CENTRAL GOVERNEMENT EMPLOYEES AND PENSIONERS HEALTH ISNURANCE SCHEME

 

CENTRAL GOVERNEMENT EMPLOYEES AND PENSIONERS HEALTH ISNURANCE SCHEME – CGEPHIS

DRAFT  
1. NAME OF THE SCHEME:
The name of  the proposed scheme  is “Central Government Employees & Pensioners Health Insurance Scheme (CGEPHIS)”.
 
2. BENEFICIARIES:
All personnel of the Central Government including All India Service officers, serving, newly recruited, retired / retiring and others who are covered under the  existing  CGHS  (Central  Government  Health  Services)    and  under  CS (MA)  [Central  Services  (Medical  Attendance)  Rules]  Rules shall  be  offered Health Insurance Scheme  on voluntary or on compulsory basis as indicated below: 
 
1.  CGEPHIS shall be compulsory to new Central Government Employees who would  be  joining  service  after  the  introduction  of  the  Health Insurance Scheme.
 
2.  CGEPHIS  shall  be  compulsory  to  new  Central  Government  retirees who would  be  retiring  from  the  service  after  the  introduction  of  the Insurance Scheme.
 
3.  CGEPHIS would be available on voluntary basis for the following:
 
a.  Existing  Central  Government  Employees  and  Pensioners  who are already CGHS beneficiaries. In this case they have to opt out of  CGHS  scheme.  They  will  also  have  the  option  of  choosing both  CGHS  and  Insurance  policy.  In  such  case  the  total insurance premium has to be borne by the member.
 
b.  Existing  Central  Government  Employees  and  Pensioners  who are  not  CGHS  beneficiaries  but  are  covered  under  CS  (MA) Rules.  Pensioners    are  however  not  covered  under  CS(MA) Rules.
 
3. TARGET GROUP:
All personnel of the Central Government including All India Service officers, serving  and  retired,  and  others who  are  covered under  the  existing CGHS and under CS  (MA) Rules shall be offered  the Health  Insurance Scheme. It is estimated that approximately 17 lakh serving employees and 7  lakh pensioners shall be offered this Scheme on compulsory / optional basis.

4. INSURANCE COVERAGE:
a)  In-patient  benefits  –  The  Insurance  Scheme  shall  pay  all  expenses incurred in course of medical treatment availed of by the beneficiaries in  an  Empanelled  Hospitals/  Nursing  Homes  (24  hours  admission clause) within the country, arising out of either illness/disease/injury and or sickness. 
NOTE:
In case of organ  transplant,  the expenses  incurred  for  the Donor are also payable under the scheme.
b)  Coverage  of  Pre-existing  diseases:  All  diseases  under  the  Scheme shall  be  covered  from  day  one.  A  person  suffering  from  any  disease prior to the inception of the policy shall also be covered. 
c)  Pre  &  Post  hospitalization  benefit:  Benefit  up  to  30  days  Pre Hospitalization  &  up  to  60  days  Post  Hospitalization  respectively which would  cover  all  expenses  related  to  treatment  of  the  sickness for which hospitalization was done.
d)  Domiciliary  Hospitalization:  The  Scheme  would  also  cover Domiciliary  Hospitalization  where  the  medical  treatment  for  such illness/disease /injury requires as in-patient treatment at empanelled Hospitals/Nursing Homes but actually taken whilst confined at home in India under the circumstances that:  
· · · ·  His/her  condition  is  such  that  patient  cannot  be moved  to  a hospital or ,
· · · ·  If no  room  is  available  in  empanelled Hospitals/Nursing home within that area.  
Note:  Pre  and  Post  hospitalization  benefit  under  this  section  would
not be covered.
 
e)  Day  Care  Procedures:  Given  the  advances  made  in  the  treatment techniques,  many medical  treatments,  formerly  requiring hospitalization, can now be  treated on a day care basis. The scheme would  also  provide  for  day  care  facilities  (less  than  24  hours hospitalization) for such identified procedures. OPD services shall not be part of Day Care facilities. 
 
1.  Eye Surgery
2.  Lithotripsy (kidney stone removal) 
3.  Tonsillectomy    
4.  D&C
5.  Dental surgery following an accident
6.  Surgery of Hydrocele
7.  Surgery of Prostrate
8.  Few Gastrointestinal Surgery
9.  Genital Surgery
10. Surgery of Nose/Throat / Ear
11. Surgery of Urinary System 
12. Dialysis
13. Chemotherapy 
14. Radiotherapy
15. Treatment related to dog bite/snake bite etc. 
16. Treatment  of  fractures/dislocation,  Contracture  releases and  minor  reconstructive procedures  of  limbs  which otherwise require hospitalization
17. Laparoscopic therapeutic surgeries that can be done in day care  
18. Identified  surgeries  under  General  Anesthesia  or  any procedure  mutually  agreed  upon  between  insurer  and health care provider.
Note:  Insurers  will  provide  the  exhaustive  list  of  Day  care procedures.
f)  The  expenses  incurred  for  treatment  taken  in  empanelled Hospitals/ Nursing Homes /Day Care Clinics by  the   beneficiaries suffering  from  such  disabilities  as  defined  in  “Section  2  (i)  of  the person with disabilities  (equal opportunities, protection of  rights and full participation) Act, 1995 (No: 1 of 1996)” which includes blindness, low  vision,  leprosy–cured, hearing  impairment,  locomotors disability, mental retardation, mental illness etc. are also payable irrespective of age and income limit subject to size limit of the family.
g)  Maternity and Newborn Benefits: 

A. Maternity benefit 
1. This means treatment taken in Empanelled Hospital/Nursing Home  arising from child birth including Normal Delivery/Caesarean  Section  including  miscarriage  or  abortion induced by accident or other medical emergency.
 
2. This benefit would be limited to  only  first  two  living  children  in respect of Dependent Spouse/Female Employee covered from day one under the policy, without any waiting period.   
 
B. Newborn benefit 
1. Newborn child (single / twins) to an insured mother would be covered from day one up to the expiry of the current policy for the expenses  incurred for treatment  taken  in  empanelled Hospitals/Nursing Homes/Day Care Clinics as  In-patient during the  currency  of  the  policy  and  will  be  treated as part of the mother subject to eligibility under  maternity benefit. However, next year  the child could be covered as a  regular member of  the family subject to size of the family.
2.  In first pregnancy, twins are born than the benefit will ceases for second pregnancy. However,  in second pregnancy twins are born than both will be covered till the expiry of the current policy.  
3. Congenital diseases of new born child shall be covered. 
   
5. FAMILY SIZE:
 
1.  Serving/Retired  Employees:  Self,  Spouse,  Two  dependent  children and  up to Two Dependent  Parents.  New  born  shall  be  considered insured from day one till the expiry of the current policy irrespective of  the number of members  covered  subject  to  eligibility  under maternity benefit.
Note:
i.  For  the  policy  period,  new  born would  be  provided  all  benefits under CGEPHIS and will NOT be counted as a separate member. The child will be treated as part of the mother.
 
ii. Verification for the new born could be done by any of the existing family members who are getting the CGEPHIS benefits.
 
iii. Member  is  required  to  enroll  new  born  child  at  the  time  of renewal of the policy prior to expiry of the policy.
 
2.  Any  additional  dependent member  in addition  to above  [Sr. No. 5 (1)] can be covered under  the Scheme by paying  the  fixed amount of premium.  This  additional  full  premium  shall  be  borne  by  the beneficiary.
 
