TENDER DOCUMENT. Social security Scheme For Business community in Punjab. Department of Excise & Taxation, Patiala

Transcription

1 1 TENDER DOCUMENT of Social security Scheme For Business community in Punjab Department of Excise & Taxation, Patiala Issued / Released on 22 nd January, 2014 TENDER NOTICE

2 2 GOVERNMENT OF PUNJAB DEPARTMENT OF EXCISE & TAXATION Social Security Scheme for Business community in Punjab A scheme to provide Accidental death and disability, Health care and Fire & Special Perils insurance cover to small dealers of Punjab (with turnover up to Rs.1Crore). There are around 1,80,000 dealers registered with Department of Excise and Taxation with turnover up to Rs. 1Crore. Department of Excise and Taxation invites Bids from Insurance Companies for providing following covers to these dealers:- a) Health Insurance of Rs.50,000/- per beneficiary. b) Accidental death and disability insurance of Rs.2.00 lacs per beneficiary. c) Fire & Special Perils Insurance of Rs.5.00 lacs for the stock kept at the registered premises of the dealer. The detailed qualification criteria, scope of work and terms & conditions of the Scheme are contained in the RFP which may be downloaded from the Department s website The Insurance Companies may submit sealed Bids in the prescribed format. Sealed bids superscribing "TENDER FOR SOCIAL SECURITY SCHEME FOR BUSINESS COMMUNITY IN PUNJAB addressed to The Excise & Taxation Commissioner, Punjab at the address given below, should reach latest by up to 4.00 P.M. The technical bid received within the time limit will be opened on at A.M in the presence of Bidders who remain present and the financial bid will be opened on at 4.00 P.M. Following schedule will be observed in this regard:- 1. Pre Proposal Conference: ( at am) 2. Last date for submission of the proposal documents: ( up to 4.00 pm) 3. Opening of technical proposals: ( at am) 4. Opening and Evaluation of financial bids: ( at 4.00 pm) The completed Bid documents should be submitted at the address mentioned below up to 4.00 pm on Excise & Taxation Commissioner (Punjab), Room no. 13, 17-Bays Building, Sector-17 D, Chandigarh, PIN No Phone: Fax: Chapter-I

3 3 Introduction A. GENERAL INFORMATION REGARDING THE SCHEME TO THE BIDDER 1. OBJECTIVE: The objective of the scheme is to provide the following three insurance covers to the small dealers of the State registered with the department of Excise & Taxation (with turnover less than Rs.1.00 Crores ): Accidental Death & Disability Insurance Cover Health Insurance Cover Fire & Special Perils Insurance Cover The selected insurance company shall be responsible for the development and designing of the system and software which would cover the scheme. This scheme is for one year. 2. BENEFICIARIES: This scheme is intended to benefit small dealers of Punjab with turnover up to Rs. 1Crore. However, any dealer already availing benefit under any State insurance scheme will not be covered under this scheme. District-wise number of dealers with turnover up to Rs.1.00Crores is given below: District Amritsar Amritsar Fazilka 5648 Gurdaspur & Pathankot Hoshiarpur 5227 Jalandhar Jalandhar Kapurthala 4703 Ludhiana Ludhiana Ludhiana SBS Nagar 2059 Tarn Taran 2351 Barnala 3639 Bathinda 9380 Faridkot 4344 Ferozepur 4784 Fatehgarh Sahib 4085 Mansa 4840 Moga 4701 Mohali 9852 Muktsar 5882 Patiala Ropar 3191 Sangrur Total No. of businessmen with turnover up to 1 Crore Note: The above numbers are subject to minor variations. 3. ENROLMENT UNIT AND ITS DEFINITION

