronary

angiography 3 weeks stay with post treatment

evidence of ECG, 2D Echo, Lab Investigations

50000 Medical

871 Card iology Refractory Cardiac Failure Inv - ECG, CPKMB,

Troponin, 2D Echo, Coronary Angiography 2

weeks stay with post treatment evidence of ECG,

2D Echo, Lab Investigations

50000 Medical

872 Card iology Infective Endocarditis Inv - ECG, 2D Echo, Blood

C/S 5 days stay with post treatment evidence of

ECG, 2D Echo, Lab Investigations

25000 MEDICAL

873 Card iology Pulmonary Embolis m Inv - MRI/doppler 5 days

stay with post treatment evidence of ECG, 2D

Echo, Lab Investigations

30000 MEDICAL

874 Card iology Complex Arrhythmias Inv - ECG, Doppler, 3

days stay with post treatment evidence of ECG,


95000 Cartoguided

875 Card iology Simple Arrhythmias Inv - ECG doppler 3 days

stay with post treatment evidence of ECG, 2D

Echo, Lab Investigations

70000 Focus

Ablation

876 Card iology Pericardial Effusion Tamponade Inv - Doppler 1

week stay with post treatment evidence of ECG,


25000 Aspiration

877 Nephrology Acute Renal Failu re-(ARF) Inv - LFT, S. Protein,

Calcium, Phosphate, uric acid, Electrolytes, Urine

protein, USG, ECG, 2D Echo, HIV, HCD, HbSAg

10 days stay in MICU with post treatment

evidence of RFT and other lab investigation

Dialysis chart

20000 Dialysis and

supportive

therapy

878 Nephrology Nephrotic Syndrome Inv - LFT, Serum protein,

Serum electrolytes, 24 hours urine, Urine protein,

Chest X-Ray, Biopsy report, USG, ECG, HIV,

HCG, HBSAg, ANA/dsDNA, BTCT 4 Days stay

with post treatment evidence of RFT and other

lab investigation

15000 Immunosuppre

ssive RX

879 Nephrology Rapid ly progressive Renal Failure (RPRF) Inv - S.

Renal Chemistry 10 days stay with post treatment

evidence of RFT and other lab investigation

35000 Medicines,

Steroids parenteral


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

880 Nephrology Chronic Renal Failure 1 (CRF ) Inv - LFT, S.

Protein, S. Ca, S. Po4, S. u ric acid, A lb/Globulin

ratio S. electro lytes, 24 hrs. urine, Spot Urine

/Creatin ine ratio, Chest X-ray, USG, ECG, HIV,

HCV, HbSAg, 2D Echo 5 days stay with post

treatment evidence of RFT and other lab

investigation

15000 Initial

treatment

and Dialysis

and supportive therapy

881 Nephrology Maintenance Haemodialysis for CRF Inv - LFT,

S. Protein, S. Ca, S. Po4, S. u ric acid,

Alb/Globulin ratio S. electrolytes, 24 hrs. urine,

Spot Urine /Creatinine ratio, Chest X-ray, USG,

ECG, HIV, HCV, HbSAg, 2D Echo 1 day stay per

dialysis with post treatment evidence of RFT and

other lab investigation

10000

month

Dialysis and

supportive

therapy

(Minimum of 8 dialysis)

882 Neurology ADEM or Relapse in Multiple sclerosis Inv - MRI

Brain & Spinal cord (3 sites) Plain and contrast,

CSF analysis, Evoked Potentials, CSF Monoclonal

Bands, HIV Profile 15 days stay with post

treatment evidence of Clin ical and Lab

Investigations

20000 Inj.

Methylprednis

olone,

supportive care,

ventilatory

support if

necessary, antacids and

vitamin

supplementatio

n,

physiotherapy + Oral steroids

for 4 weeks

883 Neurology CIDP Inv - NCS, EMG, CSF analysis, Serum

Protein electrophoresis, Nerve Biopsy 10 days


Lab Investigations

8000 Oral steroids,

azathioprine, vitamin

supplementatio

n,

physiotherapy

884 Neurology Haemorrhagic Stroke/Strokes Inv - CT Brain /

MRI Brain / MRV / MRA, ECG,

Echocardiography, Carotid and vertebral Doppler

etc. special tests for Evaluation of cause, 4-vessel

cerebral angio if necessary (DSA), lipid profile 15


and Lab Investigations

25000 antihypertensiv

e, antidiabetics,

Antacids,

Mannitol IV, IV fluids as

necessary,

Surgery if

necessary

885 Neurology Ischemic Strokes Inv - CT Brain / MRI Brain /

MRV / MRA, ECG, Echocardiography, Carotid

and vertebral Doppler etc. special tests for

Evaluation of cause, 4-vessel cerebral angio if

necessary (DSA), lipid profile 15 days stay with

post treatment evidence of Clinical and Lab

Investigations

20000 Antihypertensi

ve, Antidiabetics,

Aspirin +

Clopidogrel,

Antacids,

Mannitol IV, Heparanoids

for 5 days, IV

fluids as

necessary,

Surgery in some cases


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

886 Neurology Myopathies - Acquired NCS, Inv - EMG, Serum

CPK, Serum Calcium, Phosphate and alkaline

phosphatase, endocrine evaluation, Muscle Biopsy


Clin ical and Lab Investigations

15000 Prednisolone +

Azathioprine,

Calcium

supplementation, vitamin

supplementatio

n, Endocrine

therapy.

887 Neurology NEUROINFECTIONS - Fungal Meningit is Inv -

CT brain, MRI brain scan, CSF analysis, cell

count, ADA, culture, CSF serology for

tuberculosis antigens, Fungal studies Min 20 days

- ICU, 40 days - ward stay with post treatment

evidence of Clin ical and Lab Investigations

40000 Antacids,

Mannitol IV,

steroids,

Antifungal drugs, IV

fluids as

necessary

888 Neurology NEUROINFECTIONS - Pyogenic Meningitis Inv

- CT brain, MRI brain scan, CSF analysis, cell

count, ADA, culture Min 10 days - ICU, 7 days -

ward stay with post treatment evidence of Clinical


25000 Antacids,

Mannitol IV,

steroids,

Higher

Antibiotics, IV fluids as

necessary,

Surgery if

necessary

889 Neurology NEUROINFECTIONS - Viral

Meningoencephalitis (Including Herpes

encephalitis) Inv - CT brain, MRI brain scan, CSF

analysis, cell count, ADA, culture, CSF antibodies

for HSV Min 10 days - ICU, 7 days - ward stay

with post treatment evidence of Clinical and Lab

Investigations

25000 Antacids,

Mannitol IV,

methyl

prednisolone, Acyclovir, IV

fluids as

necessary

890 Neurology Neuromuscular (myasthenia gravis) Inv - RNS /

CT chest / CT abdomen, Neostigmine test, thyroid

profile 15 days stay with post treatment evidence

of Clinical and Lab Investigations

15000 Prednisolone +

Neostigmine +

Calcium

supplementations,

Azathioprine,

(Surgery for

thymoma),

Ventilatory care if

necessary

891 Neurology Neuropathies (GBS) Inv - NCS / EMG (1000),

Nerve Biopsy (2000), CSF analysis 10 days - ICU

20 days - Ward stay with post treatment evidence


35000 Inj.

Methylprednisolone,

supportive

care,

ventilatory

support if necessary,

antacids and

vitamin

supplementatio

n, physiotherapy

892 Neurology Optic neurit is Inv - MRI Brain & Optic nerves,

VEPs, CSF analysis 3 days stay with post


Investigations

10000 Inj.

Methylpredni

solone,

antacids and

vitamin

supplementati


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

on + oral

steroids for 2

weeks

893 Neurology Immunoglobulin Therapy - IV Investigations

indicative of d iseases 5 days stay with post


Investigations

100000 In several life

threatening

diseases i.e.

rapidly

progressive

GBS, CIDP,

Myasthenia,

Multiple

sclerosis, etc.

894 Pulmonology Bronchiectasis requiring hospitalisation Inv - HR

CT - Chest, spirometry, FOB (Fiberoptic

Bronchoscopy), IgE, Sputum culture / drug

susceptibility 10 days stay with post treatment


20000 According to

International

Guide lines

895 Pulmonology Lung Abscess, non resolving Inv - CT Scan Chest,

FOB, Pus C/S 10 days stay with post treatment


15000 Antibiotics,

Bronchial

toilet

896 Pulmonology Pneumothorax

(Large/Recurrent) HRCT Inv - Chest , VATS 10



35000 Thoracostom

y + oxygen +

antimicrobial

s, pleuredesis,

MICU

897 Pulmonology Interstitial Lung diseases Inv - Sp irometry, HRCT

Chest, Collagen Profile, Bronchoscopy, 2D Echo



30000 Steroids,

antimicrobial,

MICU

898 Pulmonology Pneumoconiosis Inv - Spirometry, HRCT Chest,

Collagen Profile, Bronchoscopy, 2D Echo 10 days


Lab Investigations

25000 Medical

Management,

MICU

899 Pulmonology Acute Respiratory Failure (without ventilator) Inv

- Serum Electrolytes, ABG, ECG, 2D Echo,

Bronchoscopy, Sputum / Bronchial Washing / ET

Suctions for Analysis 10 days stay with post


Investigations

25000 Oxygen,

Antimicrobial

s, Supportive

therapy in

MICU

900 Pulmonology Acute Respiratory Failure (with ventilator) Inv -

Serum Electrolytes, ABG, ECG, 2D Echo,

Bronchoscopy, Sputum / Bronchial Washing / ET

Suctions for Analysis 10 days stay with post


Investigations

50000 Oxygen,

Antimicrobial

s, Supportive

therapy in

MICU

901 Dermatology Pemphigus / Pemphigoid Tzanck Inv - Smear Skin

Biopsy HPE DIF Clinical Protocol 15 days stay


Investigations

25000 IV Fluids

IV

Antibiotics

IV Steroids

Pulse therapy


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

902 Dermatology Toxic ep idermal necrolysis Inv - LFT, Blood -

culture, urine Culture, Skin swab, USG abdomen

Skin biopsy - HPE, Echo - Card iogram 15 days


Lab Investigations

30000 IV Fluids

IV

Antibiotics

IV Steroids

903 Dermatology Stevens- Johnson Syndrome Inv - LFT, Blood -

culture, urine Culture, Skin swab, USG abdomen

Skin biopsy - HPE, Echo - Card iogram 15 days


Lab Investigations

20000 IV Fluids

IV

Antibiotics

IV Steroids

904 Rheumatology SLE (SYSTEMIC LUPUS ERYTHEMATOSIS)

Inv - dSDNA, ACL ANTIBODIES, ANA

PROFILE, KIDNEY

BIOPSY, HRCT,

24 Hrs URINARY PROTEIN, ENANTIGEN 10

days stay with post treatment evidence of Clinical


15000 As per

American

College of

Rheumatolog

y Guidelines.

905 Rheumatology SLE with Sepsis Inv - dSDNA, ACL Antibodies,

ANA

Profile, Kidney

biopsy, HRCT,

24 Hrs urinary protein, ENAntigen, Blood culture

/ proof of sepsis 4 weeks stay with post treatment


50000 As per

American

College of

Rheumatolog

y Guidelines.

906 Rheumatology SCLERODERMA Inv - Renal doppler, 2D

ECHO, Skin biopsy HPE Report, ANAProfile 7



15000 As per

American

College of

Rheumatolog

y Guidelines.

907 Rheumatology MCTD Mixed Connective Tissue Disorder Inv -

CPK, LDH, ENMG, MRI of muscles, MRI of

hands, kidney biopsy 24 Hrs urinary p rotein 7

Days stay with post treatment evidence of Clin ical


15000 As per

American

College of

Rheumatolog

y Guidelines.

908 Rheumatology PRIMARY

SJOGREN'S

SYNDROME Inv - 24 Hrs Urinary protein , ABG,

USG Abdomen 7 Days stay with post treatment


15000 As per

American

College of

Rheumatolog

y Guidelines.

909 Rheumatology VASCULITIS Inv - CANCA, pANCA, ANA

profile 10 days stay with post treatment evidence


10000 As per

American

College of

Rheumatolog

y Guidelines.