3.  All Members (Serving/Retired Employees) shall be insured till they are the member of the scheme unless withdrawn from the Scheme.
 
A.   Age  limit of dependent  for the purposes of CGHS and CS  (MA) Rules 1944 includes:- 
 
1.  Son  –  Till  he  starts  earning  or  attains  the  age  of  25  years, whichever is  earlier; 
 
2.  Daughters – Till she starts earning or gets married, irrespective of  age  limit  whichever  is  earlier.  Further,  Dependent divorced/abandoned  or  separated  from  their  husband  and widowed daughters – irrespective of age limit. 

3.  Sisters  –  Dependent  unmarried  /widowed  /  divorced/ abandoned / separated from their husband – irrespective of age limit.

4.  Daughter in law- Widowed – irrespective of age limit.

5.  Brothers – Up to the age of becoming a major. 

6.  Dependent Parents – As per condition of eligibility.
 
B.  Income  limit  for  dependency  of  family members  –  If monthly income  from      all  sources  of  income  is  less  than  Rs.  3,500/-  per month  plus  dearness  allowance  of  the  family member,  then  the following  would  be  entitled  to  be  treated  as  dependant  on  the employee:
 
1.  Parents
2.  Sisters
3. Widowed Sisters/Widow Daughter –in-law.
4. Widowed / Divorced / Separated Daughters,
5.  Brothers
6.  Step mother 
7.  Children.

NOTE: 
The  definition  of  dependent  shall  be  as  per  guidelines  issued  by Central Government from time to time.

C.  Addition  & Deletion of  Family Members during currency of the policy:
 
i)  Addition to the family is allowed in following contingencies during the policy:
a)  Marriage  of  the  CGEPHIS  beneficiary  (requiring inclusion of spouse’s name),  or
b)  Parents becoming dependants.
 
ii) Deletion from Family is allowed in following contingencies:
a)  Death of covered beneficiary,
b)  Divorce of the spouse,
c)  Member  becoming  ineligible  (on  condition  of dependency)

D.  New Employees/Retirees
a)  As regards the new incumbents/pensioners the coverage  in the insurance scheme  is compulsory. The data of such employees/ pensioners will be collected from the various departments.
b)  The Pay and Account Offices of all  the Ministries/Departments would  provide  the  data  to  the  insurer.  Each  of  the  New Employee/Pensioners  of  the  Ministry/Department  would  be provided  with  the  enrolment  form  which  needs  to  be  filled  in and submitted to the respective Ministry which will consolidate all  the  forms  and  forward  the  same  to  the  Nodal Officer/Ministry on monthly basis. 
c)  The said employees would have  to be covered  in  the  Insurance Scheme  from  the date of  joining/retirement. Thus  for  them  the inclusion in the policy will be made by charging the pre defined monthly  Prorata  premium  rate  which  would  be  less  than  the yearly premium rate.
 
6. IDENTIFICATION OF FAMILY:
 
Beneficiaries  shall  be  identified  by  a  “Photo  Smart  Card”  issued  by  the insurer  to  all  beneficiaries which would  have  all  personal  details, medical history, policy limits etc. of the CGEPHIS members. This card would be used across  the  country  to  access  Health  Insurance  Benefits.  The  photograph embedded  in  the  chip  of  the  Smart  Card  will  be  taken  as  the  proof  for determining the eligibility of the beneficiaries.  
 
 
7. SUM INSURED AND BUFFER / CORPORATE SUM INSURED 

A. SUM INSURED:
The  Scheme  shall  provide  coverage  for  meeting  all  expenses  relating  to hospitalization of beneficiary members up to Rs. 5, 00,000/- per  family per year  in  any  of  the  Empanelled  Hospital/Nursing  Home/Day  Care  Unit subject  to stated  limits on cashless basis  through smart cards. The benefit shall be available  to  each and every member  of  the  family on  floater basis i.e.  the  total  reimbursement  of  Rs.  5.00  lakh  can  be  availed  by  one individual or collectively by all members of the family. 
 
B. BUFFER / CORPORATE SUM INSURED:
An additional Sum Insured of Rs.25 Crore shall be provided by the Insurer as Buffer/Corporate Floater in case hospitalization expenses of a family (per illness or annual) exceed the original sum insured of Rs 5.00 lakhs. Insurer is required to inform the Nodal Agency with the details on case to case basis. 
 
 8. PAYMENT OF PREMIUM:
As  the  policy  would  be  renewed  every  year,  there  is  an  element  of uncertainty  in the  level of premiums depending upon  the actual number of enrolment and claims submitted and the inflow into the fund.  To ensure a certain degree of stability in premiums at least for a period of 3to 5 years, Insurers will quote the premium for various ranges. 

I.  These numbers will consist of both serving and retired employees.

II.  1,  00,000 persons  shall be  taken as assured beneficiaries  for  thefirst  year  to  calculate  the  estimated  premium  to  be  paid  to  theinsurer.

III.   If  the number of beneficiaries exceeds  the  first slab,  in such case the premium shall be adjusted retrospectively according to eligible stage in which beneficiaries number will fall.

IV.  L-1  will  be  considered  from  the  first  slab  of  1,  00,000  assured beneficiaries.  However,  in  next  slabs,  best  lowest  offer  shall  be picked  up  from  the  financial  quotes  given  by  the  bidder  in  their financial bid and shall ask the L-1 to match the same.

V.  Loading needs to be quoted by the insurer based on the claim ratio mentioned  below.    However,  slab  wise  best  lowest  loading  offer shall be picked up from the financial quotes given by the bidders in their financial bid and shall ask the L-1 to match the same.
                   

Claim Ratio %       Loading %
 
·   Up to 100%  :     Nil
· 101 to 120%  :       %
· 121 to 140%  :       %
· 141 to 160%  :       %
· 161 to 180%  :       %
· Above 180% :       %

NOTE:
a)  This  includes  the Management  cost,  intermediary  cost  and  burning cost  (claims      paid  and  outstanding)  etc.  If  claim  ratio  is  less,  the premium can be  taken care by refund clause mentioned at Sr. No. 9.
 
b)  This premium will be paid  to  the  Insurers  for  the beneficiaries  to be enrolled during the policy period in case of new joinees / retirees and exiting employees/pensioners. This premium will also take care of the members inadvertence missed for any reasons.  
c)  The  enrolment  period  shall  be  for  180  days  in  the  case  of  retired employees  from  the date of  introduction of  the Scheme.  In  this case, full premium  shall be paid. No  enrolment  shall be allowed after 180 days from the date of introduction of the Scheme. 
d)  In the case of new joinees and new retires, the enrolment will continue throughout  the  year.  In  this  case, premium will be paid  on pro  rata basis based on monthly calculation.
 e)  Insurer  will  submit  the  details  of  the  beneficiaries,  in  case  the premium  paid  is  utilized  to  the  extent  of  90%,  enabling  the GOI  to release  the  provisional  premium  to  take  care  of  the  enrolment  of beneficiaries for the remaining period of policy.    
f)  Insurer will submit the statement along with the details of enrolment in a prescribed format to the agency on fortnightly/monthly basis.
g)  Reconciliation  of  premium  paid  to  the  insurance  company would  be carried out at the end of the year.  

9. REFUND OF PREMIUM/ADJUSTMENT OF PREMIUM:
If  there  is  a  surplus  after  the  pure  claims  experience  on  the  premium (excluding Service Tax) at the end of the policy period, after providing 20% of the  premium  paid  towards  the  Company’s  administrative  cost,  in  the balance  80%  after  providing  for  claims  payment  and  outstanding claims, 90%  of  the  left  over  surplus will be  refunded by  the  insure  to  the Central
Government/Nodal  agency  within  30  days  after  the  expiry  of  the  policy period or shall be adjusted with renewal premium.
 