4 4 The unit of enrolment for Social Security Scheme for Business community in Punjab is businessman himself if he has proprietorship firm, nominated partner in case of partnership firm and Karta in case of Hindu Undivided Family. The partners in the partnership firm shall nominate the partner as beneficiary at the time of enrolment under the scheme. B. Scope of the Insurance Covers I. Health Care Cover of Rs. 50,000/- per beneficiary a) The beneficiaries of the scheme will be provided plastic card for health insurance cover of Rs.50,000 per annum on cashless basis for meeting expenses of hospitalization for medical and surgical procedures. b) This insurance cover is for one person only i.e. the enrolled beneficiary as per point 3 above. c) The insurance provider will be required to empanel at least one hospital per one thousand beneficiaries in each district. Say there are beneficiaries in Patiala District, the insurance providers will be required to empanel at least 13 hospitals in Patiala. The hospitals may be public or private. d) Pre-existing conditions/diseases will be covered from the 1 st day of start of policy, subject to the exclusions given in Appendix-1. e) Coverage of health services related to surgical nature for defined procedures shall also be provided on a day care basis. The Insurance Company shall provide coverage for the defined day care treatments/ procedures as given in Appendix 2. f) Pre and post hospitalization costs up to 1 day prior to hospitalization and up to 5 days from the date of discharge from the hospital shall be part of the package rates. II. Accidental Death & Disability Cover of Rs. 2,00,000/- per beneficiary a) All the beneficiaries who have been given plastic card will be given accidental death and disability insurance of Rs.2.00 lacs. b) In case of accidental death of the beneficiary, his nominee will be able to go to the website of the Insurance Provider and submit the claim or submit the claim intimation on call center. The insurance provider will be required to collect the required information/ documents and settle the claim within 30 days of its submission/ intimation. c) In case of accidental disability, the beneficiary will be able to file his claim on the website of the insurance provider using the Unique Identification Number printed on his plastic card or submit the claim intimation on call center by giving the Unique Identification Number printed on his plastic card. The insurance provider will be required to collect the required information/ documents and settle the claim within 30 days of its submission/ intimation. Note: In case a beneficiary suffers an accident and requires hospitalization and even after hospitalization is partially disabled, he will be entitled for both health insurance cover as well as accidental cover. Cover desired is comprehensive (Death + PPD + TD) with actual medical expenses. III. Fire Insurance Cover of Rs. 5,00,000/- per beneficiary a) All the beneficiaries who have been given plastic card will be given insurance cover of Rs.5.00 lacs in case of loss/damage to stock (kept at the registered premises of the beneficiary) due to fire. The insurance claim would be given as per the Average Clause defined under the IRDA guidelines. b) In case of any such loss, the beneficiary should be able to go to the website of the insurance provider and file the claim giving the Unique Identification Number printed on the plastic card or submit the claim intimation on call center by giving the Unique Identification Number printed on the plastic card. The insurance provider will be required to collect the required information/ documents and settle the claim within 30 days of its submission/ intimation.

5 5 C. Role & Responsibilities of Insurance Company 1. Engagement of TPA/Service providers. 2. Issuance of policy. 3. Enrolment of beneficiaries and issuance of plastic cards. 4. Empanelment of Public and Private hospitals for cashless treatment of the beneficiaries. List of Public Hospitals is given at Annexure 9 5. Establishment of Project Office and required infrastructure for successful implementation of this scheme. 6. Establishment of dedicated call centre with toll free helpline available on 24X7X365 basis. 7. Settlement of claims of hospitals and beneficiaries. 8. IEC and BCC activities. 9. Redressal of grievances. 10. MIS sevices. The deliverables of the insurance company have been defined in detail in the clauses/provisions/ chapters appearing here under. D. ENROLMENT OF BENEFICIARIES The insurance provider shall issue plastic card to the beneficiaries. The beneficiary will be required to produce his/her identity proof ( like aadhar card, PAN card, driving license etc. ) along with the plastic card to avail benefits under Health Insurance and to establish his/her identity for claiming insurance under Accidental Death and Disability Cover and Fire Cover. Further, the enrolment process shall continue as per schedule approved by the Nodal officer of the Department. While preparing the roster for enrolment stations, the Insurer must take into account the number of Enrolment Kits that will need to be deployed simultaneously in each enrolment station at Head and Branch Office of Excise and Taxation Department in each District. The process of enrolment shall be as under: The Insurer or its representative will take the data from Department. The Insurer or its representative will arrange for the plastic cards. The Insurer will set up enrollment station at the District Head and Branch Office of the Department in each District. The insurer will commit and place sufficient IT infrastructure and trained personnel for enrolment in each enrollment station so as to ensure enrolment of all the beneficiaries in the district within the time period provided.. It will be the responsibility of the Insurance Company to ensure that IT infrastructure is in working condition and manpower as per Appendix 4 is provided from the 1st day of the commencement of enrolment in the district. An enrolment schedule shall be worked out by the Insurer, in consultation with the Nodal officer of the Department. It will be the responsibility of Nodal officer of the Department to monitor the scheme through the officer (not below the rank of Excise and Taxation Inspector) appointed in each district. Insurer will organize training sessions for the enrolment teams so that they are trained in the enrolment process. List of identified beneficiaries should be available at the enrolment station. Insurer will place a banner in the local language at the enrolment station providing information about the enrolment and details of the scheme etc. The enrolment team will prepare software and fill the details (given in Appendix 12) and capture the photograph of each beneficiary who is getting enrolled in the scheme, on the spot. At the time of enrolment/renewal, the officer appointed by the Assistant Excise and Taxation Commissioner of the district concerned, shall verify the details of the