910 Endocrinology

Uncontrolled

Diabetes Mellitus

With Infectious

Emergencies

Pyelonephritis Inv - Urine C/S, USG 10 days stay


Investigations

20000 IV fluids

911 Endocrinology

Uncontrolled

Diabetes Mellitus

With Infectious

Emergencies

Lower Respiratory tract in fection Inv - CXR,

Sputum C/S 10 days stay with post treatment


20000 Insulin


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

912 Endocrinology

Uncontrolled

Diabetes Mellitus

With Infectious

Emergencies

Fungal sinusitis Inv - CT PNS 10 days stay with


Investigations

40000 IV & Oral

antibiotics

913 Endocrinology

Uncontrolled

Diabetes Mellitus

With Infectious

Emergencies

Cholecystitis Inv - USG, CT Abd 10 days stay


Investigations

25000 Antibiotics

and

Supportive

Therapy

914 Endocrinology

Uncontrolled

Diabetes Mellitus

With Infectious

Emergencies

Cavernous sinus thrombosis Inv - MRI,

Venogram, Twice 10 days stay with post treatment


40000 IV & Oral

antibiotics

915 Endocrinology

Uncontrolled

Diabetes Mellitus

With Infectious

Emergencies

Rhinocerebral mucormycosis Inv - CT-Scan,

(Brain PNS Chest, Abdomen) when necessary 10



40000 IV

antifungals

916 Other Endocrinal

disorders

Hypopitutarism Inv - T3 T4 TSH, basal cortisol

post-act cortisol, GH stimulat ion test, FSH, LH,

Testosterone or Estradiol GH stimulat ion test 1 yr.

needed MRI pic v isual field water deprivation test

1 yr. needed 1 week stay with post treatment


100000 Hormone

Therapy for

three months


disorders

Pituitary - Acromegaly Inv - Post glucose on

assay, prolactin, t3 t4 TSH, Basal cortisol cost

ACTH, FSH / LH, testosterone / estriol, water

deprivation test (if needed), MRI co lonoscopy if

needed, Visual field, 2D ECHO 1 week stay with


Investigations

15000 Hormone

Therapy for

three months


disorders

CUSHINGs Syndrome Inv - Cortisol assay after

dexamethasone, ACTH assay, DHEAS, MRI

pituitary CTABD, CT Chest, Dexa of Hip spine 1

week stay with post treatment evidence of Clinical


30000 Diabetes

mellitus

drugs,

Hypertension,

Osteoporosis,

infection with

antibiotics +

surgery


disorders

Delayed Puberty Hypogonadism (ex.Turners synd,

Kleinfelter synd) Inv - FSH, LH, testosterone,

estradiol, USG pelvis karyotyping, T4 TSH S-ray

bone age, X-ray skull, MRI brain DEXA 2D echo



12000 Inj

Testosterone

250mg / 3

wks., oc p ills

920 Gastroenterology Corrosive Oesophageal injury Inv - Barium

swallow 7 days stay with post treatment evidence

of Barium swallow

20000 Endoscopic

dilatation -

video / photo

Medical

treatment,

MICU stay


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

921 Gastroenterology Oesophageal foreign body Inv - X-Ray one day

stay with post treatment evidence of Endoscopic

Photograph

5000 Foreign body

removal -

photo of the

procedure

922 Gastroenterology Oesophageal perforation Inv - CT scan thorax, &

abdomen, Barium swallow 7 days stay with post

treatment evidence of CT Abdomen

25000 Conservative,

MICU stay

923 Gastroenterology Achalasia cardia Inv - UGI endoscopy / Barium

swallow one day stay with post treatment evidence

of Endoscopic Photograph

7000 Dilatation,

Botulinum,

Taxim Inj.

924 Gastroenterology Oesophageal Varices, variceal banding Inv - UGI

endoscopy one day stay with post treatment

evidence of Endoscopic Photograph

10000 Endoscopic

variceal

banding

925 Gastroenterology Oesophageal Varices, sclerotherapy Inv - UGI

endoscopy one day stay with post treatment


5000 Endoscopic

sclerotherapy

injection

926 Gastroenterology Oesophageal Fistula Inv - CT Thorax,

Gastrograffin contrast picture 3 days stay with

post treatment evidence with post treatment

evidence of Photograph of stent in position

30000 Covered

esophageal

stent, MICU

927 Gastroenterology GAVE (Gastric Antral Vascular Ectasia) Inv -

UGI Endoscopy 2 days stay with post treatment


20000 Medical +

Argon Laser

Coagulation

928 Gastroenterology Gastric varices Inv - UGI Endoscopy 3 days stay

with post treatment evidence of Endoscopic

Photograph

15000 MICU,

Endoscopic

Glue

Injection

929 Gastroenterology Acute pancreatitis (Mild) Inv - USG abdomen, S.

Amylase, S. Electrolytes, Ranson's Scoring 1

week stay with post treatment evidence of USG,

Lab Investigation

Up to

75000

MICU

930 Gastroenterology Acute pancreatitis (severe) Inv - CT Abdomen, S.

Amylase, EUS, RFT, LFT S. Electrolytes,

Ranson's Scoring, CXR, ABG 3 weeks stay with

post treatment evidence of USG, Lab Investigation

Up to

150000

MICU

931 Gastroenterology Acute pancreatitis with pseudocyst (infected) Inv -

CT Scan abdomen, EUS, Post Procedure USG 3

weeks stay with post treatment evidence of USG,

Lab Investigation

Up to

30000

Endoscopy

drainage,

Percutaneous

drainage,

surgical

drainage +

MICU

932 Gastroenterology Chronic pancreatit is with severe pain Inv - EUS,

CT Scan, Abdomen, ERCP / MRCP 7 days stay

with post treatment evidence of Lab Investigation

Up to

20000

Conservative,

ERCP +

Stenting,

ERCP, EUS

guided,

Celiac

ganglion

block, MICU

933 Gastroenterology Obscure GI beed Inv - BMFT, Capsule

Endoscopy, Enteroscopy biopsy 1 week stay with

post treatment evidence of Endoscopic photograph

50000 Argon Laser

Rx


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

934 Gastroenterology Cirrhosis with Hepatic Encephalopathy Inv - UGI

Endoscopy, Axcitic fluid analysis 11 days stay

with post treatment evidence of Lab Investigation

30000 EVL-EST,

MICU 10

days

935 Gastroenterology Cirrhosis with hepato renal syndrome Inv -

Reports of Serum Chemistry 10 days stay with

post treatment evidence of Lab Investigation

40000 Medical,

EVL-EST,

MICU 10

days

936 Gastroenterology Biliary structure 1) Post op stent Inv - EUS,

MRCP, ERCP, PTBD 7 days stay with post

treatment evidence of Radiolog ical & endoscopic

image

50000 Medical,

biliary stent

937 Gastroenterology Biliary structure 2) Post op leaks Inv -

EUS, MRCP, ERCP, PTBD 7 days stay with post

treatment evidence of Radiolog ical & endoscopic

image

75000 Medical,

biliary stent

938 Gastroenterology Biliary structure 3) Sclerosing cholangitis

Inv - EUS, MRCP, ERCP, PTBD 7 days stay with

post treatment evidence of Radiological &

endoscopic image

75000 Medical,

biliary stent

939 Interventional

Radio logy

Embolizat ion of AV malformat ion of peripheral

extremity, craniofascial and visceral per sitting


and Radiographic image

90000

940 Interventional

Radio logy

Inferior vena cava stenting single stent Post

procedure evidence of Clin ical photograph and

Radiographic image

125000

941 Interventional

Radio logy

Hepatic vein Stenting in Budd - Chiari Syndrome

single stent Post procedure evidence of Clin ical

photograph and Radiographic image

125000

942 Interventional

Radio logy

Acute stroke thrombolysis with rTPA Post


Radiographic image

100000

943 Interventional

Radio logy

Renal artery embolization with multiple coils and

microcatheter Post procedure evidence of Clin ical


100000

944 Interventional

Radio logy

Cortical venous sinus thrombolysis Post procedure

evidence of Clin ical photograph and Radiographic

image

100000

945 Interventional

Radio logy

Deep venous thrombolysis for DVT with IVC

filter Post procedure evidence of Clinical


125000

946 Interventional

Radio logy

Subclavian, Iliac, Superficial Femoral artery

stenting each with one stent Post procedure


image

125000

947 Interventional

Radio logy

Tibial angioplasty in critical limb ischemia Post


Radiographic image

120000

948 Interventional

Radio logy

Mesenteric artery angioplasty & stenting in acute

& chronic mesenteric ischemia - Single stent Post


Radiographic image

110000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

949 Interventional

Radio logy

Gastrointestinal visceral arterial embolization in

upper and lower gastrointestinal bleeding with

microcatheter Post procedure evidence of Clin ical


100000

950 Interventional

Radio logy

Bronchial Artery Embolizat ion in hemoptysis

using PVA and micro catheter Post procedure


image

60000

951 Interventional

Radio logy

Radiofrequency Tumor Ablat ion Therapy Post


Radiographic image

120000

952 Interventional

Radio logy

Embolizat ion of postoperative and post traumatic

bleeding Post procedure evidence of Clinical


100000

953 Interventional

Radio logy

Inferior Vena Cava Filter placement Post


Radiographic image

100000

954 Interventional

Radio logy

Biliary drainage procedures - External drainage

and stent placement - Single metallic stent Post


Radiographic image

100000

955 Interventional

Radio logy

Nephrostomy tube and nephroureteral stent

placement Post procedure evidence of Clinical


60000

956 Interventional

Radio logy

Uterine artery embolization in severe Menorrhagia

secondary to PPH, uterine fibroids and AVM Post


Radiographic image

80000

957 Interventional

Radio logy

Intra-arterial thrombolysis for acute ischemic

limbs Post procedure evidence of Clin ical


100000

958 Interventional

Radio logy

Permanent tunnelled catheter placement as

substitute for AV Fistula in long term d ialysis Post


Radiographic image

40000

959 Interventional

Radio logy

Central Venous stenting for Central venous

occlusion ( Brachiocephalic, subclavian vein and

sup Vena cava) Single metallic stent Post


Radiographic image

125000

960 Interventional

Radio logy

Endovascular intervention for salvaging

hemodialysis AV fistula Post procedure evidence

of Clinical photograph and Radiographic image

120000

961 Interventional

Radio logy

Balloon Retrograde Transvenous obliteration of

bleeding gastric varices ( BRTO) Post procedure


image

100000

962 Interventional

Radio logy

Preoperative portal vein embolizat ion for liver

tumors Post procedure evidence of Clinical


100000

963 Interventional

Radio logy

Chemo embolization for liver tumors using drug

and PVA or DC beads Post procedure evidence of

Clin ical photograph and Radiographic image

100000


972 procedures

Sr

No


e Rate &

Upper

ceiling

(Rs.)

964 Interventional

Radio logy

Percutaneous vertebro plasty/ cementoplasty (for

each level) Post procedure evidence of Clinical


50000

965 Interventional

Radio logy

Trans jugular intrahepatic portosystemic shunt

(TIPSS) Post procedure evidence of Clinical


150000

966 Interventional

Radio logy

Embolizat ion of Pulmonary AV Malformat ion



100000

967 Interventional

Radio logy

Preoperative Prophylactic tumor embolization



100000

968 Interventional

Radio logy

Embolizat ion of AV malformat ion of brain per

sitting with Onyx Post procedure evidence of

Clin ical photograph and Radiographic image

150000

969 Interventional

Radio logy

Carotid stenting single stent with protection device



150000

970 Interventional

Radio logy

Intracranial arterial and venous stenting Post


Radiographic image

150000

971 Interventional

Radio logy

Peripheral stent graft for peripheral aneurysms and

AV Fistulae Post procedure evidence of Clinical


150000

972 Interventional

Radio logy

Embolizat ion of Caratico-Cavernous Fistula Post


Radiographic image

150000


APPENDIX 1 B

FOLLOW UP PACKAGE

Sr.

No. System

Package Rs.

Indicative

and upper

ceiling

First Instalment Rs. Indicat ive

and upper ceiling

Subsequent 3 Instalment Rs. Indicat ive

and upper

ceiling 1 Total Thyroidectomy 3000 1200 600

2 Portocaval Anastomosis Operation of Adrenal

10000 4000 2000

Operation of Adrenal

3 Glands bilateral 4000 1600 800

Splenorenal

4 Anastomosis 10000 4000 2000

5 Warren Shunt 10000 4000 2000

6 Spleenectomy + Devascularisation + Spleno Renal Shunt

10000 4000 2000

7 Lap - Pancreatic Necrosectomy 8000 3500 1500

8 Pancreatic Necrosectomy (open) 8000 3500 1500

9 Coronary Balloon Angioplasty 10000 4000 2000

10 Renal Angioplasty 10000 4000 2000

11 Peripheral Angioplasty 10000 4000 2000

12 Vertebral Angioplasty 10000 4000 2000

13 Coronary Bypass Surgery 10000 4000 2000

14 Coronary Bypass Surgery - post Angioplasty 10000 4000 2000

15 CABG with IABP Pump 10000 4000 2000

16 CABG with aneurismal repair 10000 4000 2000

17 With prosthetic Ring 10000 4000 2000

18 Without prosthetic Ring 10000 4000 2000

19 Open Pulmonary Valvotomy 10000 4000 2000

20 Closed mitral Valvotomy 10000 4000 2000

21 Mitral Valvotomy (open) 10000 4000 2000

22 Mitral Valve Replacement (with Valve) 10000 4000 2000

23 Aortic Valve Replacement (with Valve) 10000 4000 2000

24 Tricuspid Valve Replacement 10000 4000 2000

25 Double Valve Replacement (with Valve) 10000 4000 2000

26 Carotid Embolectomy 10000 4000 2000

27 Encephalocele 4000 1600 800

28 Surgeries On adrenal gland in children

29 Open pylolithotomy 2000 800 400

30 Open Nephrolithotomy 2000 800 400

31 Open Cystolithotomy 2000 800 400

32 Laparoscopic Pylolithotomy 2000 800 400

33 Cystolithotripsy 2000 800 400

34 PCNL 2000 800 400


Sr.

No. System

Package Rs.

Indicative

and upper

ceiling


and upper ceiling


and upper

ceiling 35 ESWL 2000 800 400

36 URSL 2000 800 400

37 Endoscope Removal of Stone in Bladder 2000 800 400

38 Transurethral resection of prostate (TURP) 2000 800 400

39 TURP Cyst lithotripsy 2000 800 400

40 Open prostatectomy 2000 800 400

41 Craniotomy and Evacuation of Haematoma

Subdural

8000 3200 1600

42 Craniotomy and Evacuation of Haematoma Extradural

8000 3200 1600

43 Evacuation of Brain Abscess -burr hole 8000 3200 1600

44 Excision of Lobe (Frontal, Temporal,

Cerebellum etc.