10. ELIGIBLE HEALTH SERVICES PROVIDERS:
 
Both  Public  and  Private  Health  Providers  which  provide  hospitalization and/or  a  Day  Care  Services  would  be  eligible  for  inclusion  under  the CGEPHIS, subject to such requirements for empanelment as agreed between the Central Government and Insurers. CGEPHIS aspires to provide to all its beneficiaries high quality medical care services  that are affordable. With  this  objective,  it has prescribed National Accreditation  Board  for  Hospitals  &  Healthcare  Providers  (NABH) Accreditation as minimum eligibility criteria for empanelment of both Public and Private hospitals. 
The  Hospitals/Nursing  Homes/Day  Care  Clinics  interested  to  join  the CGEPHIS  should  be  accredited  with  NABH  /JCI  (Joint  Commission International)/ACHS (Australia) or by any other accreditation body approved by  International  Society  for  Quality  in  Health  Care  (ISQua)  as  minimum eligibility  criteria  for  empanelment  of  hospitals.  In  addition  such Hospitals/Nursing  Homes/Day  Care  Clinics  should  have  the  following facilities: 
i)  General  purpose  hospital  having  100  or  more    beds  with  the following  specialties :
General  Medicine,  General  Surgery,  Obstetrics  and  Gynecology, Paediatrics,  Orthopedics  (excluding  Joint  Replacement),  ICU  and Critical  Care  units  ,ENT  and    Ophthalmology,  (Dental  specialty  – desirable), Imaging facilities , in house laboratory  facilities and Blood Bank. 
ii)  Specialty hospitals (specialties list given below) Hospitals having less than 100 beds can apply as a   specialty hospital -provided they have at  least  25  beds  earmarked for each specialty applied  for with  at least 15 additional  beds    –  Thus  under  this  category  a  single specialty  hospital would  have  at  least  40  beds. However, under  this category a maximum of three specialties is allowed.
 
. Cardiology , Cardiovascular and Cardiothoracic  surgery        
.Urology –  including Dialysis and Lithotripsy
.Orthopedic- Surgery – including arthroscopic surgery and Joint Replacement
.Endoscopic surgery 
.Neurosurgery
 
iii)   Super-specialty Hospitals- with    150  or more  beds with  treatment facilities in at least three of  following Super Specialties in addition to Cardiology&  Cardio-thoracic  Surgery  and  Specialized  Orthopaedic Treatment facilities that include Joint Replacement surgery:
 
·  Nephrology & Urology incl. Renal Transplantation
·  Endocrinology
·  Neurosurgery
·  Gastro-enterology & GI –Surgery incl. Liver Transplantation 
·  Oncology – ( Surgery, Chemotherapy & Radiotherapy)
These hospitals shall provide treatment /services in all disciplines available in the hospital. 

iv) Cancer  hospitals  having  minimum  of  50  beds  and  all  treatment facilities  for  cancer  including  radio-therapy  (approved  by  BARC  /AERB).  

NOTE – A: 
a)  Such  Hospitals/Nursing  Homes/Day  Care  Clinics  that  obtained entry  level  pre  accreditation  certificate  from  NABH  would  also  be eligible for empanelment under CGEPHIS.
 
b)  The Hospitals/Nursing Homes/Day Care Clinics which are already empanelled  under  CGHS,  if,  desires  to  be  get  empanelled  under CHEPHIS and are not accredited by NABH/JCI/ACHS/  ISQua are required  to  apply  for NABH  accreditation within  two months  from the  date  of  empanelment  under  the  Scheme  as  per  criteria mentioned  below  at  “A”  (Criteria  for  Empanelment  of  Private Hospitals/Nursing  Homes/Day  Care  Clinics  in  addition  to  the
NABH  /JCI  /  ACHS  /  ISQua/  NABL  criteria).  A  certificate confirming to apply with NABH within the stipulated period should be given by the hospital while getting empanelled under CGEPHIS.
 
c)  Any  Hospitals/Nursing  Homes/Day  Care  Clinics  not  applying  to NABH  within  stipulated  period  shall  be  automatically  de-paneled from the Scheme.
 
d)  In  addition,  the  empanelled  Hospitals/Nursing  Homes/Day  Care Clinics having  in-house diagnostic Laboratories or using the linked diagnostic  laboratories  shall  also  apply  for  National  Accreditation Board for Testing & Calibration Laboratories  (NABL) certification of the Laboratory as per condition.
 
Note – B: 
1)  Hospitals/Nursing  Homes/Day  Care  Clinics  that  have  already applied  for  /accredited  under  NABH/JCI/NABL  shall  inform  the office of Insurer with supportive document.
 
2)  Those applying to NABH/JCI for accreditation to join the CGEPHIS shall also agree to the CGHS package rates and to the clause 11-A and 11-B mentioned below.
 
A.  Criteria  for  Empanelment  of  Hospitals/Nursing  Homes/Day  Care Clinics in addition to the NABH /JCI / ACHS / ISQua/ NABL criteria. 
 
i.  Fully equipped and engaged in providing Medical and/  or Surgical facilities.  The facility should have an operational  pharmacy  and diagnostic  services.  In case health  provider  does  not  have  an operational pharmacy and diagnostic services, they should be able to link with the same in close vicinity so as to provide ‘cash less’ service to the patient. 
 
ii.  Those  Hospitals/Nursing  Homes/Day  Care  Clinics  undertaking surgical operations should have a  fully equipped Operating Theatre of their own. 
 
iii. Fully  qualified  doctors  and  nursing  staff  under  its  employment round the clock.
 
iv.   Agreeing  to  the  cost  of  packages  for  each  identified  procedures  as
approved under the CGHS scheme.
 
a)  These package rates shall mean and include  lump  sum  cost  of inpatient  treatment/day  care/diagnostic procedures for which CGEPHIS  beneficiary  is  admitted  from  the  time  of  admission  to discharge  including  (but  not  limited  to)  Registration  charges, Admission  charges,  Accommodation  charges  including  Patients diet,  Operation  Charges,  Injection  charges, dressing  charges, Doctors/ Consultant visit charges, ICU/ICCU charges, Monitoring charges, Transfusion charges, Anesthesia charges, Pre anesthetic checkups, Operation Theater charges, Procedural Charges / Surgeon  charges,  Cost  of  surgical  disposables  and sundries  used  during  hospitalization,  Cost  of  Medicines  and Drugs,  Blood,  Oxygen  etc,  Related  routine  and  essential diagnostic  investigations,  Physiotherapy  charges  etc,  Nursing care  and  charges  for  its  services.  The  list  is  an  illustrative  one only.
 
b)  In  order to remove the scope of any ambiguity on  the  point  of package  rates,  it  is  reiterated  that  the  package  rate  for  a particular  procedure  is  inclusive  of  all  sub-procedures  and  all related  procedures  to  complete  the  treatment  procedure.  The patient  shall  not  be  asked  to  bear  the  cost  of  any  such procedure/item.
 
c)  No additional charge on account of extended period of stay shall be  allowed,  if,  the  extension  is  due  to  infection  on  the consequences  of  surgical  procedure  or  due  to  any  improper procedure.
 
d)  Cost  of  implants  is  payable  in  addition  to  package  rates  as  per CGHS ceiling rates  for defined  implants or as per actual,  in case there is no CGHS prescribed ceiling rates.
 