6 6 beneficiaries enrolled by the enrollment team, from the Department s Data. It is mandatory for the enrolment team to handover the plastic card to the beneficiary after the completion of the enrolment process either by delivering at his/her residential address or in the camps to be organized by the Department. The Insurer s representative shall also provide a booklet in the prescribed format along with plastic Card to the beneficiary indicating at least the following: o Details about the Social Security Scheme for Business community in Punjab benefits o Process/SOPs for online submission/intimation of claims ( either through website or call center ) to avail benefits under Social Security Scheme for Business community in Punjab o Start and end date of the insurance policy o List of the empanelled network hospitals along with address and contact details o Location and address of enrollment stations and their functions o The names and details of the key contact person/persons in the district o Toll-free number of call centre of the Insurer o Process for filing complaint in case of any grievance o Address and contact details of Divisional Coordinators of insurer and project incharge To prevent damage to plastic cards, it should be covered with good quality lamination. The beneficiary shall also be informed about the date on which the card will become operational (month) and the date on which the policy will end. The Insurer shall provide the enrolment data/ daily reports to the District-in-charge and Nodal Officer of the department The enrolment data shall thereafter be provided to the Nodal Officer of the department in the prescribed format with the invoice submitted by the Insurer to the Nodal officer of the Department. The post enrolment data generated by the enrolment software shall be provided by the Insurance Company or its representative to Nodal Officer of the department on monthly basis. E. Enrolment Period The enrolment period shall commence within ten days from the date of issuance of letter of award to the selected insurance company and shall continue up to 31st March, The policy plan period shall start from 1st April, 2014 and shall end on 31st March, The insurance company shall endeavor to achieve the enrolment of all eligible beneficiaries before 1 st April, 2014, and shall take all measures, including but not limited to, all out campaigning through all modes like advertisements/direct reach to beneficiaries/print media/mass media etc. to ensure achievement of maximum possible enrolment. However, if any beneficiaries are left out, the enrolment process shall be allowed to continue for the first three months of the policy plan period, referred to as Enrolment Window Period hereafter, i.e. starting from 1st April, 2014 and ending on 30th June, The premium payable against the beneficiaries enrolled during the Enrolment window period shall be on pro-rata basis. The policy plan period for all the beneficiaries of the scheme shall be co-terminus i.e, the policy plan period for all the beneficiaries shall expire on the same date i.e.31st March, THE ILLUSTRATION IS AS UNDER: Let the Enrolment period= 1st feb,2014 to31st march,2014 and the window enrolment period = 1st april,2014 to 30th june,2014 Period of Policy Start Date Policy end date Enrolment 1st Feb, st April, st March,2015

7 7 to31st march,2014 1st to 15th 30th April, st March, 2015 April, th to 30th April, th May, st March, st to 15th May, 31stMay, st March, th to 31st May, th June, st March, st to 15th June, 30th June, st March, th to 30th June, th July, st March, 2015 F. Constitution and Role/Responsibilities of State Level Bodies/Officials I. STATE LEVEL COMMITTEE (SLC) A. Constitution There shall be a State Level Committee consisting of following members:- 1. Officer not below the rank of Deputy Excise and Taxation Chairman Commissioner, nominated by Excise & Taxation Commissioner, Punjab 2. One Representative from Finance Department Member 3. One Representative from Health Department Member 4. One Representative from Insurance Provider Member B. Role of State Level Committee The State Level Committee will be responsible for the overall implementation of Social Security Scheme for Business community in Punjab in the State. Coordinate with Government of Punjab and Insurance Providers. Drafting the policies and procedures. Drafting the bid forms. The committee shall oversee and monitor the tendering process till the selection of the company. II. NODAL OFFICER The Nodal Officer is an officer of the Excise & Taxation department not below the rank of Deputy Excise and Taxation Commissioner, nominated by Excise & Taxation Commissioner, Punjab. A. Role of Nodal Officer of the Department Ensure effective implementation of Social Security Scheme for Business community in Punjab Support and assistance to the Insurance Company. Ensure that the premium is paid in time to the insurance company Ensure the audits are being conducted on regular intervals. Ensuring the dissemination of information to the officials by organizing meetings and workshops. Hold grievance committee meetings on pre-scheduled days every month and ensure that necessary entries are made on the web site regarding all the complaints/ grievances received and decisions taken there on in the grievance committee Check the functioning of Helpline on regular basis Provide rent free space in each of the district for setting up of Enrollment Station to the Insurance Company. III. SUPPORT AT DISTRICT LEVEL The Assistant Excise and Taxation Commissioner of the District concerned will authorize an

8 8 Officer not below the rank of Excise and Taxation Inspector to monitor and support the insurance provider in the implementation of Social Security Scheme for Business community in Punjab at the district level. G. GRIEVANCE REDRESSAL COMMITTEE A. Constitution The Grievance Redressal Committee will consist of following members: 1. Assistant Excise & Taxation Commissioner of the District Chairman 2. One Representative of Civil Surgeon Member 3. Excise and Taxation Officer nominated by Assistant Member Excise & Taxation Commissioner of the District 4. One Representative from Insurance Provider Member B. Grievance Redressal Mechanism The grievances/disputes of beneficiaries, empanelled hospitals and insurance company will be settled by the Grievance Redressal Committee. The complainant will approach Grievance Redressal Committee for the dispute settlement and the committee should take a decision within 30 days of receiving the complaint. If either of the parties is not satisfied with the decision, they can Appeal to the Deputy Excise and Taxation Commissioner of the division concerned, within 30 days of the decision of Grievance Redressal Committee at the district level. The Deputy Excise and Taxation Commissioner of the division concerned shall decide the case within 30 days of receiving the Appeal after giving the opportunity of being heard to all the parties. The decision of the Deputy Excise and Taxation Commissioner on such issues will be final and binding on the concerned parties. Chapter-II Health Care Cover