8000 3200 1600

45 Excision of Brain Tumour Supratentorial 8000 3200 1600

46 Parasagittal 8000 3200 1600

47 Basal 8000 3200 1600

48 Brain Stem 8000 3200 1600

49 C P Angle Tumour 8000 3200 1600

50 other tumors 8000 3200 1600

51 Excision of Brain Tumour Subtentorial 8000 3200 1600

52 Ventriculoatrial/Ventriculoperitoneal Shunt 8000 3200 1600

53 Subdural Tapping 8000 3200 1600

54 Ventricular Tapping 8000 3200 1600

55 Abscess Tapping 8000 3200 1600

56 Vascular Malformations 8000 3200 1600

57 Peritoneal Shunt 8000 3200 1600

58 Atrial Shunt 8000 3200 1600

59 Meningo Encephalocele 8000 3200 1600

60 Meningo myelocele 8000 3200 1600

61 Ventriculo-Atrial Shunt 8000 3200 1600

62 Excision of Brain Abscess 8000 3200 1600

63 Aneurysm Clipping 8000 3200 1600

64 External Ventricular Drainage (EVD) 8000 3200 1600

65 Trans Sphenoidal Surgery 8000 3200 1600

66 Trans Oral Surgery 8000 3200 1600

67 Endoscopy Procedures 8000 3200 1600

68 Intra-cerebral Hematoma Evacuation 8000 3200 1600

69 Temporal Lobectomy 8000 3200 1600

70 Lesionectomy Type -1 8000 3200 1600

71 Lesionectomy Type -2 8000 3200 1600


Sr.

No. System

Package Rs.

Indicative

and upper

ceiling


and upper ceiling


and upper

ceiling 72 Temporal Lobectomy Plus Depth Electrodes 8000 3200 1600

73 Stay in General Ward @Rs. 500day 8000 3200 1600

74 Stay in Neuro ICU @Rs. 4000day 8000 3200 1600

75 Surgical Treatment (Up to) 8000 3200 1600

FOLLOWUP PACKAGES - MEDICAL

Sr.

No. Disease Package First

Instalment

Subsequent

3 Instalment

1 Acute Severe Asthma with Acute respiratory

failure

10000 4000 2000

2 COPD Respiratory Failure (infective exacerbation)

10000 4000 2000

Term baby with persistent pulmonary

3 hypertension Ventilation -HFO 6000 3000 1000

hyperbilirubinemia Clinical sepsis

4 Term baby with seizures ventilated 5000 2000 1000

5 Acute Severe Asthma with (Ventilated ) 4000 1600 800

6 Infective Endocarditis 10000 4000 2000

7 Meningo- encephalitis (Non Ventilated) 6500 2000 1500

8 Meningo- encephalitis ( Ventilated) 6500 2000 1500

9 Status Epilepticus 6500 2000 1500

10 Intra Cranial bleed 6500 2000 1500

11 Congenital heart disease with congestive

cardiac failure

5000 2000 1000

12 Acquired heart disease with congestive cardiac failure

5000 2000 1000

13 Steroid Resistant Nephrotic syndrome

Complicated or Resistant

5000 2000 1000

14 Anaemia of unknown cause 5000 2000 1000

15 Pyogenic meningitis 5000 2000 1000

16 Neuro Tuberculosis 5000 2000 1000

17 Neuro Tuberculosis with ventilation 5000 2000 1000

18 Convulsive Disorders/Status Epilepticus (fits)

5000 2000 1000

19 Encephalitis/Encephalopathy 10000 4000 2000

20 Acute Myocardial infarction 10000 4000 2000

21 Infective Endocarditis 10000 4000 2000

22 Complex Arrythmias 10000 4000 2000

23 Nephrotic Syndrome 5000 2000 1000

24 ADEM or Relapse in Multiple- sclerosis 5000 2000 1000

25 CIDP 5000 2000 1000

26 Haemorrhagic Stroke/Strokes 5000 2000 1000


Sr.

No. System

Package Rs.

Indicative

and upper

ceiling


and upper ceiling


and upper

ceiling 27 Ischemic Strokes 5000 2000 1000

28 NEUROINFECTIONS -fungal meningitis 5000 2000 1000

29 NEUROINFECTIONS - pyogenic

meningitis

5000 2000 1000

30 Meningoencephalitis (Including Herpes encephalitis)

5000 2000 1000

31 Neuromuscular (myasthenia gravis) 4000 1600 800

32 Interstitial lung diseases 10000 4000 2000

33 Pneumoconiosis 3500 1400 700

34 Pemphigus/Pemphigoid 6000 2400 1200

35 SLE (SYSTEMIC LUPUS

ERYTHEMATOSIS)

6000 2400 1200

36 SCLERODERMA 6000 2400 1200

37 MCTD MIXED CONNECTIVE TISSUE 6000 2400 1200

38 MCTD MIXED CONNECTIVE TISSUE 6000 2400 1200

39 VASULITIS 6000 2400 1200

40 Hypopitutarism 8000 3500 1500

41 pituitary – Acromegaly 6500 2000 1500

42 Delayed Puberty Hypogonadism (ex. Turners synd, kienfelter synd)

7000 2500 1500

43 Gastric Varices 7000 2500 1500

44 Chronic Pancreatitis with severe pain 7000 2500 1500

45 Cirrhosis with Hepatic Encephalopathy 7000 2500 1500

46 Cirrhosis with Hepato renal syndrome 7000 2500 1500


APPENDIX II

WORKING PATTERN

Health Camps Rural /Sub district /District/Women

Hospital and Primary Health Centre Accident sites Direct to Hospital

Online preauthorization by Insurance and

Society doctors of call center through

Arogyamitra of network hospital on same

day Admission and Treatment

Discharge & follow up

Online payment within 7 working days of discharge

Social Audit

Claim Processing

Billing

Preliminary Verification & Diagnosis


APPENDIX -III

AAROGYAMITHRA

Aarogyamithra is Friend of Health; Aarogyamithra is a concept unique to Rajiv Gandhi Jeevandayee Yojana. Aarogyamithras act as facilitators for the patients. In fact they form face of this insurance scheme.

Aarogyamithras are to be selected by the stakeholders of Self Help Group (SHG) movement / Local bodies i.e. Gram Panchayat, Municipality, Municipal Corporation/Government Hospital

in order to ensure performance efficiency and acceptability among local communities. The following qualifications are prescribed.

1. Graduate

2. Native & Resident of the same PHC area 3. Good communication skills

4. Prefers to move around the villages 5. Functional knowledge of computers

Help of local bodies and NGOs may be taken by the insurer to hire the services of local persons in each PHC / Rural / Sub district / General / District Hospital. The working of the Aarogyamithras will be monitored on a daily basis by the regional coordinators and district

coordinators of the Insurance Company in coordination with the Gram Panchayat, Municipality, Municipal Corporation, Civil Surgeon, District Administration, etc. All the

Aarogyamithras are to be provided with cell phones (CUG connection) by the Insurance Company for instant communication and networking. The Insurance Company shall also provide uniforms (Aprons compulsorily) for all Aarogyamithras.

The following table shows the indicative number of PHC‟s / Government Hospitals where Aarogyamithras are to be placed:

Districts Population Approx.no of Beneficiary Families

No. of

PHCs

No. of

RH

SDH

100

SDH

50 GH WH DH

Other Hosp. (Corporation/ra

ilway / Defense)

Medical College

Hospitals Total

Mumbai

City 3338031 482073

H.

posts-

182,

Disp =

162

0 0

0 0

Hospitals

-18

Medical

Colleges-4,

Dental=3,

Specialist Hospitals

=5 374

Mumbai

Suburban 8640419 1340828

Dhule 1707947 398000 41 7 1 1 0 0 0 0 1 51 Raigad 2207929 570000 55 11 1 2 0 0 1 0 0 70 Nanded 2876259 545000 64 12 1 2 0 0 0 0 1 80 Solapur 3849543 831000 77 16 1 2 0 0 0 0 1 97 Amravati 2607160 560000 56 12 1 2 0 1 1 0 0 73 Gadchiroli

970294 183000 45 10 0 3 0 0 1 0 0 59

Total 26197582 4909901 682 68 5 12 0 1 3 18 15 804

In addition to the above the Insurance Company has to select and post at least three Aarogyamithras in each Network Hospitals for round the clock monitoring of the patients. The total number will depend up on the exact number of the Network Hospitals. The

insurance Company shall follow the instructions of Rajiv Gandhi Jeevandayee Arogya Yojana Society in this regard.

Training of Aarogyamitras

Training for Aarogyamitras shall be done by the Insurance Company on the instructions of the society.


Role of Aarogyamitras in PHC / CHC / Government/ District Hospitals 1. ROLE OF PHC AROGYAMITHRAS

a) IN THE PHC / HOSPITAL

Publicity and awareness.

Maintain helpdesk at hospital. Receive the beneficiary. Verify the Beneficiary criteria. (Eligibility Criteria)

Facilitate consultation with Doctor (PHC Doctor / Nearest Govt. Hospital Doctor)

Fill up the referral card. Guide the patient to the next center. To counsel the patients who may require any one of the listed surgeries.

To facilitate either to a Government Hospital for further tests or to Network Hospital depending upon the advice of the doctor.

To guide the patient to Network Hospital. Follow-up the referred cases. In effect to act as, a guide and friend for the prospective beneficiary families

under Rajiv Gandhi Jeevandayee Yojana. Any work assigned by Rajiv Gandhi Jeevandayee Arogya Yojana Society from

time to time. b) OUTSIDE THE PHC / HOSPITAL

To send daily MIS of the patients.

To spread the awareness of the scheme in the villages. To spread the awareness about the scheduled camps by network hospitals in

the villages. To coordinate with network hospitals and help conduct camps. Mobilize the patients for camps.

Follow up the patients identified in the camp to report to network hospital. Coordinate with Civil Surgeons, Medical Superintendents, Gram Panchayat,

Municipalities, Corporations, ANMs, Women Health Volunteers and Self-Help Groups for effective implementation of the scheme.

Move around the villages and encourage patients to come to avail the benefits

of the scheme. Educate villagers about the scheme and distribute brochures and other material.

Keep in touch with the District Coordinator. Follow up the Beneficiary families before and after Surgery. Any work assigned by the Rajiv Gandhi Jeevandayee Arogya Yojana Society

from time to time. 2. ROLE OF DISTRICT HOSPITAL AAROGYAMITHRAS

Apart from the duties enlisted above the Aarogyamithras in District Hospitals will Facilitate the Patient for specialist consultation and tests. Fill up the referral card (part-B) properly.

Counsel the patient. Any work assigned by the Rajiv Gandhi Jeevandayee Arogya Yojana Society

from time to time. 3. ROLE OF AAROGYAMITHRAS AT NETWORK HOSPITAL

Maintain Help Desk at Reception of the Hospital.

Receive the patient referred from (PHC or Network). Work round the clock in shift to cater to the needs of emergencies.

Verify the documents of the patients. Obtain digital photograph of the patient. Facilitate the Patient for consultation and admission.


Liaison with coordinator / administration of the hospital. Counsel the patient regarding treatment / surgery.

Facilitate early evaluation and posting for surgery. Facilitate hospital send proper pre-authorization.

Follow-up preauthorization procedure and facilitate approval. Follow-up recovery of patient. Facilitate payment of transport charges as per the guidelines.

Facilitate cashless transaction at hospital. Facilitate discharge of the patient.

Obtain feedback from the patient. Counsel the patient regarding follow-up. Coordinate with PHC / Government Hospital Aarogyamithras for follow up of

beneficiary. Follow-up the patient referred by the hospital during the camps.

Coordinate with the head-Office and Medical officers for any clarifications. Send daily MIS. Facilitate Network Hospital in conducting Health Camps as scheduled.

Any work assigned by the Rajiv Gandhi Jeevandayee Arogya Yojana Society from time to time.


APPENDIX- IV

PROCEDURE FOR ENROLLMENT OF HOSPITALS

The Public and Private Hospitals will be jointly empanelled within the State of Maharashtra by Rajiv Gandhi Jeevandayee Arogya Yojana Society and Insurance Company following the

empanelment procedure lay down by Rajiv Gandhi Jeevandayee Arogya Yojana Society. The hospitals having minimum of 50 inpatient hospital beds with adequate facilities and offering

the services as stipulated below shall be empanelled after being scrutinized and recommended by the Empanelment and Disciplinary Committee. Empanelment and Disciplinary Committee will constitute four doctors. Two doctors will be nominated by

Insurance Company and two by Rajiv Gandhi Jeevandayee Society. The minimum number of inpatient beds criteria will not be revised from 50. It would be the responsibility of the

Insurer for enrolment of Network Hospitals in the State of Maharashtra to give adequate facilities for the treatment of the patients when they present themselves.

PROCEDURAL STEPS FOR ENROLLMENT OF HOSPITALS/NURSING HOME:

i. Advertise for seeking on line expression of interest from the public and private hospitals

ii. Preparation of the short list of the hospitals qualifying eligibility criteria iii. Inspections by joint panel of 4 Physicians to the eligible hospitals for confirmation

of eligibility and capacity. iv. Joint panel of 4 Physicians to recommend the eligible for hospital for specific

packages

v. RGJAY / Selected Insurer would approve the recommendations vi. Send invitation to the administrator of selected hospital for signing MoU. vii. Signing of MoU between Network Hospitals and Insurer. (Please refer Appendix )

(It is worth noting that the procedure of empanelment of hospitals would be ongoing.) Hospital / Nursing Home: means any institution in Maharashtra established for indoor

medical care and treatment of disease and injuries and should be registered under Bombay Nursing Home Registration Amendment (2005) Act and Public Hospitals.

