Circular as per the provisions of IRDAI (TPA – Health Services)

Document text

DlldM INSURANCE REGULATORY AND ir.tai DEVELOPMENT AUTHORITY OF INDIA CIRCULAR Circular as per the provisions of IRDAI (Third Party Administrators - Health Services) Regulations, 2016, to all TPAs, Life, Non-Life and Stand alone Health Insurance Companies. _ Circular Reference No. IRDA/TPA/REG/CIR/059/03/2016, dated 28-03-2016 Issued on : 28-03-2016 m~ ~. cm:m(@, <itl/O(<i11•1, ~-soo 004. 'lfficf (() : 91-040-2338 1100, ~: 91-040-6682 3334 i-iR: irda@irda.gov.in ir-1': www.irda.gov.in Page 1 of 89 Parisharam Bhavan, 3rd Floor, Basheer Bagh, Hyderabad-500 004. India. Ph.: 91-040-2338 1100, Fax: 91-040-6682 3334 E-mail : irda@irda.gov.in Web.: www.irda.gov.in Sr. Annexure No. Form No. No 1 -- -- 2 -- -- 3 -- -- 4 -- -- 5 Annexure - 1 TPA- 1 6 Annexure - 2 -- 7 Annexure - 3 TPA- 1A 8 Annexure - 4 TPA- 2 9 Annexure- 5 TPA- 3 10 Annexure - 6 TPA-4 11 Annexure - 7 TPA- 4A 12 Annexure - 8 TPA- 5 13 Annexure - 9 -- 14 Annexure - 10 TPA- 6A 15 Annexure - 11 -- 16 Annexure - 12 TPA - 7 17 Annexure - 13 -- 18 Annexure - 14 TPA- 7A 19 Annexure - 15 -- 20 Annexure - 16 TPA- 8 21 Annexure - 17 TPA- 6B 22 Annexure - 18 TPA- 6C 23 Annexure - 19 TPA- 60 24 Annexure - 20 TPA - 6E 25 Annexure - 21 -- Annexure - 21 -- 26 Annexure - 23 TPA - 6F 27 Annexure - 24 -- 28 Annexure - 25 TPA- 6G 29 Annexure - 26 TPA- 6H 30 Annexure - 27 -- 31 Annexure - 2.8 TPA - 9 32 Annexure - 29 -- 33 Annexure - 30 -- t,Ham INSURANCE REGULATORY AND inlai DEVELOPMENT AUTHORITY OF INDIA INDEX Particulars Page No. Objective 3 Applicability 3 Legal & other provisions 3 Effective Date 4 Application for Grant of Fresh Certificate of Registration to TPA 5 - 10 Check-list for Documentation to be submitted along with Form TPA - 11 1 and Procedural requirements for obtaining Fresh TPA Registration Format for Certificate of Registration 12 Declaration and Undertaking with respect to fit and proper criteria 13-16 Form for Intimation of appointment or change in Director, or Key 17 Managerial Personnel. Aoolication for issue of Duplicate Certificate of Registration. 18 Format for Duplicate Certificate of Registration 19 Application For Change In Shareholding Pattern 20- 21 List of documents to be submitted for consideration of application for 22-23 change in shareholding pattern Status of Shareholding Pattern of a TPA Company 24 Minimum Business Requirements for TPAs 25 Application for Renewal of Certificate of Registration 26-28 List of documents to be attached with the Application for Renewal of 29 TPA Registration. Format for Certificate of Renewal of TPA Registration 30 List of documents to be submitted along with application for 31 Voluntary Surrender of TPA Registration. Form for Annual Report by TPA and Schedule 1 to 7 under the.said 32- 41 form TPA-8. Format for Quarterly and Cumulative Claims data for TPAs 42- 44 Annual Certificate in the matter of Working Capital and income of a 45 TPA Company. Annual Declaration and Undertaking by a TPA Company 46 Annual Form on Service Level Agreement Details 47 Minimum Standard clauses in agreement between Insurer and TPAs 48-49 Minimum Standard clauses in agreement between Insurer, TPAs and 50-72 Network Providers as the case may be. Periodical returns - Half-yearly information on non-insurance health 73 schemes Stipulations in the matter of Non Insurance Services under Health 74 Care Schemes Format for Half-yearly Information on services rendered in India or in 75 foreign jurisdictions for policies issued by Indian Insurers Format for Half-yearly Information on health services rendered to 76 foreign travel policies issued by Foreign Insurers Corporate Governance norms for TPAs 77-78 Form for intimation of opening and closing of the branches or change 79-81 in office address. Maintenance of Records 82 Claim Forms and Pre-Authorization Forms 83-89 i:rft~~, mmrcm, ci!!/0(,itlll , ~-500004. 'lfmf ({) : 91-040-2338 1100, ~ : 91-040-6682 3334 i -i@: irda@irda.gov.in ~: www.irda.gov.in Page 2 of 89 Parisharam Bhavan, 3rd Floor, Basheer Bagh, Hyderabad-500 004. India. Ph.: 91-040-23381100, Fax: 91 -040-6682 3334 E-mail : irda@irda.gov.in Web.: www.irda.gov.in 1. OBJECTIVE: t11;1am INSURANCE REGULATORY AND inlai DEVELOPMENT AUTHORITY OF INDIA IRDAI (TPA - Health Services) Regulations, 2016 were notified on 14-03-2016. Vide various provisions of the said regulations the Authority has to specify the Regulatory Norms, Forms, Formats, and Check list etc., for compliance by all TPAs and other regulated entity, if applicable. The objective of this circular is to set out regulatory requirements that a concerned applicant or registered entity, as the case may be, shall comply with. 2. APPLICABILITY: This circular is applicable to all applicant TPAs, registered TPAs and the insurers wherever applicable. 3. LEGAL AND OTHER PROVISIONS: 3.1 This circular is issued under the provisions of Section 34 (1) of Insurance Act, 1938 and under the powers vested with Reg. 2 (1) (I) of IRDAI (TPA - Health Services) Regulations, 2016. 3.2 "Key Managerial Person referred in this circular includes the Chief Executive Officer, Chief Administrative Officer, Chief Operating Officer, Chief Finance Officer or Chief Accounts Officer and Chief Medical Officer." 3.3 In this circular where name and details of CEO or CAO are sought in case both these officers are in existence details of both officials shall be submitted. 3.4 Where shareholders are referred in these forms information shall be submitted in respect of those shareholders who are having 5% and above stake in the TPA Company. 3.5 The periodicity of the reports shall be as mentioned under respective annexure in tbis circular. -qtt?;Tq 'lfcR, <flmT <@, iil:/Al.iillll, ~-500 004. ~ (() : 91-040-2338 1100, tl;cm: 91-040-6682 3334 {-i@: irda@irda.gov.in ~: www.irda.gov.in Page 3 of 89 Parisharam Bhavan, 3rd Floor, Basheer Bagh, Hyderabad-500 004. India. Ph.: 91-040-2338 1100, Fax: 91-040-6682 3334 E-mail: irda@irda.gov.in Web.: www.irda.gov.in inlai ~ 1 ufl t1 inn R4f.:It111-1 ch 3m R4 chm ~ INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY OF INDIA 4. Standard Pre-Authorization And Claims Forms; The Insurers, TPAs and Network Providers, as the case may be shall use the following forms specified at Annexure - 30, while rendering health services; 4.1 Claims Form Part - A: Claim Form Is Applicable For Health Insurance Policies Other Than Travel And Personal Accident Policies. 4.2 Claim Form Part - B: Claim Form To Be Filled In by the Hospital 4.3 Pre-Authorization Form Part - C: Request for Cashless Hospitalization for Health Insurance Policy. 5. Effective date: The provisions of this circular shall be applicable with immediate effect or as specified in the respective provisions of this circular. "tlft9All ~. moo <R1, cil:iA<~llll, ~-500 004. ~ (() : 91-040-2338 1100, ~ : 91-040-6682 3334 t-i8: irda@irda.gov.in ~: www.irda.gov.in ~;~;.~~,a~ ~\\l Joint Director (Health) Page 4 of 89 Parisharam Bhavan, 3rd Floor, Basheer Bagh, Hyderabad-500 004. India. Ph.: 91-040-23381100, Fax: 91-040-6682 3334 E-mail: irda@ irda.gov.in Web.: www.irda.gov.in Page 5 of 89 Annexure – 1 As per Regulations 7 (1) of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA – 1 APPLICATION FOR GRANT OF CERTIFICATE OF REGISTRATION TO TPA Instructions for filling up the form: 1. It is important that before this application form is filled in, the regulations made by the Authority are studied carefully. 2. Applicant must submit a duly completed application form together with all appropriate, supporting documents to the Authority. 3. Application for registration will be considered only if it is complete in all respects. 4. A separate Fit & Proper criteria form shall be submitted in respect of Directors, Promoters, Shareholders and Key Managerial Personnel appointed by the applicant Company,. Where any of the Key Managerial Persons referred herein is appointed subsequent to receipt of Certificate of Registration, form shall be submitted subsequently as specified in TPA – 2 or TPA – 3. 5. Application for grant of Certificate of Registration (CoR) to the TPA shall be signed by at least two directors of Applicant Company. 6. Information which needs to be supplied in more details may be given on separate sheets which should be attached to the application form. 1 PARTICULARS OF THE APPLICANT: 1.1 Name of the Applicant / TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 (B) Address for Correspondence: Principal Place of business or Corporate Office Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.4 (c) Name of Chief Executive Officer or Chief Administrative Officer. 1.5 (d) Name of Chief Medical Officer 2 ORGANISATION STRUCTURE OF APPLICANT TPA COMPANY: 2.1 Date of Incorporation Day _____ Month ______ Year _______ Place _________ 2.2 RoC Registration / CIN details 2.3 Scope of business as described in the Memorandum of Association (To be given in brief along with copy of Memorandum and Articles of Association registered with the RoC). 2.4 List of major shareholders (holding 5% and above of applicant directly or along with associates companies) Page 6 of 89 Shareholding as on:___(dd/mm/yyyy)__ Sr. No. Name of shareholder No. of Shares held % age of total paid up capital of the company Foreign Direct / Indirect Investment Yes or No 1 2 2.5 Name of Promoters Sr. No Complete Name of Promoter (only initials shall not be provided) Complete Address, Landline and Mobile numbers e-mail id No. of Shares held in applicant TPA Company Percentage of shares held in applicant TPA Co. 1 2 2.6 Particulars of all Directors Sr. No. Complete Name of Director (only initials shall not be provided) and DIN No. Complete Address, Landline and Mobile numbers e-mail id No. of Shares held in applicant TPA Company (if any) Percentage of shares held in applicant TPA Co. (if any) 1 2 2.7 Details of Director having Medical Qualification A Name B Address C Qualification Name of Course Undergone Name of the Institute University Affiliation Registration particulars with MCI Duration of the Course Year of Passing Degree Certificate No. (Attach proof of valid registration with MCI) 2.8 Details of Chief Medical Officer (CMO) (other than Director having Medical Qualification) A Complete Name B Address C Qualification Name of Course Undergone Name of the Institute University Affiliation Registration particulars with MCI Duration of the Course Year of Passing Degree Certificate No. (Attach proof of valid registration with MCI) I I I I I I Page 7 of 89 2.9 Details of CEO / CAO (in case if both are appointed by applicant Company details to be furnished separately) A Complete Name B Details of Academic Qualification Name of the Institute University Affiliation Reg. No. / Degree Particulars Programme Details Name of Course Undergone Duration of the Course Year of Passing Marks / Grade Obtain ed C Details of Associate / Fellow Ship examination passed as conducted by Insurance Institute of India (III) or equivalent: Name of the Institute Registration Particulars Diploma No. Marks / Grade Obtained Associate / Fellow Ship Certificate No. issued by III D Details of practical training undergone in the field of Health Administration as approved by Authority; Name of the Institute Registration Particulars Duration of Training Year of training Certificate issued. 2.10 Name and activities of associate companies or subsidiary companies or joint venture companies of the Applicant TPA Company Sr. No. Name of Company Address with telephone no., Mobile no., e-mail Nature of Business and the Type of activity Names of Promoters and Directors Stake of TPA / applicant company Remarks if any 1 2 2.11 Whether any one or more promoters or directors of the associate or subsidiary or joint venture companies are interested in the TPA / applicant's business? 2.12 Name and Address of the Principal bankers of the applicant, if any. I I I I I I I I Page 8 of 89 2.13 Name and address of the statutory auditors, if any 2.14 Whether your company and / or any of your present promoter(s) / shareholder(s) / director(s) under the name of any other Company had applied earlier with the Authority or now applied with any of the insurers for grant of Individual or Composite Insurance Agency registration, Intermediary or Insurance Intermediary registration. 2.15 If yes, please give details of applicant(s) and status of that application. 3 Business Information 3.1 Three years business plan document with projected business volume in terms of servicing of policies, insured members and income of the applicant company. 3.2 Organization Chart showing functional responsibilities (to be enclosed separately) 3.3 Particulars of Key Managerial Personnel Sr. No. Name of Key Managerial Person and Designation Date of appointment Previous Work Experience. And experience with particular reference to TPA activities, if any Functional areas 1 2 3.4 Details of infrastructure like office space, equipment and manpower available with the applicant TPA Company. (specify whether existing or proposed) 3.5 Details of experience in TPA – Health Services and other services. (History, major events and present activities. Experience including outside India of the promoting Companies, if any, may also be indicated) 4 FINANCIAL INFORMATION 4.1 Capital Structure in case of Promoter(s) is / are Firm / Company etc. (Amount INR in Lakhs) Sr. No. Particulars Year prior to the preceding Financial Year (FY) of current FY Preceding Financial Year Current Financial Year Please specify relevant FY 1 Authorized Capital 2 Issued capital 3 Paid-up capital 4 Gross Revenue Page 9 of 89 5 Aggregate of Current Assets 6 Aggregate of Current Liabilities 7 Net Profit / (Loss) 8 Free reserves (excluding re- valuation reserves) (Attach copies of audited financials for respective three years) 4.2 Capital Structure in case of Promoter(s) is / are individuals, financial net worth certificate containing details of assets and liabilities, duly certified by the practicing chartered accountants for all the individuals for the preceding three Financial years. (Amount INR in Lakhs) Sr. No. Name of Individual promoter (s) Year prior to the preceding Financial Year (FY) of current FY Preceding Financial Year Current Financial Year Please specify relevant FY 1 2 (Attach proof of net worth duly certified by a practicing Chartered Accountant) 5 Schedule of proposed fees and costs to be charged by the applicant company for the various services offered (Please furnish details). 6 The Authority may call for further information based on the information furnished in this form. 7 Details of Fee Payment Amount ____________ DD No. / UTR No. Favouring: Dated Drawn On Note: A non-refundable fee. 8 Declaration THIS DECLARATION CUM UNDERTAKING IS TO BE SIGNED BY ANY TWO OF THE DIRECTORS OF APPLICANT COMPANY a) None of the Directors is a minor. b) None of the Directors and the promoters is found to be of unsound mind by a court of competent jurisdiction. c) None of the Directors and the promoters is found guilty of criminal misappropriation or criminal breach of trust or cheating or forgery or an abetment of or attempt to commit any offence by a court of competent jurisdiction. d) None of the Directors and the promoters is found guilty of or knowingly participated in or connived with for any fraud, dishonestly or misrepresentation against an insured or an insurer. e) CEO or CAO and CMO possesses the requisite qualifications and practical training as specified by Insurance Regulatory and Development Authority of India. The CEO, CAO and CMO of the company is / are also fit and proper as per Regulation 11 of the TPA Regulations. f) The Applicant Company did not violate the code of conduct specified by Insurance Regulatory and Development Authority of India. g) We warrant that we have truthfully and fully answered the questions above and provided all the information which might reasonably be considered relevant for the purposes of granting or renewing the Certificate of Registration. h) I declare that the information supplied in the application form is complete and correct. i) The promoters and the directors of the Applicant Company are not engaged in any business apart from the proposed TPA activity as defined in the TPA regulations. The stake / the shares held by I I I Page 10 of 89 the applicant company in any of the other Companies are duly disclosed to the Authority. (Note: Where it is to be determined whether officials referred herein are involved in any other insurance or insurance related activities or not, TPA Company shall furnish the detailed information separately along with the form) j) The TPA Company has not committed any breach of the provisions of the applicable Acts, Regulations and / or circulars issued by the Authority from time to time. k) None of the director(s) / promoter(s) / shareholder(s) Key managerial person(s) of our company is directly or indirectly engaged in any other insurance or insurance related activity(s). l) We, the promoters and directors of this Company have gone through Corporate Governance guidelines for TPAs issued by the Authority and this application is submitted in compliance of the same. m) We confirm that all information furnished is correct in the event if it is proved that any information submitted is wrong or incorrect we undertake that the Certificate of Registration granted is subject to the provisions of the Act and Regulations notified by the Authority. Date: For and on behalf of (Name of Applicant Company) Place: (Name of Director) (Name of Director) Page 11 of 89 Annexure – 2 As per Regulations 7 (1) of IRDAI (TPA – Health Services) Regulations, 2016 Check-list for Documentation to be submitted along with Form TPA - 1 and Procedural requirements for obtaining Fresh TPA Registration. 