9 9 I. Package Rate for Health Care Insurance Component The Insurer s liability for any medical or surgical treatment, procedure or intervention or listed day care procedure under the benefits package shall be no more than the Package Rates for that medical or surgical treatment, procedure or intervention or listed day care procedure that is set out in Appendix 3. If hospitalization is due to a medical condition, a flat per day rate will be paid depending on whether the Beneficiary is admitted in the General Ward or the Intensive Care Unit (ICU). These package rates (in case of surgical procedures or interventions or day care procedures) or flat per day rate (in case of medical treatments) will include: Registration Charges Bed charges (General Ward). Nursing and Boarding charges Surgeons, Anaesthetists, Medical Practitioner, Consultants fees etc. Anaesthesia, Blood, Oxygen, O.T. Charges, Cost of Surgical Appliances etc, Medicines and Drugs, Cost of Prosthetic Devices, implants, X-Ray and other Diagnostic Tests etc, Food to patient Expenses incurred for consultation, diagnostic test and medicines up to 1 day before the admission of the patient and cost of diagnostic test and medicine up to 5 days of the discharge from the hospital for the same ailment / surgery Any other expenses related to the treatment of the patient in the hospital. The package rates can be amended by State Level Committee before the issuance of bid or renewal of contract as the case may be. However, if this is done during the currency of the policy period then it shall only be done with the mutual consent of the Insurer and State Level Committee. Provided that the Beneficiary has sufficient insurance cover remaining at the time of seeking treatment, surgical or medical procedure or intervention or day care procedure for which package rates have been decided, claims by the Empanelled Health Care Provider will not be subject to pre-authorization process by the Insurer. The list of common procedures and package charges is set out in Appendix 3 to this tender, and will also be incorporated as an integral part of service agreements between the Insurer and its empanelled providers. II. Eligible Health Care Providers & Procedure of Empanelment The Insurance Company shall make sure that adequate number of both public and private health care providers shall be empanelled in each district. The Insurer shall also make efforts that the empanelled health care providers are spread across different blocks of the district. Both public and private healthcare providers which provide hospitalization and/or daycare services would be eligible for empanelment under Social Security Scheme for Business community in Punjab. The Insurer shall ensure that the enrolled beneficiaries under the scheme are provided with the option of choosing from a list of empanelled health care providers for the purposes of seeking treatment. Health Care Providers having adequate facilities and offering services as stipulated in the guidelines will be empanelled after being inspected by qualified technical team of the Insurance Company. If it is found that there are insufficient health care providers in a district or that the facilities and services provided by health care providers in a district are inadequate, then the State Level Committee can reduce the minimum empanelment criteria specified in this tender on a case-by-case basis. A. The criteria for empanelment of hospital is provided as follows: a. Public Health Care Providers: All Government hospitals as decided by the State Government (including Community Health Centers) shall be empanelled provided they possess the following minimum facilities Telephone/Fax, The complete transaction enabling infrastructure as has been defined in Appendix 8

10 10 An operational pharmacy and diagnostic test services, or should be able to link with the same in close vicinity so as to provide cashless service to the patient. Maintaining of necessary records as required and providing necessary records of the Social Security Scheme for Business community in Punjab patients to the Insurer or his representative as and when required. A Bank account which is operated by the health care provider through Rogi Kalyan Samiti or equivalent body. b. Private Health Care Providers: The criteria for empanelling private hospitals and health facilities would be as follows: At least 10 functioning inpatient beds or as determined by State Level Committee. The facility should have an operational pharmacy and diagnostic test services, or should be able to link with the same in close vicinity so as to provide cash less service to the patient. Those facilities undertaking surgical operations should have a fully equipped Operating Theatre of their own. Fully qualified doctors and nursing staff under its employment round the clock. Maintaining of necessary records as required and providing necessary records of the insured patient to the Insurer or his representative as and when required. Registration with Income Tax Department. Telephone/Fax B. Additional Responsibilities of the Health Care Providers In addition to providing cashless treatment, the healthcare provider shall: Display clearly their status of being an empanelled provider of Social Security Scheme for Business community in Punjab in the prescribed format approved by Nodal officer of the Department outside/ at their main gate. Provide a functional help desk for giving necessary assistance to the Social Security Scheme for Business community in Punjab beneficiaries. At least two persons in the hospital will be nominated by the hospital who will be trained in different aspects of Social Security Scheme for Business community in Punjab and related hardware and software by the Insurance Company. Display a poster near the reception/admission desks along with the other materials supplied by the Insurer for the ease of beneficiaries and Insurer. The template of Empanelled status and poster for reception area will be approved by the Nodal officer of the Department. Make claims on the Insurer electronically, on the basis of the plastic Card presented by the Beneficiaries at the time of registration, admission and discharge. Send hospitalization data of Social Security Scheme for Business community in Punjab patients electronically on a daily basis to the State/Company server. Maintain such records and documentation as are required for the Insurer to preauthorize treatments and process claims. Cooperate with the Insurer and the State Level Committee and provide access to the Insurer and State Level Committee to all facilities, records and information for the conduct of audits or any other performance evaluations of the performance by the Empanelled Health Care Provider. Comply with the provisions of all applicable laws, statutes, rules and regulations, as amended from time to time. The Insurer shall specify in the MOU/ Agreement entered with the empanelled hospitals as well as otherwise conveyed to the empanelled hospitals that the parties herein shall not be responsible in any manner, whatsoever, for settling any claims arising on account of any loss or damages suffered by any beneficiary as a result of the treatment administered, complications arising thereof, or lapses on the part of the empanelled hospitals /treating doctor and therefore, the empanelled hospitals /treating doctors may seek adequate professional indemnity insurance cover at their own cost. D. Process for Empanelment of Hospitals Insurance Company will undertake following activities for the empanelment of hospitals: Prepare a list of eligible public and private hospitals in a district which can be empanelled in Social Security Scheme for Business community in Punjab after taking inputs from State Level Committee. Organize a district workshop in the district for sensitization of public and private