A. Infrastructure and Manpower (General):

a. Should have at least 50 inpatient medical beds with adequate spacing of 65 sq. feet per

bed with qualified and registered paramedical staff. b. Should have Separate Male and Female General Wards.

c. Hospital should be fully equipped and engaged in providing Medical and Surgical facilities for the specialty for which it is to be empanelled.

d. In-house round the clock basic diagnostic facilities. (May also have link facilities for

high end tests like MRI, CT Scan etc.) e. Fully equipped Operation Theatre of its own wherever surgical operations are carried

out with qualified and registered nursing staff under its employment round the clock. f. Post-op ward with ventilator and other required facilities. g. ICU facility with requisite staff.

h. Fully qualified doctors of modern medicine should be physically in charge round the clock.

i. Casualty with Duty doctor and nursing staff. j. Availability of trained / Qualified / registered paramedics. k. Round the clock availability of specialists in the concerned specialties of support fields

within short notice. l. Shall be able to facilitate round the clock advanced diagnostic facilities either in-

House or with Tie-up with a nearby Diagnostic Center. m. Shall be able to facilitate round the clock Blood Bank facilities either In-house or with

Tie-up with a nearby Blood Bank.


n. Shall be able to facilitate round the clock Ambulance facilities either own or with Tie-up with a nearby Service Provider.

o. Maintaining complete record as required on day-to-day basis and is able to provide necessary records of the insured patient to the Insurer or his representative as and

when required. p. Having sufficient experience in the specific identified field. q. Shall have all necessary infrastructure required for preauthorization round the clock.

r. Should have at least 50 inpatient medical beds with adequate spacing and supporting staff as per norms. 25% beds should be reserved for beneficiary families under Rajiv

Gandhi Jeevandayee Arogya Yojana exclusively apart from legal provisions. (At least 12 beds or 25% of total beds whichever is more) In case of charitable hospitals 10 % beds should be reserved for indigent and 10% for economically weaker sections. Out

of remaining 80% beds 25% beds should be reserved for beneficiary families under Rajiv Gandhi Jeevandayee Arogya Yojana exclusively.

s. Shall have round the clock laboratory facilities either In-house or with Tie-up with a nearby laboratory with qualified pathologist either in-house or with tie up.

t. Hospital should have line list of procedures carried out in following proforma.

1) Name of patient 2) Age 3) Sex 4) Address 5) Diagnosis 6) Name of surgery /

Treatment.7) Date of admission 8) Date of discharge.

B. Infrastructure and Manpower (Specific):

a. For Empanelment of Cancer Therapy

Services of fully qualified Medical Oncologist, Radiation Oncologist and Surgical

Oncologist - all or either and equipment for Cobalt therapy, Linear accelerator and Brach therapy – all or either to be empanelled for Cancer Surgeries and Chemo and Radio-Therapies.

Hospital should have qualified and registered oncologist, oncosurgeon and Radiotherapists. Tumour board comprising of qualified and registered oncologist,

oncosurgeon and Radiotherapists will decide comprehensive treatment plan of patient. If hospital has no Radiotherapy equipment and Radiotherapist it should have tie up with nearest Radiotherapy center.

Note: A combination of both professional and the equipment is essential.

b. For Empanelment of Poly Trauma

Shall have Emergency Room Setup with round the clock dedicated duty

doctors of Modern Medicine. Shall have round the clock anesthetist services

Shall be able to provide round the clock services of Neurosurgeon, Orthopedic

Surgeon, CT Surgeon and General Surgeon, Vascular Surgeon and other support specialties.

Shall have dedicated round the clock Emergency operation theatre, Surgical ICU, Post-Op Setup with qualified and registered staff.

Shall be able to provide necessary cashless diagnostic support round the clock

including specialized investigations such as CT, MRI, Emergency biochemical investigations.

c) For Empanelment of Pediatric Congenital Malformations and Post-Burns

Contractures

Shall have Services of qualified specialists in the field Viz. Pediatric Surgeon, Plastic Surgeon with dedicated theatres, post-operative setup and staff.

d) For Empanelment of Prostheses (Artificial limbs)

Shall have full time services of Orthopedic Surgeon and Prosthetic and orthotic Engineer or technician to be empanelled to provide prostheses package under

the scheme.


Shall facilitate supply, fitting of appropriate prosthesis and gait training of patient by physiotherapist / Occupational therapist.

Shall ensure that an appropriate prosthesis is prescribed based on occupation of the person and standard prosthesis is supplied as per quality norms of BIS

(Bureau of Indian Standards). Shall also facilitate free replacement of leather parts and ensure total

replacement of Prosthesis in case of damage during guarantee period of 3

years. And

e) Hospital shall provide following amenities for the beneficiary families:

1. Provide space and separate Rajiv Gandhi Jeevandayee counter/ kiosk as per the design for Aarogyamitras (Health Coordinators)

2. Provide Computer with networking (dedicated broadband with minimum 1 mbps speed), printer, scanner, biometric reader and digital camera.

3. Provide free food for the patient including includes morning tea, breakfast, lunch, afternoon tea at 4 PM and dinner. Type of diet should be according to guidance of concerned treating specialist and qualified dietician.

4. Provide one time transport / transportation charges for patient equivalent to State Transport fare or ordinary class of Railway fare from network hospital to

taluka headquarter. 5. Free OPD consultation. 6. Free diagnostic tests and medical treatment required for beneficiary families

irrespective of surgery. 7. Provide the round the clock services of a dedicated Medical Officer to work as

Rajiv Gandhi Jeevandayee Medical Coordinator (MCO) for the scheme and he will be responsible to Rajiv Gandhi Jeevandayee Arogya Yojana Society and the Insurer for doing various activities under the scheme including Health

Camps, Follow-up of referred patients form camps, diagnosis, outpatient details, E-Preauthorization, Surgeries, Feedback on the patient‟s condition and

services offered by the hospital during hospital stay of the patients, discharges, deaths if any, follow-up free consultation of the patients and distribution of medicines after discharge etc. The Insurance Company shall

provide CUG (Closed User Groups) Connection to all MCOs. Selection of hospital for treatment will be according to choice of patient subject to

availability of beds in that selected hospital. 8. Provide follow-up with free consultation diagnostics and medicines. 9. Minimum one free Health Camp in village in a fortnight for the screening of

the Beneficiary families patient suffering from the identified ailments. Hospital may have a mobile team with diagnostic equipment and team of

doctors as specified by the Rajiv Gandhi Jeevandayee Arogya Yojana Society for this purpose. Villages shall be identified by the society in consultation with district administration and communicated to the hospitals / insurance

company. Hospital shall provide services of Rajiv Gandhi Jeevandayee medical Camp Coordinator (MCCO) for organization of health camps. The

Hospital shall follow the camp policy of the society. The Insurance Company shall provide CUG Connection to all MCCOs.


APPENDIX- V

ACTIVITY CHART FOR INSURANCE COMPANY



award date

Identifying the Project Officer Tasks will be completed within 7

days of awarding contract

Setting up of Project Office with infrastructure in MCGM limits

Tasks will be completed within 30 days of awarding contract

Appointment of Medical Officers Tasks will be completed before

commencement of scheme i.e. 2 October 2011

Establishment of other staff Tasks will be completed before


Preparatory meeting with hospitals Tasks will be completed before commencement of scheme i.e. 2

October 2011

Inspection of hospitals vis-à-vis scheme requirements, identification of Rajiv Gandhi Jeevandayee Medical

Coordinator(RJMCCO), signing of MOU and Empanelment of Hospitals

Tasks will be completed before commencement of scheme i.e. 2

October 2011

Issue of CUG connections to RJMCOs and RJCCOs Tasks will be completed before commencement of scheme i.e. 2

October 2011

Installation of kiosk, computer and accessories and 1 mbps connectivity

Tasks will be completed before commencement of scheme

Printing & distribution of publicity material Tasks will be completed before


Printing & distribution of stationery related to work

flow of the scheme.

Tasks will be completed before


Appointment of Aarogyamithras

In PHCs / Govt. Hospitals

In Network Hospitals



Training of Aarogyamithras, distribution of Aprons

and CUG mobiles


commencement of scheme

Training of Doctors Tasks will be completed before commencement of scheme

Training of other staff Tasks will be completed before


IT enabling Immediate

Establishment of 24 Hrs. Call Center Tasks will be completed before


Establishment of other infrastructure Tasks will be completed before commencement of scheme i.e. 2

October 2011

Establishment of infrastructure in the districts Tasks will be completed before




award date


Preparatory meetings and trainings at district level for inaugural mega-camps

Tasks will be completed 20 days before commencement of scheme

i.e. 2 October 2011

Handing over of adequate space for office of Rajiv Gandhi Jeevandayee Society in the jurisdiction of

Municipal corporation of Greater Bombay.

Tasks will be completed before commencement of scheme i.e. 2

October 2011


APPENDIX VI

HEALTH CAMP POLICY

Health camps are main source of mobilizing beneficiary families under the scheme. Effective conduct of health camps is key to success of scheme.

Activities

1. IEC Activities by network hospitals through

Pamphlets, posters, banners.

Public address system.

Drumbeating.

Audiovisual media – TV, Local cable.

SHG, Village meetings.

Exhibitions.

2. Facilities in camp

Shade in form of shamiyana.

Pedestal fans.

Sitting arrangement in form of chairs.

Snacks and drinking water.

3. Treatment of minor ailments List of common drugs. No Category Sr No Form Drug Strength Min Qty

1 Anti-inflammatory/

Antipyretic/Analgesic

1 Tab Ibuprofen 400 mg 500

2 Tab Paracetamol 500 mg 1000

3 Tab Aspirin 300/500

mg

500

4 Tab Diclofenac Sodium 100 mg 1000

2 Antiallerg ic 5 Tab Chlorpheneramine

maleate

4mg 5000

3 Antiamoebic 6 Tab Metronidazole 400 mg 800

4 Antihelminthic 7 Tab Albendazole 400mg 100

5 Antibiotic 8 Tab Nofloxacin 400 mg 1000

9 Tab Ciprofloxacin 500 mg 5000

10 Cap Ampicillin 250 mg 500

6 H1 Antagonist 11 Tab Ranit idine 150 mg 1000

7 Antacid 12 Tab Antacid 2000

8 Vitamin and iron

supplement

13 Tab Multivitamin 2000

14 Tab Iron+Folic acid 2000

15 Tab B-Complex 1000

16 Tab Vit – C 500 mg 1000

17 Cap Vit A and D 2000

9 For Children 18 Syrup Paracetamol 125mg/5

ml

20

19 Syrup Ampicillin 125mg/5

ml

10

20 Syrup Antitussive 20

4. Other Activities

1) Provide treatment for common ailments and common drugs in the camps and

prevent spread of communicable diseases.

Provide free consultation for ailments other than those covered under the

scheme.

Provide common drugs for general ailments as indicated in the list below.

Hospital shall carry at least 10 types of drugs from the above list and should have at least one drug from each category.


Distribution of all drugs for children ( Category 9) is mandatory.

Stock of above drugs must be carried to the camp, however hospitals are free to distribute more number of drugs.

Minimum Rs 1500 worth medicines must be carried to the camp.

Hospitals may carry generic drugs instead of proprietary preparations to keep

cost of medicines low. 2) Network hospitals to provide professional incentives to Government Doctors participating in the camp to encourage their active participation and cooperation. Each

Medical officer has to be given incentives of Rs 250. At least two Medical officers from one network hospital or four medical officers if camp is organized by two

network hospitals should attend the camp. Each network hospital shall pay incent ive for two medical officers.

5. Allocations

In order to encourage the above activities in the camps by network hospitals, Government has decided to provide financial support to the hospitals through RGJAY society to the tune

of Rs 5000 for each camp and activity wise allocation of said amount is as listed below.

Sr No

Activity Amount allocated in Rs

1 IEC Activity 1500

2 Basic necessities to patients such as shamiyana, chairs, water, fans,

snacks etc.

1500

3 Providing common drugs to patients as indicated in the list 1500

4 Incentive to Government Medical officers 500

Total 5000

6. Confirmation of camps, indenting, approval, organizing, claiming and reimbursement of

amount. The entire process of intimation, confirmation, indenting, details of camp organization and claiming of money will be through health camp module in the RGJAY society website.

The RGJAY society will communicate the schedule of camps well in advance and same will be available online in the login of hospital for confirmation.

Confirmation and indenting – The details of Doctors and paramedics and equipment to be carried attending camp shall also be indicated online. The indent for each camp should be

put up by each hospital online as under. o Details of IEC activities with specific proposals and estimated amount.

o Details of facilities to be provided. o Details of common drugs to be distributed. o Incentives to be given to Government Medical officers with names of

Medical officers tied for camp.

Approval – Based on indent RGJAY society will approve amount subject to 5000 rupees

per hospital per camp. The approval status can be viewed online. Approved amount can be denied in case of rescheduling camp after confirmation.

Organizing the camp – The hospital shall conduct camp as per schedule. Hospital should

ensure that an Arogyawardhini Medical Camp Coordinator (MCCO) is earmarked for the purpose and sent to campsite to undertake camp IEC activities and arrange for facilities

provided for the camp.

Documentation for camp

Each patient is given OPD card. The diagnosis and treatment is mentioned on card.

Medicines are given as per prescription and details mentioned in drug dispensing register.


The signature and thumb impression of patients in Annexure B is scanned and uploaded at the time of claiming camp amount.

The referral card is given to patients to patients who are referred under the scheme with details of hospital referred, name of consultant, mobile number of

network arogyamithra in Annexure C. The details of outpatients referred and patients will be recorded, a copy of same

is signed by Government Medical officer, Medical officer of network hospital

and Arogyamithra of network hospital and same is scanned and uploaded online at the time of claiming camp amount.

Incentives given to Government Medical officer is obtained in acquaintance in Annexure E.