e)  Cost  of External Equipments  required  for  treatment  as  listed  in CGHS scheme  (Appendix  – A)  is payable  in addition  to package rates as per CGHS ceiling rates  for defined External Equipments or  as  per  actual,  in  case  there  is  no  CGHS  prescribed  ceiling rates.
 
f)  Expenses incurred for treatment of new born baby are separately payable in addition to delivery charges to mother.
 
g)  Package  rates  envisage  duration  of  indoor  treatment  as follows:
 
·  Upto 12 days: for Specialized (super specialty) Treatment.
·  Upto 7 days:   for other Major surgeries.
·  Upto 3 days:   for Laparoscopic surgeries/ Normal delivery.
·  1 day:             for Day Care/ Minor surgeries
 
h)  Entitlements  for  various  types  of  wards:  CGHS  beneficiaries are  entitled  to  facilities  of  private,  semi-private  or  general ward depending  on  their  pay  drawn  in  pay  band/  pension.  These entitlements are amended  from  time to time and the  latest order in  this  regards  needs  to  be  followed.  The  entitlement  is  as follows:-
 
S.No.  – Pay  drawn  in  pay  band/Basic Pension  – Entitlement
1.   Upto Rs. 13,950/-  ………………………………General Ward
2.   Rs. 13,960/- to 19,530/-  ………………………  Semi-Private Ward
3.  Rs. 19,540/- and above  ………………………    Private Ward
 
1. Private ward is defined as a hospital room where single patient is accommodated  and  which  has  an  attached  toilet  (lavatory  and bath). The room should have  furnishings  like wardrobe, dressing table,  bed-side  table,  sofa  set,  carpet,  etc.  as  well  as  a  bed  for attendant.  The room has to be air-conditioned.
2. Semi  Private Ward  is  defined  as  a hospital  room where  two  to three  patients  are accommodated and which has  attached  toilet facilities and necessary furnishings.  
3. General ward is defined as a hall that accommodates four to ten patients. 

NOTE: 
a)  Treatment in higher Category of accommodation than the entitled category is not permissible.
b)  The  package would  cover  the  entire  cost  of  treatment  of  the patient  from  date  of  admission  to  his/  her  discharge  from hospital  and  any  complication while  in  hospital, making  the transaction truly cashless to the patient as per CGHS package rates.
c)  The applicable CGHS rates under the Scheme would be for the policy period and shall not be amended during the currency of the  policy.  Rates  for  such  procedures  which  are  not  in  the CGHS  list,  can  only  be  considered,  if,  finalized  during  the policy period. 
d)  Procedures will be subject to Cashless  services  and  a  pre-authorization procedure, as per Clause – 11.  
e)  Districts may be clubbed under respective State/Zones by the Central  Government  for  the  application  of  CGHS  package rates.
v)  Maintaining the necessary records as required and the Insurer or his  representative/Central  Government/Nodal  Agency  will  have an access to the records of the insured patient. 
vi)  Allowing  the  Insurer or his representative / Central Government / Nodal Agency  to visit, carry out  the  inspection as and deemed fit.
vii)  The  Private  Empanelled  Hospitals/Nursing  Homes/Day  Care Clinics be legally responsible for user authentication. 
viii) Telephone, Fax, Scanner and have atleast 256 KBPS broadband internet connectivity. Each  empanelled  Hospital/Nursing Home/Day Care Clinics shall posses a Personal Computer with 2 smart  card  readers.  These  empanelled  Hospitals/Nursing Homes/Day  Care  Clinics must  have  the  capacity  to  submit  all claims / bills in electronic format to the Bill Clearing Agency and must  also  have  dedicated  equipment,  software  and  connectivity for such electronic submission. NIC concurrence is required.
 
B.  Additional  Benefits  to  be  Provided  by  Empanelled Hospitals/Nursing Homes /Day Care Clinics In addition to the benefits mentioned above, both Empanelled Public and Private  Hospitals/Nursing Homes/Day Care Clinics should  be  in  a position  to  provide  following  additional  benefits  to  the  CGEPHIS beneficiaries:
1)  Free OPD consultation including pre and post hospitalization consultation.
2)  Has  to  display  its  status  of  being  a  preferred  provider  of CGEPHIS  at  the  reception / admission  desks  and  to  keep  the displays  and  other  materials  supplied  by  the  Insurer  for  the ease of beneficiaries, Central Government and Insurer.
3)  Agrees  to provide a separate help desk headed by paramedical for  providing  the  necessary  assistance  round  the  clock  to  the CGEPHIS beneficiary.
C. Delisting of hospitals: Empanelled  Hospitals/Nursing  Homes/Day  Care  Clinics  would  be  de-
listed  by  the  Insurer  from  the  CGEPHIS  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.
 
11. CASHLESS ACCESS SERVICE:

The  Insurer  has  to  ensure  that  all  CGEPHIS members  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  Scheme.  The  service  provided  by  the Insurer  along with  subject  to  responsibilities  of  the  Insurer  as  detailed  in this clause is collectively referred to as the “Cashless Access Service.” The  services  have  to  be  provided  by  the  Empanelled  Hospitals/Nursing Homes/Day  Care  Clinics  to  the  beneficiary  based  on  Photo  Smart  Card authentication  only without  any  delay.  The  beneficiaries  shall  be  provided treatment free of cost for all such ailments covered under the Scheme within the  limits /sub-limits  of  defined  package  rates  and  sum  insured,  i.e.,  not specifically excluded under the scheme.
 
A.  Pre-Authorization  for  Cashless  Access  in  case  of Emergency/Planned  Hospitalization  for  Listed  /Non  Listed  packaged procedures: 
Packaged procedures would mean the rates for various procedures approved by  the CGHS  based  on  city  and  the  same  shall  be  treated  for  that State/Zone.  It would  be  the  responsibility  of  the  Insurer  to  have  all  empanelled hospitals/nursing homes/ day care clinics agreed to the same. Once  the  identity  of  the  beneficiary  and/  or  his/her  family  member  is established by verifying the Photo Smart Card, shall be swiped Photo Smart Card  for  on  line  verification and    following procedure  shall be  followed  for providing the health care facility listed/not listed in packages:
 
Request  for  Authorization  shall  be  forwarded  by  the  Empanelled Hospitals/Nursing Homes/Day Care Clinics after obtaining due details from the treating doctor in the prescribed format i.e. “Request for Authorization Letter”  (RAL).  The  RAL  needs  to  electronically  send  to  the  24-hour Authorization  /Cashless  department  of  the  Insurer  along  with  contact details of treating physician, as it would ease the process. The medical team of Insurer would get in touch with treating physician, if necessary.
 
a.  The  RAL  (Request  for  Authorization  Letter)  should  reach  the Authorization Department of Insurer within 6 hrs of admission in case of emergency or within 3 days prior to the expected date of admission, in case of planned admission.
 
b.  In  failure of the above “clause a”, the clarification for the delay needs to be forwarded along with RAL by the Empanelled Hospitals/Nursing Homes/Day Care Clinics.
 
 
c.  Treatment code is required to be selected from the  packaged procedures and mentioned in RAL in case of listed procedure.
 
d.  The RAL form should be dully  filled  in  all  cases  with  clearly mentioned Yes or No. There should be no nil, or blanks, which will help in providing the outcome at the earliest. Along with RAL copies of diagnostic  test  reports should also be  forwarded electronically or  the case may be.
 