11 11 hospitals about the scheme provision and procedures. Based on the list of hospitals prepared and willingness of the health care providers, the Insurance Company will prepare and submit a final list of public and private hospitals which will be empanelled in a district to the Nodal Officer of the department. Enter into the Services Agreements with the public and private health care providers which have agreed to be empanelled in a district, prior to commencement of enrolment for such district. Provide Hospital Authority Code to the hospital after receiving it from the Nodal officer of the Department before the commencement of the policy. Ensure the training of the Hospital personnel during the Hospital Workshop and individually as well, along with the refresher training as and when needed E. Agreement with Empanelled Hospital The Insurance Company will sign agreements with empanelled Health Care Providers, to provide Benefits under Social Security Scheme for Business community in Punjab. The Insurer shall obtain the prior written approval from the State Level Committee for the draft Agreement between Insurer and Hospital. F. Delisting of Hospitals An empanelled hospital would be de-listed from the Social Security Scheme for Business community in Punjab network if it is found that guidelines of the Scheme are not followed by them and services offered are not satisfactory as per laid down standards. The Insurance Company will follow the Guidelines for de-empanelment for hospitals as given in Appendix 5. G. List of Empanelled Health Care Providers to be submitted The Insurer should provide list of empanelled health providers in each district, before the commencement of the enrolment in that district, to the Nodal officer of the Department with details as given in Appendix 6. The Insurer will need to submit the information about the health care providers, which will be empanelled after the commencement of the enrolment process in the district, every month to the Nodal Officer of the Department. Insurer will also ensure that details of these hospitals are conveyed to the beneficiaries through updates on the website of the Department from time to time. Chapter-III Claim Management

12 12 I. Method of Availing Insurance Benefit: The endeavor of the insurance provider should be to come out with very beneficiary-friendly process of filing and settling claims. 1. Accidental Death & Disability Insurance and Fire Insurance Cover The insurer will provide the link of its website at the Department s website The beneficiary to avail the accidental death and fire claim will go to the insurance company s website through the link at the Department s website. The beneficiary will authenticate its identity by logging in the Unique Identification Number printed on the plastic card on the provided website. After authentication the beneficiary will submit the claim online to avail benefits against accidental death, partial or permanent disability or loss of stock due to fire. The beneficiary shall also be allowed to lodge his claim through call centre, whereby his call shall be registered and he will be provided with a call registration number for the purpose of future reference through a confirmation SMS. After the beneficiary has intimated his claim either through online mode or through call centre, it shall be the sole responsibility of the insurer to contact the beneficiary and collect necessary information/documents/data required to process and settle his claim within the stipulated time period of 30 days from the date of intimation of the claim. The details of process of online submission of claims through website or call centre shall be described in the booklet issued to each beneficiary along with the plastic card at the time of enrolment. 2. Health Insurance Cover The Insurer has to ensure that all the Beneficiaries are provided with adequate facilities so that they do not have to pay any deposits at the commencement of the treatment or at the end of treatment to the extent as the Services are covered under the Social Security Scheme for Business community in Punjab. Each empanelled hospital/health service provider shall install the requisite software to authenticate and validate the beneficiary and the insurance cover. The services have to be provided to the beneficiary with the minimum of delay for pre authorization (if necessary). Reimbursement to the hospitals should be based on the electronic transaction data received from hospitals on a daily basis. The detailed process and steps for Cashless Access Service has been provided in Appendix 7. II. Claim Management A. Payment of Claims and Claim Turnaround Time The Insurer will observe the following discipline regarding settlement of claims received from the empanelled hospitals/ beneficiaries: The Insurer will ensure that Claim, of the Empanelled Hospital in case of health cover and of the nominee or beneficiary in case of accidental death or disability cover and beneficiary in case of fire cover, is settled and money sent to the hospital/nominee/beneficiary within ONE MONTH of receipt/ collection of claim data by the Insurance Company or their representatives. In case a claim is being rejected, this information will also be sent to empanelled hospital/nominee/beneficiary within ONE MONTH along with the claim rejection information. Insurer will also inform the hospital/nominee/beneficiary that it can appeal to the Grievance Redressal Committee if it feels so. The contact details of the Grievance Redressal Committee will need to be provided by the Insurance Company along with each claim rejection letter. In both the cases, i.e. where a claim is either being settled or being investigated, the process shall be completed within One Month The counting of days in all the cases will start from the day when claims are intimated/ collected/ received by the Insurance Company or its representative. The Insurer may collect at their own cost complete claim papers from the Empanelled Hospital /nominee/beneficiary, if required for audit purposes. This will not have any bearing on the claim settlement to the provider.