1. Submission of Completed Application along with attachment wherever necessary; a) Submission of relevant information as required in the FORM TPA – 1. This form shall be filled in completely and signed by two directors of the applicant Company. b) Remittance of requisite fee by demand draft / NEFT payable at Hyderabad, as prescribed under Regulation 3 (6) of IRDAI (TPA – Health Services) Regulations, 2016. In addition to the prescribed fee applicable service tax to be also paid. c) Submission of printed copy of applicant’s Memorandum and Articles of Association registered with the RoC. The main objects of the Memorandum and Articles of Association shall be in line with Regulations. d) Ensure that Director having Medical Qualification has effective and valid registration with Medical Council of India. e) Ensure compliance to the qualification, training and passing of examination requirement as specified in Regulation 11 of IRDAI (TPA – Health Services) Regulations, 2016. This is a requirement to be complied with before any application could be considered for grant of registration. f) Information pertaining to the CEO/CAO are to be submitted. Refer to Regulation 11 for details. g) Details of Directors, Shareholders, Promoters, and Key Managerial Personnel are to be provided in the prescribed format. h) Details of statutory auditors and Principal Bankers along with the Bank Account Number of applicant. i) Details of existing or proposed infrastructure with regard to office space/ trained manpower, etc. for the registered office / corporate office. j) Organization chart giving a complete picture of the company’s activities like IT, claims settlement, marketing, accounts, back office etc. k) Format for fit and proper criteria for Directors, Promoters, Shareholders, and Key Managerial Personnel of applicant TPA Company in the prescribed Form TPA – 2 at Annexure – 4, as mentioned in this circular. l) Bring on record any other information, which is relevant to the nature of services rendered by the applicant for the growth and promotion of insurance business. m) An undertaking to the following effect shall be furnished with the Authority; n) Any other requirements as deemed necessary by the Authority. Page 12 of 89 Annexure – 3. As per Regulations 9 (1) of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA – 1A Certificate of Registration 1. In exercise of the powers conferred by sub-section (1) of section 42D of the Insurance Act, 1938 (4 of 1938), the Authority hereby grants the Certificate of Registration to ______________________________________ to act as Third Party Administrator under that Act. 2. Registration Number for the Third Party Administrator is ______________ 3. This Registration shall be valid from ____________ to ___________ 4. This Registration is subject to the Act, Insurance Regulatory and Development Authority Act, 1999 (4 of 1999) and Insurance Regulatory and Development Authority of India (Third Party Administration – Health Services) Regulation, 2016 and shall not be construed to be in compliance with or in conformity to any other Act, rules or regulations. Place : Date: For and on behalf of Insurance Regulatory and Development Authority of India Page 13 of 89 Annexure - 4 Declaration and Undertaking Form to be filled in by each of the Directors, Promoters, Shareholders, and Key Managerial Personnel of the TPA Company. Form TPA - 2 Instructions for filling up the form: a. Declaration and Undertaking’ prescribed for the purpose of conducting due diligence to determine the 'fit and proper' status. b. A separate form needs to be submitted by each individual i.e. Directors, Promoters, Shareholders, Key Managerial Personnel of the TPA Company or applicant TPA Company. c. A separate form needs to be submitted in cases where both CEO & CAO are appointed by the TPA Company. d. This form to be submitted with the Authority at the time of fresh application for grant of TPA registration, change in any of the Directors, Shareholders, Key Managerial Personnel of TPA Company or Change (other than Sr. No. 1 & 2 of the following format) in any of the information already furnished in respect of the promoters or officials referred herein. 1 PARTICULARS OF THE APPLICANT OR REGISTERED TPA COMPANY: 1.1 Name of the TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 2. Personal Details of Director or Promoter or Shareholder or Key Managerial Personnel as the case may be; Sr. No. Particulars of Information a. Complete name b. Complete name of Father c. Complete name of Spouse (if any) d. Date of Birth e. Nationality f. Permanent Address g. Present Address h. Phone No (Business Direct) i. Cell No. j. Fax No. k. e-mail id l. web address: m. PAN under the Income Tax Act and Name and address of Income Tax Circle n. Passport No. (if any) o. Position in the TPA Company and current position held from p. Relevant knowledge and experience in insurance (if any) q. Description of duties and responsibilities r. Any other information relevant to position Page 14 of 89 3. Academic Qualifications: Sr. No. Name of Institute Country Qualification Year of study / Graduation 4. Professional Qualification / Training: Sr. No. Name of Institute Country Qualification Year of study / Graduation Sr. No. Name of Professional Body (s) with whom membership / affiliation is in existence, if any. Date of first grant of Membership / Affiliation Date for validity of Membership / Affiliation Membership / Affiliation No. Remarks, if any 5. Present Shareholding in this company (if any). Status as on: _____________ (dd/mm/yyyy) Sr. No. No. of shares held % of shares held 6. Equity Interest in other Companies / Shareholding held in other companies (if any) as on dd/mm/yyyy: Sr. No. Name of the Company No. of shares held % of shares held 7. Directorship / Partnership / Proprietor positions held in other companies (if any) as on dd/mm/yyyy: Sr. No. Name of the Company Position held in the Company Period (From dd/mm/yyyy – To dd/mm/yyyy) 8. Working Experience (if any) in the preceding Eight Financial Years: Sr. No. Name of the employer Nature of Business Designation Description of duties Period (From dd/mm/yyyy – To dd/mm/yyyy) I I I I I I I I I I I I Page 15 of 89 9. Relevant FIT & Proper Criteria; (If answer is YES to any of the questions relating to Directors, promoters shareholders and the Key Managerial Personnel of TPA Company), please give full details, separate sheet may be attached for the same); Sr. No. Particulars of Information Yes / No. a. Have you of ever registered or obtained license or registration from any of the regulatory authorities under any law such as SEBI, RBI, IRDAI, PFRDA etc. b. Is there any other business carried out under any name other than the TPA Company / Applicant Company. c. Have you ever been refused or restricted by any regulatory authority to carry on any business, trade or profession for which a specific license or registration or other authorization is required by law. d. Have you been ever censured or disciplined or suspended or refused permission or license or registration by any regulatory authority to carry on any business activity. e. Have you been subject to any investigations or disciplinary proceeding or have been issued warning or reprimand by any regulatory authority f. Have you been convicted of any offence or subject to any pending proceedings under any law g. Have you been banned from entry at any profession / occupation at any time. h. Details of prosecution, if any, pending or commenced or resulting in conviction in the past for violation of economic laws and regulations i. Details of criminal prosecution, if any, pending or commenced or resulting in conviction in the past against you j. Do you attract any of the disqualifications envisaged under Section 164 of the Companies’ Act 2013? k. Have you been subject to any investigation at the instance of Government department or agency? l. Have you at any time been found guilty of violation of rules / regulations / legislative requirements by customs / excise / income tax / foreign exchange / other revenue authorities, if so give particulars m. Have you at any time come to the adverse notice of a regulator such as RBI, SEBI, IRDAI, DCA. (Though it shall not be necessary for a candidate to mention in the column about orders and findings made by regulators which have been later on reversed / set aside in toto, it would be necessary to make a mention of the same, in case the reversal / setting aside is on technical reasons like limitation or lack of jurisdiction, etc, and not on merit. If the order of the regulator is temporarily stayed and the appellate / court proceedings are pending, the same also should be mentioned). n. Any other explanation / information in regard to items I and II and other information considered relevant for judging fit and proper 10. Undertaking: I, confirm that the above information is, to the best of my knowledge and belief, true and complete. I, undertake to keep the Authority fully informed, as soon as possible, of all events, which take place subsequent to my appointment, which are relevant to the information provided above. Place: Signature: Date: Name: ------------------------------------------------------------------------------------------------------------------------------- Page 16 of 89 Undertaking from the Applicant or Registered TPA Company. It is hereby declared that the particulars furnished by the officials in Form TPA – 2 are examined. The Company also carried out the due diligence with regard to the appropriateness of the persons in appointing them to the said positions and found that the persons so appointed are fit to hold the said positions and comply with relevant regulatory provisions governing the management and administration of the TPA Company. Date: For and on behalf of (Name of Applicant or Registered TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) Page 17 of 89 Annexure – 5 As per Regulations 11 (3) of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA – 3 Form for Intimation of appointment or termination or change in Director and or Key Managerial Personnel if any. (Note: Form to be submitted within 15 days of appointment or termination or change) 1 Details Sr. No. Name Address with telephone no., Mobile no., e-mail id Cessation or termination or Appointment Date of cessation or termination / Appointment 1 2 In case of Appointment of Director having Medical Qualification or Chief Medical Officer, furnish the following additional information; 1.1 A Name B Address C Qualification Name of Medicine Course Undergone Name of the Institute University Affiliation Registration particulars with MCI Duration of the Course Year of Passing Registration no. issued by MCI 2 In case of Appointment of other than Medical Director and CMO 2.1 A Name & Designation 3 Declaration and Undertaking’ prescribed for the purpose of conducting due diligence at the time of appointment to determine the 'fit and proper' status shall be furnished in prescribed format i.e. Form TPA – 2 at Annexure – 4 of this circular in all cases of appointment. 4. Any other relevant information to be declared with respect to official appointed. Date: For and on behalf of (Name of TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) I I I I I I I I I I I I I I Page 18 of 89 Annexure – 6 As per Regulations 12 (1) of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA - 4 Application for issue of Duplicate Certificate of Registration 1 PARTICULARS OF THE TPA COMPANY: 1.1 Name of the TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 (B) Address for Correspondence: Principal Place of business or Corporate Office Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.4 (c) Name and Designation of Chief Executive Officer or Chief Administrative Officer. 2 Details of Certificate of Registration A TPA Registration No. B Date of Registration or renewal of Registration (DD/MM/YYYY) C Date of Expiry for Current Certificate of Registration (DD/MM/YYYY) D Reason for loss / Mutilation of Original Certificate of Registration. 3 Fee Payment; A non-refundable fee of Rs. Two Thousand only plus applicable service tax need to be paid to IRDAI Payment Details DD / UTR No. ______________________ Date _______________ Name of Bank 4 Declaration THIS DECLARATION IS TO BE SIGNED BY ANY TWO OF THE DIRECTORS OF TPA COMPANY a) I / We hereby apply for duplicate CoR in accordance to the provisions of regulation 12. b) I/we therefore request the Authority to kindly issue a duplicate CoR in light of the circumstances explained above. c) I / We -------(Name(s) of Director/s)--------------------------------- solemnly declare and confirm that the particulars given above are true to the best of our knowledge and belief. Date: For and on behalf of (Name of TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) I I I I I Page 19 of 89 Annexure – 7 As per Regulations 12 (3) of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA – 4A DUPLICATE CERTIFICATE OF REGISTRATION 1. In exercise of the powers conferred by sub-section (1) of section 42D of the Insurance Act, 1938 (4 of 1938) the Authority hereby grants the Certificate of Registration to ______________________________________ to act as Third Party Administrator under that Act. 2. Registration Number for the Third Party Administrator is ______________ 3. This Registration shall be valid from ____________ to ___________ 4. This Registration is subject to the Act, Insurance Regulatory and Development Authority Act, 1999 (4 of 1999) and Insurance Regulatory and Development Authority of India (Third Party Administration – Health Services) Regulation, 2016 and shall not be construed to be in compliance with or in conformity to any other Act, rules or regulations.. Place : Date: For and on behalf of Insurance Regulatory and Development Authority of India Page 20 of 89 Annexure - 8 As per Regulations 13 (2) of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA – 5 APPLICATION SEEKING APPROVAL FOR CHANGE IN SHAREHOLDING PATTERN 1 PARTICULARS OF THE TPA COMPANY: 1.1 Name of the TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 (B) Address for Correspondence: Principal Place of business or Corporate Office Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 2 FINANCIAL INFORMATION 2.1 Capital Structure (Amt in INR) Sr. No. Particulars Amount 1 Authorized Capital 2 issued capital 3 Paid-up capital 4 Free reserves (excluding re- valuation reserves) 2.2 FDI Details # Shareholder Name Total Equity Share Capital % Holding Column Code a b c 1 Indian 2 Foreign Direct 3 Foreign Indirect 3 Details of change in Shareholding 3.1 Date of change in Shareholding effected, if any (DD/MM/YYYY) 3.2 Reasons for change in shareholding pattern. (Applicant TPA may attached separate sheet wherever necessary) 3.3 Details for proposed change in shareholding Page 21 of 89 3.4 Effect of Change in shareholding pattern on the FDI 3.5 Details of proposed shareholding pattern; Sr. No. Name of the Share holder Prior to transfer of shares (1) After the transfer of shares (2) Remarks (if any) No. of shares held Percentage of Paid up share capital No. of shares held Percentage of Paid up share capital held 4 Declaration THIS DECLARATION IS TO BE SIGNED BY ANY TWO OF THE DIRECTORS OF APPLICANT COMPANY a) I/we therefore request the Authority to kindly approve change in shareholding pattern. b) I / We -------(Name(s) of Director/s)--------------------------------- solemnly declare and confirm that the particulars given above are true to the best of my knowledge and belief. Date: For and on behalf of (Name of TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) # Category of Shareholder (Foreign Direct/Foreign Indirect / Indian) Particulars of changes in shareholding (Purchase / Sale / Fresh Issue) Name and Address of the shareholder Business or Profession Shareholding as at end of DD/MM/YYYY (Number) Shareholding as at end of (DD/MM/YYYY) (Amount in INR) Percentage of change in shareholding Column Code a b c d e f g 1 2 3 4 5 Type of Share holding Total Equity Share Capital % Holding Column Code a b c 1 Indian 2 Foreign Direct 3 Foreign Indirect I Page 22 of 89 Annexure – 9 As per Regulations 13 (2) of IRDAI (TPA – Health Services) Regulations, 2016 List of documents to be submitted for consideration of application for transfer of ownership when the transfer is exceeding 5% of the total paid up capital If the proposed transferee is a corporate entity: 1. A certified copy of resolution of the Board of Directors of TPA Company approving the proposed change in shareholding. 2. The shareholding pattern after effecting the transfer, as per the format mentioned at Table – 1 hereunder, duly certified by a practicing Chartered Accountant or Company Secretary 3. A certified copy of the Board Resolution of the transferee approving the acquisition of the shares of TPA Company. 4. The details of the monetary consideration for transfer of shares. 5. A certified copy of the structure and shareholding pattern of the transferee Company. 6. Detailed Information, if any of the proposed shareholders are FII, NRI, PIOs or Foreign Nationals. 7. Detailed Information if any of the present directors of the TPA Company are already associated with the transferee. 8. The audited accounts of the transferee for the past three years, along with the certified copies of IT return. 9. A certificate from the practicing Chartered Accountant to the effect that the transferee is not an NBFC, if applicable. No Objection Certificate obtained from RBI, wherever necessary, for acquisition of these shares if transferee is a Non- banking financial company. A declaration that NoC is not required as the case may be. 10. The detailed list and activities of subsidiary or joint venture or associate companies/ firms of the transferee. 11. An undertaking from the transferee that; None of the director(s) / promoter(s) / shareholder(s) / Key managerial personnelof transferee company is / are engaged in any other insurance or insurance related activity(s). (Note: Where it is to be determined whether officials referred herein are involved in any other insurance or insurance related activities or not, TPA Company shall furnish the detailed information separately along with the form) 12. The details of any other proposed changes in the TPA Company, if any. 13. Format for fit and proper criteria for Directors, Promoters, Shareholders, and Key Managerial Personnel of TPA Company in the prescribed Form TPA – 2 at Annexure – 4 as specified in this circular. 14. Any other documents, data, information, clarification as may be required by the Authority. Page 23 of 89 If the proposed transferee is an Individual: 1. The shareholding pattern (as per Table - 1) prior and after effecting the transfer duly certified by a practicing Chartered Accountant or Company Secretary. 2. The net worth certificate containing details of assets and liabilities duly certified by practicing Chartered Accountant and copies of Income Tax returns as filed with Income Tax Authorities, for the preceding three financial years of the transferee. 3. The details of the monetary consideration for the transfer of shares 4. A certified copy of resolution of the Board of Directors of TPA Company approving the proposed change in shareholding. 5. Certificate from practicing Chartered Accountant about sources of funds to be invested in the Company by the transferee/s. 6. Complete particulars if the transferee is engaged in any other insurance or insurance related activities OR where the transferee is not engaged in any other insurance or insurance related activities, an undertaking from the transferee that; he / she is / are not engaged in any other insurance or insurance related activity(s). 