e. If, given medical data is not sufficient for the medical team of Authorization Department to confirm the eligibility, it will  be responsibility of  the Empanelled Hospitals/Nursing Homes/Day Care Clinics  to  provide  the  complete  details  without  any  further  delay, failing which it would be treated as violation of the norms. 
 
f.  In  case  of  non  listed  procedure,  the  Empanelled  Hospitals/Nursing Homes/Day  Care  Clinics  and  Insurer  shall  negotiate  the  cost  of package based on  the  type of  treatment required;  the agreed amount shall become a package rate of that procedure.
 
g.  Insurer  guarantees  payment  only  after  receipt  of  RAL  and  the necessary medical details. Only after Insurer has ascertained the rates as  per CGHS  prescribed  rates  and  or negotiated  the  packages  (if no rates are fixed by CGHS), with provider, shall  issue the Authorization Letter  (AL). This  shall be  completed within 12 hours of  receiving  the RAL and response shall be sent by the insurer.
 
h.  In case the ailment is not covered, insurer can deny the authorization. In  such  case  it  would  be  the  responsibility  of  the  Empanelled Hospitals / Nursing Homes/Day Care Clinics  to  inform  the beneficiary accordingly.
 
i.  The  Insurer needs to file a report to Nodal Agency explaining reasons for denial of every such claim on day to day basis.
 
j.  Authorization  letter  [AL] will mention  the  authorization  number  and the amount guaranteed as a CGHS package rates and negotiated rates for  such  procedure for which package has  not  been  fixed  earlier. Empanelled  Hospitals / Nursing  Homes/Day  Care  Clinics  must  see that these rules are strictly followed.
 
k. The guarantee of payment is given only for the necessary  treatment covered and mentioned in the  request  for Authorization letter (RAL) for hospitalization.
 
l.  The entry on the Smart Card at the time o  admission  as  well  at discharge would record  the authorization number as well as package amount  for  listed  procedure  and  agreed  package  amount  by  the Empanelled Hospitals/Nursing Homes/Day Care Clinics and  Insurer in case of non listed procedure. Negotiated package would be entered manually  by  the  hospital  since  this  would  not  be  available  in  the package list on the computer.
 
m. Having  carried  out  these  activities,  the  insurer  shall  have  to  ensure that  all data are uploaded  on  the  insured’s  server  and  a  read-only access shall be provided, through a link, to the officials / departments as may be authorized by the MoHFW. 
B. Business Contingency Plan (BCP) (Off Line Procedure)
In the event on-line system becoming inoperative for any reason, the insurer shall resort to the Business Contingency Plan by default (BCP).
On visit  to an Empanelled Hospitals/Nursing Homes/Day Care Clinics,  the beneficiary’s details shall  be  verified.  Once  the  identity  of  the  beneficiary and/ or his/her  family member  is established by verifying the Photo Smart Card  manually  (Xerox  copy  of  the  Smart  Card  shall  be  kept  by  the Empanelled  Hospitals/Nursing  Homes/Day  Care  Clinics  for  record purpose) following procedure shall be followed for providing the health care facility  listed/not  listed  in packages  in addition  to procedure envisaged at
 
a.  A  manual  pre-authorization  form  filled  up  and  faxed  to  Insurer within 6 hours of admission along with copy of diagnostic reports.
 
b.  The same shall be authorized within a turnaround time of not more than 12 hours.
 
c.  Cashless  treatment  shall  be  given  accordingly,  without  charging any money from the beneficiary.

d.  On completion of treatment discharge documents are signed. 

e.  Having carried out these activities, the insurer shall have to ensure that all data are uploaded on the  insured’s server and a read-only access  shall  be  provided,  through  a  link,  to  the  officials  /departments as may be authorized by the MoHFW. 

Note: 
In cases where  the beneficiary  is admitted  in a hospital during  the current policy period but  is discharged after  the end of  the policy period,  the claim has  to be paid by  the  insurance  company under operating policy  in which beneficiary was admitted
 
12. RUN-OFF PERIOD

A  Run-Off  period  of  one  month  will  be  allowed  in  case  of cancellation/  non  renewal  of  the  policy.  This  means  that preauthorization’s  done  till  the  cancellation/  non  renewal  of  the  policy period and  treatment/surgeries  for such preauthorization’s done up  to one month after the expiry of policy period,  all such claims will be honored.
                                               
14. REPUDIATION OF CLAIMS
 
In  case  of  any  claim  is  found  untenable,  the  Insurer  shall  communicate reasons  to  the Health  provider  and Designated  Authority  of  the Central  / Nodal  Agency  for  this  purpose  with  a  copy  to  the  Beneficiary.    All  such claims shall be reviewed by the Central Government on monthly /quarterly basis.
 
 
15. ENROLMENT:
The  enrolment  of  the  beneficiaries would  be  undertaken  by  the  Insurance Company selected by Central Government/Nodal Agency.  The Insurer shall enroll  the beneficiaries as per procedure  laid down below    and  shall  issue Photo Smart cards as per Central Government specifications and handover the same to the CGEPHIS beneficiaries.
 
(a)  The enrolment period  in  the  first year shall be  for 180 days  in the  case  of  retired  employees  and  60  days  in  case  of  serving employee. However, in the case of new joinees and new retirees the enrolment will continue throughout the year.

(b)  Insured  will  have  the  option  to  change  the  details  regarding dependent beneficiary  in  the smart card; however  the  total number of dependents cannot be more than the number fixed at the time of renewal at designated district Kiosk setup by  the  insurer within 60 days prior to the expiry period of the policy.

(c)  The Insurer will arrange for preparation of the Photo Smart Card as per the Guidelines provided.  
 
(d)  At  the  time of delivering the smart card, the  Insurer shall provide a booklet  along  with  Photo  Smart  Card  to  the  CGEPHIS  beneficiary indicating  the  list  of  the  Networked  Hospitals,  the  availability  of benefits and  the names  and  details  of  the  contact person/persons, and toll-free number of call centre.  To prevent damage to the smart card, a plastic jacket should be provided to keep the smart card.

(e)  If the smart card is lost within the policy period then beneficiary can get a new card issued at the designated District Kiosk, by paying to the  insurer, a pre-defined  fee agreed by Central government / Nodal Agency.

(f)  To address  the problems of  incorrectness,  functionality of cards etc and enrolment could not be done by  the beneficiary  for any reason; the same would be done at designated district kiosk by the insurer. 

(g)  Advance  publicity  shall  be  given  by  the  Insurer  and  Central Government/Nodal Agency on Pan India basis.

(h)  Insurance Company would carry out enrolment at agreed designated District  office  of  the  Insurer  in  case  of  Pensioners  and  scan document  will  be  given  for  the  purpose  on  the  spot.  In  case  of Serving  Employees  the  data  will  be  collected  from  Head  of Department  level.  In both  the  cases photo Smart Cards along with the  enrollment  kit  shall  be  sent  by  the  insurers  directly  to  the insured  persons  at  their  respective mailing  addresses  at  insurer’s cost.
(i)  Insurance Company will also provide a web-based application, which would  be  available  to  Head  of  Departments  of  the Ministries/Departments.  The  empanelled  Hospitals/Nursing
Homes/Day Care Clinics and the beneficiaries shall have the access to the website to see their relevant information.

(j)  Nodal Agency at the Health Ministry will also monitor data related to Insurance plan like enrolment etc through this website.

(k)  The Scheme as well as  the enrolment  form would be put up on  the web-site  of  the  various  Ministries/Departments  on  a  permanent basis.
 