13 13 In case of fire insurance cover, as per IRDA guidelines Average Clause will be applicable at the time of settlement of claim. Average clause is explained below: Average clause = Loss of stock x Sum insured Value of total stock on the date of fire Illustration 1: M/s AB ltd. has stock on the date of fire Rs. 50 Lakhs. The sum insured is Rs. 5 lakhs. The loss incurred and as surveyed by the loss assessor of the firm is 50 lakhs. Claim Amount = x = Rs. 5,00, Illustration 2: M/s AB ltd. has stock on the date of fire Rs. 50 Lakhs. The sum insured is Rs. 5 lakhs. The loss incurred and as surveyed by the loss assessor of the firm is 30 lakhs. Claim Amount = x = Rs. 3,00, B. Repudiation of Claim In case of any claim being found untenable, the insurer shall communicate reasons in writing to the Grievance Redressal Committee and the Empanelled Hospital/nominee/beneficiary for this purpose within ONE MONTH of receiving the claim electronically. A final decision regarding rejection, even if the claim is getting investigated, shall be taken within ONE MONTH. Chapter-IV

14 14 Other Terms and Conditions I. Delivery of Services by Intermediaries The Insurer may enter into service agreement(s) with one or more intermediary institutions for the purposes of ensuring effective implementation and outreach to Beneficiaries and to facilitate usage by Beneficiaries of Benefits covered under this tender. The Insurer will compensate such intermediaries for their services at an appropriate rate. The role of Third Party Administrators may include among others the following: To manage and operate the Enrolment process To manage and operate the empanelment and de-empanelment process To manage and operate the Enrollment station. To manage and operate the claim settlement process To manage and operate the Toll Free Call Centre Field Audit at enrolment stations and hospitals Provide IEC and BCC activities, especially for Enrolment. Ensures cashless service provided to beneficiary. II. Project Office Insurer shall establish a separate Project Office at convenient place for coordination with the State Level Committee/ Nodal officer of the Department at the State Capital on a regular basis. Excluding the support staff and people for other duties, the Insurer within its organization will have at least the following personnel exclusively for Social Security Scheme for Business community in Punjab and details of these persons will be provided to the Nodal officer of the Department at the time of signing of MoU between Insurer and State Level Committee: One State Coordinator Responsible for implementation of the scheme in the State At least One Divisional coordinator for each of the participating Divisions Responsible for implementation of the scheme in the districts. This person should be working full time for Social Security Scheme for Business community in Punjab The Project Office will perform the following functions: To operate a 24 hour call center with toll free help line in local language and English for purposes of handling queries related to benefits and operations of the scheme, including information on Providers and on individual account balances. Managing Enrollment Stations for issuance of plastic cards and installing infrastructure as explained in Appendix 4 or providing any other services related to this scheme as defined by Nodal officer of the Department. Management Information System functions, which includes collecting, collating and reporting data, on a real-time basis. Generating reports, in predefined format, at periodic intervals, as decided between Insurer and Nodal officer of the Department. Information Technology related functions which will include, among other things, collating and sharing data related to enrolment and claims settlement. Paperless Claims settlement for the hospitals with electronic clearing facility within One Month of receiving the claims from the hospitals/ beneficiaries. Publicity for the scheme so that all the relevant information related to Social Security Scheme for Business community in Punjab reaches beneficiaries, hospitals etc. Hospital Empanelment of both public and private providers based on empanelment criteria. Feedback functions which include designing feedback formats, collecting data based on those formats from different stakeholders like beneficiaries, hospitals etc., analyzing feedback data and suggest appropriate actions. Coordinate with district level Officers in each district. Coordinate with Nodal officer of the Department / State Level Committee. III. Management Information Systems (MIS) Service