7. Format for fit and proper criteria for Directors, Promoters, Shareholders, and the Key Managerial Personnel of TPA Company in the prescribed Form TPA – 2 at Annexure – 4, as specified in this circular 8. Any other documents, data, information, clarification as may be required by the Authority. Format to be furnished about Share holding Pattern prior and after effecting the proposed share transfer; TABLE - 1 Sr. No. Name of the Share holder Prior to transfer of shares (1) After the transfer of shares (2) Remarks (if any) No. of shares held Percentage of Paid up share capital No. of shares held Percentage of Paid up share capital held Note: 1. If the current shareholding pattern is not the same as the shareholding pattern at the time of registration/ last renewal (whichever is later), the details of the same should also be provided 2. The names of the share holders who do not hold/never held more than 5% should be shown in ‘Others’ unless they are associated or part of Promoter share holders Page 24 of 89 Annexure – 10 As per Regulations 13 (2) of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA – 6A REPORT ON STATUS OF SHAREHOLDING PATTERN OF A TPA COMPANY (To be furnished whenever there is a change in the Shareholding pattern) 1 Name of the TPA : 2 Financial Year 3 Details of Share holding pattern. (To be furnished separately both prior to effecting the Change and after effecting the change in the shareholding pattern) Sr. No. Name of Shareholder Address Category of Shareholder (Foreign Direct/Foreign Indirect / Indian) Number of Shares Hold Percentage of shareholding Date of acquiring share of TPA Remarks Column Code a b c d e f g 1 2 3 4 5 Date: For and on behalf of (Name of TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) I Page 25 of 89 Annexure – 11 As per Regulations 14 of IRDAI (TPA – Health Services) Regulations, 2016 Minimum Business Requirements of TPAs The following Minimum Business Requirements to be fulfilled by every TPA registered with the Authority during each financial year. TABLE- A Number of Financial Years Completed since 01-04-2016 or date of granting the Certificate of Registration, whichever is later Number of policies serviced Parameter - 1 Number of lives serviced Parameter – 2 Second Year 2500 5000 Third Year 5000 10000 Fourth Year to Sixth Year 10000 25000 From Seventh Year onwards 15000 50000 Where TPAs are exclusively servicing Group Health Insurance Policies, they shall fulfil twice the number of policies prescribed under Parameter – 1 as an additional number of lives in the respective years in addition to those prescribed under Parameter – 2. For such TPAs the norms prescribed under Parameter – 1 are not applicable. Those TPAs who wish to exclusively service Group Policies shall inform the Authority at the commencement of the Financial Year. Every TPA shall endeavor to enter into Health Services Agreement with at least two insurers during second and third years of business, a minimum of three insurers during fourth to sixth year of business and a minimum of four insurers from seventh year onwards. Provided the agreements to be entered with the number of insurers stipulated herein may be fulfilled at any time during the course of the applicable Financial Year. The TPAs that received the Certificate of Registration on or after 01st October of the Financial Year shall consider the subsequent financial year as the first financial year for fulfillment of the minimum business norms stipulated at Table – A. In respect of the applications received for the renewal of the certificate of registration, the business procured in the applicable preceding Financial Years shall be taken into consideration while determining the fulfillment of minimum business requirements in accordance to the provisions of Regulation 15 (C) (6). Where a TPA Company has completed more than six months business in a financial year and due for renewal, such TPA Company shall fulfill the proportionate business in respect of the completed number of months in that incomplete financial year. In case if a TPA Company has completed less than six months in a financial year and due for renewal, that period may be ignored. These Minimum Business Requirements shall be applicable for all the TPAs registered with the Authority from 01st April, 2016 and the existing TPA Companies shall comply with the minimum business requirements from 01st April, 2016 onwards. Annexure – 12 Page 26 of 89 As per Regulations 15 of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA – 7 APPLICATION FOR RENEWAL OF CERTIFICATE OF REGISTRATION Instructions for filling up the form: 1. It is important that before this application form is filled in, the regulations made by the Authority are studied carefully. 2. Applicant must submit a duly completed application form together with all appropriate, supporting documents to the Authority. 3. Application for renewal of registration will be considered only if it is complete in all respects. 4. Application for renewal of Certificate of Registration (CoR), shall be signed by at least two directors of Applicant Company. 5. Information which needs to be supplied in more details may be given on separate sheets which should be attached to the application form. 1 PARTICULARS OF THE TPA COMPANY: 1.1 Name of the TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 (B) Address for Correspondence: Principal Place of business or Corporate Office Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 2 Details of Certificate of Registration A TPA Registration No. B Date of First grant of Registration (DD/MM/YYYY) C Date of Renewal of Registration (DD/MM/YYYY) (if applicable) D Date of Expiry of Current Certificate of Registration (DD/MM/YYYY) 3 Details of Promoters, Directors, Shareholders, and Key Managerial Persons of the TPA Company. Sr. No. Complete Name (only initials shall not be provided) Relationship with TPA Company i.e. (Promoter, Directors, Shareholders, Key Managerial Persons) Director having Medical Qualification (Yes / No) No. of Shares held in TPA Company (if any) Percentage of shares held in TPA Co. (if any) Remarks (if any) 1 2 3 4 Details about change, if any in respect of the following. A Information about the change of shareholding pattern, if any, since the date of intimation to the Authority: Page 27 of 89 B Change of the Directors, if any, since the date of intimation to the Authority: C Change in the Key Managerial Personnel, if any, since the date intimation to the Authority: Note: Wherever there is a change in respect of (A), (B) and (C) referred above furnish information as per the applicable format specified under this circular. 5 Details of business done by TPA Company. (To be reported as per provisions of Regulations or Circular as issued by the Authority) A Completed years of functioning as a registered TPA B Business details Sr. No. Years since granting the Certificate of Registration (e.g. Second Year / Third Year / Forth Year) 1st applicable Financial Year (FY) 2nd applicable Financial Year 3rd applicable Financial Year Please specify relevant FY 1 Number of policies serviced (as per Parameter – 1 of Authority Circular) 2 Number of lives serviced (as per Parameter – 2 of Authority Circular) 3 No. of service level agreements entered into with insurers. 6 Fee Payment; A non-refundable fee of Rs. Fifteen Thousand plus applicable service tax, need to be paid to IRDAI Payment Details DD / UTR No. ______________________ Date _______________ Name of Bank 7 Particulars of Joint Venture Companies, Subsidiary Companies Incorporated by the TPA Company, changes effected thereon if any, subsequent to grant of Certificate of Registration. Sr. No. Name of Company Date of Incorpo ration Address with telephone no., Mobile no., e-mail Nature of Business and the Type of activity Names of Promoters and Directors Stake of TPA / applicant company Remarks if any 1 2 I I I I Page 28 of 89 8 Declaration THIS DECLARATION CUM UNDERTAKING IS TO BE SIGNED BY ANY TWO OF THEDIRECTORS OFAPPLICANT COMPANY a) None of the Directors is a minor b) None of the Directors and the promoters is found to be of unsound mind by a court of competent jurisdiction. c) None of the Directors and the promoters is found guilty of criminal misappropriation or criminal breach of trust or cheating or forgery or an abetment of or attempt to commit any offence by a court of competent jurisdiction. d) None of the Directors and the promoters is found guilty of or knowingly participated in or connived with for any fraud, dishonestly or misrepresentation against an insured or an insurer. The director of TPA Company having Medical Qualifications, has the approved medical qualification and has valid registration with the Medical Council of India. e) CEO or CAO possesses the requisite qualifications and practical training as specified by Insurance Regulatory and Development Authority of India. The CEO, CAO of the company is / are also fit and proper as per Regulation 11 of the TPA Regulations. f) TPA Company is not engaged in any other business apart from TPA activity as defined in the TPA regulations. The TPA Company has not committed any breach of the provisions of the applicable Acts, Regulations and / or circulars issued by the Authority time to time. The Company did not violate the code of conduct specified by Insurance Regulatory and Development Authority of India. g) We declare that we have truthfully and fully answered the questions above and provided all the information which might reasonably be considered relevant for the purposes of renewing the Certificate of Registration. h) We declare that the information supplied in the application form is complete and correct. i) The TPA Company has not committed any breach of the provisions of the applicable Acts, Regulations and / or circulars issued by the Authority from time to time. j) It is hereby declared that the TPA Company during the time of the registration with the Authority from ___ (date of granting the CoR / Date of Renewal of the Registration)__ has complied with the minimum business norms as specified by the Authority. (Note: Furnish the substantiating reasons, if any, separately where the minimum business norms were not fulfilled as specified in each of the relevant Financial Year) k) None of the director(s) or promoter(s) or shareholder(s) or Key managerial personnel of the TPA Company are engaged directly or indirectly in any other insurance or insurance related activity(s). (Note: Where it is to be determined whether officials referred herein are involved in any other insurance or insurance related activities or not, TPA Company shall furnish the detailed information separately along with the form.) Date: For and on behalf of (Name of Applicant Company) Place: (Name of Director) (Name of Director or CEO / CAO) (Seal of the Company) I Page 29 of 89 Annexure – 13 As per Regulations 15 of IRDAI (TPA – Health Services) Regulations, 2016 List of documents to be attached with the Application for Renewal of TPA Registration. 1. Form TPA-7 (Application form) duly filled in. 2. DD / NEFT towards renewal fee including applicable service tax amount. 3. Shareholding pattern of the company as on date of submission of the Application, if there is any change, subsequent to the intimation to the Authority in terms of the relevant provisions of the Regulation duly certified by a practicing Chartered Accountant or a practicing Company Secretary in format TPA-6A. 4. Working capital certificate duly certified by the Statutory Auditors of the company in the format TPA-6C 5. Certified (by Practicing Chartered Accountant or Practicing Company Secretary) copy of Memorandum and Articles of Association issued by Registrar of Companies (to submit the certified copies only in case of changes from the earlier MoA/AoA submitted to the Authority) 6. Any other document, data, information, clarification as may be required by the Authority. Page 30 of 89 Annexure – 14 As per Regulations 15 (F) (9) of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA – 7A CERTIFICATE OF RENEWAL OF REGISTRATION Certificate of Registration No. _____ 1. The registration of M/s. ___________________________________ is hereby renewed as per provisions of Act, Insurance Regulatory and Development Authority Act, 1999 ( 4 of 1999) and IRDAI (TPA – Health Services) Regulations, 2016 to act as Third Party Administrator. 2. This Registration shall be valid from (DD/MM/YYYY) to (DD/MM/YYYY). 3. This Registration is renewed subject to the condition that the TPA shall comply with all the provisions of the Act, Insurance Regulatory and Development Authority, Act 1999 (4 of 1999), and Insurance Regulatory and Development Authority of India (Third Party Administrator – Health Services) Regulations, 2016, the rules or regulations made there under and the Guidelines, Circulars & Directions issued by the Authority from time to time. Place : Date: For and on behalf of Insurance Regulatory and Development Authority of India Page 31 of 89 Annexure – 15 As per Regulations 17 (1) of IRDAI (TPA – Health Services) Regulations, 2016 List of documents to be submitted along with application for Voluntary Surrender of TPA Registration. 1. Application by TPA for surrender of Certificate of Registration of TPA mentioning the reason for surrender and to be signed by any two of the Directors of TPA. 2. A certified copy (Certified by two directors of TPA Company) of resolution of the Board of Directors recording reasons for surrender of the registration of the TPA Company. 3. A confirmation from the CEO or CAO that no fresh business is accepted from the date of the resolution of the Board seeking surrender of the registration of the TPA Company. 4. Original Certificate of Registration / Renewed Certificate of Registration issued by the Authority. (or Duplicate Certificate of Registration as the case may be) 5. An undertaking from any two Directors of the TPA Company that the company shall comply with the provisions of the Regulation 18 of IRDAI (TPA – Health Services) Regulations, 2016. 6. Particulars of the notification made to the Registrar of Companies and compliance with their requirements under Companies Act for deletion of Main Objects of MOA/AOA or produce proof of steps taken to de-register the company with Registrar of Companies. 7. To submit the statistics on claims in Form TPA – 6Bfrom the date of last submission to the Authority till the date of the last transaction. 8. Any other documents, data, information, clarification as may be required by the Authority. Page 32 of 89 Annexure – 16 As per Regulations 19 (9) of IRDAI (TPA – Health Services) Regulations, 2016 Annual Report by Third Party Administrator FORM TPA – 8 1 PARTICULARS OF THE TPA: 1.1 Name of the TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 Financial year 1.4 Board of directors as on.....(end of concerned FY)........and changes in the board since the date of statement of the preceding year. Sr. No. Name of Director and DIN No. Age Address with telephone no., Mobile no., e-mail Details of Directorship in other Companies Particulars of Change in Board (Cession / Appointment) Date of Change in Board 1 2 1.5 Details of Chief Executive Officer (CEO) Sr. No. Name of CEO Age Address with telephone no., Mobile no., e-mail Qualifications Details of Directorship in other Companies Date of joining with TPA Company as a CEO 1.6 Details of Chief Administrative Officer (CAO) Sr. No. Name of CAO Age Address with telephone no., Mobile no., e-mail Qualifications Details of Directorship in other Companies Date of joining with TPA Company as a CAO 1.7 Details of Chief Medical Officer (CMO) Sr. No. Name of CMO Age Address with telephone no., Mobile no., e-mail Qualifications Details of Directorship in other Companies Date of joining with TPA Company I I I I I Page 33 of 89 1.8 Name and Address of Auditors 1.9 Enumeration of TPA services provided : 1.10 Enumeration of standing arrangements with hospitals and with doctors : Number of agreements with Network Providers Number of agreements with Doctors 1.11 Summary of TPA Business: a. No. of insurers with whom agreements entered with. b. Lives covered under Health Policies (to be reported as per provisions of Reg. 14 of TPA Regulations and Circular in the matter issued by the Authority) c. Policies Served (to be reported as per provisions of Reg. 14 of TPA Regulations and Circular in the matter issued by the Authority) d. Number of Hospitals tied up by the TPA (beginning of concerned FY) e. Hospitals tied up during (for the concerned FY) f. Total Hospitals terminated or removed during (concerned FY) g. Total Hospitals tied up as on (end of concerned FY) 1.12 Summary of TPA services: Sr. No. Particulars of Services No. of Policies Serviced No. of lives Serviced Amount of Premium Serviced wherever available. (INR in Lakh) 1 Individual / Retail Health Insurance Policies 2 Group Health Insurance Policies (other than RSBY or other similar policies issued by insurers) 3 Policies issued under RSBY or other similar policies issued by insurers 4 Pre-Insurance Medical Examination 5 Foreign Travel Policies issued by Indian insurer 6 Foreign Travel Policies issued by Foreign insurer 7 Non-insurance healthcare schemes sponsored by Central / State Government. I I Page 34 of 89 Schedule – 1, FORM TPA – 8-RA Revenue Account for the year ending 31st March ________ Expenses Income I. Directors’ remuneration II. Staff expenses (a) salaries, provident fund (b) other benefits III. Office expenses (a) Rent, rates and taxes (b) Electricity, water (c) House-keeping and Cleaning (d) Others (e) Travel (f) Entertainment (g) Lease rent of equipments (h) Post, telecommunication and similar expenses (i) Audit fees (j) Legal Expenses (k) Repairs and maintenance (l) Depreciation (m) Motor Vehicle Expenses (n) Other expenses (Please specify) (o) Loss on sale of investments or assets (p) Profit/Loss for the year IV. Operating Expenses I. Income (a) Income from insurers (Indian & foreign) (b) From others (please specify) (c) Investment income (d) Profit on sale of investments or assets Page 35 of 89 Schedule – 2, FORM TPA – 8-PL Profit and Loss Appropriation Account for the year ending 31st March.................... Particulars Amount (Rs.) Particulars Amount (Rs.) Loss Brought Forward Profit Brought Forward Loss for the year Profit for the year Dividend for the year Transfer from reserves Tax on Dividend Loss Carried forward Transfer of Reserves Deferred tax credit Other allocations from profit Provision for taxation Differed tax liability Taxation of earlier year Profit carried forward Page 36 of 89 Schedule – 3, FORM TPA – 8-BS Balance Sheet as at 31st March ................. Liabilities Amount (Rs.) Amount (Rs.) Assets Amount (Rs.) Amount (Rs.) Authorized Capital Building / Properties Cost Issued Capital Less Depreciation Paid up Capital Reserves & Surplus Furniture & Fixtures Amounts Due to Less Depreciation a) Insurers b) Hospitals Air Conditioners c) Doctors Less Depreciation d) Others Electrical Installation Secured Loan Less Depreciation Office Equipments Unsecured Loan Less Depreciation Computer Software Deferred Tax Liability Less Depreciation Bank Overdraft Motor Vehicles Less Depreciation Current Liability Sundry Creditors Investments Provisions Government Securities (Market Value) Others Loan & Debenture (Market Value) Other Investments (Market Value) Receivables From Insurers Others Cash & Bank Balances TOTAL TOTAL Page 37 of 89 Schedule – 4 Schedule of the income received towards various activities during the FY _______ Sr No Description Income / Remuneration received during the FY (Amt. INR in Lakhs) 1 Towards Health Services of the Individual policies issued by Indian Insurers 2 Towards Health Services of the Group Insurance policies issued by Indian Insurers 3 Pre-insurance medical examination 4 Towards Health Services in the foreign jurisdiction in respect of the policies issued by Indian Insurers 5 Towards Non Insurance Services rendered 6 Towards Servicing of policies issued by foreign Insurers 7 Other income (please specify accounting head wise other income received) TOTAL Schedule – 5 Schedule of apportionment of Expenses to various activities during the FY ___________ Sl No Description Expenses incurred during the FY (Amt. INR in Lakhs) 1 Health Services of the policies issued by Indian Insurers 2 Health Services in the foreign jurisdiction in respect of the policies issued by Indian Insurers 3 Non Insurance Services rendered 4 Servicing of policies issued by foreign Insurers 5 Other Expenses Incurred (to specify) Schedule – 6 1. Data of claims received during the year .......... Benefit Based Policies Cashless Claims Reimbursement Claims Total Number of Claims Amount of Claims Number of Claims Amount of Claims Number of Claims Amount of Claims No of claims Amount of claims Page 38 of 89 2. Data of Settled Claims in respect of Individual Policies; Description (to be reckoned from the date of receipt of Claim) Benefit Based Claims Cashless Claims Reimbursement Claims Total Number of Claims Amount of Claims Number of Claims Amount of Claims Number of Claims Amount of Claims No of claims Amount of claims within 1 months from date of receipt of claim Between 1 – 3 Months Between 3 to 6 Months More than 6 months 3. Data of settled Claims in respect of Group Policies; Description (to be reckoned from the date of receipt of Claim) Benefit Based Claims Cashless Claims Reimbursement Claims Total Number of Claims Amount of Claims Number of Claims Amount of Claims Number of Claims Amount of Claims No of claims Amount of claims within 1 months from date of receipt of claim Between 1 – 3 Months Between 3 to 6 Months More than 6 months 4. Data of settled Claims in respect of Total (Individual Policies + Group Policies); Description (to be reckoned from the date of receipt