(l)  Any Employee / Pensioner who opts for the Insurance Scheme shall remain  the  member  of  the  scheme  with  future  renewals automatically  awarded  unless  he/she  opts  out  of  the  scheme.  The beneficiary is required to submit the declaration to the MOH&FW for discontinuation from the Scheme 90 days prior to expiry of the policy.  In  such  cases  the  benefits  shall  cease  on  the  expiry  of  the policy.

ENROLMENT PROCESS 
The process of enrolment shall be as under:
 
A. Serving Employees: 
1.  Departments  and  offices  will  call  for  options  from  employees  to  join voluntary CGEPHIS with or without existing CGHS/CS (MA) benefits. 
2.  Head of Department of the Administrative Ministry/Department would be the contact point for the Insurance Companies. 
3.  Enrolment forms giving details about self and family and authorization to  the department  for  recovery of premium on a monthly basis would be consolidated by  the Administrative Ministry/Department. The data of  the beneficiary and dependent members  to be covered along with 2 recent  passport  size  photo  and  copy  of  enrolment  form  will  be forwarded to Insurance Company on monthly basis. 
4.  Insurance Company will issue Smart Cards on the basis of information received of the beneficiaries for enrolment.
5.  Such Smart Cards along with  the enrollment kit shall be sent by  the insurers  directly  to  the  insured  persons  at  their  respective  mailing addresses at insurer’s cost within 7 days. 
 
B. Retired Employees:
1.  In case of Retired Employees, wide publicity of the Scheme should be given  through  various  media  sources  like  advertisement  in  local newspapers, Cable network etc.  

2.  A  notice  would  be  posted  in  the  pension  paying  branches (approximately  30,000  in  numbers)  /  post  offices  giving  details  of proposed Scheme.   
 
3.  Information can also be disseminated through pensioners associations and other related agencies.  

4.  Enrolment  forms  would  be  made  available  with  Pension  Paying Branches/ Post Offices as well as on the website of the Departments/ Ministries.

5.  The  enrolment  process  for  the  pensioners  shall  continue  as  per schedule  agreed  by  the  Government/Nodal  Agency.  Insurer  in consultation with  the Central Government/Nodal Agency /shall chalk out  the  enrolment  programme  by  identifying  enrolment  stations  at Insurers  district  offices  during  fixed  period  to  complete  the  task  in scheduled time.

6.  Retired employees opting  for  the  scheme would  fill up  the enrolment form giving details relating to self and dependent members along with the  proof  of  self  and  dependents  as  per CGEPHIS Guide  Line  along with 2 recent passport size photos each at Insurers district offices for
enrolment under the scheme along with his /her first contribution by cheque only. 

7.  The  enrolment  form would be accompanied by authorisation  form  to the  pension  paying  agency  to  debit  contribution  of  his/her  future premium for the purpose of continuing as a member of the Insurance Scheme. 

8.  Insurance  companies  will  issue  scanned  Photo  document  to pensioners  on  the  basis  of  information  received  at  the  time  of enrolment  of  the  beneficiaries.  Photo  Smart  Cards  along  with  the enrollment  kit  shall  be  sent  by  the  insurers  directly  to  the  insured persons at their respective mailing addresses at insurer’s cost.

9.  Copy  of  enrolment  form  along with  the  authorization  form would  be sent  to  Central  Pension  Accounting  Office  for  preparation  of  the data. Central Pension Accounting Office will pass on the authorization form  of  the  pensioners  to  the  respective  pension  paying  units  for deduction of premium for future renewals.
 
10. Limited  access  to  the  database  available  with  the  Central  Pension Accounting  Office/  MOHFW  would  be  available  to  the  Insurance Company.
 
B.  For Future Employees and Pensioners:
 
a.  All  future  employees  and  future  pensioners  shall  necessarily  be covered under CGEPHIS. 
b.  At  the  time  of  their  entry  into  or  retiring  from  service  they  are required  to  carry  out  certain  documentary  formalities  at  their respective  places  of  posting  and  the  ministry.  Enrollment  into CGEPHIS  shall  be  dovetailed  to  such  activities  and  the documentation  for  the same shall be made an  integral part of  the entry / exit exercise. 
c.  The  insurer shall have to provide enrolment forms  (printed as well as soft versions) at all such locations.
d.  Employee shall fill up form enrolment form, authorization form for deducting  the  contribution  and  submit  2  resent  passport  size photographs of the family each (individual) to DDO/ Nodal Officer.
e.  Insurer  shall  arrange  to  collect  the  enrolment  form  &  family photograph  from  the  respective  DDOs/  Nodal  Officers  under acknowledgement. 
f.  After  required  processing,  all  relevant  data  shall  be  uploaded  on the server and smart cards shall be issued by the insurers. 
g.  Such  Smart Cards  along with  the  enrolment  kit  shall  be  sent  by the  insurers  directly  to  the  insured  persons  at  their  respective mailing addresses at insurer’s cost. 
h.  The  insurance  cover  shall  be  effective  from  the  date  of  joining  or retirement of an employee. 
i.  All  these  activities  shall  have  to  be  uploaded  on  the  insured’s server  on  a  read-only  access,  a  link,  shall  be  provided  to  the officials / departments as may be authorized by the MoHFW.
Note:  The  Insurer  will  have  to  complete  the  following  activities
before the start of the enrollment process:
 
·  Empanelment  of  the  Hospitals/Nursing  Homes/Day  Care Clinics
·  Setting up of District Kiosk
·  Prepare  the  enrollment  kit  and  get  it  approved  by  the Government.
 
16.  SPECIFICATIONS  FOR  SMART  CARDS  AND  SOFTWARE:  NIC concurrence is required.
 
The  Smart  Cards  to  be  used must  have  the  valid  Compliance  Certificate from National Informatics Centre, New Delhi. The specifications of the smart card are listed as below. 
 
·  Microprocessor based Integrated Circuit(s) card with Contacts, with
minimum 64 Kbytes available EEPROM.

·  Compliant with ISO/IEC 7816-1,2,3 and SCOSTA 1.2b/SCOSTA-
CL  1.2  with  all  latest  errata  and  addendum  (ref. http://scosta.gov.in).

·  Must have a  valid SCOSTA or SCOSTA-CL Compliance Certificate from NIC. 

·  Supply Voltage 3V or 5V – nominal.

·  Protocol T=0 or T=1.

·  Data Retention minimum 10 years.

·  Write cycles minimum 300,000 numbers.

·  Chip Temperature Range –25 to +70 Degree Celsius.

·  Operating Temperature Range –25 to +55 Degree Celsius.

·  Composite  layered  Construction  of  PETG  (middle  layer)  and  PVC (outer layers). Ratio of PETG and PVC content should be 50% each.

·  Surface  –  Glossy  with  pre  printed  content  as  provided  by Department.
a.  Smart Card shall be the property of the Central Government and shall be insurer-neutral. The insurer shall have no proprietary rights over it and, therefore, shall not be entitled to place its name, logo etc. on the same.  
 
b.  The  Smart  Card  Chip  Memory  File  System  and  Layout  shall  be provided by MoH/NIC.

c.  The  Smart  Card  Visual  Zone  layout  shall  be  designed  by  the short listed bidder and approved by MoH. 

d.  Insurer    shall  provide  following  Smart  Card  related  software  and services,

i.  Smart Card Sourcing as per the specifications given above.
ii.  Smart Card Personalization as per the Layout provided by MoH.
iii.  Smart Card  Key Management  System  as  per MoH/NIC wetted architecture.  
iv.  Developing  all  Smart  Card  based  Transaction  applications  as per MoH/NIC wetted architecture. 
e.  The  card  shall  universal  acceptability,  across  the  country,  by  all empanelled  hospitals  /  nursing  homes/Day  care  clinics  in  the insurer’s panel. 
f.  To address  the problems of  incorrectness and  functionality of  cards, the insurers shall be required to open kiosks in all major cities as may be advised by the MoHFW.
g.  Preparation of transaction systems, mechanism for data transfer, and establishment of district kiosks and uploading of MIS on the websites advised by the MoHFW shall be the responsibility of the insurer.
 