15 15 The Insurer will provide real time access to the Enrolment, Hospitalization, Claim Settlement, Claim repudiation data as received by it to the Nodal officer of the Department. This should be done through a web based system. In addition to this, the Insurer shall provide Management Information System reports whereby reports regarding enrolment, health-service usage patterns, claims data, customer grievances and such other information regarding the delivery of benefits as required by the Nodal officer of the Department. The reports will be submitted by the Insurer to the Nodal officer of the Department on a regular basis as agreed between the Parties in the prescribed format. All data generated under the scheme shall be the property of the Department. IV. Call Center Services The Insurer shall provide toll free telephone services with a facility of a minimum of five lines and provision for answering the queries in local language, for the guidance and benefit of the beneficiaries whereby the Insured Persons shall receive guidance about various issues by dialing a State Toll free number. This service provided by the Insurer is referred to as the Call Centre Service. The insurer will bear the cost of establishment and running of this call centre for the entire policy period. The Insurer shall operate a call centre for the benefit of all the insured Persons. The Call Centre shall function from 6 am to 10 pm a day, 7 days a week and round the year. The cost of operating of the number shall be borne solely by the Insurer. As a part of the Call Centre Service the Insurer shall provide all the necessary information about Social Security Scheme for Business community in Punjab to any beneficiary who calls for this purpose. The call centre shall have access to all the relevant information of Social Security Scheme for Business community in Punjab in the State so that it can provide answer satisfactorily. The Insurer undertakes to provide services to the Insured Persons in English and local languages. The Insurer will intimate the state toll free number to all beneficiaries along with addresses and other telephone numbers of the Insurer s Project Office. As a part of the Call Centre Service the Insurer shall provide the following. Automated Complaint Registry (Members can register complaints against any public health system/provider with their ID Card Number). Redressal call shall be made within 120 minutes of receipt of such registry. Answers to queries related to coverage and benefits under the Policy. Information on Insurer s office, procedures and information related to Scheme General guidance on the Scheme. Information on cash-less treatment at hospitals. Information on empanelled hospitals and contact numbers. Claim status information. Advising the hospital/ beneficiaries regarding the deficiencies in the documents for a full claim. Any other relevant information/related service to the Beneficiaries. Maintaining the data of receiving the calls and response on the system. Any related service to the Government/Department. V. Procedure of Payment of Premium State Government will, on behalf of the identified beneficiaries, make the payment of the premium to the Insurance Company based on the enrolment of the identified beneficiaries and delivery of plastic cards to them. The total annual premium payable to the insurer shall be paid by the State Government to the insurer during one year period of the policy plan period. Payment of premium will be as follows: The State Government shall pay the premium to the Insurance Company on the basis of the bill raised by it for Premium, in relation to enrolments completed in that month. Along with its invoice, the Insurer shall provide the complete enrolment data acquired by the insurance company to the Nodal officer of the Department in electronic form.

16 16 The State Government shall pay the installment of the payable Premium within 15 days of receipt of the invoice from the Insurer, subject to verification of the enrolment by the respective Officer appointed in each district. It will be the responsibility of the State Government to ensure that the premium to the Insurance Company is paid according to the schedule mentioned above to ensure adherence to compliance of Section 64 VB of the Insurance Act Premium payment to the Insurance Company will be based on Reconciliation of invoice raised by Insurer and enrolment list verified by Officer appointed for the purpose of verification of the data in each district. VI. Period of Contract and Insurance a. Term of the Contract: The Contract between the State Level Committee and the Insurer shall become effective on the date of signing and shall continue to be valid and in full force and effect until expiration of the Policy Cover Period of Policy issued by the Insurer, including any renewal of such Policy, under the Contract or until early termination, whichever is earlier. The decision regarding extending the contract of the Insurance Company on yearly basis will be taken by the State Level Committee. Even after the end of the contract period, the Insurance Company needs to ensure that the server and TPA services are available till the reconciliation with and settlement of claims of the hospitals empanelled/ beneficiaries. b. Issuance of Policy: The terms and conditions set out in the Policy issued by Insurer to the Department shall: (i) clearly state the Policy number; (ii) clearly state the Policy Cover Period under such Policy and (iii) contain terms and conditions that do not deviate from the terms and conditions of insurance set out in the Contract(s). In the event of any discrepancy, ambiguity or contradiction between the terms and conditions set out in the Contract(s) and in the Policies issued for a district, the Contract(s) provisions shall prevail. c. Commencement of policy in districts The Policy Cover Period under the Social Security Scheme for Business community in Punjab for all district(s) shall commence from the first day of April, Policy will commence from 1 st April, 2014 and end on 31 st March, VII. Penalty Clause and Termination Failure to abide with the terms will attract penalty related but not limited to the following: 1. Failure in following the guidelines specified in Appendix Claim Servicing 3. Grievance Redressal S No Activity Time frame from the date of issuance of Letter of Award/ time period specified herein 1 Setting up of Project Office with adequate infrastructure 10 days 0.05% 2 Commencement of enrolment From the date of 0.05% Penalty per week or part thereof for the delay in execution in % of amount of payable half yearly premium installment