of Claim) Benefit Based Claims Cashless Claims Reimbursement Claims Total Number of Claims Amount of Claims Number of Claims Amount of Claims Number of Claims Amount of Claims No of claims Amount of claims within 1 months from date of receipt of claim Between 1 – 3 Months Between 3 to 6 Months More than 6 months Page 39 of 89 5. Data of Claims in respect of Individual Policies recommended for repudiation Description (to be reckoned from the date of receipt of Claim) Benefit Based Claims Cashless Claims Reimbursement Claims Total Number of Claims Amount of Claims Number of Claims Amount of Claims Number of Claims Amount of Claims No of claims Amount of claims within 1 months from date of receipt of claim Between 1 – 3 Months Between 3 to 6 Months More than 6 months 6. Data of Claims in respect of Group Policies recommended for repudiation Description (to be reckoned from the date of receipt of Claim) Benefit Based Claims Cashless Claims Reimbursement Claims Total Number of Claims Amount of Claims Number of Claims Amount of Claims Number of Claims Amount of Claims No of claims Amount of claims within 1 months from date of receipt of claim Between 1 – 3 Months Between 3 to 6 Months More than 6 months 7. Data of Claims in respect of Total Policies (Individual + Group Policies) recommended for repudiation; Description (to be reckoned from the date of receipt of Claim) Benefit Based Claims Cashless Claims Reimbursement Claims Total Number of Claims Amount of Claims Number of Claims Amount of Claims Number of Claims Amount of Claims No of claims Amount of claims within 1 months from date of receipt of claim Between 1 – 3 Months Between 3 to 6 Months More than 6 months (Note: In respect of data on Repudiations, amount of claim made by the policyholder to be mentioned as the amount of claim repudiated) Page 40 of 89 8. Data of Claims Outstanding in respect of Individual Policies; Description (to be reckoned from the date of receipt of Claim) Benefit Based Claims Cashless Claims Reimbursement Claims Total Number of Claims Amount of Claims Number of Claims Amount of Claims Number of Claims Amount of Claims No of claims Amount of claims within 1 months from date of receipt of claim Between 1 – 3 Months Between 3 to 6 Months More than 6 months 9. Data of Claims Outstanding in respect of Group Insurance Policies; Description (to be reckoned from the date of receipt of Claim) Benefit Based Claims Cashless Claims Reimbursement Claims Total Number of Claims Amount of Claims Number of Claims Amount of Claims Number of Claims Amount of Claims No of claims Amount of claims within 1 months from date of receipt of claim Between 1 – 3 Months Between 3 to 6 Months More than 6 months 10. Data of Claims Outstanding in respect of Total Policies (Individual + Group Policies) Description (to be reckoned from the date of receipt of Claim) Benefit Based Claims Cashless Claims Reimbursement Claims Total Number of Claims Amount of Claims Number of Claims Amount of Claims Number of Claims Amount of Claims No of claims Amount of claims within 1 months from date of receipt of claim Between 1 – 3 Months Between 3 to 6 Months More than 6 months (Note: In respect of data on Claims Outstanding, amount of claim made by the policyholder to be mentioned as the amount of claim Outstanding) Page 41 of 89 Schedule – 7 1. Directors Report; to be attached separately. (Note: Inter alia, (i) to disclose the shareholding structure as at the end of financial year, (ii) Discuss Corporate Governance norms put-in place) 2. Auditors Report including audited financial and all notes, schedules to audited financials; to be attached separately. ---------------------------------------------------------------------------------------------------------------------------- Undertaking from Registered TPA Company. It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in Form TPA – 8 and Schedule 1 to 7 there under towards various activities of the TPA Company during the FY __________ were examined, and are true and correct. It is also declared that the TPA Company did not receive any other income or remuneration from any other sources other than the one that is declared in the above Schedule. Date: For and on behalf of (Name of Applicant or Registered TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) ------------------------xx-------------------------------- Certificate from the Statutory Auditors of the TPA Company Certified that the above information about financials furnished in annual report and Schedules 1 to 5 therein by ___________(TPA Co.) is as extracted from the transactions of the TPA Company (Name of the TPA Company) for the Financial Year ____________. Date: For and on behalf of (Name of Auditors) Place: Name & Signature of Practicing Chartered Accountant (Affix seal in case it is a firm / associate) Page 42 of 89 Annexure – 17 As per Regulations 19 (10) of IRDAI (TPA – Health Services) Regulations, 2016 FORM TPA – 6B Quarterly and Cumulative Claims data for TPAs Instructions for submission of the form: Information for both Quarterly and Cumulative data to be furnished every quarter. Data to be furnished within 30 days of the end of the preceding quarter (e.g: Data for April-June Quarter to be furnished by 30th July) 1 PARTICULARS OF THE TPA COMPANY: 1.1 Name of the TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 (B) Financial Year 1.4 (c) Quarter for which Data is to be furnished (April-June / July – September / October – December / January – March) 1.5 (d) Name of Insurer (insurer wise data to be submitted in following format) Claims Data: Furnish the following information in separate tables; 1. Table – 1a: Government Hospitals who are Network Providers; 2. Table – 1b: Government Hospitals who are not Network Providers; 3. Table – 2a: Private Hospitals who are Network Providers; 4. Table – 2b: Private Hospitals who are not Network Providers; (Amount in INR) Sr. No. Particulars Cashless Claim Reimbursement Claim Benefit Based Total No. of Claims Amt. of Claims No. of Claims Amt. of Claims No. of Claims Amt. of Claims No. of Claims Amt. of Claims Column Code (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) 1 Claims pending at the beginning of the quarter 2 New claims received during the quarter 3 Claims settled 4 Claims repudiated 5 Claims pending at the end of the quarter {(1+2) – (3+4)} Aging of pending claims* Furnish the following information in separate tables; Page 43 of 89 1. Table – 1a: Government Hospitals who are Network Providers; 2. Table – 1b: Government Hospitals who are not Network Providers; 3. Table – 2a: Private Hospitals who are Network Providers; 4. Table – 2b: Private Hospitals who are not Network Providers; (Amount in INR) Sr. No. Particulars Cashless Claim Reimbursement Claim Benefit Based Total No. of Claims Amt. of Claims No. of Claims Amt. of Claims No. of Claims Amt. of Claims No. of Claims Amt. of Claims Column Code (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) 1 Claims pending for less than 1 month 2 Claims pending for 1-3 months 3 Claims pending for 3.-6 months 4 Claims pending for 6-12 months 5 Claims pending for 1-2 years Claims pending for more than 2 years. * Reckoned from date of first intimation. Aging of settled claims** Furnish the following information in separate tables; 1. Table – 1a: Government Hospitals who are Network Providers; 2. Table – 1b: Government Hospitals who are not Network Providers; 3. Table – 2a: Private Hospitals who are Network Providers; 4. Table – 2b: Private Hospitals who are not Network Providers; (Amount in INR) Sr. No. Particulars Cashless Claim Reimbursement Claim Benefit Based Total No. of Claims Amt. of Claims No. of Claims Amt. of Claims No. of Claims Amt. of Claims No. of Claims Amt. of Claims Column Code (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) 1 Claims settled for less than 1 month 2 Claims settled for 1-3 months 3 Claims settled for 3.-6 months 4 Claims settled for 6-12 months 5 Claims settled for 1-2 years 6 Claims settled for more than 2 years. ** Reckoned from date of first intimation. Page 44 of 89 Aging of repudiated claims*** Furnish the following information in separate tables; 1. Table – 1a: Government Hospitals who are Network Providers; 2. Table – 1b: Government Hospitals who are not Network Providers; 3. Table – 2a: Private Hospitals who are Network Providers; 4. Table – 2b: Private Hospitals who are not Network Providers; (Amount in INR) Sr. No. Particulars Cashless Claim Reimbursement Claim Benefit Based Total No. of Claims Amt. of Claims No. of Claims Amt. of Claims No. of Claims Amt. of Claims No. of Claims Amt. of Claims Column Code (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) 1 Claims repudiated within 1 month 2 Claims repudiated within 1-3 months 3 Claims repudiated within 3.-6 months 4 Claims repudiated within 6-12 months 5 Claims repudiated within 1-2 years 6 Claims repudiated within more than 2 years. *** Reckoned from date of receipt of last requirement. Date: For and on behalf of (Name of TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) Page 45 of 89 Annexure – 18 As per Regulations 19 (11) of IRDAI (TPA – Health Services) Regulations, 2016 Annual Certificate in the matter of Working Capital of a TPA Company. Form TPA – 6C Instructions for Submission of required certificate: 1. Periodicity of submission of this certificate is Annual i.e. as at as at 31st March of every financial year. 2. To be submitted with the Authority along with Annual Report of the TPA Company. 3. This certificate is to be certified by Auditors of a TPA Company. 1 PARTICULARS OF THE TPA COMPANY: 1.1 Name of the TPA : 1.2 Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 Financial Year 1.4 Methodology adopted for calculation of Working Capital (Refer provisions of Reg. 6 of IRDAI (TPA – Health Services) Regulations, 2016). 2 Computation of Working Capital for the period upto / Financial year ___________ Sr. No Description Amount in Rs. 1 Granular Details of the components of Assets considered 2 Granular Details of the components of Liabilities considered Working Capital Certified that the above particulars of the working capital of _____ (name of TPA Company)_____ are correct and the above details are extracted from financial statements of the TPA Company for the period up to / Financial year ___________. Date: For and on behalf of (Name of Auditors) Place: Name & Signature of Practicing Chartered Accountant (Affix seal in case it is a firm / associate) Page 46 of 89 Annexure – 19 As per Regulations 19 (11) of IRDAI (TPA – Health Services) Regulations, 2016 Declaration and Undertaking by TPA Company. Form TPA – 6D Instructions for Submission of required Declaration and Undertaking: 1. Periodicity of submission of this Declaration and Undertaking is annual. 2. This declaration and undertaking shall be signed by any two directors of a TPA Company. 3. This declaration and undertaking is to be submitted to the Authority along with Annual Report of the TPA Company. 1 PARTICULARS OF THE TPA COMPANY: 1.1 Name of the TPA : 1.2 Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 Financial Year 2 We ___(names of directors)___ the directors of _____(name TPA Company)____ hereby declare and undertake that; a) CEO or CAO possesses the requisite qualifications and practical training as specified by Insurance Regulatory and Development Authority of India. The CEO, CAO of the company is / are also fit and proper as per Regulation 11 of the TPA Regulations. Such a CEO or CAO are engaged in day to day administration of the activities of the TPA and also in ensuring compliance of regulatory requirements. b) The TPA Company is not engaged in any other business apart from Health Services by TPAs, as defined in the TPA regulations. c) A Director with required medical qualification and an appointed Chief Medical Officer have valid registration with the Medical Council of India or Medical Council of the state. d) None of the director(s), promoter(s), shareholder(s), and Key managerial personnel of our company is or are, directly or indirectly engaged in any other insurance or insurance related activity(s). (Note: Where it is to be determined whether officials referred herein are involved in any other insurance or insurance related activities or not, TPA Company shall furnish the detailed information separately along with the form) e) The Company did not violate the code of conduct or not committed any breach of the provisions of the applicable Acts, Regulations and / or circulars issued by the Authority from time to time. Date: For and on behalf of (Name of Applicant Company) Place: (Name of Director) (Name of Director or CEO / CAO) Page 47 of 89 Annexure – 20 As per Regulations 20 (4) of IRDAI (TPA – Health Services) Regulations, 2016 Service Level Agreement Details (Annual Form to be furnished along with the Annual Report) FORM TPA – 6E 1 PARTICULARS OF THE TPA: 1.1 Name of the TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 Financial year 1.4 1.5 Details of Service level Agreements (SLAs); S No Cumulative SLAs till beginning of the Year SLAs entered in the Year Total SLAs at the end of the year 1 2 3 Fresh Renewal Modification Termination Total Fresh Renewal Modification Termination Total Fresh Renewal Modification Termination Total 1.6 a Details of Service level Agreements (SLAs); SLA details for complete financial year to be provided. (for the period / up to the period ) S No. Name of the Insurer Type of Services to be rendered (Retail Policy / Group Policy/ RSBY / PIMS / Others – Please specify Type of SLA (Fresh / Renewal / Modification) Date of Purchase of stamp viz Non Judicial Stamp Paper / e- stamp / Special Adhesive / franking / any other mode Date of Agreement dd/mm/yyyy Validity of Agreement From (dd/mm/yyyy) To (dd/mm/yyyy) Date: For and on behalf of (Name of Applicant Company) Place: (Name of Director) (Name of Director or CEO / CAO) Page 48 of 89 Annexure – 21 As per Regulations 20 (5) of IRDAI (TPA – Health Services) Regulations, 2016 Minimum Standard clauses in agreement between Insurer and TPAs. 1. The specific services to be rendered by the TPA, the procedure, as prescribed by the insurer, to be followed by the TPA for providing each of such services as agreed to. 2. The fee payable to the TPA for each of the services rendered by the TPA as detailed below. The complete details on the basis on which payment becomes payable shall be documented. Rate of Service Fee Details of Services Provided Details of Fee payable 3. Turnaround times for each of the services to be rendered by the TPA, the course of action in case of default of services. 4. The TPA and or insurer responsibilities in enforcing the agreement. 5. Confidentiality requirements. 6. Termination notice 7. Inspection, Audit and Access rights to the office of TPAs by insurers on regular or on ad-hoc basis. 8. Arbitration and Dispute resolution 9. The minimum details to be incorporated on the id-cards such as; photograph of the insured, name of the insurer, emergency contact number, logo of the insurer. 10. Issue of ID cards, Nature of the Cards (Smart with QR etc.), cost of issuing ID cards and the course of action in case of default. 11. Procedure for cashless facility as per Schedule – A. 12. Procedure for de-empanelment of network providers as per Schedule - B. 13. Customer Service and relations. 14. Services rendered by the TPA to be compliance with the extant laws. 15. Intimation of changes to the insurers, in the key positions in the office of the TPA. 16. Code of conduct. 17. Obligations of the Insurer towards the TPA 18. Obligations of the TPA towards the insurer; such as; notifying (i) the objectionable conduct of either the network provider or any other hospital (ii) fraudulent activities of the policyholder or the claimant (iii) the objectionable activities of other health service providers like diagnostic centers (iv) the objectionable activities pertaining to health services by any insurer or insurance intermediary or any other person. Page 49 of 89 19. A clause that obligates TPAs to disclose the policy holders on demand, the rates agreed towards Health Services with the Network Providers with whom the TPA had entered into an agreement. 20. The rates agreed by the network providers towards various health services to be offered under the agreement and the duration or period for which they are valid or when they are reviewable. Page 50 of 89 Annexure – 22 As per Regulations 20 (5) of IRDAI (TPA – Health Services) Regulations, 2016 Minimum Standard Clauses in an agreement amongst Insurers, Network Providers and TPAs Insurance companies may offer policies providing cashless service to the policyholders provided the services are offered in network providers who have been enlisted to provide medical services either directly under an agreement with the insurer or by an agreement amongst health services provider, the TPA and the insurer. The Authority prescribes, inter alia, the following clauses to be included in such agreements as stipulated in the Agreements which shall be entered into between insurers, network providers, TPAs and shall cover the following, amongst others: 1. Scope of services provided by the network provider 2. the tariff applicable with respect to various kinds of healthcare services being provided by the network provider. 3. a clause empowering the insurer to cancel or otherwise modify the agreement in case of any fraud, misrepresentation, inadequacy of service or other non-compliance or default on the part of TPA or network provider; provided no such cancellation or modification shall be done by the insurer unless the concerned TPA or network provider is given an opportunity of being heard. 4. at the discretion of the Insurance Company, a standard clause providing for continuance of services by a network provider to the insurance company either directly or through another TPA, if the TPA is changed or the agreement with TPA is terminated. 5. an enabling clause to the network provider for opting out of network for reasons of inadequacy of service rendered either by the TPA or by the Insurance Company. 6. a clause specifically requiring only the insurance company the power to deny a claim. 7. a clause enabling insurer or the TPA that is representing an Insurer to inspect the premises of the network provider at any time without prior intimation. 8. Turnaround times for each of the services rendered by the parties, the course of action in case of default of services. 9. The responsibilities and obligations of each of the parties to the agreement in enforcing the agreement. 10. Display of information on cashless services by the network provider at prominent location, preferably at the reception and admission counter and Casualty/Emergency departments. 11. Confidentiality requirements Page 51 of 89 12. Termination notice 13. enabling clause to the Insurers or the TPA that is representing an Insurer to carry out Inspection, Audit and Access rights to the network providers either on regular or on ad-hoc basis 14. Arbitration and Dispute resolution 15. Procedure for cashless facility as in Schedule – A 16. Procedure for de-empanelment of network providers as in Schedule – B 17. Procedure to furnish the standard Discharge summary as in Schedule – C 18. Procedure to furnish the Standard Format for Provider Bills as in Schedule – D 19. Payments to be made through direct electronic fund transfer subject to deduction of tax at source as applicable under the relevant laws. 20. Payment reconciliation process on a regular basis. 21. Customer services and relations 22. Services rendered by the TPA shall be in compliance with the extant laws. 23. Code of Conduct. 