AGREEMENT This Agreement is Executed on this day of, 2011 between Alankit Health Care TPA Limited (AHCL) duly registered under the Companies Act 1956, having its corporate Office at 2E/21, Alankit House, Jhandewalan Extension, New Delhi 110055 (hereinafter referred to as AHCL which expression shall unless it be repugnant to the context or meaning thereof shall mean and include its successors in office and assigns). AND Located at (here in after referred to as Empanelled Hospital, which expression shall unless it be repugnant to the context or meaning thereof shall mean and include its successors and assignees) WHEREAS Alankit Health Care TPA Limited (AHCL) is a Third Party Administrator (TPA) approved by Insurance Regulatory & Development Authority (IRDA) for providing Health related Medical Services to individual or in groups to its Beneficiaries, Clients, Members, Policy Holder of Insurance Companies in India hereinafter referred to as Member under different Health Insurance Plans / Schemes / Mediclaim Policy formulated by Insurance Companies and administered by AHCL and have created a network of Empanelled Hospitals. WHEAREAS Empanelled Hospital is desirous to join the said Network of Empanelled Hospitals and is willing to extend medical facilities / inpatient hospitalization benefits and treatment relating to the ailments to Members as per Mediclaim / Mediclaim Package covered under various healthcare management plan on the agreed terms and conditions. NOW THIS AGREEMENT WITNESSETH THAT: 1. Empanelled Hospital confirmed and declares that, they have all the Medical, Non Medical approvals, authorizations, registrations, licenses required as per relevant applicable law and also have adequate Infrastructure, Para Medical and Medical Staff with adequate knowledge & experience to provide the Medical services of the highest level to the member Patients in a reliable and professional manner. 2. Empanelled Hospital also undertakes to hold all the requirements of law in so far as these apply on them and in accordance with the provisions of the law and regulations which are enacted by the Central & State Governments, local bodies from time to time including the system required for disposal of Bio Medical Waste as per the environment law. 3. Empanelled Hospital declares that, they have never committed a criminal offence which prevents them from admitting indoor Patients and that no criminal charge of any kind has ever been filed against them for Medical Negligence against the Hospital/Medical personnel by the Medical Association/Council/Court. They also undertake to inform the AHCL regarding any complaint of medical Negligence which may be filed against them during the period of this agreement. 4. That the AHCL shall provide to each member with a Medi Claim identity card having photograph of the member, his/her name, age, sex, name of insurer, policy no, Card No., and validity duly attested by Authorized Person from AHCL which shall be presented for the purpose of assisting Empanelled hospital in verifying member identity and policy /coverage details. Any clarification with regard to the status /
eligibility of any member Patient, the hospital should correspond with the AHCL. In certain cases, where ID Card does not have photograph, the following Photo ID can be considered valid for identification of Member: a) For Minors: Photo ID of School / Ration Card OR Previous TPA ID Card of the patient. b) For Adults: Driving License, Pan Card, Election Card, Passport, Employment Card, Previous TPA ID Card / or any other Card /Document issued by Govt.Authorities. 5. The AHCL shall provide thirty days (30 days) advance notice to the Empanelled Hospital of any changes in covered services or conditions of coverage applicable thereto. 6. That the agreement is valid for a period of three years from the date of signing of agreement. At the end of three years term, if either party does not give any notice for discontinuance of this agreement / services, than the said agreement will deemed to be continued for another term of 3 years and so on. 7. If empanelled hospital or any of its staff members found to be involved in any of the fraudulent / unfair trade practice / lack of rendering services to customers, which causes harm to AHCL in any manner (Financial / Non Financial), than AHCL has the right to De panel the empanelled hospital at its sole discretion with immediate effect and will recover all the losses / penalty from the empanelled hospital. 8. That the Empanelled Hospital shall admit the member into the Hospital after due verification of the member s eligibility by verifying all the details given on the identity card and give the member appropriate and best treatment 9. In case the Empanelled Hospital finds any tampering, false or incorrect information or anything to that effect in the identification card of any member, the Empanelled Hospital shall immediately inform the AHCL on which the AHCL shall take necessary steps and instruct the Empanelled Hospital with regards to future course of action in that case. 10. Pre existing diseases/ailments/injuries or any other relevant information which existed prior to taking the Mediclaim Policy by the Member or during the Policy shall be specified and verified by the Treating Consultant of Empanelled Hospital at the time of admission in our Pre Authorisation letter duly signed by the Patient/Insured.. The Empanelled Hospital shall recover the cost of treatment relating to the disease which is not covered under the policy as per denial letter of AHCL. 11. Empanelled Hospital will instruct / convey to their team of doctors, attached consultants to provide treatment to the member(s) for which he / she is hospitalized / admitted, only for the required number of days which is absolutely necessary and to carry out investigation and treatment required for that particular ailment. 12. AHCL will not be held responsible in any manner for the outcome of treatment or quality of care provided by the Empanelled Hospital to the Member. Empanelled Hospital shall only be responsible to pay any costs, damages or compensation demanded by the Member for not providing adequate Treatment as per the established Norms/Procedure.