MCCO of network hospital shall also take declaration as to successful conduct

of camp signed by MO PHC, Arogyamitra of concerned PHC. Network hospital shall also upload it for claim. Annexure F.

Utilization certificate shall be claimed online Annexure G. Reimbursement – RGJAY society based on uploaded and submitted documents

will reimburse the amount once in a month.

7. Role of District Administration in conducting the camps.

1. Spreading awareness of camp.

2. Camp inaugurated by Local MLA and all Public representatives are informed regarding camp.

3. Drinking water to be arranged by panchayat. 4. Snacks for doctors and staff to be arranged by arogyamitras or Medical officers. Cost

will be borne by network hospital.

5. Two MOs from Government and two from network hospital should be deputed for camp.

6. DMHOs shall take necessary steps to distribute common medicines. 7. The patients referred from camps are followed to report to network hospital by

Arogyamithras of PHC and Network hospital.

8. District coordinator of RGJAY society and insurance company should speak to AMCCO of network hospital and ensure that all activities are taking place.


APPENDIX VII

DRAFT MOU BETWEEN INSURER AND NETWORK HOSPITAL

MEMORANDUM OF UNDERSTANDING

RGJAY – PHASE I

This Agreements is made at Mumbai on this ______ the day of ___ 2011 between ____________________ INSURANCE COMPANY LTD., a Company incorporated under

the Companies Act 1956 and having its Registered & Corporate Office at ________________________represented by _________________________hereinafter

referred to as “Insurer” which expression shall unless it be repugnant to the context or meaning thereof shall deem to mean and include its successors and assignees of the ONE PART

AND _______________________________________________ rep by

Managing Superintendent / Director / Proprietor and having its Registered Office at _________________________________________________________________________________________________________________________________________ hereinafter

referred to as PROVIDER which expression shall unless it be repugnant to the context or meaning thereof be deemed to mean and include its successors and assignees of the OTHER

PART. WHEREAS, Insurer is an insurance company licensed under IRDA to transact Health, Accident and Overseas Medical Insurance, Providing Healthcare insurance coverage to its

Insured / Beneficiary families having got the mandate from the Government of Maharashtra to cover yellow ration card holders (“BPL”) and Orange card holdersne (APL) belonging to 8

(eight) districts namely, Mumbai city, Mumbai Suburban District, Dhule, Raigad, Solapur, Nanded, Amravati, and Gadchiroli, of the State of Maharashtra (“Beneficiary families”) against specified surgical / Therapeutic procedures (972 procedures and 121 follow up

procedures) for which purpose Insurer has created a network of service Providers . ________________________________________________ desires to join the said network of

Providers and is willing to extend cashless medical facilities for the surgical / Therapeutic procedures as per “RGJAY Manual on Surgical & Medical Treatments for Cashless Treatment of BPL and APL Population of RGJAY society to members of Below Poverty

Line (BPL and APL ) families identified either by RGJAY Health Card or yellow / orange Ration Card and referred to them by the Insurer under the RGJAY Health Insurance Scheme

of the Government of Maharashtra. Now this agreement witnesses as under. Article 1: Definitions

1.1 „RGJAY society‟: RGJAY Health Care RGJAY society.

1.2 „IRDA‟: Insurance Regulatory and Development Authority. 1.3 „Hospital‟: Hospital Registered under Bombay Nursing Home Act with minimum 50

beds. HOSPITAL / NURSING HOME:

Means any Government institution or Private institution in Maharashtra established for

indoor medical care and treatment of disease and injuries and should be registered under Bombay Nursing Home Registration ( Amendment 2005) Act and PNDT Act

(Wherever Applicable). II. Infrastructure and Manpower (General):

a) Should have at least 50 inpatient medical beds with adequate spacing and

supporting staff as per norms. b) Should have Separate Male and Female General Wards

c) Fully equipped and engaged in providing Medical and Surgical facilities for the respective specialties


d) In-house round the clock basic diagnostic facilities for biochemical, Pathological and radiology tests such as Calorimeter/ Auto analyzer, Microscope, X-ray, E.C.G,

USG.etc. e) Fully equipped Operation Theatre of its own wherever surgical operations are

carried out with qualified nursing staff under its employment round the clock. f) Post-op ward with ventilator and other required facilities g) ICU facility with requisite staff

h) Fully qualified doctor(s) of modern medicine should be physically in charge round the clock.

i) Casualty/duty doctor/Appropriate nursing staff j) Availability of Qualified/trained paramedics k) Round the clock availability of specialists in the concerned specialties and support

fields within short notice. l) Shall be able to facilitate round the clock advanced diagnostic facilities either In-

House or Tie-up facility with a nearby Diagnostic Center m) Shall be able to facilitate round the clock Blood Bank facilities either In-House or Tie-up facility with a nearby Blood Bank

n) Shall be able to facilitate round the clock Ambulance facilities either own or Tie-up facility with a nearby Service Provider

o) Maintaining complete record as required on day-to-day basis and is able to provide necessary records of the insured patient to the Insurer or his representative as and when required.

p) Having sufficient experience in the specific identified field q) Shall have all necessary infrastructure required for preauthorization round the clock

r) Shall have round the clock laboratory facilities either In-house or with Tie-up with a nearby laboratory with qualified pathologist either in-house or with tie up. s) Hospital should have line list of procedures carried out in following proforma.

1) Name of patient 2) Age 3) Sex 4) Address 5) Diagnosis 6) Name of surgery / Treatment.7) Date of admission 8) Date of discharge.

III. Infrastructure and Manpower (Specific)

For Empanelment of Cancer Therapy

Services of fully qualified Medical Oncologist, Radiation Oncologist and Surgical

Oncologist – all or either and equipment for Cobalt therapy, Linear accelerator and Brachy therapy – all or either to be empanelled for Cancer Surgeries and Chemo and

Radio-Therapies. Hospital should have qualified and registered oncologist, oncosurgeon and Radiotherapists. Tumour board comprising of qualified and registered oncologist, oncosurgeon and Radiotherapists will decide comprehensive

treatment plan of patient. If hospital has no Radiotherapy equipment and Radiotherapist it should have tie up with nearest Radiotherapy center.

Note: A combination of both professional and the equipment is essential. b. For Empanelment of Poly Trauma

1. Shall have Emergency Room Setup with round the clock dedicated duty doctors of

Modern Medicine. 2. Shall have round the clock anesthetist services

3. Shall be able to provide round the clock services of Neurosurgeon, Orthopedic Surgeon, CT Surgeon and General Surgeon, Vascular Surgeon and other support specialties.

4. Shall have dedicated round the clock Emergency theatre, Surgical ICU, Post-Op Setup with qualified staff.

5. Shall be able to provide necessary cashless diagnostic support round the clock including specialized investigations such as CT, MRI, emergency biochemical investigations.


c. For Empanelment of Pediatric Congenital Malformations and Post-Burns

Contractures

Shall have services of qualified specialists in the field Viz., Pediatric Surgeon, Plastic Surgeon with dedicated theatres, post-op setup and staff.

d. For Empanelment of Prostheses (Artificial limbs)

1. Shall have full time services of Orthopedic Surgeon to be empanelled to provide prostheses package under the scheme.

2. Shall facilitate supply, fitting of appropriate prosthesis and gait training of patient by physiotherapist.

3. Shall ensure that an appropriate prosthesis is prescribed based on occupation of the person and standard prosthesis is supplied as per quality norms of BIS (Bureau of Indian Standards).

4. Shall also facilitate free replacement of leather parts and ensure total replacement of Prosthesis in case of damage during guarantee period of 3 years.

and

IV. Hospital shall provide following additional benefit to the BPL (Ye llow ration

card holder) and APL (orange ration card holders with Annual income < Rs.

100000) beneficiary families related to identified systems:

a. Provide space and separate RGJAY counter/kiosk as per the design for

Aarogyamithras. b. Provide Computer with networking (dedicated broadband with minimum 1mbps speed), printer, scanner, bar code reader and digital camera.

c. Provide free food for the patient d. Provide transport/transportation charges for patient.

e. Free OPD consultation. f. Free diagnostic tests and medical treatment required for beneficiary families irrespective of surgery.

g. Provide the services of a dedicated Medical Officer to work as Rajiv Gandhi Jeevandayee Medical Coordinator (MCO) for the scheme and he will be responsible to

the Society and the Insurer for doing various activities under the scheme including Health Camps, Follow-up of referred patients from camps, diagnosis, outpatient details, E-preauthorization, Surgeries, Feedback on the patient‟s condition and services

offered by the hospital during hospital stay of the patients, discharges, deaths if any, follow-up free consultation of the patients and distribution of medicines after

discharge etc. The Insurance Company shall provide CUG (Closed User Groups) Connection to all MCOs. h. Provide follow-up free consultation diagnostics and medicines under follow-up

packages for 121 identified procedures annexed at provided under the scheme, the package amount will be directly reimbursed to the hospital by the Society.

i. Minimum one free Health Camp in village in a week for the screening of the BPL patient suffering from the identified ailments. Hospital may have a mobile team with diagnostic equipment and team of doctors as specified by the Society for this purpose.

Villages shall be identified by the Society in consultation with district administration and communicated to the hospitals/insurance company. Hospital shall provide services

of Medical Camp Coordinator (MCCO) for organization of health camps. The Hospital shall follow the camp policy of the Society. The Insurance Company shall provide CUG Connection to all MCCOs.

1.4 „Network Hospital‟ / NWH: Hospital empanelled under RGJAY. 1.5 „MOU‟: Memorandum of Understanding between the Insurance & Empanelled Hospital.

1.6 „Surgery / Surgeries‟: means cutting abrading, suturing, laser or otherwise physically changing body tissues and organs by qualified medical doctor who is authorized to do so


1.7 „Therapy / Therapies‟: Standard way of medical treatment to the patient as per the medical protocols of Allopathic medicine.

1.8 „Treatment‟: Medical management by qualified Doctor in the Network Hospital. 1.9 „Aarogyamitra‟: First contact person for RGJAY patient at Network Hospital.

1.10 MCOs (RGJAY Medical Coordinator) - Medical Coordinator from the Network Hospital with minimum MBBS qualification to coordinate with RGJAY society / Insurer 1.11 „MCCOs‟ an Officer designated as RGJAY Medical Camp Coordinator for the scheme

to coordinate with RGJAY society / Insurer through Arogyamitra. 1.12 „IEC‟: Information, Education & Communication.

1.13 „TAT‟: Turn Around Time. 1.14 „Per-Authorization‟: Pre-Authorization is a process by which an Insured Person obtains written approval for certain medical procedures or treatments, from RGJAY society /

Insurance. 1.15 „EDC‟: Empanelment & Disciplinary Committee.

Article 1a: Effective Date

1a. This agreement will be in force for a period of one year from 02.10.2011 to 01.10.2012 for Phase I. Renewal or unit otherwise terminated as provided for in this

MOU an shall be extended by mutual consent under same and conditions. 1b. In case of Renewal intimation of Scheme by the insurer, the Provider agrees to extend

services to beneficiary families of RGJAY Scheme beyond the effective date until otherwise terminated and all the services rendered by the Provider shall be considered for subsequent renewal period.

Article 2: General Provisions

2.1 General Undertaking:

Provider warrants that it has all the required facilities for performing the enlisted surgeries / procedures / therapies as specified in clause. No. 3 2.2 Minimum Bed Strength and Specialty Wise Bed Capacity

Provider declares that the hospital has the required number of bed capacity (50) under the scheme and will declare the specialty wise allocation of beds in the Performa submitted below

and uploaded in RGJAY society portal.

Total Bed Strength

Code Specialty Total No. of Beds

S1 General Surgery

S2 ENT

S3 Ophthalmology

S4 Gynecology & Obstetrics

S5 Orthopedics

S6 Surgical Gastroenterology

S7 Cardio Thoracic Surgery

S8 Pediatric Surgery

S9 Genito Urinary Surgery

S10 Neuro Surgery

S11 Surgical Oncology

S12 Medical Oncology

S13 Radio Oncology

S14 Plastic Surgery

S15 Polytrauma

S17 Prosthesis

M1 Critical Care

M2 General Medicine


Total Bed Strength

Code Specialty Total No. of Beds

M3 Infectious Diseases

M4.1 Pediatric Intensive Care

M4.2 Neonatal Intensive Care

M4.3 Pediatric General

M5 Cardiology

M6 Nephrology

M7 Neurology

M8 Pulmonology

M9 Dermatology

M10 Rheumatology

M11 Endocrinology

M12 Gastroenterology

M 13 Interventional Radiology

2.3 Allocating minimum 25% of beds in network hospital for RGJAY patients:

Provider agrees to provide at least 25 % of their bed capacity available for occupation by RGJAY patients for treatment under each specialty available in the hospital and under which

the procedures are covered in the RGJAY Scheme.

2.4 Conduct of OP services:

2.4.1 Provider agrees provide separate OP facilities for RGJAY patients. To be manned by

“Medical Coordinator” of the hospital (MCO) and Aarogyamitra(s). 2.4.2 Provider agrees to do general counseling for all OP patients to ascertain their eligibility under RGJAY to avoid later conversion of cash patients at a later date.

2.5 Conversion of cash patients into RGJAY:

Provider agrees to take a declaration from patient at the time of admission itself on the

applicability or otherwise of RGJAY in his/her case. In emergency / trauma cases, patients may be allowed 48 hours after admission to claim RGJAY benefit. 2.6 Online Updating of Bed Occupancy:

Provider agrees to upload the bed occupancy under each specialty for which hospital is empanelled as and when required.