24. TPAs and insurers shall endeavour to agree with the network providers for display of rates agreed for rendering health services to policy holders. Page 52 of 89 Schedule – A Provider Services – Cashless Facility Admission Procedure The insured shall be provided treatment free of cost for all such ailments covered under the policy within the limits / sub-limits and the sum insured, i.e., coverages not specifically excluded under the policy. The Provider shall be reimbursed as per the tariff agreed under the service level agreement for different treatments or procedures. The procedure to be followed for providing cashless facility shall be: I. Preauthorization Procedure – Planned Admissions: 1. Request for hospitalization shall be forwarded by the provider immediately after obtaining due details from the treating doctor in the preauthorization form prescribed by the Authority i.e. “request for authorization letter” (RAL). The RAL shall be sent electronically along with all the relevant details in electronic form to the 24-hour authorization /cashless department of the insurer or its representative TPA along with contact details of treating physician and the Insured. The insurer’s or its representative TPA’s medical team may consult the treating physician or the insured, if necessary. 2. If the treating physician of the provider identifies any disease or ailment as pre- existing, the treating physician shall record it and also inform the insured immediately. 3. In cases where the symptoms appear vague / no effective diagnosis is arrived at, the medical team of the insurer or its representative TPA may consult with treating physician / insured, if necessary. 4. The RAL shall reach the authorization department of insurer or its representative TPA 7 days prior to the expected date of admission, in case of planned admission. 5. If “clause 3” above is not followed, the clarification for the delay needs to be forwarded along with the request for authorization. 6. The RAL form shall be dully filled in clearly mentioning Yes or No and/or the details as required. The form shall not be sent with nil or blank replies. 7. The guarantee of payment shall be given only for the medically necessary treatment cost of the ailment covered and mentioned in the request for hospitalization. Non covered items as per terms and conditions of the policy, like Telephone usage, food provided to relatives/attendants, Provider registration fees etc must be collected directly from the insured. 8. The authorization letter by the insurer or its representative TPA shall clearly indicate the amount agreed for providing cashless facility for hospitalization. Page 53 of 89 9. In the event of the cost of treatment increasing, the provider may check the availability of further limit with the insurer or its representative TPA. 10. When the cost of treatment exceeds the authorized limit, request for enhancement of authorization limit shall be made immediately during hospitalization using the same format as for the initial preauthorization. The request for enhancement shall be evaluated based on the availability of further limits and the hospital may be required to provide valid reasons for the same. No enhancement of limit is possible after discharge of insured. 11. Further, the insurer or the TPA who is acting on behalf of the Insurer shall accept or decline such additional expenses within a maximum of 24 hours of receiving the request for enhancement. Absence of receiving the reply from the [Insurance Company] within 24 hours shall be construed as denial of the additional amount. 12. In case the insurer has opted for a higher accommodation / facility than the one eligible under the policy , the Provider shall explain the effect of such option and also take a written consent from the beneficiary at the time of admission as regard to owing the responsibility of such expenses by the insured including the proportionate expenses which have a direct bearing due to upgradation of room accommodation/facility. In all such cases the Insurer [Insurance Company] shall pay for the expenses which are based on the eligibility limits of theinsured. However provider may charge any advance amount/security deposit from the insured only in such cases where the insured has opted for an upgraded facility to the extent of the amounts to be collected from the insured . 13. Insurance company guarantees payment only after receipt of RAL and the necessary medical details. The Authorization Letter (AL) shall be issued within 48 hours of receiving the RAL. 14. In case the ailment is not covered or the given medical data is not sufficient for the medical team of the authorization department to confirm the eligibility, insurer or its representative TPA shall seek further clarification/ information immediately. 15. Authorization letter [AL] shall mention the authorization number and the amount guaranteed for the procedure. 16. In case the balance sum available is considerably less than the cost of treatment, provider shall follow their norms of deposit/running bills etc. However provider shall only charge the balance amount over and above the amount authorized under the health insurance policy against the package or treatment from the insured. 17. Once the insured is to be discharged, the Provider shall make a final request for the pre-authorization for any residual amount along with the standard discharge summary and the standard billing format. Once the provider receives final pre- Page 54 of 89 authorization for a specific amount, the insured shall be allowed to get discharged by paying the difference between the pre-authorized amount and actual bill, if any. Insurer upon receipt of the complete bills and documents shall make payment of the guaranteed amount to the provider directly. 18. Due to any reason if the insured does not avail treatment at the Provider after the pre authorization is released and any payment is made in this regard, the Provider shall return the amount to the insurer immediately. 19. All the payments in respect of pre-authorised amount shall be made electronically by the insurer to the provider as early as possible but not later than a week, provided all the necessary electronic claim documents are received by the insurer. 20. Denial of authorization (DAL) for cashless is by no means denial of treatment by the health facility. The provider shall deal with such case as per their normal rules and regulations. 21. Insurer shall not be liable for payments to the providers in case the information provided in the “request for authorization letter” and subsequent documents during the course of authorization, is found incorrect or not disclosed. 22. Provider, insurer and its representative TPA shall ensure that the procedure specified in this Schedule is strictly complied in all respects. II. Preauthorization Procedure – Emergency Admissions: 1. In case of emergencies also, the procedure specified in Clause (I) (1), (2) and (3) shall be followed. 2. The insurer or its representative TPA may continue to discuss with treating doctor till conclusion of eligibility of coverage is arrived at. However, any life saving, limb saving, sight saving, emergency medical attention cannot be withheld or delayed for the purpose of waiting for pre-authorisation. Provider meanwhile may consider treating him by taking a token deposit or as per their norms. 3. Once a pre-authorisation is issued after ascertaining the coverage, Provider shall refund the deposit amount to the insured if taken barring a token amount to take care of non covered expenses. III. Preauthorization Procedure – RTA / MLCs: 1. If requesting a pre-authorisation for any potential medico-legal case including Road Traffic Accidents, the Provider shall indicate the same in the relevant section of the standard format. 2. In case of a road traffic accident and or a medico legal case if the victim was under the influence of alcohol or inebriating drugs or any other addictive Page 55 of 89 substance or resort to intentional self injury, it is mandatory for the Provider to inform this circumstance of emergency to the Insurer or its representative TPA. IV. Authorization letter (AL): 1. Authorization letter shall mention the amount, guaranteed class of admission, eligibility of the patient or various sub limits for rooms and board, surgical fees etc. wherever applicable, as per the benefit plan for the patient. 2. The Pre-Authorization letter shall also mention Validity of dates for admission and number of days allowed for hospitalization, if any. The Provider shall see that these rules are strictly followed; else the AL will be considered null and void. 3. In the event of the room category, if any, not being available the same shall be informed to the Insurer or its representative TPA and the Insured. For such cases if the Insured is admitted to a class of accommodation higher than what he is eligible for, the provider shall collect the necessary difference, if any, in charges from the Insured. 4. The AL has a limited period of validity – which is 15 days from the date of sending the authorization. 5. AL is not an unconditional guarantee of payment. It is conditional on facts presented – when the facts change the guarantee changes. V. Reauthorization: 1. Where there is a change in the line of treatment – a fresh authorization shall be obtained from the insurer immediately – this is called a reauthorization. 2. The same pre-authorization form shall be used for the reauthorization, and the same turnaround times as specified shall apply. VI. Discharge: 1. The following documents shall be included in the list of documents to be sent along with the claim form to the Insurer or its representative TPA . These shall not be given to the Insured. a. Original pre authorization request form, b. original authorization letter, c. Original discharge card, d. original investigation repots, e. all original prescription and pharmacy receipt etc 2. Where the Insured requires the discharge card/reports he or she can be asked to take photocopies of the same at his or her own expenses and these have to be clearly stamped as "Duplicate & originals are submitted to [Insurance Company]". Where, the insured requests for any of the original reports, the Page 56 of 89 insurer shall arrange forwarding the originals by duly endorsing the settlement of the claim on such original reports. However, the insurer or its representative TPA may retain a copy of such reports as per their operational requirements. 3. The discharge card/Summary shall mention the duration of ailment and duration of other disorders like hypertension or diabetes and operative notes in case of surgeries. The clinical detail shall be sufficiently and justifiably informative. In addition, the Provider shall provide all the relevant details pertaining to past treatment availed by the Insured with the Provider. 4. Signature of the Insured on final Provider bill must be obtained. 5. In the event of death or incapacitation of the Insured , the signature of the nominee or any of Insured’s family who represents the Insured subject to reasonable satisfaction of Provider shall be sufficient for the Insurer to consider the claim. 6. Standard Claim form duly filled in duly presented to the Insured for signing and identity of the Insured shall be confirmed by the provider. VII. Billing: 1. The Provider shall submit original invoices directly to Insurer or its representative TPA and such invoices shall contain, at the minimum, following information: a. the Insured’s full name and date of birth; b. the policy number; c. the Insured’s Address d. the admitting consultant; e. the date of admission and discharge; f. the procedure performed and procedure code according to ICD-10 PCS or any other Code as specified by the Authority from time to time; g. the diagnosis at the time of treatment and diagnosis code according to ICD-10 or any other Code as specified by the Authority from time to time;; h. whether this is an interim or final bill/account; i. the description of each Service performed, together with associated Charges, j. the agreed standard billing codes associated with each Service performed and dates on which items of Service were provided; and. k. the Insured signature (in original). 2. The Provider shall submit the following documents with the final invoice: a. copy of Pre-Authorisation letter; b. fully completed claim form (or the relevant claim section of the Pre- Page 57 of 89 Authorisation letter), signed by the Insured and the treating consultant for the Treatment performed; c. original and complete discharge summary in the standard form and billing form in the standard form, including the treating Consultant's operative notes; d. original investigation reports with corresponding prescription/request; e. pharmacy bill with corresponding prescription/request: f. any other statutory documentary evidence required under law or by the Insured’s policy;and g. photocopy of the Insured’s photo identification (eg voter's Smart card/ ID card, passport or driving licence etc). 3. The Provider shall submit the final invoice and all supporting documentation required within 2 days of the discharge date. Page 58 of 89 Schedule-B PROCESS NOTE FOR DE-EMPANELMENT OF PROVIDERS Process to be Followed For De-Empanelment of Providers: Step 1 – Putting the Provider on “Watch-list” 1. Based on the claims data analysis and/ or the visits carried out on a Provider, if there is any doubt on the performance of a Provider, the Insurance Company or the TPA that is representing an Insurer can put that Provider in the “watch-list”. 2. The data of such Provider shall be analysed very closely on a daily basis by the Insurance Company or the TPA that is representing an Insurer for patterns, trends and anomalies. Step 2 – Suspension of the Provider 3. A Provider can be temporarily suspended in the following cases: a. For the Providers which are in the “Watch-list” if the Insurance Company or the TPA that is representing an Insurer observes continuous patterns or strong evidence of irregularity based on either claims data or field visit to Providers, the Provider shall be suspended from providing services to policyholders/insured patients and a formal investigation shall be instituted. b. If a Provider is not in the “Watch-list”, but the insurance company or the TPA that is representing an Insurer observes at any stage that it has data/ evidence that suggests that the Provider is involved in any unethical practice/ is not adhering to the major clauses of the contract with the Insurance Company involved in financial fraud related to health insurance patients, either the Insurer or the TPA that is representing an Insurer, may immediately suspend the Provider from providing services to policyholders/insured patients and a formal investigation shall be instituted. 4. A formal letter shall be send to the Provider regarding its suspension with mentioning the timeframe within which the formal investigation will be completed. Step 3 – Detailed Investigation 5. The Insurance Company or the TPA that is representing an Insurer can launch a detailed investigation into the activities of a Provider in the following conditions: a. For the Providers which have been suspended. b. Receipt of complaint of a serious nature from any of the stakeholders Page 59 of 89 6. The detailed investigation may include field visits to the Providers, examination of case papers, recording the statement of the policyholders/insured (if needed), examination of Provider records etc. 7. If the investigation reveals that the report/ complaint/ allegation against the Provider is not substantiated, the Insurance Company would immediately revoke the suspension (in case it is suspended). A letter regarding revocation of suspension shall be sent to the Provider within 24 hours of that decision. Step 4 – Action by the Insurance Company or the TPA that is representing an Insurer 8. If the investigation reveals that the complaint/allegation against the Provider is correct then the following procedure shall be followed: a. The Provider must be issued a “show-cause” notice seeking an explanation for the aberration. b. After receipt of the explanation and its examination, the charges may be dropped or an action can be taken. c. The action could entail one of the following based on the seriousness of the issue and other factors involved: i. A warning to the concerned Provider, ii. De-empanelment of the Provider. 9. The entire process should be completed within 30 days from the date of suspension. Step 5 – Actions to be taken after De-empanelment 10. Once a Provider has been de-empanelled by insurer or the TPA that is representing an Insurer, following steps shall be taken: a. A letter shall be sent to the Provider regarding this decision b. This information shall be sent to all the other Insurance Companies which are doing health insurance business and where the action is taken by a TPA in formation shall be also sent to all other TPAs. c. An FIR shall be lodged against the Provider by the insurer or the TPA that is representing an Insurer at the earliest in case the de-empanelment is on account of fraud or a fraudulent activity. d. The Insurance Company or the TPA that is representing an Insurer which had de-empanelled the Provider, may be advised to notify the same in the local media, for the information of policyholders/insured about the de-empanelment, so that the policyholder do not utilize the services of that particular Provider. e. If the Provider appeals against the decision of the Insurance Company, all the aforementioned actions shall be subject to the dispute resolution process agreed in the service level agreement. Page 60 of 89 Schedule – C STANDARD DISCHARGE SUMMARY: 1. Components of Standardization: a. List of standard contents in the discharge summary b. Standard guidelines for preparing a discharge summary so that the interpretation of the terms in the documents and the information provided is uniform. 2. Standard Contents of Discharge Summary Format: a. Patient’s Name*: b. Telephone No / Mobile No*: c. IPD No: d. Admission No: e. Treating Consultant/s Name, contact numbers and Departments/Specialty: f. Date of Admission with Time: g. Date of Discharge with Time: h. MLC No / FIR No*: i. Provisional Diagnosis at the time of Admission: j. Final Diagnosis at the time of Discharge: k. ICD – 10 code(s) or any other codes, as recommended by the Authority, for Final diagnosis*: l. Presenting Complaints with Duration and Reason for Admission: m. Summary of Presenting Illness: n. Key findings, on physical examination at the time of admission; o. History of alcoholism, tobacco or substance abuse, if any: p. Significant Past Medical and Surgical History, if any*: q. Family History if significant/relevant to diagnosis or treatment: r. Summary of key investigation during Hospitalization*: s. Course in the Hospital including complication if any*: t. Advice on Discharge*: u. Name & Signature of treating Consultant / Authorized Team Doctor: v. Name & Signature of Patient / Attendant*: * refer to guide notes below. 