17. EXCLUSIONS 
 
The  Insurer shall not be  liable  to make any payment under this Scheme  in respect  of  any  expenses  whatsoever  incurred  in  connection  with  or  in respect of:
A. Hospitalization Benefits:
1)  Conditions that do not require hospitalization: 
a)  Condition  that  do  not  require  hospitalization.  Outpatient Diagnostic, Medical  and Surgical  procedures or  treatments unless necessary  for  treatment  of  a  disease  covered  under  Day  Care
procedures or Inpatient hospitalization. 
 
b)  Expenses  incurred  at  Hospital  or  Nursing  Home  primarily  for evaluation  /  diagnostic  purposes  only  during  the  hospitalized period.  Expenses  on  vitamins  and  tonics  etc  unless  forming  part  of treatment for injury or disease as certified by the attending physician. Expenses on telephone, tonics, cosmetics / toiletries, etc.
 
2.  Any dental treatment or surgery which is corrective, cosmetic or of aesthetic  procedure,  including  wears  and  tears  etc.  unless  arising from  disease  or  injury  which  requires  hospitalization  for  treatment including  following  dental  treatment which  indicates  that  the  teeth  are the real source of disturbance. 
 
a)  Jaw bone disease treatment 
b)  Wholesale removal of teeth
c)  Surgical  operations  needed  for  removal  of  Odontomes  and impacted wisdom tooth
d)  Gum boils under oral surgery.
e)  Treatment  of  pyorrhea  and  Gingivitis  may  also  be reimbursed  as  it  is  covered  under  the  term  “Gum treatment”.
f)  Extraction,
g)  Scaling and Gum treatment
h)  Filling of teeth
i)  Root Canal treatment.
 
3)  Congenital  external  diseases  etc:  Congenital  External  Diseases  or Defects  or  Anomalies,  Convalescence,  General  Debility,  “Run  Down” condition or Rest Cure.
 
4)   Sex change or treatment which results from or is in any way related to sex change.
 
5)  Vaccination/Cosmetic  or  of  aesthetic  treatment:  Vaccination, Inoculation  or  change  of  life  or  cosmetic  or  of  aesthetic  treatment  of  any description and Plastic Surgery other than as may be necessitated due to an accident or as a part of any illness. Cost of Spectacles / Contact Lens.
 
6) Suicide etc: Intentional self-injury/Suicide/Self manmade injuries.
 
7) Naturopathy, Homeopathy, Unani, Siddha, Ayurveda: 
 
a)  Homeopathy,  Unani,  Siddha,  Ayurveda  treatment  unless  taken  as inpatient in a network hospital. 
 
b)  Naturopathy,  unproven  procedure  or  treatment,  experimental  or alternative  medicine  including  acupressure,  acupuncture,  magnetic and such other  therapies etc. Any  treatment received  in convalescent home,  convalescent  hospital,  health  hydro,  nature  care  clinic  or
similar establishments.
 
8)  External and/or durable Medical/Non-medical equipment of any kind used  for  diagnosis  and/or  treatment  except  covered  under  CGHS scheme.
                  
B. Maternity Benefit Exclusion Clauses:
 
a.  Those  insured  persons  who  are  already  having  two  or  more  living children will not be  eligible  for  this benefit. Claim  in  respect  of  only first  two  living  children  will  be  considered  in  respect  of  any  one insured  person  covered  under  the  policy  or  any  renewal  thereof.  In such situation any such child born during the policy period, the same shall be covered as an additional member at the time of renewal only.
 
b.  Expenses  incurred  in  connection with  voluntary medical  termination of pregnancy during the first twelve weeks from the date of conception are  not  covered  except  induced  by  accident  or  other  medical emergency to save the life of mother.

c.  Pre-natal and post-natal expenses are not covered unless admitted in Hospital/nursing home and treatment is taken there. 
 
18. INFRASTRUCTURE OF INSURER

Insurer shall establish an exclusive Project Office at convenient place for coordination with the Central Government/Nodal agency at the National level.  The  project  office  shall  coordinate  with  Central  Government/Nodal 
 
Agency  on  a  daily  basis  and  ensure  effective  implementation  of  CGEPHI Scheme.  Accordingly,  Insurer  will  also  have  the  dedicated  unit  at Zonal/State and district level.
 
The Project Manager shall be appointed within 7 days and the project office shall be placed by the Insurer at New Delhi within 30 days of signing of  the  contract  having  sufficient  people with  appropriate  qualification  and experience to perform various functions.  

19. MANAGEMENT INFORMATION SYSTEMS  (MIS) SERVICE THROUGH
DEDICATED WEBSITE

The  Insurer  shall  provide  Management  Information  System  (MIS)  reports regarding  the  enrolment,  admission,  pre-authorization,  claims  settlement and  such  other  information  regarding  the  Services  as  required  by  the Government/Nodal Agency. The  reports will be submitted by  the  INSURER to  the Government/Nodal Agency on a regular basis as agreed between  the Parties.
 
a)  A dedicated website  for data  sharing purpose  shall be designed by the insurer which shall be having real time data base pertaining to the scheme  implementation  &  servicing.  Persons  having  authority  to access  the data  can  access  the website with user name & password supplied by the insurer.
 
b)  The  information  shall  be  available  on  real  time  basis  on  Insurers Website and shall also be uploaded on central server for MoHFW’s use and  analysis  and  uploading  on  its web  portal.    For  this  purpose  to provide for a Central Govt. Server under MoHFW where real-time data
pertaining  to  District/State  wise  Enrolment  status,  Claims, Treatments  rendered,  Hospitals  Data  etc  can  be  uploaded  by  the Insurance Company  on  periodical  basis. Claims,  Treatment  data  etc shall automatically updated on the Insurer state server as & when the details are punched at Hospital level.
 
c)  Insurer will also upload such data required by MOHFW. 
 
20. CALL CENTER SERVICES

The Insurer  shall provide  dedicated telephone  services  for  the  guidance and   benefit   of    the   CGEHIS beneficiaries whereby   the    Insured  Persons  shall  receive  guidance  about  various  issues  by  dialing  a  National  Toll free   number exclusively  for  this scheme.   This   service   provided  by  the Insurer  as  detailed  below  is  collectively  referred  to  as  the  “Call Centre
Service”.
 
I. Call Centre Information

The Insurer shall operate a Call Centre for the benefit of all Insured  Persons. The Call Centre shall function for 24 hours a day, 7 days  a week  and  round  the year. As a part of the Call  Service  the  Insurer  shall  provide  the  following :
 
a)  Answers    to   queries    related    to   Coverage   and   Benefits   under the  Policy.
b)  Information on Insurer’s office, procedures and information related to CGEPHIS.
c)  General guidance on the CGEPHIS.
d)  Information on   cash-less    treatment   subject    to    the   availability of medical details   required by  he  medical team of  the Insurer.
e)  Information on Network Providers and contact numbers.
f)  Claim status information.
g)  Advising  the  hospital  regarding  the  deficiencies   in  the  documents  for  a  full  claim.
h)  Any other relevant information/related service to the Beneficiaries.
i)  Any  of  the  required  information  available  at  the  Call  Centre to  the  Government/Nodal Agency.
j)  Maintaining  the  data  of  receiving  the  calls  and  response  on  the system.
k)  Any related service to the Government/Nodal Agency.
 