2.7 The first point of contact for all the patients (out patients and in patients) coming under the Scheme will be the Aarogyamitra positioned at Network Hospital. 2.8 The Provider agrees to follow ALL the guidelines in rendering the services to RGJAY

patient annexed hereto as part & parcel of this MOU. The Provider also agrees to follow and adhere to the guideline issued by the RGJAY society / Insurer from time to.

2.9 The Provider agrees to follow & adhere to the ON-LINE workflow of the RGJAY community Insurance Scheme in providing services to RGJAY patients. 2.10 Eligibility Criteria:

The provider agrees to follow the guidelines on eligibility criteria for admission of patients under RGJAY Health Scheme as mentioned here under and the Following guidelines are re-

emphasized by the RGJAY society to be followed by Network hospital in cases where clarifications are sought. No Situation Requirement for benefit

1 No Health Card with beneficiary

Valid Yellow or Orange Ration Card coupled with Aadhaar

number and in case Aadhaar number not taken any Photo ID

card issued by Govt. agencies ( Driving license, election identity

card with photograph) to correlate the patient name &

photograph. (In instance of emergency ad mission, provisional

preauthorization may be given subject to confirmation of it

against submission of photo identity before discharge.)


2

Children born after issue of card i.e . name

and photo not available on card or valid

yellow/Orange ration card

Photograph of child with either parent along with Health card/

valid Yellow or Orange ration card of either parent and Birth

certificate issued by hospital or other authorized entit ies

3

Name is there in Yellow or Orange Ration

Card and matches with name in photo

identity. But the card is invalid as it does

not match with the digitized list.

Not eligib le fo r benefit package

(The yellow /Orange ration card is cancelled after verification

by department but still the family is holding it)

Satisfactory Performance Certificates from the clients of institutions must be submitted with no adverse reports. These certificates shall be from the clients/end users where diet services were provided.

Article 3: Specialty / Specialties Empanelled for

3.1 Provider hereby declares that the hospital has requisite infrastructure as per RGJAY

guidelines in relation to specialty services for which empanelment is done and agrees to provide quality diagnostic and treatment services as per the standard protocols.

3.2 Provider hereby declares that hospital did not exclude any other specialty service

deliberately from the scheme inspire of having such facility and agrees to empanel for the specialties for which adequate infrastructure is available.

3.3 The Hospital hereby declares that the bed capacity of the hospital is more than 50 with adequate infrastructure and manpower as per standard guidelines and agrees to provide separate male and female wards with toilet and other basic amenities.

3.4 The Hospital declares that it has a well-equipped ICU to meet the emergency requirements of the patients belonging to all categories empanelled for and agrees to

facilitate round clock diagnostic and specialist services as per the requirement mentioned in clause 4.

3.5 Specialties Provider agrees not to refuse admission of RGJAY patient in any specialty

where it has consultants and equipment. A minimum of 25% of overall bed capacity and of beds in each specialty have to be made available to RGJAY patients in network

hospital. 3.6 Provider agrees to follow the guidelines issued by the RGJAY society / Insurer on

specific specialties annexed herewith (Refer Annexure V, XXVII)

Article 4: Empanelment

4.1 Infrastructure and Manpower (General):

Well-equipped theatre Casualty / 24 hrs. duty doctor / Appropriate nursing staff Availability of trained paramedics

Post-op ward with ventilator and other required facilities. ICU with concerned specialty

Round the clock lab and image logy support Availability of specialists in support fields. Facilities for Interventional Radiology and availability of concerned specialist.

4.2 Infrastructure and Manpower (Specific):

Provider agree to provide to provide the services the services of fully qualified

Medical Oncologist, Radiation Oncologist and Surgical Oncologist –and equipment for Cobalt therapy, Linear Accelerator and Brach therapy – to be empanelled for Cancer Surgeries and Chemo and Radio-Therapies.

Note: A combination of both professional and the equipment is essential. If equipment for

Radiotherapy are not available, there should be tie up with nearest Radiotherapy center. Chemotherapy and Radiotherapy should be administered only by professionals well

versed in dealing with the side-effects that the treatment can cause.


Patients with Hematologic malignancies (Ex Leukemia, Lymphomas and Multiple Myeloma) and Pediatric malignancies (Any patient < 14 years of age) should be

treated by qualified by medical oncologist. Chemotherapy has to be administered to the patient as in-patient treatment only.

Provider agrees to provide the services as per the packages and adhere to the treatment protocols (Refer Annexure-IV)

The Service Provider will agree to quote batch no. of the drugs and attach empty vials

and ampoules with labels intact along with the bills. The Provider will agree to give patients feedback through Multimedia having webcam

and mike. The provision for live viewing of the patient will be provided in the RGJAY society portal.

4.4 For Empanelment of Poly Trauma :

The Provider will have Emergency Room Setup with round the clock dedicated duty doctor.

Provider will have round the clock anesthetist services. Provider will be able to provider round the clock services of Neuron-surgeon,

Orthopedic Surgeon, CT Surgeon and General Surgeon, Vascular Surgeon and other

support specialties. Provider will have dedicated round the clock Emergency theatre, Surgical ICU, Post-

Op Setup with qualified staff. Provider will be able to provide necessary cashless diagnostic support round the clock

including specialized such as CT, MRI, emergency biochemical investigations.

Provider should put all necessary infrastructure required for preauthorization round the clock.

4.5 For Empanelment of Pediatric Congenital Malformations and Post-Burns

Contractures: Provider will have services of qualified specialists in the field Viz., Pediatric Surgeon

with dedicated theatres, post-op setup and staff. 4.6 For Empanelment of Prostheses (Artificial limbs)

The hospital shall have full time services of Orthopedic Surgeon to be empanelled to provide prostheses package under the scheme.

Hospital shall facilitate supply, fitting of appropriate prosthesis and gait training of

patient by physiotherapist. Hospital shall ensure that an appropriate prosthesis is prescribed based on occupation

of the person and standard prosthesis is supplied as per quality norms of BIS (Bureau of Indian Standards).

Hospital shall also facilitate free replacement of leather parts and ensure total

replacement of Prosthesis in case of damage during guarantee period of 3 years. 5.7. For empanelment of laboratory services, the signatory should essentially be a

qualified pathologist 5.8. For empanelment of Cancer treatment, the facility should have tumour board

which decides comprehensive treatment plan of patient. Tumour board should

consist of qualified oncologists, oncosurgeon. Linkage to Referral facility for radiotherapy would be permissible.

Article 5: Specialties for which empanelment is done

No. Specialty Service Available /

Not

Available

Specialist

Name

Qualification

SURGICAL SPECIALTIES

1. General Surgery

Qualified General Surgeon with post



Not

Available

Specialist

Name

Qualification

graduate degree in General Surgery

Well Equipped theatre facility with trained staff

Post-op with Ventilator Support

SICU Facility

Availability of support specialty of

General Medicine, Pediatrics.

1a. For Laparoscopic Surgeries

Surgeon having requisite training and having performed at least 100 procedures

for laparoscopic surgery (documentary evidence to be produced)

2. Orthopedic Surgery

Qualified Orthopedic Surgeon

Well-equipped theatre with C-Arm

facility

Trained paramedics

Well-equipped Post-op facility with Ventilator Support

Round the clock lab support with CT,MRI

3. Gynecology and Obstetrics

Qualified Gynecologist

Expertise trained in laparoscopic procedure with minimum 100 performances

Well Equipped theatre

Post-op ventilator & Pediatric reconstruction facilities.

Support services of Pediatrician

4. Ophthalmology

Qualified Ophthalmologist , trained vireo

Retinal and orthotics Surgeon

Optometry facility

Well-equipped theatre facility

5. ENT

Qualified ENT Surgeon

Well-equipped theatre

Post-op with ventilator support

Audiology support

6. Cardio-thoracic surgery

CT Surgeon

CT theatre

Cath –lab

Cardiologist support


ICCU

Other cardiac infrastructure

7. Plastic Surgery



Not

Available

Specialist

Name

Qualification

Qualified Plastic Surgeon with MCh in plastic surgery or other equivalent degree recognized by MCI

Well Equipped Theatre

SICU

Post-op rehab / Physio-therapy support

8. Neurosurgery

Qualified Neuro-Surgeon (M.Ch. Neurosurgery or equivalent

Well Equipped Theatre with qualified

paramedical staff

Neuro ICU facility


Step down facility

Facilitation for round the clock MRI, CT and other support bio-chemical

investigations

9. Urology

Qualified urologist

Well-equipped theatre with C-ARM

Endoscopes investigation support


Sew lithotripsy equipment

10. Pediatric Surgery

Qualified pediatric surgeon

Well-equipped theatre

Pediatric and Neonatal ICU support

Post-op with ventilator and pediatric

resuscitator facility

Support services of pediatric

11. Surgical Gastroenterology

Qualified Surgical Gastro-Enterologist

Well Equipped Theatre

Endoscope equipment

Post –op with ventilator support

Centre Must have done at least 100

Endoscope Surgeries

SICU

B. MEDICAL SPECIALTIES

1. General Medicine

Qualified General Physician with post graduate degree in General Medicine, Or

Equal

2. General Medicine

Qualified General Physician with post graduate degree in General Medicine , Or

Equal

3. General Medicine



Not

Available

Specialist

Name

Qualification

Qualified General Physician with post graduate degree in General Medicine, or Equal

4. Pediatric

Qualified pediatrician

NICU & PICU fully equipped

Round the clock Pediatric / Emergency service room with Pediatrician

Pediatric resuscitation faculty

5. Cardiology

Qualified Cardiologist with DM or

Equivalent Degree

ICU Facility with cardiac monitoring and ventilator support

Hospital should facilitate Round the clock

cardiologist services

Availability of support specialty of General Physician & Pediatrician

5a. Cardiac Interventions and Procedures

Qualified Cardiologist with experience in interventions and procedures

Fully equipped Cath lab Unit with qualified and trained Paramedics

Must have Backup CT Surgery Unit to perform Cardiac Surgeries.


interventions

6. Nephrology

Qualified Nephrologists with DM or Equivalent Degree

Hemodialysis facility

AMC and Physician Support

7. Medical-Gastro Entomology

Qualified Gastro Enterologist with DM or Equivalent Degree.

Endoscopy facility

AMC and Physician Support


Endoscopic procedures

8. Endocrinology

Qualified Endocrinologist with DM or Equivalent Degree

AMC with ventilator and Physician

Support.

9. Neurology

Qualified Neurologist with DM or Equivalent Degree.

EEG, ENMG, Angio-CT facility of



Not

Available

Specialist

Name

Qualification

Neurological study

Neuro ICU Facility with ventilator support

Physician Support

10. Dermatology

Qualified Dermatologist with MD or

Equivalent Degree.

AMC and Physician Support.

11. Pulmonology

Qualified Pulmonologist

RICU facility

Spirometry and bronchoscope facility

Physician Support

12 Rheumatology

Qualified Pulmonologist

MICU Facility

Physician and Orthopedic Support

Physiotherapy Support

C COMMINED SERVICES FOR

CANCER THERAPY

1. Cancer

Services of qualified Medical Oncologist

Services of qualified Surgical Oncologist

Services of qualified Radiation Oncologist if in-house Radiotherapy

equipment.

Fully equipped Radiotherapy Unit

SICU or tie up with nearest Radiotherapy center.

Interventional Radiology

Availability of DSA equipment

Qualified and trained interventional radiologists

Article 6: Cashless Services under Package

6.1 The Provider agrees to provide total cashless transaction to the Beneficiary right from his reporting to discharge under the scheme.

6.2 Provider agrees to provide treatment as per the packages worked out by the RGJAY society the package includes consultation, medicine, diagnostics, implants, food, cost of transportation, hospital charges etc. In other words the package should cover the entire

cost of patient from date of reporting to his discharge from hospital 10 days after surgery, making the transaction truly cashless to the patient. And under no

circumstances shall charge any money extra within the treatment period of package. 6.3 The Provider agrees to issue a test requisition slip to the patient which will empower the

patient to approach the concerned diagnostic/test centers within the hospital or otherwise

and do the tests without any cash transaction. The details of the Tests done and their results will be uploaded in the portal by the MCO of the Provider.


6.4 Provider agrees to keep all the RGJAY patients admitted till 10 days of postoperative or till patient recovered satisfactorily in all those cases where operation was performed.

6.5 The hospital agrees to the package to be authorized even for those patients who were admitted as non-RGJAY out of ignorance but subsequently identified as RGJAY

beneficiary during the course of his/her stat in the hospital. In the meanwhile ant payment received from the patient shall be refunded immediately after getting pre-authorization approval and before discharge of the patient from the hospital duly

obtaining a receipt from the patient. 6.6 Hospital shall assist and facilitate the patient to procure compatible blood for the

surgeries and therapies. The Hospital shall provide blood from their own blood bank subject to availability within the package. In case of non-availability the hospital shall make efforts to procure from other blood banks, Red Cross, Voluntary Organizations,

etc. The Hospital shall also issue a copy of the request letter to the patient. Article 7: Package Rates

7.1 The Package rates are given in the Booklet (RGJAY Manual on Surgical & Medical Treatments for Cashless Treatment of beneficiary Population) will form a part and parcel of the MOU and which will be the basis and binding for the treatment cost of

various procedures and as per the package rates. 7.2 The Package rates are the maximum rate indicated for each surgical procedure However,

the settlement of the claims will be made on the basis of actual bill submitted by the provider.

7.3 Provider has agreed to the continuation of the agreed tariff for the period of this

agreement. 7.4 In the event of more than one procedure is being undertaken in one sitting other than

those of routine/standard components of the surgical procedure, the package amount will be decided by the technical committee in consolation with treating doctor and decision of this committee will be final and binding on the hospital.