3. GUIDE NOTES FOR FILLING DISCHARGE SUMMARY FORMAT: a. The patient’s name shall be the official name as appearing in the insurance policy document and the attendants should be made aware that it cannot be changed subsequently, because in some cases the Page 61 of 89 attendants give the nick names which are different from documented names. As a matter of abundant precaution, all personal information should be shown to the patient/attendant and validated with their signature. b. The contact numbers shall be specifically those of the patient and if pertaining to attendant, the same should be mentioned. c. Where applicable, copy of MLC/FIR needs to be attached d. Responses to point (2) (b), (k) and (p) are desirable but not mandatory e. Significant past medical and surgical history shall be relevant to present ailment and shall provide the summary of treatment previously taken, reports of relevant tests conducted during that period. In case history is not given by patient, it should be specified as to who provided the same. f. Summary of key investigations shall appear chronologically consolidated for each type of investigation. If an investigation does not seem to be a logical requirement for the main disease/line of treatment, the admitting consultant should justify the reason for carrying out such test / investigation. g. The course in the hospital shall specify the line of treatment, medications administered, operative procedure carried out and if any complications arise during course in the hospital, the same should be specified. If opinion from another doctor from outside hospital is obtained, reason for same should be mentioned and also who decided to taken opinion i.e. whether the admitting and treating consultant wanted the opinion as additional expertise or the patient relatives wanted the opinion for their reassurance. h. Discharge medication, precautions, diet regime, follow up consultation etc should be specified. If patient suffers from any allergy, the same shall be mentioned. i. The signatures/Thumb impression in the Discharge Summary shall be that of the patient because generally the patient is discharged after having improved. In other cases like Death summary or transfer notes in case of terminal illness, the attendant can sign. In such cases, the inability of the patient to sign should be recorded by the attending doctor. Page 62 of 89 Schedule - D STANDARD FORMAT FOR PROVIDER BILLS 1. Components of standardization: Standardization involves three components: i) Bill Format ii) Codes for billing items and nomenclature iii) Standard guidelines for preparing the bills 2. Format specified: The bill is expected to be in two formats i) The summary bill and ii) The detailed breakup of the bills 3. Explanation and Guidelines – Summary Bill i. The summary format is annexed in the Schedule – D1 ii. The Bill shall be generated on the letter head of the provider and in A4 size to aid scanning The summary bill shall not have any additional items (only nine) iii. The provider has to mention the service tax number in case they charge service tax to the Insurance Company iv. The payer mentioned in the Bill has to be necessarily the Insurance Company and not the TPA. v. In case of package charged for any procedure / treatment the provider is expected to mention the amount in Serial Number (9) only. Items beyond the package are to be mentioned in Serial Numbers (1) to (8). vi. The patient / attendant signature is mandatory on the summary bill vii. The additional guidelines to fill the summary format shall be as below: Field Name Remarks Provider Name Legal entity name and not the trade name Provider Registration Number Registration number of the provider with local authorities. once the clinical establishments (registration and regulation) bill, 2007 is passed, then registration number under this act Address Address of the Facility where member is admitted. A provider can have more than one facility. IP No Unique number identifying the particular hospitalization of the member Patient Name Full name of the patient Payer Name Name of the Insurance company with whom the member is insured. In case of cash patient then the Page 63 of 89 field is to be left blank. If the bill is raised to more than one insurer then the primary insurer who has given cashless is to be mentioned. The name of insurance company needs to be mentioned and not the TPA. Member address Full address of the member Bill Number Bill number of the provider Bill Date Date on which the bill is generated. PAN Number PAN Number – Mandatory Service Tax Regn No Registration number from service tax authorities. Mandatory in case service tax is charged in the bill Date of admission Date of admission of the member in case of IPD cases. In case of Day care procedures, this is the date of procedure Date of discharge Date of discharge of the member in case of IPD cases. In case of Day care procedures, this is the date of procedure(same as date of admission) Bed Number Bed number in which the patient is admitted. In case the member is admitted under more than one bed number, all the numbers have to be mentioned. SL No 1 of billing Summary All items under the primary head ‘100000’ in the detailed bill have to be summarized into this. In case the procedure is packages, then only bills amount beyond the package needs to be mentioned here. SL No 2 of billing Summary All items under the primary head ‘200000’ in the detailed bill have to be summarized into this. In case the procedure is packages, then only bills amount beyond the package needs to be mentioned here. SL No 3 of billing Summary All items under the primary head ‘300000’ in the detailed bill have to be summarized into this. In case the procedure is packages, then only bills amount beyond the package needs to be mentioned here. SL No 4 of billing Summary All items under the primary head ‘400000’ in the detailed bill have to be summarized into this. In case the procedure is packages, then only bills amount beyond the package needs to be mentioned here. SL No 5 of billing Summary All items under the primary head ‘500000’ in the detailed bill have to be summarized into this. In case the procedure is packages, then only bills amount beyond the package needs to be mentioned here. Page 64 of 89 SL No 6 of billing Summary All items under the primary head ‘600000’ in the detailed bill have to be summarized into this. In case the procedure is packages, then only bills amount beyond the package needs to be mentioned here. SL No 7 of billing Summary All items under the primary head ‘700000’ in the detailed bill have to be summarized into this. In case the procedure is packages, then only bills amount beyond the package needs to be mentioned here. SL No 8 of billing Summary All items under the primary head ‘800000’ in the detailed bill have to be summarized into this. In case the procedure is packages, then only bills amount beyond the package needs to be mentioned here. SL No 9 of billing Summary All items under the primary head ‘900000’ in the detailed bill have to be summarized into this. If more than one procedure is done, the total amount of the two procedures needs to be summarized Total Bill amount Sum total of all items 1 to 9 in the bill Amount paid by the member Amount of bill paid by the member including co-pay, deductible, non-medical items etc incl discount offered to member, if any. Amount charged to Payer Amount payable by Insurance company Discount Amount Amount offered as discount to the insurance company Service tax Service Tax chargeable to insurance company Amount Payable Total amount payable by insurance com[any including service tax Amount in words Above mount in words for the sake of clarity Patients signature Signature of the patient or the attendant of the patient needs to be mandatorily taken Authorized signatory The signature of the authorized signatory at the provider Page 65 of 89 4. Explanation and Guidelines – Detailed Breakup of the Bill I. The summary format is annexed in Schedule – D2 II. The Bill shall be generated on the letterhead of the provider and in A4 size paper to aid scanning. III. The billing has to be done at level 2 or 3 IV. In case of medicines/consumables, the relevant level code three has to be mentioned (40100, 401002) and the text should indicate the actual medicine used V. If providers have outsourced the pharmacy to external vendors. In such cases the providers can attach the original bills separately. However, the summary of this has to be mentioned in the summary bill. VI. In case of pharmacy returns the same, the code originally used is to be used with a negative sign in the units VII. In case of cancellation of any service, the same code originally used is to be used with a negative sign indicating reversal VIII. The date on which the service is rendered is to be mentioned in the bill. This would be a. the date of requisition in case of investigations b. date of consultation for professional fees c. date of requisition in case of pharmacy/consumables irrespective of when they were used d. Date of return of pharmacy items for pharmacy returns. IX. The additional guidelines to fill the summary format shall be as below, except that the first section of the bill is same as the bill summary referred in 3 above. Field Name Remarks Date Date on which service is rendered. For example, this is the date of investigation, date of procedure etc. Code Level 2 or 3 code of the billing item as per the codes(annex III) Particulars Text explanation of the item charged Rate Per unit price (per day room rent, per consultation charge) Unit No of units charged(hours, days, number as appropriate) Amount Rate*unit(s) Page 66 of 89 Schedule – D1 SUMMARY BILL FORMAT Provider Name …………………….…… … Bill Number …….……………..……… … Provider registration No. Bill Date Address PAN Number IP No Service Tax Regn No Patient Name Date of admission Payer Name XXXX Insurance Company Ltd Date of Discharge Member Address Bed Number Billing Summary Sl No Primary Code Particulars Amount 1 100000 Room & Nursing Charges 2 200000 ICU Charges 3 300000 OT Charges 4 400000 Medicine & Consumables 5 500000 Professional Fees' 6 600000 Investigation Charges 7 700000 Ambulance Charges 8 800000 Miscellaneous Charges 9 900000 Package Charges Total Bill Amount 0 Amount paid by member ………………………… ……0 Amount charged to Payer 0 Discount Amount 0 Service Tax 0 Amount Payable 0 Amount in Words Rupees Zero Only Patients Signature Authorised Signatory Page 67 of 89 Schedule – D2 DETAILED BREAKUP FORMAT PART - I Provider Name …………………….… …… Bill Number …….……………..…… …… Provider registration No. Bill Date Address PAN Number IP No Service Tax Regn No Patient Name Date of admission Payer Name Date of Discharge Member Address Bed Number Billing Details Sl No Date Code Particulars Rate Nos (Unit) Amount 1 101001 General Ward Charges 500 1 500.00 2 401001 XXX medicine 50 2 100.00 3 401001 XXX Medicine – return 50 -1 -50.00 Page 68 of 89 PART - II Level 1 Code Level 1 Level 2 Code Level 2 Level 3 Code Level 3 Remarks 100000 Room & Nursing Charges 100000 Room & Nursing Charges 101000 Room Charges 100000 Room & Nursing Charges 101000 Room Charges 101001 General Ward charges 100000 Room & Nursing Charges 101000 Room Charges 101002 Semi-private room charges 100000 Room & Nursing Charges 101000 Room Charges 101003 Single Room charges 100000 Room & Nursing Charges 101000 Room Charges 101004 Single Deluxe room charges 100000 Room & Nursing Charges 101000 Room Charges 101005 Deluxe room charges 100000 Room & Nursing Charges 101000 Room Charges 101006 Suite charges 100000 Room & Nursing Charges 101000 Room Charges 101007 Electricity charges 100000 Room & Nursing Charges 101000 Room Charges 101008 Bed sheet charges 100000 Room & Nursing Charges 101000 Room Charges 101009 Hot water charges 100000 Room & Nursing Charges 101000 Room Charges 101010 Establishment Charges 100000 Room & Nursing Charges 101000 Room Charges 101011 Alpha/Water Bed Charges 100000 Room & Nursing Charges 101000 Room Charges 101012 Attendant Bed Charges 100000 Room & Nursing Charges 102000 Nursing charges 100000 Room & Nursing Charges 102000 Nursing charges 102001 Nursing fees 100000 Room & Nursing Charges 102000 Nursing charges 102002 Dressing 100000 Room & Nursing Charges 102000 Nursing charges 102003 Nebulization 100000 Room & Nursing Charges 102000 Nursing charges 102004 Injection charges 100000 Room & Nursing Charges 102000 Nursing charges 102005 Infusion pump charges 100000 Room & Nursing Charges 102000 Nursing charges 102006 Aya Charges 100000 Room & Nursing Charges 102000 Nursing charges 102007 Blood Transfusion Charges 100000 Room & Nursing Charges 103000 Duty Doctor fee 100000 Room & Nursing Charges 103000 Duty Doctor fee 103001 Duty Doctor fee 100000 Room & Nursing Charges 103000 Duty Doctor fee 103002 RMO Fees 100000 Room & Nursing Charges 104000 Monitor charges 100000 Room & Nursing Charges 104000 Monitor charges 104001 Pulse Oxymeter charges If used in normal Room 200000 ICU Charges 200000 ICU Charges 201000 ICU Charges 200000 ICU Charges 201000 ICU Charges 201001 Burns Ward 200000 ICU Charges 201000 ICU Charges 201002 HDU charges 200000 ICU Charges 201000 ICU Charges 201003 ICCU charges 200000 ICU Charges 201000 ICU Charges 201004 Isolation ward charges 200000 ICU Charges 201000 ICU Charges 201005 Neuro ICU charges 200000 ICU Charges 201000 ICU Charges 201006 Pediatric/neonatal ICU charges 200000 ICU Charges 201000 ICU Charges 201007 Post Operative ICU 200000 ICU Charges 201000 ICU Charges 201008 Recovery Room 200000 ICU Charges 201000 ICU Charges 201009 Surgical ICU Page 69 of 89 200000 ICU Charges 202000 ICU Nursing charges If ICU nursing charged separately 200000 ICU Charges 202000 ICU Nursing charges 202001 Nursing fees If ICU nursing charged separately 200000 ICU Charges 202000 ICU Nursing charges 202002 Dressing If ICU nursing charged separately 200000 ICU Charges 202000 ICU Nursing charges 202003 Nebulization If ICU nursing charged separately 200000 ICU Charges 202000 ICU Nursing charges 202004 Injection charges If ICU nursing charged separately 200000 ICU Charges 202000 ICU Nursing charges 202005 Infusion pump charges 200000 ICU Charges 203000 Monitor charges 200000 ICU Charges 203000 Monitor charges 203001 Monitor charges 200000 ICU Charges 203000 Monitor charges 203002 Pulse Oxymeter charges If used in ICU 200000 ICU Charges 203000 Monitor charges 203003 Cardiac Monitor charges 200000 ICU Charges 204000 Monitor charges 203004 IABP charges 200000 ICU Charges 204000 Monitor charges 203005 Phototherapy Charges 200000 ICU Charges 204000 ICU Supplies & equipment 200000 ICU Charges 204000 ICU Supplies & equipment 204001 Oxygen charges 200000 ICU Charges 204000 ICU Supplies & equipment 204002 Ventilator charges 200000 ICU Charges 204000 ICU Supplies & equipment 204003 Suction pump charges 200000 ICU Charges 204000 ICU Supplies & equipment 204004 Bipap charges 200000 ICU Charges 204000 ICU Supplies & equipment Pacing Charges Temporary Pacemaker 200000 ICU Charges 204000 ICU Supplies & equipment 20406 Defibrillator Charges 300000 OT Charges 300000 OT Charges 301000 OT rent 300000 OT Charges 301000 OT rent 301001 Major OT charge 300000 OT Charges 301000 OT rent 301002 Minor OT Charge 300000 OT Charges 301000 OT rent 301003 Cath Lab Charges 300000 OT Charges 301000 OT rent 301004 Theatre charges Page 70 of 89 300000 OT Charges 301000 OT rent 301005 Labour Room Charges 300000 OT Charges 302000 OT Equipment charges 300000 OT Charges 302000 OT Equipment charges 3 C-arm charges 300000 OT Charges 302000 OT Equipment charges 302002 Endoscopy charges 300000 OT Charges 302000 OT Equipment charges 302003 Laproscope charges 300000 OT Charges 302000 OT Equipment charges 302004 Equipment charges If not specified 300000 OT Charges 302000 OT Equipment charges 302005 Monitor charges for OT monitoring 300000 OT Charges 302000 OT Equipment charges 302006 Instrument charges for OT instruments 300000 OT Charges 303000 OT Drugs & Consumables 300000 OT Charges 303000 OT Drugs & Consumables 303001 OT Drugs 300000 OT Charges 303000 OT Drugs & Consumables 303002 Implants 300000 OT Charges 303000 OT Drugs & Consumables 303003 OT Consumables includes guide wires, catheter etc 300000 OT Charges 303000 OT Drugs & Consumables 303004 OT Materials 300000 OT Charges 303000 OT Drugs & Consumables 303005 OT Gases 300000 OT Charges 303000 OT Drugs & Consumables 303006 Anaesthetic drugs 300000 OT Charges 304000 OT Sterlization 300000 OT Charges 304000 OT Sterlization 304001 CSSD Charges 400000 Medicine & Consumables charges 400000 Medicine & Consumables charges 401000 Medicine & Consumables charges 400000 Medicine & Consumables charges 401000 Medicine & Consumables charges 401001 Ward Medicines OT drugs under OT charges 400000 Medicine & Consumables charges 401000 Medicine & Consumables charges 401002 Ward Consumables 400000 Medicine & Consumables charges 401000 Medicine & Consumables charges 401003 Ward disposables 400000 Medicine & Consumables charges 401000 Medicine & Consumables charges 401004 Ward Materials 400000 Medicine & Consumables charges 401000 Medicine & Consumables charges 401005 Vaccination drugs 500000 Professional fees charges 500000 Professional fees charges 501000 Visit charges 500000 Professional fees charges 501000 Visit charges 501001 Consultation Charges Page 71 of 89 500000 Professional fees charges 501000 Visit charges 501002 Medical Supervision Charges 500000 Professional fees charges 501000 Visit charges 501003 Professional fees 500000 Professional fees charges 502000 Surgery Charges 500000 Professional fees charges 502000 Surgery Charges 502001 Surgeons Charges 500000 Professional fees charges 502000 Surgery Charges 502002 Assisstant Surgeons Fee Would also include Standby Surgeon 500000 Professional fees charges 503000 Anaesthetists fee 500000 Professional fees charges 503000 Anaesthetists fee 503001 Anaesthetists fee 500000 Professional fees charges 503000 Anaesthetists fee 503002 OT standby charges Providers charge for standby anaesthetist 500000 Professional fees charges 504000 Intensivist Charges 504000 500000 Professional fees charges 505000 Technician Charges 505000 OT /Cath Lab Technician 500000 Professional fees charges 505000 Physiotherapy 500000 Professional fees charges 504000 Procedure charges 500000 Professional fees charges 504000 Procedure charges 504001 Bedside procedures Catheterization, Central IV Line, Tracheostomy, Venesection 500000 Professional fees charges 504000 Procedure charges 504002 Suture charges 600000 Investigation Charges 600000 Investigation Charges 601000 Bio Chemistry Serum Sodium, Ueres etc 600000 Investigation Charges 602000 Cardiology charges for procedures like echo, ECG etc 600000 Investigation Charges 603000 Haemotology charges cross matching etc 600000 Investigation Charges 604000 Microbiology charges blood culture, C&S 600000 Investigation Charges 605000 Neurology for EMG, EEG etc 600000 Investigation Charges 606000 Nuclear medicine PET CT, Bone scan etc 600000 Investigation Charges 607000 Pathology charges 600000 Investigation Charges 608000 Radiology services X-ra, CT, MRI etc 600000 Investigation Charges 609000 Serology charges 600000 Investigation Charges 610000 Medical Genetics Chrosomal Analysis etc 600000 Investigation Charges 611000 Profiles Profiles instead of individual tests (Lipid profile, LFT etc) 700000 Ambulance Charges 700000 Ambulance Charges 701000 Ambulance Charges 800000 Miscellaneous charges 800000 Miscellaneous charges 801000 Admission charges 800000 Miscellaneous charges 802000 Attendant food charges 800000 Miscellaneous charges 803000 Patient food charges Page 72 of 89 800000 Miscellaneous charges 804000 Registration charges 800000 Miscellaneous charges 805000 MRD Charges 800000 Miscellaneous charges 806000 Documentation charges 800000 Miscellaneous charges 807000 Telephone charges 800000 Miscellaneous charges 808000 Bio Medical Waste Charges 800000 Miscellaneous charges 809000 Taxes Luxury Tax/Surcharge/Service Charge Excluding VAT & Service Tax 900000 Package Charges To be used only in case of packages 900000 Package Charges 901000 Cardiac Surgery ICD-10- PCS CABG To be used only in case of packages 900000 Package Charges 902000 CardiologyPackage s ICD-10- PCS PTCA To be used only in case of packages 900000 Package Charges 903000 Cath Lab ICD-10- PCS CAG To be used only in case of packages 900000 Package Charges 904000 Dental Procedures ICD-10- PCS Root Canal Treatment To be used only in case of packages 900000 Package Charges 