13. Empanelled Hospital shall provide inpatient Services to a member in Planned Surgical /Chronic Cases only after the hospital had received Authorization letter from the AHCL in advance. However In case of Emergency Empanelled Hospital shall attend to the Patient immediately and also process the Pre authorization request with all details filled therein simultaneously which should be sent to AHCL for getting required approval. Any Mis representation by the Hospital would call for rejection of the request/claim and AHCL would not be held responsible for the same in any manner whatsoever. 14. The Participating Hospital shall inform the AHCL within 24 hours of admission of a valid member in writing by Fax, e mail or any other modality. In cases of Planned Admission, Empanelled Hospital should get approval for same 48 Hrs before admission. 15. Empanelled Hospital shall allow AHCL s Doctor/official to visit the Member during his / her hospitalization. AHCL shall not interfere with the medical treatment of the patient. However, the medical team of AHCL reserves the right to discuss the treatment plan with treating doctors. Empanelled Hospital shall provide AHCL the access to medical records, indoor papers, other relating documents and billing on case to case basis and also provide copies of same if required. 16. The Empanelled Hospital shall make available to the AHCL such information / additional information and assistance as may be required by the AHCL in regard to settlement of the claim of the Empanelled Hospital. 17. While submitting a claim the Empanelled Hospital shall draw the Bill / Claim according to the agreed tariff with AHCL or as permitted by GIPSA Companies / Govt. Agencies, whichever is less. 18. This agreement shall be in force from the date herein above mentioned and either party can terminate the agreement with a one month prior written notice to the other party. 19. The Empanelled Hospital shall ensure that all members are admitted/treated as the case may be on a priority basis in this context means making available to the members, services like admission/treatment, beds on an urgent basis. The AHCL s member will be given due preference or priority and shall not be held up for wants of funds. In case there is no accommodation available for the members in the Empanelled Hospital the Provider shall make all attempts through his good offices to accommodate the member. 20. The Empanelled Hospital shall not take any deposit of any kind or any amount of money in lieu of deposit at the time of admission from the members of the AHCL. 21. The Empanelled Hospital shall have no objection to the AHCL using its name, as a preferred provider, in their advertising and promotional literature. 22. The Provider Hospital shall refer to AHCL letter wherein most of the Non payable items are mentioned and the cost of same can be recovered from the member at the time of Discharge from Hospital. This includes difference in Room Rent and other charges if the member had availed higher Room Rent Category as specified in our Authorisation letter.
23. Empanelled Hospital will submit the final bill to AHCL along with all the necessary documents / reports as per the agreed Schedule of Charges preferably within 7 days from the date of discharge of the Member(s). In case of failure to submit the claim within 30 days AHCL will not be held responsible for the payment of the said claims. 24. In case certain billed items are not correlated with corresponding Report or any higher charges such charges will be deducted from the final bills. 25. The final bill must the submitted along with the following documents / Reports: a. Readable Copy of Member ID Card b. Claim form duly filled and signed by Hospital and Member Patient /insured. c. AHCL Authorization letter/letters d. Original final Hospital Bill with detailed break up of consumables, miscellaneous & other charges duly signed by Patient. In case of Packages, details to be provided if required by AHCL e. Original & Complete Discharge Summary / Card in every respect having all necessary details with regards to treatment given by Empanelled Hospital. f. Original Investigation reports with all Film and break up. g. Drugs/Pharmacy bills with break up. Date wise h. Deposit Receipt paid by Member if any. i. Any other related documents. 26. Empanelled Hospital shall also endeavor to comply with future requirement of insurer like standardized billing, ICD 10 Coding, ECS Facility FTGS, NEFT & other Bank details etc and any other mandatory requirement of Insurers or by statutory authorities. 27. Any revision in the Schedule of Charges / Tariff will be submitted to AHCL at least 30 days prior to the effective date. On receipt of Revised Schedule of Charges / Tariff, the same will be mutually discussed and approval of insurers shall be obtained within a month. The decision of insurer shall be conveyed accordingly. How ever, no revised Schedule of Charges will be accepted before completion of one year. 28. Empanelled Hospital agrees that the schedule of rates submitted is the lowest and if any other schedule of rates during the tenure is found lower, Empanelled Hospital will refund such additional charges levies on AHCL. 29. The empanelled hospital needs to be approved by the Agency/organization mandated by GIPSA / any insurance Company on the terms and conditions agreed between the Agency and Concerned Empanelled Hospital and only those rates would be applicable in all Claims. All earlier rates agreed to between AHCL and Empanelled Hospital would be superseded by those rates wherever applicable.