7.5 Provider under any circumstances will not refuse to undertake procedure on the ground of insufficient package.

7.6 In all other disputes related to package rates and technical approvals of preauthorization‟s the matter will be referred to a technical committee of the RGJAY society and decision of the committee is binding on the provider.

Article 8: Cost of evaluation of patients

8.1 The cost of various treatment/tests conducted on the beneficiary family members who

are evaluated but ultimately do not undergo Surgery or Therapies will be borne by the Provider themselves and the Provider will not charge any fee for consultation and investigation from the Beneficiary.

Article 9: Quality of Services

9.1 Provider agrees to provide separate and Free OPD consultation. However there will not

be any discrimination to RGJAY patients vis-a-vis other paying patients in regard to quality of services.

9.2 Provider shall agree to provide free diagnostic tests and medical treatment for

beneficiary families irrespective of surgery / Therapy required according to good business practices.

9.3 The Provider will treat RGJAY Beneficiary families in a courteous manner and according to good business practices.

9.4 The Provider will extend admission facilities to the Beneficiary families round the clock.

9.5 The Provider will have themselves covered by proper indemnity policy including errors, omission and professional indemnity insurance and agrees to keep such policies in force

during entire tenure of the agreement.


9.6 Provider will ensure that the best and complete diagnostic, therapeutic and follow-up services based on standard medical practices / recommendations are extended to the

Beneficiary. 9.7 The provider agrees 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.

9.8 The provider agrees to provide quality medicines, standard prostheses. Implants and

disposables while treating the beneficiary families. 9.9 The Provider agrees to assist and cooperate with the medical auditing team from the

RGJAY society / Insurer as and when required. 9.10 The Provider agrees to provide video recorded evidence of patient counseling before

surgery in order to avoid legal complications / any adverse reaction by patients or

Patient‟s relatives or by public in the event of unacceptable outcome. 9.11 The hospitals Morbidity and Mortality cases will be subject to scrutiny by the RGJAY

society / Insurer. (Refer ANNEXURE –V & XIV) 9.12 The provider agrees to take sole responsibility in submitting the patient details online

and if any discrepancy is found in this regard the Provider agrees to abide by decisions

of EDC. Article 10: Services of Medical Coordinator

Provider will have a Medical Officer / Medical Officers designated as RGJAY Medical Coordinator/s (MCO) for the scheme to coordinate with society through Arogyamitra. The provider agrees to submit the details of appointed MCO‟s as per the

ANNEXURE XXII The provider should promptly inform the insurer about change if ant in the MCO

designated the tenure of the agreement. The following will be the responsibility of MCOs (RGJAY Medical Coordinator):

1. He / She will ensure that all required evaluation including diagnostic tests are done

free of cost for all beneficiary families and the details of the same along with reports are captured in the RGJAY society portal.

2. He / She will upload the OP/IP status of the patient. 3. He / She will guide the patient in all aspects and sign the investigation request.

4. He / She have to cross check whether diagnosis is covered in the scheme. If doubtful about the plan of management then should coordinate with treating specialist along

with Package list as specified in the Rajiv RGJAY Medical on Surgical & Medical Treatments for Cashless Treatment of BPL Population – 3rd edition.

5. He / She should facilitate the admission process of Patient without any

delay. 6. After admission He / She will collect all the necessary investigation reports before

sending for approval. 7. He / She will upload the admission notes and preoperative clinical notes of the patient. 8. He / She will ensure that preauthorization request is sent only for those who are on bed

(IP) 9. He / She will ensure before sending Preauthorization that all documents like health

card or valid ration card (yellow/orange) coupled with aadhar number, Patient photo and also necessary reports like CT Films, X-Ray films, Angio CD etc. are uploaded in the system.

10. He / She will coordinate with insurance and RGJAY society doctors as need arises.

11. Preauthorization kept pending from Insurance and RGJAY society will be verified on a regular basis and necessary corrections to be done by MCO.

12. He / She will furnish daily clinical notes (Per Operative and Post-operative).


13. He / She will upload 3 Photographs of the Patient taken preoperative bedside, immediate post-operative showing operation wound and at the time of discharge.

14. He / She will update surgery and discharge details and hand over signed copy of the summary along with follow-up advice in preprinted stationary supplied.

15. He / She will ensure free follow –up consultations, routine investigations and distribution of drugs to be supplied by the Provider to the beneficiary families. And also refer ANNEXURE –VI

16. He / She will ensure to update the details of on bed status of patients time to time as per the format (Refer ANNEXURE-XX) on the display board placed at the

Arogyamithra Kiosk / reception desk. 17. The Provider will have a Data Entry Operator and each data entry operator will be

linked to the respective MCO and the final responsibility of the data fed by the data

entry operator will be vested on MCO of the Hospital. The provider agrees to submit the details of Data Entry Operator as per the ANNEXURE XXV.

Article 10.1 Mode of communication

10.1 (i) The Provider agrees to use the Closed User Group (CUG) mobile pho ne given by

insurer to MCOs & MCCOs exclusively for the purpose official communications related to RGJAY Scheme. Any mis-utilization of CUG by the MCOs & MCCOs the

insurer reserves the right to initiate action against the service Provider. (ii) The Provider agrees to use only RGJAY Messaging Services provided on the Web

Portal for any kind of official communications related to RGJAY scheme. The Email-

Ids of MCOs & MCCOs provided by the RGJAY society/ Insurance will be used as their communication method.

Article 11 Documentation and MIS

11.1 The provider will ensure that documentation of RGJAY patients are done using standard formats supplied / available online such as admission card, referral card,

investigation slip, discharge summary etc. 11.2(i) RGJAY society Insurer reserves the right to visit the Beneficiary and check his

medical data with or without intimation as and when required.

(ii) The provider will allow the General Managers / Deputy General Managers / Field staff / Doctors. Vigilance officials and other officials from the RGJAY society and

Insurance Company to inspect the hospitals without obstruction and co-ordinate with them during Surprise and Regular Inspections.

11.3 Provider will furnish periodical reports to RGJAY society / insurer on the progress of the scheme as per the formats prescribed for this purpose.

11.4 Provider will not give any document to facilitate the RGJAY patient to obtain any

other relief like CMRF etc. Provider will not claim any other relief for the procedures covered under the scheme. Any deviation in this regard may attract Delisting of the

hospital. 11.5 The Provider agrees to keep printouts of all online documents in the case sheet and

make available as and when required for verification by field staff / doctors of the

RGJAY society / Insurance. Article 12: Display of Boards & Banners

12.1 Provider agrees to display their status of preferred Provider of RGJAY Community Health Insurance Scheme at their reception / admission desks.

12.2 Provider agrees to display their status of specialties empanelled in RGJAY

Community Health Insurance Scheme at their reception / admission desks. 12.3 Provider agrees to display availability of beds in the hospital and also display specialty

wise bed occupancy under RGJAY Community Health Scheme at their reception / admission desks. (Refer ANNEXURE-XX)


12.4 Provider agrees to display the process flow of RGJAY within the hospital at the RGJAY kiosk.

12.5 Provider agrees to make available of the list of diseases with package rates covered under RGJAY community Health Insurance scheme in the form of Booklet supplied

by the RGJAY society/ Insurer at their reception / admission desks. 12.6 Provider agrees to display other materials supplied by RGJAY society /Insurer for the

ease of Beneficiary families.

Article 13: RGJAY Kiosk and Aarogyamithra Services

13.1 The Provider will allow RGJAY Assistance Counter / Kiosk to be established at the

reception of the Provider free of cost. (Photograph of the space annexed herewith (Refer ANNEXUR-1))

13.2 The Provider will provide following infrastructure and network facility to the counter.

P.C., Printer, Scanner, Digital Camera, Webcam, Barcode reader, Mike, Speakers, Stationary etc. (Refer ANNEXURE - XVII) The System and other peripherals should

be provided exclusively for the use of Aarogyamithra who can use the resources at any point of time.

13.3 The Provider will provide a dedicated 2MB broadband connectivity to the Computer

to be exclusively used by the Aarogyamithra to access the web for online MIS. e-preauthorization etc.

13.4 The Provider will allow Aarogyamithra access to the wards and patients data to facilitate onward transmission to the Company for e-pre-auth, claims, correct MIS etc.

13.5 The Provider will update the date of surgery, discharge / death of the beneficiary in the

RGJAY society portal. 13.6 The Provider will intimate Aarogyamithta and MCO regarding emergency admissions

of the Beneficiary during non office hours. Article 14 Preference to Beneficiary families

14.1 The Provider agrees not to deny admission for the beneficiary for want of

preauthorization approval. 14.2 The provider agrees to provide a separate ward for RGJAY Beneficiary families.

14.3 The provider agrees to provide separate Operation Theatre and weekly schedules for the surgeries / therapies to be performed for the Beneficiary families.

Article 15 Capacity for Surgeries

15.1 The provider agrees to handle a minimum number of cases in each specially including trauma cases based on their available infrastructure as under:

CATEGORY SPECIALTY Capacity to admit

number of patients /Day

(Bed Strength)

A MEDICAL SPECIALTIES

General Medicine

Critical Care

General Medicine

Infectious Diseases

Pediatrics

Neonatal Intensive Care

Pediatric Intensive Care

Pediatrics (General)

Cardiology (Medical Management)

Nephrology

Neurology

Endocrinology

Medical Gastroenterology


CATEGORY SPECIALTY Capacity to admit

number of patients /Day

(Bed Strength)

Dermatology

Rheumatology

Pulmonology

B SURGICAL SPECIALTIES

General Surgery

Orthopedics

ENT

Ophthalmology

Gynecology and Obstetrics

Cardiac Interventions

Cardiothoracic Surgery

Surgical Gastroenterology

Genitourinary Surgery

Neuro Surgery

Pediatric Surgery

Plastic Surgery

C SPECIAL SERVICES

Cancer

Medical Oncology

Surgical Oncology

Radiation Oncology*

15.2 The Provider agrees to submit the vacancy level in pre-operative words, ICU, Post-Operative wards and also upload the same in the RGJAY society portal on a daily

basis. Article 16 Medical Camps

16.1 The Provider will conduct free medical camps at least once a week at the place

specified by the RGJAY society to identify the members of the BPL families who may require surgeries covered under the scheme as per the schedule given by the RGJAY

society/for such surgeries. The camp policy as given in Annexure II will be scrupulously followed.

16.2 The Provider will carry necessary diagnostic equipment such as ECG, Echo

Ultrasound etc. to these free medical camps. 16.3 The Provider will provide services of concerned specialists namely Cardiologists, CT

Surgeon, Neurosurgeons, Urologists, Oncologists, Gynecologists. Plastic Surgeon, Pediatric Surgeon, General Physicians to the camp to facilitate proper evaluation of the patients.

16.4 The Provider will submit the camp confirmation and indent (Annexure-III) online as given in camp policy in the prescribed format to RGJAY society/ Insurance at least

one week in advance of the stipulated date. 16.5 The Provider will inform all the stakeholders such as district Administration,

concerned public representatives, PHC / AH / DH staff etc. well in advance for

successful conduct of the camp. 16.6 The Provider will spread awareness about the camp through Publicity in coordination

with District Coordinator. Regional coordinator, PHC staff and Aarogyamithras. 16.7 The Provider will provide patient data to RGJAY society / Insurance in the prescribed

form at the end of the camp.

16.8 The Provider will enter the details of the patients screened and referred at the camps on the RGJAY society website on the same day of the camp.


16.9 The Provider will coordinate constantly with the Medical camps cell of the RGJAY society in all matters related to Medical camps.

16.10 The patients referred from the camp will be followed up and transported to the Hospital within 10 days of the camp unless the patient is not willing, in which case the

same should be recorded and updated in the Website. 16.11 Provider will have an Officer designated as RAJIV GANDHI JEEVANDAI Medical

Camp Coordinator (MCCOs) for the scheme to coordinate with RGJAY society /

Insurance through Aarogyamithra The provider agrees to submit the details of appointed MCCO‟s as per the ANNEXURE XXIV.

The provider agrees to inform the insurer & RGJAY society about the change in the MCCO designated if any, during the tenure of the agreement. The Provider will give the full time services of RGJAY Medical Camp Coordinator

(MCCO) to coordinate all activities related to camps and patient follow up from camps.

The following will be the responsibilities of RGJAY Medical Camp Coordinator

(MCCOs)

Confirmation of camps online and indenting online.

Carrying out the IEC activities within camp area at least 7 days before the camp date.

Providing facilities like shamianas, chairs, screening enclosures.

Providing common medicines in the camps.

Arrange for distribution of incentives to the medical officers.

Coordinating and ensuring participation of specialists.

Arranging the diagnostic equipment

Coordinate with PHC doctors / government Doctors. Public Representatives, SHG

groups and Local Administration.

Raising claims online for the camps conducted.

Follow – up of patients referred from Camps as per clause 16.10

And other responsibilities mentioned in ANNEXURE – XV.

Article 17: Admission of Beneficiary

17.1 Request for examination and if necessary hospitalization for surgical procedures on

behalf of the Beneficiary will made by the “RGJAY Help Desk” at PHC/ Government Hospital or by the “RGJAY Assistance Counter / Kiosk” at Network Hospital.

17.2 Aarogyamithras at RGJAY Assistance Counter / Kiosk at the Network Hospital will

coordinate with the Provider from the time of admission till discharge after the surgical procedure.

Article 18: e-Pre- Authorization

18.1 Pre-authorization request will be sent only after admission and the patient will be there in the hospital as inpatient till final decision on the Preauthorization is made.