905000 ENT ICD-10- PCS FESS To be used only in case of packages 900000 Package Charges 906000 Gastroenterology ICD-10- PCS Gastrectomy - Partial To be used only in case of packages 900000 Package Charges 907000 General Surgery ICD-10- PCS Inguinal hernia To be used only in case of packages 900000 Package Charges 908000 Gynaecology ICD-10- PCS LSCS To be used only in case of packages 900000 Package Charges 909000 Nephrology ICD-10- PCS Nephrectomy To be used only in case of packages 900000 Package Charges 910000 Neuro Surgery ICD-10- PCS Craniotomy To be used only in case of packages 900000 Package Charges 911000 Oncology Procedures ICD-10- PCS IMRT To be used only in case of packages 900000 Package Charges 912000 Opthalmology procedures ICD-10- PCS Cataract To be used only in case of packages 900000 Package Charges 913000 Orthopaedic Surgery ICD-10- PCS Bilateral TKR To be used only in case of packages 900000 Package Charges 914000 Plastic Surgery ICD-10- PCS Skin Grafting To be used only in case of packages 900000 Package Charges 915000 Pulmonology Packages ICD-10- PCS Pleural Tapping To be used only in case of packages 900000 Package Charges 916000 Urology ICD-10- PCS ERCP To be used only in case of packages 900000 Package Charges 917000 Vascular Surgery ICD-10- PCS Embolectomy To be used only in case of packages Page 73 of 89 Annexure – 23 As per Regulations 22 (4) of IRDAI (TPA – Health Services) Regulations, 2016 Half Yearly information on services rendered for non-insurance health schemes. (Note: to be furnished within 30 days of the end of every half year. For e.g: Report for April to September to be furnished by 30th October) Form TPA – 6F 1 PARTICULARS OF THE TPA COMPANY: 1.1 Name of the TPA : 1.2 Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: --------- ------- 1.3 Financial Year 1.4 Half Year for which Data is furnished (April – September / October – March) 1.5 Name of non-insurance scheme and concerned Central / State Government (Scheme wise data to be submitted in following format) The above information furnished is the correct information and as per the records of the Company. It is further declared that other than the permitted non insurance health schemes no other non-insurance activity has been serviced or carried out by our Company. Date: For and on behalf of (Name of TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) Sr. No. Name of Scheme and Description of Services Offered Central Govt / Department / State Govt Geography covered No. of Transactions Number of lives serviced. Amount of remuneration received (Rs. INR in Lakhs) For the Half-Year Up to the Half-Year For the Half-Year Up to the Half-Year For the Half-Year Up to the Half-Year Page 74 of 89 Annexure – 24 As per Regulations 22 (4) of IRDAI (TPA – Health Services) Regulations, 2016 Non Insurance Services under Health Care Schemes 1. A TPA may render Health Services to health care schemes promoted, sponsored or approved by Central Government or any State Government of India. 2. A TPA may render services in wellness and Health promoting programmes, only if such activities are covered under insurance policy as issued by the concerned insurer, with whom a TPA has agreement for rendering of Health Services. 3. Provided that in accordance with these guidelines a TPA shall not provide any services; (i) directly or indirectly to non-insurance healthcare schemes promoted or sponsored by other than Central Government or State Government of India or the wholly or Partly owned bodies / undertakings of Central Govt or State Governments. (Note: Where there is any doubt the matter shall be referred to the Authority for approval) (ii) directly or indirectly to the policyholder or insured, except the health services as per agreement with the insurer and within the terms of the concerned policy contract. Page 75 of 89 Annexure – 25 As per Regulations 22 (4) of IRDAI (TPA – Health Services) Regulations, 2016 Half Yearly Information on services rendered in Indian or in foreign jurisdictions for policies issued by Indian Insurers (to be furnished within 45 days from the date of closure of Half Year) Form TPA - 6G 1 PARTICULARS OF THE TPA COMPANY: 1.1 Name of the TPA : 1.2 Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 Financial Year 1.4 Half Year for which Data is furnished April – September; October - March 1.5 Name of insurer (Insurer wise data to be submitted in following format) Sr N o Name of Country where services offered Name of Indian Insurer that issued policy Number of policies serviced Number of claims serviced No. of Claims Outstanding Amount of claims paid (Rs. INR in Lakhs) Amount of remuneration received (Rs. INR in Lakhs) For the Half Year Up to the Half Year For the Half Year For the Half Year For the Half Year For the Half Year For the Half Year For the Half Year For the Half Year For the Half Year The above information furnished is the correct information and as per the records of the Company. It is further declared that other than the above permitted health services no other services for non-insurance activity has been rendered or carried out by our Company. Date: For and on behalf of (Name of TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) Page 76 of 89 Annexure – 26 As per Regulations 22 (4) of IRDAI (TPA – Health Services) Regulations, 2016 Half Yearly Information on health services rendered to foreign travel policies issued by Foreign Insurers (to be furnished within 45 days from the date of closure of every Half Year) Form TPA - 6H 1 PARTICULARS OF THE TPA COMPANY: 1.1 Name of the TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 Financial Year 1.4 Half Year for which Data is furnished April – September; October - March 1.5 Name of foreign insurer ( foreign Insurer wise data to be submitted in following format) Name of Foreign Insurer: Sr No. Country of Principal place of Foreign Insurer Geographical location (Name of Indian state) where health services are rendered Number of policies serviced Number of claims serviced No. of Claims Outstanding Amount of claims paid (Rs. INR in Lakhs) Amount of remuneration received (Rs. INR in Lakhs) For the period Up to the period For the period Up to the period For the period Up to the period For the period Up to the period For the period Up to the period (Note: Information to be furnished Foreign Insurer wise Indian State wise) The above information furnished is the correct information and as per the records of the Company. It is further declared that other than the permitted health services no other services for non-insurance activity has been rendered or carried out by our Company. Date: For and on behalf of (Name of TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) Page 77 of 89 Annexure – 27 As per Regulations 23, Schedule – II (2) (z) of IRDAI (TPA – Health Services) Regulations, 2016 Corporate Governance norms for TPAs 1. Board of the applicant TPA Company or Registered TPA Company; a) shall ensure for providing of true and correct information to the Authority. b) shall ensure proper due diligence before submitting any of the data / information with the Authority including information about Key Managerial Persons of the Company. c) shall have a system of monitoring complaints disposal and ensure that corrective action taken for system related improvement. d) shall ensure at all times that, there shall not be any conflict of interest of their TPA Company with any other insurance or insurance related activity or business. e) shall oversee, i) claim settlement process as per claim settlement guidelines issued by concerned insurers, ii) time frames / TAT / processes with respect to their TPA business. iii) polices with respect to Information Technology (IT), of their TPA Company. f) shall appoint CEO or CAO, who is having required qualification as stipulated in IRDAI (TPA – Health Services) Regulations, 2016 and put in place procedures to ensure that they are responsible for complying all regulatory and statutory requirements stipulated either in the Regulations notified by the Authority or any other relevant statutory provisions. Such CEO or CAO who is responsible for compliance shall report to the Board of the TPA Company about the status of all compliance matters at least two times in a Financial Year. g) may endeavour to appoint at least one Independent Director who shall be fit & proper as per these extant regulations with adequate experience in the field of Health Care or Health Insurance or TPA business. shall be responsible to put in place internal controls in the TPA Company. h) shall be responsible to put in place effective internal audit i) may delegate the activities referred at (h) above to board appointed sub-ordinate committee. But the minutes of the said subordinate committee shall be placed before the Board in the immediate Board meeting. 2. The Board is responsible for appointing the statutory auditors of the TPA Company. 3. The Board is responsible to ensure that all directors appointed comply with all the statutory provisions inter alia Companies Act, 2013. Page 78 of 89 4. Annual Report prescribed under Form TPA – 8 and all the Forms, Schedules there under shall be disclosed in the website of the TPA Companies. 5. Every TPA Company shall disclose on their respective website the geography wise names and addresses of the Network Providers with whom it has entered into an agreement. Such list shall be updated on the real time basis. Page 79 of 89 Annexure – 28 As per Regulations 25 (2) of IRDAI (TPA – Health Services) Regulations, 2016 Form for intimation of opening and closing of the branches or change in office address. (to be filed as and when a branch is closed or opened or there is a change in the address) FORM TPA – 9 Instructions for filling up the form: 1. TPAs are requested to submit concerned PART (e.g. Part A, B,C,D etc.) of this form duly fill-in and signed for the records of the Authority. 1 PARTICULARS OF THE TPA COMPANY: 1.1 Name of the TPA : 1.2 (A) Address - Registered Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 (B) Address for Correspondence: Principal Place of business or Corporate Office Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 2 Details of Certificate of Registration A TPA Registration No. B Date of First grant of Registration (DD/MM/YYYY) C Date of Renewal of Registration (DD/MM/YYYY) D Date of Expiry of current Certificate of Registration (DD/MM/YYYY) PART – A Every TPA that opened the branches shall submit the respective particulars in the following format within 15 days of opening the said branches. A Number of Branches opened: B Name and address of the locations of the branches opened: C Date of opening the branch: D Name of the person in-charge of the Branch: PART – B Every TPA that closed the branches shall submit the respective particulars in the following format within 15 days of closing the said branches. A Number of Branches Closed B Name and address of the locations of the branches Closed: Page 80 of 89 C Date of opening the branch D Date of Closing the branch: E Reason for closing the branch: PART – C : Change in Branch / Registered Office Address Every TPA shall furnish the particulars of the change in address of its Corporate office or the registered office or Branch Office in the following format within 15 days from the date of effecting the change. 1 PARTICULARS OF THE TPA Company: 1.1 Name of the TPA : 1.2 Old Address – Corporate / Registered / Branch Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- 1.3 New Address – Corporate / Registered / Branch Office: Pin code: __________ Landline No: _________________ E-mail:________________________ Fax No: ---------------- # New Address of office Region City/ Town/ Village State Person in Charge No. of staff Date of Opening of Office Whether in operation or not (Yes/No) Date of Closure (IF h = 'No' THEN Date of Closure ELSE Blank) Column Code a b c d E f g h i PART – D : To be submitted only in case of existence of foreign offices Every TPA shall furnish the particulars of the Representative Offices or Liaison Offices or Branch Offices opened / closed in Foreign Countries within 15 days of opening / closing the office. A Financial Year B Reporting for Opening or Closing of Foreign Office C Type of Office Opened or Closed: D Name of Foreign Country where the Office Opened / Closed: E Number of offices opened for the period F Number of offices closed for the period G Number of offices opened up to the period H Number of offices closed up to the period I Foreign Country wise number and details of offices in operation: I Page 81 of 89 Sr. No. Name of Foreign Country Type of Office (Representative Or Branch Office) Number of offices Address and Telephone number each office Name of In- charge Persons responsible for operations of each of the office Date: For and on behalf of (Name of TPA Company) Place: (Name of Director) (Name of Director or CEO / CAO) Page 82 of 89 Annexure – 29 As per Regulations 19 (2) of IRDAI (TPA – Health Services) Regulations, 2016 Other than books and accounting records which are to be maintained as per the extant provisions of the Companies Act, 2013, every TPA and the Insurer shall maintain all their other records as specified hereunder: 1. Service Level Agreements (SLAs): SLAs entered into with insurer, network provider as the case may be shall be maintained at least for a period of five years from date of expiry the said agreements. 2. Other operational and transactional records: TPAs shall maintain these records at least for a period of five years or as agreed between the TPA and the insurer. All TPAs and Insurers shall endeavour to maintain the records in electronic form. Page 83 of 89 Annexure – 30 As per Regulations 20 (5) of IRDAI (TPA – Health Services) Regulations, 2016 Part A: Claim Form For Health Insurance Policies Other Than Travel and Personal Accident Part B: Claim Form Part C: Request for Cashless Hospitalization for Health Insurance Policy QETAILS OF PRIMARY INSURED: CLAIM FORM FOR HEAL TH INSURANCE POLICIES OTHER THAN TRAVEL AND PERSONAL ACCIDENT - PART A TO BE FILLED IN BY THE INSURED The issue of this Form is not to be taken as an admission of liability (To be filled in block letters) a)PolicyNo :~-::1 [:_:1[_7'._][_J[~~-I □C[J □□□□ r:::J □□r=:J t) Sl.t'C/Ceiificalet-b: □□□□□□□□□□ c) Company/ TPAID No CJ r:_1[JC7.J~'00 [JD ::JD OU O O [] I d)- ~□□□□□□□n□□□□□□□□□□□□□□□□□□0□□0 □□□□□0□□□□~ () ~M=~ □□no □□□c □□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□g ~D DDDDDDDDDDDD DD DD DDDDDD D DD DOODODDODDDDDD z )> ~oc□□□□□□□□□□□□□□□□□ -□□□□□□□□□□□□□□□□□□□, PinCode.LJOD':JDC Phone No D DD Oi:JOODDOO Email ID:~-- - ----------~ DETAILS OF INSURANCE HISTORY: a) CuTe!ltly ro,ered cy ar,; otre' Maida ml Heath lnsu.arce O Yes [] t-b b) Date ct cxmrercarent ct first lnsu-arce wthou b"eac CJ D G [±] O Q C/l c)llye,,rori:eri;ram170[JOO[_J[JOOOO DD[J Pdio,,t-b DDDDDD DDDDDDDDDDDDDD ~ -I &m lnscred (Rs.) :l [J O O O [J d) rave ya, ooen ra;ptalized in tt-e last far yms siraa ira,µim ct tt-e cmra:i? 0 Yes O t-b Date O @] D D 5 Oagms --=--=--=--=--=--=--=----=--=--=--=--=--=-======~~~~~~~~~~~-~ e) Prellicusly ro,ered cy ar,; c.tte- Maidam/ 1-eith irrum::e: 0 Yes O t-b Z □□□□□□□□□□□□□□□ lro Q If yes, Garp:r,y Narre DETAILS OF INSURED PERSON HOSPITALIZED: - - -- - a) Narre □□□□□ □□□□□□□□□□□□G □~□□□□~ □~~~□D00~ □□□□ b) Gender· Male [J Female O c)Age. yearsOO months DO d)DateolBirth OGJ ['JEJ OD e) ReatimshptoPnmayinsITTld: Self O Sj:nJse O Oild O Father O IVtlhe,- 0 Ota- 0 (AeaseSµtify) ~============: C/l Seniire O Self Errpoyed O H::mmaker[J Stulent O fle!Jred O Ota- 0 (AeaseSpejfy) ~------------ ~ Q O::a..patim -I g) /'£Jdress (if clfferentfianatxNe) [_JO DD[] DD D [] 0 D D DD DD DD DD DD ODO DD DODOO ODDO 5 n□□□o~□□u □□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□□~ ~□□□□□□□□□□~□□□□□□□□ -□□□□□□□□□□□□□□□□□□□, ~~□□c~ □□ -h □□□□□□□□□□□ -n~-- - ----------~ DETAILS OF HOSPITALIZATION: a)Narreriftsptaw-e-e!mitted. [JO [ JDDOO DDDDDDD[JDDDDODDDDD DDDDDODDDOO b) Rron Categay cx:ruped cay care O Sirgle c:x:a.parcy O Twn stairg O 3 r:,: rrae beds per rocm O c) i-t,;ptalizatim due to e) Date of Admission: lnjuy [: Illness 0 □LJ l\falennty 0 QTime OG d) Die ct lrjuy / Date Osease first cl3eded /Oate ct Ds!ivery @ [2] G} E) G] [J 0@:J g) Date of Discharge IT) [I] E]@J G] CJ h) Time GJ G i) li !nJury give cause Self inflicled 0 Road Traffic Accident 0 Substance Abuse / Alcohol Consumplion 0 i. If Medico legal: i1 Reported to police O Yes O No ii, MLC Report & Police FIR attached O Yes O No j)Systemof Medicine: ~--------------~ DETAILS OF CLAIM: a) Ceials ct tt-e treetrrent expa,ses dajmed 1. Pre-hospitalization Expenses. 111. Post-hospitallzatJon Expenses· v. Ambulance Charges: Rs.cc □□□□□ Rs. □□□□□□□ Rs.OCDDODD ii. Hospitalization Expenses: iv. Heallh-Check up Cost: vi. Others (codeJ:0 Total Rs . □□□□□□□ Rs . □□□□□□□ Rs.[] □□□□□ Rs . □□□□□□□ vii. Pre-hospitalization penod days O C, D viii. Post-hospitalization period: days ODD n) Claim for Domicthary Hospitahz.allon c) Details of Lump sum/ cash benefit claimed 1 Hospital Daily Cash· iii Critical Illness Benefit D Yes O No (If yes. provide details in annexure) RsOl:JDDD DD Rs □□□□□□□ ii. Surgical Cash Rs. 0 0 DODO D ,v. Convalescence Rs. DD DD DD D v. Pre/Post hospitallzabon Lump sum benefit Rs DD DODD D vi.Others ODD Rs. ODDDODO Total Rs. DODODOO DETAILS OF BILLS ENCLOSED: Claim Documents Submitted- Check List: ~ Claim Form Duly signed Copy of the ciaim inlimation, if any Hospital Main Bill Hospital Break-up Bill 0 Hospital Bill Payment Receipt 0 Hospital Discharge Summary 0 Phamnacy Bill D Operation Theatre Notes 0 ECG D Doctor'S request for investigation O Investigation Reports (Including CT 0 b~~~isu~~;j~~ dns 0 Others SI. No ! Bm_N=j-l_! -~~~e ~+ I- j-_ -_- --~s_s:~:_~_1 __ --_--_-_,-I_T_H:~:P·_il:d_l :_,i_n B_ill _____________ f----t----t-A-ml-ou-nt+(R_s--+) -1--< _ 11 _____ J.•---i.--+- , , i-- Pre-hospitalization Bills:_Nos 1 +- · Post-hosprtalizalion Bills: Nos --r~J-_-~--,-!