30. Empanelled Hospital will give 10% discount on Schedule of Charges. Further discount on volume of business on mutually agreed terms. 31. AHCL reserves the right to enter into an agreement with other Empanelled Hospital for implementing TPA services and the Empanelled Hospital have no objection for the same and vice versa. 32. Empanelled Hospital undertakes to maintain confidentiality of this agreement and not to reveal any information, documents, data, trade secrets, in any manner to any individual, body, entity which they receives during the course of providing services in accordance with this agreement directly or indirectly to any unauthorized person with or without any consideration including terms of this agreement, nature of service, consideration for the services, Members details etc. 33. Empanelled Hospital declares that, their undertaking and declaration with respect to this agreement are pre requisite for the TPA to enter into an agreement and without these undertaking / declaration, the TPA would not have been willing to enter into an agreement with Empanelled Hospital. These undertakings / declarations will be in force for the entire duration of this agreement and minimum three years after this agreement is terminated. 34. AHCL and the Empanelled Hospital shall be and act as independent parties, and under no circumstance shall this Agreement be construed as one of agency, partnership or joint venture or employment between any of them. The relationship between AHCL and the Empanelled Hospital under and / or in pursuance of this Agreement is on a Principal to Principal basis. Consequently, neither Party shall be entitled to represent the other and/or make any commitment on behalf of and/or in the nature of the other to or before any public body or authority and/or any other party. 35. The Empanelled Hospital hereby undertakes to indemnify and to keep AHCL indemnified, saved and harmless from time to time and at all times from and against any and all losses, costs, damages, penalties, actions, suits, proceedings, liabilities, judgments, settlements, claims, demands, duties, taxes and all other expenses (including legal expenses/fees) of any kind whatsoever which may arise against or be incurred by AHCL, its directors, employees or its agents in connection with any action/ omission of the Empanelled Hospital, its employees or its agents (i) pursuant to or relating to this Agreement or arising as a consequence of breach of any of the terms and conditions of this Agreement, including without limitation to these Terms and Conditions. 36. In case of any dispute or difference arising between the parties hereto in any of the matter under this agreement or interpretation or implementation of any of the terms and conditions herein, each party may as soon as practicable give to other party notice in writing of the existence of such questions or disputes specifying its nature and point of issue. If the parties cannot resolve the matters by mutually acceptable solutions within 15 days, the said matter / dispute shall be referred to the arbitrator as per the provision of Indian Arbitration Act. Any decision or award made by the arbitrator shall be a legally binding over both the parties. The expenses so incurred shall be borne equally by both the parties. The arbitration would be conducted at Delhi only and the language of the proceedings would be English. 37. In case any of the party not abide by the award given by the Arbitrator, than this agreement shall be construed, interpreted and applied in accordance with and shall
be governed by the laws applicable in India. The court at Delhi shall have the exclusive jurisdiction to entertain any dispute arising out of or in relation to this agreement. 38. Each Party shall bear its own legal, accounting, professional and advisory fees, costs and expenses incurred by it in connection with this Agreement and subsequently. Provided however, that all stamp duty as may be payable in respect of this Agreement shall be borne and paid by Empanelled Hospital. 39. Any amendment /addition / deletion in the clauses of this agreement can be effected as an addendum after the written approval from both the parties. 40. This Agreement constitutes the entire agreement of the Parties and supersedes all prior agreements and undertakings (both oral and written, including all correspondence) if any, between the Parties with respect to the subject matter hereof. IN WITNESS WHEREOF, both the parties have signed this Agreement on the day, month and year above mentioned in the presence of the following witnesses: Alankit Health Care TPA Limited Empanelled Hospital WITNESSES: 1. 2.
OUR CONTACT DETAILS Authorization Department: Contact for any assistance for availing cashless facility 1. E mail ID: health@alankit.com 2. Toll Free / Contact No.:011 42541256 60 3. Fax No.:011 42541266 67 Empanelment Department: Contact for any change in provider information, hospital tariff, or other cases concerned to this: 1. E mail ID: health@alankit.com 1. Toll Free /Contact No.:011 42541290 2. Fax No.:011 42541266 67 Customer Care Department: For Cashless Claim Inquiry 2. E mail ID: health@alankit.com 3. Toll Free / Contact No.:011 42541256 60 4. Fax No.:011 42541266 67