II.  Language
The  Insurer  undertakes  to  provide  services  to  the  Insured  Persons in  English and local languages.
 
III.  Toll Free Number/Fax Number
a)  The    Insurer   will   operate   a   dedicated National Toll Free   number  with a facility  of  a  minimum  of  10 lines.  The  cost  of  operating  of   the   number shall  be  borne  solely  by  the  Insurer.  The  toll free  numbers  will be  restricted  only  to  the  incoming  calls  of  the clients  only.  Outward    facilities    from    those    numbers    will    be barred  to  prevent  misuse.
 
b)  The Insurer will operate a dedicated National Toll Free Fax. The  cost of    operating    of    the    number    shall    be    borne    solely    by    the Insurer.  
 
IV.  Insurer to inform Beneficiaries
The Insurer will intimate the National Toll Free number/Fax number to all beneficiaries  along with  addresses and  other  telephone numbers  of  the Insurer’s City units / Zonal units and Project Office. 
21. DISPUTE RESOLUTION AND GRIEVANCE REDRESSAL
 
If any dispute arises between  the parties during the subsistence of  the policy  period  or  thereafter,  in  connection  with  the  validity,  interpretation, implementation or alleged breach of any provision of  the scheme,  it will be settled in the following way:

a.  Dispute between Beneficiary and Health Care Provider/Care Provider and the Insurance Company: Grievance Redressal centre shall be set up in each District/State level for all possible  redressal  of  grievance  of  beneficiaries/Health  provider  by  the Insurer. 

b.  Dispute between Insurance Company and the Central Government A  dispute  between  the Central Government  /Nodal  Agency  and  Insurance Company shall be referred to the respective Chairmen/ CEO’s/CMD’s of the Insurer  for resolution.  In the event that the Chairmen/ CEO’s / CMD’s are unable  to resolve  the dispute within  {60  } days of  it being referred to  them, then  either  Party may  refer  the  dispute  for  resolution  to  a  sole  arbitrator who  shall  be  jointly  appointed  by  both  parties,  or,  in  the  event  that  the parties are unable to agree on the person to act as the sole arbitrator within {30 } days after any party has claimed for an arbitration in written form, by three arbitrators, one  to be appointed by each party with power  to  the  two arbitrators so appointed, to appoint a third arbitrator.
·  The  law  governing  the  arbitration  shall  be  the  Arbitration  and Conciliation Act, 1996 as amended or re-enacted from time to time.
·  The  proceedings  of  arbitration  shall  be  conducted  in  the  English language.
·  The arbitration shall be held in New Delhi, India.

22. AGREEMENTS:
a)  Service Level Agreements (SLAs)/MOUs shall be signed with Insurance Companies  and  proper  mechanism  for  ensuring  compliance established including penalty clauses.
b)  Insurer will also enter  into SLAs/MOUs with other  intermediaries  for ensuring compliance established including penalty clauses.
 
23.  TERM  &  TERMINATION  OF  AGREEMENT  BETWEEN  INSURER  &
CENTRAL GOVERNMENT

 
The  Agreement  shall  take  effect  on  the  date  of  signature  hereof  by  both Parties, and  shall  remain  in  force  till  the  end  of  the policy period  and  the runoff period subject to a right to the Central Government to terminate the Agreement, on the basis of review of the performance of the INSURER before the same period. The Central Government will review the performance of the INSURER based on factors including but not limited to:
a)  Compliance with the guidelines specified in respect of enrolment & transaction.
b)  The  facilities  set  up  and  arrangements  made  by  the  INSURER toward  servicing  the  beneficiaries  such  as  quality  assurance, handling  of  grievances,  availability  of  benefits  and  hassle  free transactions etc agreed to between stakeholders.
c)  Empanelment of Hospitals/ Nursing Homes/Day Care Clinics.
d)  The quality of service provided.
e)  The beneficiaries’ satisfaction reports received. 
f)  Grievance Redressal. 
g)  Any  withholding  of  information  as  sought  by  the  Central Government  at  the  bidding  and  implementation  stage  of  the Scheme; and
h)  Such other factors as the Central Government deems fit.

The Agreement may be terminated:
a)  By the Central Government before the period mentioned above.
b)  By both parties by mutual consent provided it gives the other party at least 60 days prior written notice.

In case of termination as given above:
a.  The  Insurer will  pay  back  to  the Central Government within  one week  the unutilized amount of premium  left plus service  tax after settlement of claims for which the preauthorization is given till date of termination.
b.  If  the  insurer  fails  to do as per clause above,  the  insurer will pay the Central Government, the total package amount for all the cases for which preauthorization has been given, but claim not settled. 
 
c.  In  addition  to  above  the  Insurer  shall  pay  interest  at  the  rate  of 12%  per  annum  on  the  amount  refundable  as  determined  by clauses  (a) and  (b) above  for the period extending  from the date of premium paid till the date of receipt of refund.
 
d.  The Central Government reserves  the right  to re-allot the policy  to any  other  insurer as  it deems  fit  for  the  rest  of  the period  in  the event of  termination and  the  Insurer shall not have any claims  to it.
 
24. PERFORMANCE PARAMETERS AND PENALTY CLAUSE:
 
Insurer  is  required  to  perform  multiple  activities  in  performance  of  their obligations arising  out  of  the  insurance  contract  to  them. Any  activity not performed  by  the  insurer  within  the  given  time  line  shall  hamper implementation of CGEPHIS  from  the planned date. Such activities will be required to be completed within the specified period from the date of award of  the insurance  contract  to  them  failing  which  a  penalty  as  specified percentage on total premium shall be payable by them to the Govt. of India for the period of delay. 
 
25. NODAL MINISTRY:
 
a)  The Ministry of Health & Family Welfare would be  the Nodal Agency for the implementation of CGEPHIS.
 
b)  A Coordination Committee having the representatives from Ministry of Health  &  Family  Welfare,  Ministry  of  Finance  and  Department  of Administrative  Reforms  &  Public Grievances  for  monitoring  the implementation of the Scheme on a regular basis.
 
c)  Nodal Cell at  the Health Ministry will monitor data  related  plan  like enrolment,  empanelment  of  hospitals,  authorization  status,  claims status,  utilization  statistics,  network  hospital  status  and  other MIS through  a website maintained by the Insurer.
 
 
26. MEDICAL AUDIT:
 
The  Insurance  Company  shall  also  carry  out  inspection  of  hospitals, investigations,  on  the  spot  verification  of  inpatient  admissions,  periodic medical  audits,  to  ensure  proper  care  and  counselling  for  the  patient  at network  hospital  by  coordinating with  hospital  authorities,  feedback  from patients,  attend  to  complaints  from  beneficiaries,  hospitals  etc  on  regular basis. Proper records of all such activities shall be maintained electronically by the Insurer.

36 thoughts on “CENTRAL GOVERNEMENT EMPLOYEES AND PENSIONERS HEALTH ISNURANCE SCHEME”

  1. sir,
    i’m a consultant pathologist running a pathology diagnostic lab. i would like to register myself in the CGHS PROGRAMME, please forward me the guidelines for application.

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