----,----+\-------------+-- Ph-amn- a~cy-Bi-lls--~----------+------+---+--<-+---+--+---< ; ' I I (/) m () -I 5 z 0 (/) m () ·--1 5 z m (/) m () -I 5 z -·i - - l _ -+- \- -\-- --1~- i- -r--- --·-------+------------------l--+--1-+---+--+--l---l .,,, - 1 --7- - r---1 ---; -+-.;·l -! - : ---i--:- -r . : -r-------+-----------------l--+--1-+---+---+--t---l = OE= TA=IL~S=OF~P= RI M=A= RY~l=NS=UR=E~ □•s~B=A=NK=A=CC=O= U N=T~ : ---------------- ----------------- 10 C7CTJOCT[_j'_ LJ '_i\_] □□□LJ □□□□□□□□□□□□□□ □□ ~ c)Bank Name and Branch O []C: [] CJQO O O D D OD ODO[JDDDD§§§§ § § § § §§§ § § § g --- --- ---------4 e)IFSC Code □□ Z di Cheque/ DD Payable details G) • (IMPORTANT: PLEASE TURN OVER) Papp 84 of 89 Ut:.L.LAKl-4..1 IUN I:) Y I Ht:. IN::,UKtU'. I hereby declare that the information furnishea 1n this claim form 1s true & co·rrect to the best of my knowledge and belief 1f I have made any false or untrue statement. suppression or concealment of any material fact w:th respect to questions asked in relation to this claim. my nght to claim reimbursement shall be forfeited 1 also consent & authonze TPA / insurance company to seeK necessary medical information I documents from any hospital I Medical Practitioner who has attended on the person against whom this claim ts made. I hereby declare that I have included all the bills I receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post•hospitalization claim. if anv Date: c--~D C ~- Place: L__ ____________ ~ GUIDANCE FOR FILLING CLAIM FORM -PART A (To be filled in by the insured) DATA ELEMENT DESCRIPTION FORMAT SECTION A · DETAILS OF PRIMARY INSURED a) Policy No Enter the policy number As allotted by the insurance company b) SI. No/ Certificate No Enter the social insurance number or the certificate number of As allotted by the organization social health insurance scheme C) Company TPA ID No. Enter the TPA ID No License number as allotted by IRDA and printed in TPA documents. d) Name Enter the full name of the policyholder Surname, First name, Middle name e) Address Enter the full postal address Include Street. City and Pin Code SECTION B • DETAILS OF INSURANCE HISTORY a) Currently covered by any other Mediclaim I Health Indicate whether currently covered by another Mediclaim / Tick Yes or No Insurance? Health Insurance b) Date of Commencement of first Insurance without break Enter the date of commencement of first insurance Use dd-mm-yy format c) Company Name Enter the full name of the insurance company Name of the organization in full Policy No Enter the policy number As allotted by the insurance company Sum Insured Enter the total sum insured as per the policy In rupees d) Have you been Hospitalized m the last four years since Indicate whether hospitalized in the last four years Tick Yes or No inception of the contract? Date Enter the date of hospitalization Use mm•yy format Diagnosis Enter the diagnosis details Open Text e) Previously Covered by any other Medicla1m/ Health Indicate whether previously covered by another Mediclaim / Tick Yes or No Insurance? Health Insurance n Company Name Enter the full name of the insurance company Name of the organization in full SECTION C • DETAILS OF INSURED PERSON HOSPITALIZED a) Name Enter the full name of the patient Surname, First name, Middle name b) Gender Indicate Gender of the patient Tick Male or Female c) Age Enter age of the patient Number of years and months d) Date of Birth Enter Date of Birth of patient Use dd-mm-yy format e) Relat1onsh1p to primary Insured Indicate relationship of patient with policyholder Tick the right option. If others, please specify. n Occupation Indicate occupation of patient Tick the right option. If others. please specify g) Address Enter the full postal address Include Street. City and Pin Code h) Phone No Enter the phone number of patient Include STD code with telephone number 1) E-mail ID Enter e•mail address of patient Complete e•mail address SECTION D • DETAILS OF HOSPITALIZATION a) Name of Hospital where admitted Enter the name of hospital Name of hospital in full b) Room category occupied Indicate the room category occupied Tick the right option C) Hospitalization due to Indicate reason of hospitalization Tick the right option d) Date of Injury/Date Disease first detected/ Date of Enter the relevant date Use dd-mm-yy format Oeliverv e) Date of admission Enter date of admission Use dd•mm•yy format n Time Enter time of admission Use hh:mm format g) Date of discharge Enter date of discharge Use dd-mm-yy format h) Time Enter time of discharge Use hh:mm format 1) If lnJury give cause Indicate cause of injury Tick the rig ht option If Medico legal Indicate whether injury is medico legal Tick Yes or No Reported to Police Indicate whether police report was filed Tick Yes or No MLC Report & Police FIR attached Indicate whether MLC report and Police FIR attached Tick Yes or No j) System of Medicine Enter the system of medicine followed in treating the patient Open Text SECTION E · DETAILS OF CLAIM a) Details of Treatment Expenses Enter the amount claimed as treatment expenses In rupees (Do not enter paise values) b) Claim for Domlc1liary Hospitalization Indicate whether claim is for domiciliary hospitalization Tick Yes or No c) Details of Lump sum/ cash benefit claimed Enter the amount claimed as lump sum/ cash benefit In rupees (Do not enter paise values) d) Cla1m Documents Subm1tted•Check List Indicate which supporting documents are submitted Tick the right option SECTION F. DETAILS OF BILLS ENCLOSED Indicate which bills are enclosed with the: amour ts in rupees SECTION G . DETAILS OF PRIMARY INSURED'S BANK ACCOUNT a) PAN Enter the permanent account number As allotted by the Income Tax department bi Account Number Enter the bank account number As allotted by the bank C) Bank Name and Branch Enter the bank name along with the branch Name of the Bank in full d) Cheque/ DD payable details ~ Enter the name of the beneficiary the cheque/ DD should be Name of the individual/ organization in full made out to e) IFSC Code Enter the IFSC code of the bank branch IFSC code of the bank branch in full SECTION H • DECLARATION BY THE INSURED Read declaration carefully and mention date (in dd·mm:yy format), place (open text) and sign I (/) m (') -i 0 z :i: I Page 85 of 89 CLAIM FORM - PART B TO BE FILLED IN BY THE HOSPITAL The issue of this Form is not to be taken as an admission of liability Please include the original preauthorization request form in lieu of PART A (To be filled. in block letters) DETAILS OF HOSPITAL al Name of the hospital bi Hospital ID c) Type of Hospital Network 0 Non Network 0 (If non network fill section E) (/) m () -i d)Nameofthetreatingdoclor l_::-_:'_JUC::JO.DOCO::::JQJ~[]J[I]::JO~C:::;][IJOC D::_;,;J[Du][ii:::::;:JJJDCGDG3uJC:D O e) Qualification- c-==- ----.::__~=] D Registration No. with State Code DD D DDDCJD z g) Phone No. DDDDDDDDDDD )> I DETAILS OF THE PATIENT ADMITTED al Name of the Patient ~Lu~LJLLJLJ~LJLJLLJ~~~wu ~~~WLJ~L~W~WW~ LJLJ~~w~ ~LJ bl IP Registration Number lJ L'. L_j O [JO Ii D c) Gender: Male O Female 0 d) Age Years D [J Months G] G] e) Date of birth:[}J Q] EJ E] [J W gi f) Da!e of Admission: □□ g)Time [JG] GJE] h) Date of Discharge: [}] QJ i)Time 0G GDGD ~ 0 ii Type ol Adm,ssion: Emergency O Planned 0 Day Care O Maternity 0 k)lfMatemity i. Date of Delivery: ~ [}] ii. Gravida Status: DOD z CD I) Slatus al 11me of discharge. Discharge to home O Discharge to another hospital O Deceased 0 m) Total claimed amount DD DD DD D DETAILS OF AILMENT DIAGNOSED (PRIMARY) a) ICD 10 Codes Description b) ICD 10 PCS Description i. Primary Diagnosis D ii. Additional Diagnosis: i. Procedure 1: ii. Procedure 2: t,~ I iii. Co-morbidities: 1v. Co-morbidities, ! I '---- iii. Procedure 3: I (/) -+---- -----~ m ~-~--- -----'---------~ () iv. Details of Procedure! I I B I I z () d) Pre-authonzation obtained. 0 Yes O No e) Pre-authorization Number DDDDDDDDDDDDD I) lf authonzation by network hospital not obtained give reason g) Hosp1t~~ation due to Injury: 0 Yes O No i. !f Yes, give cause Self-inflicted 0 Road Traffic Accident 0 Substance abuse I alcohol consumption 0 1i If Injury due to Substance ab~se I alcohol consumpbon, Test Conducted to establish this: 0 Yes O No (If Yes, attach reports) iii. If Medico legal: 0 Yes O No iv. Reported to Police: 0 Yes O No v FIRno.i]t.JD □□[Ji~L[ □□ CLAIM DOCUMENTS SUBMITTED - CHECK LIST 0 Claim Form duly signed 0 Original Pre-authorization request 0 Copy of the Pre-authorization approval letter [] Copy of photo ID card of patient verified by hospilal [] Hospital Discharge summary [] Operation Theatre notes Ll Hospital main bill [J Hospital break-up bill v, If not reported lo police give reason- 0 Investigation reports 0 CT/MR/\JSGIHPE investigation reports 0 Doctor's reference slip for investigation D ECG 0 Pharmacy bills 0 MLC report & Police FIR 0 Original death summary from hospital where applicable 0 My other, please specfy DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NE1VIQRK HOSPITAL) a)Address of the Hospital LJL LJLJ ~L LJLJ ~LJL LJLJ ~DC: DD =ic: □□=i nr- 1 n 7nnr- n 7n1 nn 7n □in □=:JC: □□=:l□C: □D=:l□C: □D=:J C: D □~LJ LLLJ~LJLJLLJ~LJLLJLJ~LJ City --" - 1,-fl11·11777nn1nn7nn Staten7nn11nn77nn1nnn7nn Pin CodeTJ --1 □ 0 [j □ b)PhoneNo. DDDDDDDDDD c) Registration No. with State Code O DD DD D DD (/) m () -i 0 z 0 (/) m () -i 0 d) Hospital PAN DcJOODDOOD[J e) Number of Inpatient beds ODD f) Facilities available in the hospilal: LOT : O Yes O No ii. ICU · OYes O No ~ Ill Others [_~==:_==-----------------------~ I DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY) We hereby declare lhat the informatmn furnished m lht!'Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact, (J) our nght to claim under this claim shall be forfeited m Date· Place Signature and Seat of the Hospital Authority: Page 86 of 89 () -i 0 z "Tl GUIDANCE FOR FILLING CLAIM FORM - PART B (To be filled in by the hospital) DATA ELEMENT DESCRIPTION FORMAT SECTION A - DETAILS OF HOSPITAL a) Name of Hospital Enter the name of hospital Name of hospital in full b) Hospital ID Enter ID number of hospital As allocated by the TPA C) Type of Hospital Indicate whether In network or non network hospital Trek the right option d) Name of treating doctor Enter the name of the treating doctor Name of doctor in full 8) Qualification Enter the qualifications of the treating doctor Abbreviations of educational qualifications 0 Registration No. with State Code Enter the registration number of the doctor along with the state As allocated by the Medical Council of India code g) Phone No. Enter the phone number of doctor Include STD code with telephone number SECTION B- DETAILS OF THE PATIENT ADMITTED a) Name of Patient Enter the name of hospital Name of hospital in full b) IP Registration Number Enter insurance provider registration number As allotted by the insurance provider c) Gender Indicate Gender of the patient Tick Mate or Female d) Age Enter age of the patient Number of years and months e) Date of Birth Enter date of admission Use dd-mm-yy format D Date of Admission Enter date of admission Use dd-mm-yy format g) Time Enter time of admission Use hh:mm format h) Date of Discharge Enter date of discharge Use dd-mm-yy format i) Time Enter time of discharge Use hh:mm format j) Type of Admission Indicate type of admission of patient Tick the right option k) If Maternity Date of Delivery Enter Date of Delivery if maternity Use dd-mm-yy format Gravida Status Enter Gravida status If maternity Use standard format I) Status at time of discharge Indicate status of patient at time of discharge Tick the right option m) Total claimed amount Indicate the total claimed amount In rupees (Do not enter paise values) SECTION C- DETAILS OF AILMENT DIAGNOSED (PRIMARY) a) ICD 10 Code Primary Diagnosis Enter the ICD 10 Code and description of the primary Standard Format and Open text diaanosis Additional Diagnosis Enter the ICD 1 O Code and description of the additional Standard Format and Open text diaanosis Co-morbidities Enter the ICD 1 O Code and description of the co-morbidities Standard Fonmat and Open text b) ICD 10 PCS Procedure 1 Enter the ICD 1 O PCS and description of the first procedure Standard Format and Open text Procedure 2 Enter the ICD 1 O PCS and description of the second procedure Standard Format and Open text Procedure 3 Enter the ICD 10 PCS and description of the third procedure Standard Format and Open text Details of Procedure Enter the details of the procedure Open text C) Pre-authorization.obtained Indicate whether pre-authorization obtained Tick Yes or No d) Pre-authorization Number Enter pre-authorization number As allotted by TPA e) If authorization by network hospital not obtained, give Enter reason for not obtaining pre-authorization number Open text reason D Hospitalization due to injury Indicate if hospitalization is due to injury Tick Yes or No Cause Indicate cause of injury Tick the right option If injury due to substance abuse/alcohol consumption, Indicate whether test conducted Tick Yes or No test conducted to establish this Medico Legal Indicate whether injury is medico legal Tick Yes or No Reported To Police Indicate whether police report was fiied Tick Yes or No FIR No Enter first information report number As issued by police authorities If not reported to police, give reason Enter reason for not reporting to police Open Text SECTION D - CLAIM DOCUMENTS SUBMITTED-CHECK LIST Indicate which supporting documents are submitted SECTION E- DETAILS IN CASE OF NON NETWORK HOSPITAL a) Address Enter the full postal address Include Street, City and Pin Code b) Phone No Enter the phone number of hospital Include STD code with telephone number c) Registration No. with State Code Enter the registration number of the doctor along with the state As allocated by the Medical Council of India code d) Hospital PAN Enter the permanent account number As allotted by the Income Tax department e) Number of Inpatient beds Enter the number of inpatient beds Digits 0 Facilities available in the hospital Indicate facilities available in the hospital Tick the right option. If others, please specify SECTION F • DECLARATION BY THE HOSPITAL Read declaration carefully and mention date (in dd:mm yy format), place (open text) and sign and stamp Page 87 of 89 DETAILS OF THE THIRD PARTY ADMINISTRATOR a1 Name oi T~ / Insurance company b) Toi! lree phone number c) Toll free FAX PLEASE, F/>.J. SCAN PAGE 1 ONL\ REQUEST FOR CASHLESS HOSPITALISATION FOR HEAL TH INSURANCE POLICY PA RT -C TO BE FILLED BY THE INSURED I PATIENT (To be filled in block letters) al Name of the Patient: ['.II _II T.=:.r= :='=:JC:LJU_JLJLLJ_I _JLJLLJLJ _JLJLLJ_JLJLLJLJ_JLLJLJ_JLJL LJ b) Gender !] Male C) Age Years r·1 [ J Months [I [ I d)Dale of birth [ ID DD DDD[J [ ' -71r1,-y·7,~r-,'][·1 D Contact number of ,-, [J □□[]□□□□[-1 ]-' ,,,,--- .J,~-----c---- [' e)Con(actnumber Ji~IL_!LJL .Jl_.i _ __l[_j[. _ attending relative: _I ~ · _}l)lnsuredcardlDnumber: JLUc.......!~i' W~_;,_j_J'_! -~~-- J h) Policy number I Name of corporate jj [i LJ f_'j ]j LJ lj [, CJ CJ C1 LJ LJ [ i DD D i) Employee ID DDDDDD D J) Currently do you have any other tvtediclaim I Health insurance: [Ires CcmpanyName D=:JOOCOO=:J=:JDC □□□=iooc C G:ve details k) Do you have a family physician r1 Yes r:1 No I) Name of lhe family physician L'..1 L_I LL _J _I LJ L LJ LJ _J LJ L LJ LJ _J LJ LJ L LJ _J LJ jj ml Con lac I number, if any I][] LJ :-! [] [] [] r.J [] D (PLEASE COMPLETE DECLARATION ON THE REVERSE SIDE OF THIS FORM) TO BE FILLED BY THE TREATING DOCTOR I HOSPITAL a)Nameoflhe\realingdoclor f' 1l1-i1'7171n71-1n1nn-1n1nn7nf7f' b) Con\acfnumber Ci□□□□□□□□['J d )Relevant clinical findings: c) Nature of ILLNESS/ Disease ~=~-•-- wi!h presenting complaints ~---=-------- 1----------------- ----1 e) Durafioo ol lhe present ailment [1 D I] Days , Dale of ftrsf consultation: ]:i D □□ f) Prov1st0nal diagnosis ~-- . . -------- - ------i I ·-----··-- -------- - -------~ □Ci u. Pasl hist<X)' of present ailment if any: I ICD1 0 Code DDDODDDDDD g) Proposed line of freatmen\ · [l Medical Managernenl IJ Surgical Managemenl [ I Intensive care IJ lnvesflgation 0 Non allopathic treatment ,---- i) Roule of drug administration: h) If fnves\Jgation & I or fledical Management provide details t=---------i >---------------------1 i) If Surgical, name of surger; : E~==-----~- i.lCD 10 PCS Code DDDDDDDDDD k) How did injur; occur: j) If other treatments proYide details: >---------------- -----1 I) In case of accidenl: i. ls 1tRTA. rJ Yes O No II, Date of injur;: DD OB GJD iii. Reported to Police [lYes O No iv. FIRNo ODD v Injury/ Disease caused due to substance abuse I alcohol consumption: l] Yes Q No vi.Tes\ conducted to establish this : []Yes [)-Jo (If Yes al\ach reports) !) ln case of Matemi!y Details of the patient admitted a) Date of adm1ssIon- [lG CCI []P □□ c) ts this an emergency/ a planned hospr!alI2al!on event? D D I Emergency Date of Delivery: b)lime ['.J[J EJD I I Planned \ di Expecled no. of days stay in hospital· Days e) Room Type ~ I I I I I D Per Day Room Rent+ Nursing & Service Charges + Patient's Diet g) Expected cost for investigation+ diagnostics h) ICU Charges i) OT C!1arges. j) Pro!essional fees Surgeon + Anesthetist Fees 'f· consultation Charges· k) Medicines + Consumables+ Cost of Implants (if applicable please specify} Other hospital expenses if any: I) All inc!ustve package charges if any applicable m) Sum Total expected cost of hospitalization Rs. Rs. Rs. Rs. I Rs I Rs. I Rs. CJDDDDDD Rs. DDDDDD['J 00 Mandatory: Past History of any chronic illness 0 Diabetes I \ Heart Disease I I Hypertension I I I I I I I I I I 11 Hyperlipidemias Osteoarthritis Aslhma I COPD I Bronchitis Cancer Alcohol or drug abuse Any HIV or STD I Related ailments \Any other Ailment give details: If yes, since (month I year) □□ DD I I I I ·I I, I I I 'I I 'I (PLEASE READ VERY CAREFULLY) DECLARATION We confirm having read underslood and agreed to the Declaral1ons on the reverse of this form a;Nameoflhefiea\ingdoctor I ' o-=.c-]r:-..:1=i □:::J□C □:::JDC □n77nrl'7n71nn7nnl'ln7fi7n1<17 f'I b)Oualilicat,on ['f 'i[lL'LJ[J[J c) Regis\ra\ion No.wi\h S\ale Ccde DDDDDDDI] Hospital Seal (Must include Hospilal ID) Patient/ Insured Name & Signature: {IMPORTANAT PLEASE TURN OVER) Page 88 of 89 P/•~~[ 2· N·> TOBL: I AY E Dl'.::,:,ANN l:G DECLARATION BY THE PATIENT I REPRESENTATIVE 1 l agree to allow the hospital lo submit all original documents pertaining to hospitalization to the lnsurerfT.P.A after the discharge I agree lo sign on the Final Bill & !he Discharge Summary, before my discharge 2 Payment to hospital 1s governed by the tenns and conditions of the policy. In case the Insurer I TPA is not liable to settle the hospital bill, I undertake to settle the bill as per the terms and conditions of lhe policy 3. Alt non-medical expenses and expenses not relevant to current hospitalization and the amounts over & above the limit authorized by the lnsurerff.P.A not governed by the terms and conditions of the pohcy will be paid by me. 4. I hereby declare to abide by the terms and conditions of the pohcy and 1f at any lime the facts disclosed by me are found to be false or mcorrect I forfeit my claim and agree to indemnify the Insurer / T.PA 5. I agree and understand tha! T P.A 1s in no way warrantmg the service of the hospilal & that the Insurer I TPA 1s in no way guaranteeing that the services provided by the hospital will be of a particular quality or standard 6. I hereby warrant the truth of the forgoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment with respect to the claim, my right to claim reimbursement of the said expenses shall be absolutely forfeited. i I agree to indemnify the hospital against an expenses incurred on my behalf, which are not reimbursed by the Insurer I TPA. a) Patient's/ lnsured's Name: b) Contact number: _ ___ ___________ _ d) Patient's J lnsured's Signature: HOSPITAL DECLARATION 1 We have no objection to any authorized TPA / Insurance Company official verifying documents pertaining to hospitalization. 2 Al! valid onginal documents duly countersigned by the insured/ patient as per the check.list below will be sent to TPA / Insurance Company within 7 days of the patienl's discharge 3. All non medical expenses , OR expenses not relevant to hosp1tal12ation or illness. OR expenses disallowed in the Authorization Letter of the TPA / Insurance Co, OR arising out of mcorrect information in jhe pre-authonsallon form will be collected from the patient. 4 WE AGREE THAT TPA I INSURANCE COMPANY WILL NOT BE LIABLE TO MAKE THE PAYMENT IN THE EVENT OF ANY DISCREPANCY BETWEEN THE FACTS IN THIS FORM AND DISCHARGE SUMMARY or other documenls 5. The patient declaration has been signed by !he patient or by his representative in our presence. 6 We agree to provide clarifications for the queries ra1sed regarding this hospitalization and we take the sole responsibility for any delay in offering clarifications. 7. We will abide by the terms and condihons agreed in the MOU Hospital Seal Doctor's Sign ature DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM i. Detailed Discharge Summary and all 8itls from the hospital 2. Cash Memos from the Hospitals/ Chemists supported by proper prescription. 3. Receipts and Pathological Test Rerorts from Pathologists supported by note from the attending Medical Practitioner/ Surgeon recommending such pathological Tests 4 Surgeon's Cert1fica1e stating nalure:- of operation performed and Surgeon's 8111 and Receipt. 5 Certificates from attendmg Medical Practitioner f Surgeon that the patient 1s fully cured. Page 89 of 89