17 17 activity as per the defined procedure and in accordance with the provisions laid herein. 3 Making available the required no. of adequate manpower and required infrastructure at designated enrolment stations/ identified locations in each district for enrolment of beneficiaries 4 Achieving target enrolment of at least 1 lac beneficiaries within enrolment period/ enrolment window period 5 Establishment of 24 Hrs Call Center and adequate manpower handling the call centre 6 To identify the public/private Hospitals that comply with minimum eligibility, networking with them, signing of the MOUs with the Hospitals,installation and operationalization of necessary softwares/ hardwares, training of the hospitals with respect to the terms and conditions of the Scheme, making all necessary arrangements with the Network Hospitals for hassle free and smooth delivery of cashless service from the Hospitals from the date of the start of the Policy Plan Period 7 To provide adequate manpower, so as to ensure free flow of daily MIS pertaining to enrolment and ensure that progress of scheme is reported to State Level Committee/Nodal officer of the Department in the desired format on a realtime basis start of enrolment period As per the schedule notified by the nodal officer of the Department Enrolment period/enrolment window period 15 days before t he start of policy plan period By 25 th March 2014 or atleast 5 days prior to the start of policy plan period, whichever is earlier. As per the schedule notified by the nodal officer of the Department 0.05% 1% 0.05% 0.05% 0.05%

18 18 8 (a) Settlement of claims of hospitals/ beneficiaries More than 5% of the claims of the hospitals/ beneficiaries remain pending beyond the prescribed period of 30 days up to further 30 days 0.05% 8(b) Settlement of claims of hospitals/beneficiaries. 9 Dedicated Website as per the Department's requirement 10 Minimum number of 1 empanelled hospital per 1000 beneficiaries to be maintained for the duration of entire policy period. More than 5% of the claims of the hospitals/ beneficiaries remain pending beyond 60 days By 31st March,2014 From the date of start of policy to the date of expiry of policy plan period. 0.1% 0.05% Rupees five lacs for each day of default and within the overall limit of rupees one crore. 11(a) Settlement of grievances of hospitals/beneficiaries and compliance of actions/ decisions awarded by grievance redressal committee/ designated authority More than 5% of the grievances of the hospitals/ beneficiaries remain pending after the award of decision by the grievance Redressal committee,beyond the period prescribed upto 30 days 0.05% 11(b) Settlement of grievances of hospitals/beneficiaries and compliance of actions/ decisions awarded by grievance redressal committee/ designated authority More than 5% of the grievances of the hospitals/ beneficiaries remain pending after the award of decision by the grievance Redressal committee,beyond 60 days from the prescribed period.1% In case of termination of the contract following process will be followed: The Policy Cover Period of each of the Policies issued by the Insurer shall terminate on the expiry of the termination notice period, unless the State Level Committee has issued a written request to the Insurer before that date to continue providing Cover under the Policies issued by it. The Insurer shall, upon the written request of the State Level Committee, continue to provide the Cover under the Policies until such time that the State Level Committee appoints a substitute insurer and the cover provided by the substitute insurer commences. The last date of effectiveness of the Policies shall be the Termination Date.

19 19 The Insurer will pay back to the State Government within one week the unutilized amount of premium after settlement. The Insurer will pay the total package amount for all the cases before returning the premium. Notwithstanding the termination of the Contract(s), the Insurer shall continue to discharge all of its liabilities in respect of all claims made under Health Care Insurance and the claims of accidental death or disability cover and fire cover under process, on or prior to the Termination Date. Upon termination of the Contract(s) and receipt of a written request from the State Level Committee at least 7 days prior to the Termination Date, the Insurer shall assign its rights and obligations, other than any accrued payment obligations and liabilities, under its Services Agreements with the Empanelled Health Care Providers and its agreements with other intermediaries in favor of the State Level Committee or the substitute insurer appointed by the State Level Committee. VIII. Standardization of Formats The Insurance Company shall use the standardized formats for cashless transactions in case of Health Care Insurance, Accidental Death and Disability Cover and Fire Cover, discharge summary, billing pattern and other reports in consultation with the Nodal officer of the Department. IX. IEC and BCC Interventions Insurance Company in consultation with State Level Committee will prepare and implement a communication strategy for launching/implementing the scheme. The objective of these interventions will be to inform the beneficiaries regarding enrolment and benefits of the scheme. Insurer needs to share a draft IEC and BCC plan with the State Level Committee within 15 days of signing of the contract. The cost of IEC and BCC activities will be borne by the Insurer. X. Capacity Building Interventions The Insurance Company shall design training/ workshop / orientation program for Empanelled Health Care Providers and implement the same with support of Nodal officer of the Department. The training packages shall be jointly developed by the Nodal officer of the Department and the Insurance Company. At least following training shall be implemented by the Insurance Company: Enrollment Team Training To be done for each enrollment team during the enrollment period Hospital Training At least once a year for all the empanelled hospital in each district separately for Public and Private providers State and District Officers of the Insurance Company At least once a year for these officers for each of the district Insurer will need to share a draft Capacity Building plan with the State Level Committee within 15 days of signing of the contract. The cost of these Capacity Building interventions will be borne by the Insurer. XI. Audit Mechanism: a. Medical Audit The Insurance Company shall carry out regular inspection of hospitals, periodic medical audits, to ensure proper care and counseling for the patient at network hospitals by coordinating with hospital authorities. Specifically, the Insurer shall conduct a periodic medical audit of a specified sample of cases, including random verification of hospital admissions and claims. The medical audit should compulsorily be done by a qualified medical doctor who