18.2 The Provider will submit the e-pre-authorization, after admitting the patient as in-patient, on the RGJAY Website complete in all aspects including the signed copy of

consent of the patient. All relevant test reports along with Digital photograph of the Beneficiary taken in the hospital should also be uploaded. Catheterization CD, MRI films, X-rays, biopsy reports will be uploaded, cytology and biopsy reports / slides

should be submitted. 18.2a Insurer undertake to approve the Preauthorization in consultation with the RGJAY

society indicating the relevant package rates within 12 working hours of the receipt of the request for pre-authorization form as well as the required data and information online.

18.2b the Provider agrees to update the surgery online immediately after performing the Surgery. However, the validity period of the pre-authorization is 14 days from the

date of approval. The Provider agrees to update clinical notes of ALL cases (both Pre


& Post pre-authorization notes) in the Website on daily basis. If the surgery / therapy is not update within 14 days after approval of pre authorization will automatically get

cancelled in the RGJAY Portal. The provider should obtain fresh approval for the cancelled pre-authorization by mentioning valid reasons and the Insurer / RGJAY

society reserves the right to approve the request of pre-authorization. After Approval of pre-authorization, if the patient is not found on bed at the time of routine check by officials of RGJAY society Insurer and in case the provider unable to

present the patient during the routine check by officials of RGJAY society/Insurer, the RGJAY society/ Insurer reserves the right to cancel the Preauthorization immediately

without any intimation. 18.2c If the provider is not able to conduct the operation within a reasonable time for any

reason other than medical such as non availability of beds or specialists, the Provider

will arrange for the operation to be conducted at any other appropriate Network Hospitals in consultation with Insurer.

18.2d The provider agrees that the approval of Pre-authorization by RGJAY society / Insurance is mere approval for eligibility of case for Assistance under scheme and should not be construed as approval of choice of the treatment & outcome

consequences thereof which is sole responsibility of treating Doctor. 18.2e Any deficiency in documentation & ONLINE updation of data and protocols by the

provider which may lead to pending of Pre-authorization approval, the responsibility for such delay leading to delay in treatment & outcome is solely responsible of the Provider.

18.2f The provider agrees that any Rejection of Pre-authorization shall not be construes as denial of treatment to the patient and outcome thereof, it is a mere rejection of

assistance under the scheme guidelines. The provider agrees to exercise best of his judgment and counsel the patient about the alternate ways of providing such care including the option of referring the patient to Govt. Institution where such facility

exists. 18.3 Preauthorization preferably will be given to the network hospital whichever does the

preliminary screening either at the Medical camp or at the hospital. Second pre-authorization for the same patient from different network hospital will not be entertained for the same procedure unless medically warranted or surgical procedure is

unduly delayed by the first hospital without proper medical grounds. 18.4 Insurer reserves the right to disallow the claim if the Surgery / Therapy is performed

before any approval from the Insurer / RGJAY society and pre-authorization is obtained at a later date keeping the insurance / RGJAY society in dark about the surgery /therapy.

18.5 The provider agrees to send the enhancement requests before the discharge of the patient through E-mail or by fax and follow the enhancement guidelines

(ANNEXURE-XXI) and enhancement module manual in the booklet (RGJAY manual for Surgical and Medical treatments for Cashless Treatment of BPL Population- 3rd edition.) The Provider agrees to abide by the decision of Technical Committee and

shall extend cashless facility to the patient. 18.6 The provider agrees to obtain emergency Telephonic Approval for emergency cases

only. The Insurer / RGJAY society reserves the right to cancel the Emergency telephonic approval, if the provider fails to update the pre-authorization online within 72 hours of Emergency telephonic approval. The provider also agrees to perform the

surgery / therapy obtained through telephonic intimation within 24 hours form the date and time of telephonic approval. The Provider also agrees to update the surgery/

therapy done for telephonic instructions online mentioning the date & time along with specific remarks and photographic evidences while updating the online pre-authorization, starting from the telephonic intimations. (Refer Annexure-XXVII).


Article 19: Transport of Patients

19.1 The Provider agrees to transport of bear the cost of transport charges (To & fro)

incurred by the beneficiary and agrees to arrange the same at time of discharge and obtain acknowledgment from the patient accordingly. The Provider agrees to obtain

signature of beneficiary on the acknowledgment sheet generated from the portal and upload the scanned copy to RGJAY Web portal.

Article 20: Free food to patients

20.1 The Provider agrees to provide free food to the patients as envisaged in the package rates either through in-house pantry or by making alternate arrangements like

supplying from nearby canteen. Article 21: Discharge and Follow up

21.1 Intimation of the impending discharge of the Beneficiary need to be advised to

RGJAY Assistance Counter at least one day before the discharge of the patient. 21.2 The discharge has to be done in the presence of MCO and Aarogyamithra concerned

and update the details ONLINE. 21.3 At the time of Discharge the transportation cost to and fro has to be reimbursed to the

Patient, if the Hospital has not provided the transportation. The acknowledgment of

receiving the amount for transportation has to be generated from the RGJAY society portal and the signed copy has to be uploaded.

21.4 Discharge summary will be generated from the RGJAY society portal in a pre-printed stationary to be supplied. The Discharge summary will consist of all the treatment details of the Patient at the Hospital and the follow up regime for the Patient including

consultation and medication. 21.5 All the patients must be provided with follow-up medicines after discharge by the

provider as part of the package. 21.6 If the same Patient is coming back to the Hospital, the follow up derails have to be

uploaded in the RGJAY society portal.

21.7 Satisfaction letter of the Patients has to be generated from the RGJAY society portal and the signed copy has to be uploaded.

21.8 The MCO & Aarogyamithra should counsel the patient for all the precautions to be taken for the post-operative care.

21.9 All patients who requite follow-up medicines will be advised by the provider to come

back on 11th day of discharge for first follow0up mandatory. The date of first follow-up will be generated by the RGJAY society portal along with the discharge summary.

21.10 The subsequent follow-ups for the above cases will be as per the follow-up guidelines (Refer ANNEXURE-VI)

21.11 The Provider will agree to provide follow-up services for a period of ONE YEAR

under the Scheme. 21.12 The provider will provide free post-transplant immunosuppressive therapy for a period

of six months from date of surgery (1st to 6th month), irrespective of agreement period for all cases of renal transplant within package. The provider will do cashless post-transplant immunosuppressive therapy for the remaining period of six months (7 th to

12th month) under RGJAY II. 21.13 The provider will agree to provide free post-surgical physiotherapy services, wherever

required for the agreement period. Article 22: Billing Procedure / Checklist for the Provider at the time of Patient‟s

discharge

22.1 It is admitted and agreed that the Provider is aware that this MOU has arisen for the purpose of implementation of the RGJAY Community Health Insurance Scheme

(RGJAY I & II) intended for Below Poverty Line families in specified Districts of Maharashtra and accordingly the Provider will in no circumstance charge or seek any payment from the Beneficiary families but will look only to for indemnity, and that too


only to the limits/ schedule of fees in respect of procedures referred to earlier and agreed to under this MOU.

22.2 Signature or the LTI of the patient / Beneficiary will be obtained on final hospital bills and the discharge form.

22.3 The provider will submit the following to Original discharge summary, original investigation reports. All original prescriptions, Procedure CD‟s MRI films, X-rays, Post-Operative slides with Biopsy report, 3 Photographs of the patient taken

preoperative bedside, immediate post-operative showing operation wound and at the time of discharge, Case Sheet with Operation Notes Breakup of the bills (Room Rent,

Investigations, Procedure charges & pharmacy receipt) etc. These are to be made available to for Claim payment, while submitting the bill. The copies of the discharge summary signed by the Beneficiary will be uploaded in the web. A summary of the

bills raised will also be uploaded. 22.4 Letter of satisfaction from the patient should also be obtained and sent along with the

bills to in prescribed format. 22.5 Provider should ensure that Chemo Therapy Drugs are physically administered to the

Patients. Provider should produce bills by coating batch no. and attaching empty vials

& ampoules with intact labels. 22.6 The Provider will have-an Officer designated as Billing Head in order to follow the

process the online work flow. The provider agrees to submit the details of Billing Head as per the ANNEXUR XXIII.

Article 23: Payment Terms and Conditions

23.1 Insurer agrees to pay all the eligible bills within 7 working days. Subject to submission of all supporting documents including post-operative investigations and reports as

required online and the photocopies of daily progress report and ICU charts should be sent by courier.

23.1a The payments to the provider are made the Insurer after deducting Taxes (TDS) as per

prevailing IT Rules, and accordingly Insurer will issue the Form No. 16A t the end of Financial Year. Provider hereby agrees to comply all the formalities required in

fulfilling regulations of Income Tax Dept. (Refer ANNEXURE-XXVI) 23.2 The provider agrees to submit the core banking number IFSC code to the insurer to

facilitate electronic fund transfer for settling the claims. (Refer ANNEXURE-XIX)

23.3 The Provider agrees to submit all the claims for the surgeries / Treatments performed within 60 days from the date of discharge of patient.

23.4 The provider agrees to perform Surgeries / Treatment within 30 days from the date of expiry of this agreement for all the Pre-authorizations obtained during the period and submits the claim as per clause 23.3 above.

Article 24: Limitations of liability and indemnity

24.1 The Provider will be responsible for all commissions and omissions in treating the

patients referred under the scheme and will also be responsible for all legal consequences that may arise. Insurer /RGJAY society will not be held responsible for the choice of treatment and outcome of the treatment or quality of the care provided by

the provider and should any legal complications arise and is called upon to answer the provider will pay all legal expenses and consequent compensation, if any.

24.2 The Provider admits and agrees that if any claim arises out of alleged deficiency in service on their part of on the part of their men or agents, then it will be the duty of the provider to answer such claim. In the unlikely event of Insurer being proceeded

against for such cause of action and any liability was imposed on them, only by virtue of its relationship with the provider and then the provider will step in and meet such

liability on their own. 24.3 Notwithstanding anything to the contrary in this Agreement, neither Party will 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 of negligence.

24.4 The Provider undertake for applicability of terms and conditions mentioned and in all the MOUs executed for all the phases in- lieu of this MOU.

Article 25: Confidentiality

25.1 All the stakeholders undertake to protect the secrecy of all the data of Beneficiary families and trade or business secrets of and will not share the same with any

unauthorized person for any reason whatsoever within or without or consideration. 25.2 The provider agrees to protect the confidentiality under this agreement and ensures not

to recruit ex-employees of insurer anytime during this agreement and also for a further

period of one year from the date of expiry of this an agreement. Article 26: Termination

26.1 Any deficiency in service by the empanelled hospitals (Provider) or noncompliance of the provisions of MOU will be scrutinized by the Empanelment & Disciplinary Committee (EDC) comprising of representative from the RGJAY society and Insurer

and make deliberations to suspend / de-list / stop payments or any other appropriate action based on the nature of the complaint against the Provider. The Provider shall

abide by the deliberations made by the EDC and RGJAY society. Article 27: Jurisdiction

27.1 Any dispute arising of this MOU will be subject to arbitration as per Arbitration Act

and subject to the jurisdiction of Maharashtra courts only. 27.2 Any amendments in the clauses of the Agreements can effected as an addendum, after

the written approval from both the parties. Article 28: Non-exclusivity

28.1 Insurer reserves the right to appoint other Provider/s for implementing the packages

envisaged herein and provider will have no objection for the same and vice-versa.

In witness thereof this agreement executed by or on behalf of the parties on the day and year mentioned above.

Signed and delivered by: Provider:

Through its Managing Director / by Sri/Smt. ______________________________________

Sign _______________________________ In presence of Sri/ Smt. ____________________________________ Sign _______________

____________________________________________________________________

Through its Chief Operating Officer Sri / Smt. ___________________________________

Sign ___________________________________ In presence of Sri / Smt ____________________________________Sign ______________


“Rider A”

1 Resolution of dispute: In the event of any question, dispute or differences in respect of contract or terms and

conditions of the contract or interpretation of the terms and conditions or part of the terms and conditions of the contract arises, the parties may mutually settle the dispute amicably.

2 Arbitration:

If any dispute arises between the parties hereto during the subsistence of this Agreement of thereafter, in connection with the validity Interpretation implementation

or alleged breach of any provision of this Agreement, the parties shall refer such dispute to their respective chairmen/CEO‟s for resolution. In the event that the chairmen/CEO‟s are unable to resolve the dispute within 30 days of it being referred to

them, then either Party may refer the dispute for resolution to a sole arbitrator who will be Additional Chief Secretary / Principal Secretary Public Health and Family Welfare

Department Government of Maharashtra, or, in the event that the parties are unable to agree on the person to act as the sole arbitrator within 30 days after any party has claimed for an arbitrators in written form, by three arbitrators, one to be appointed by

each party with power to the two arbitrators so appointed, to appoint a third arbitrator. The arbitration proceedings shall be carried out as per the Indian Arbitration and Concillation Act, 1996 and the rules made thereunder.

3 Governing Language: English language version of the contract shall govern its interpretation.

4 Applicable Laws:

The contract shall be governed in accordance with the law prevailing in India, Act, Rules, Amendments and orders made theron from time to time.

5 Indemnification:

The contractor shall indemnify the purchaser against all actions, suit, claims and demand or in respect of anything done or omitted to be done by contractor in connection with the contract and against any losses or damages to the purchaser in consequence of any action or suit being brought against the contractor for anything done or omitted to be done by the contractor in the execution of the contract.

6 Jurisdiction

All the suits arising out of the contract shall be instituted in the court of competent jurisdiction situated in Mumbai only and not elsewhere.

7 Saving clause

No suits, prosecution or any legal proceedings shall lie against the Joint Director of Health Services (Procurement Cell), Mumbai or any person for anything that is done in good faith or intended to be done in pursuance of RFP.