This Agreement made by and between

TATA AIG GENERAL INSURANCE COMPANY LIMITED, a company incorporated under

the Companies Act 1956 and having its registered office at Peninsula Business Park, Tower
‘A’, 15th Floor, G K Marg, Lower Parel, Mumbai - 400013 and its branch office at
______________________________________, Hyderabad. (hereinafter referred to as
‘Insurer’) of the FIRST PART;

And

____________________________________________, a ________ incorporated/registered

under the ____________ and having its registered office at _________________ and its
branch office at ______________________________________. (hereinafter referred to as
‘Hospital’) of the SECOND PART;

‘The Insurer’, and ‘Hospital’ are individually referred to as a ‘Party’ or ‘party’ and
collectively as ‘Parties’ or ‘parties’).

WHEREAS Tata AIG is an insurance company registered under the applicable provisions of
the Insurance Act, 1938 for carrying on general insurance business;

WHEREAS the Hospital is a health care provider duly recognized and authorized by
appropriate authorities to impart heath care services to the public at large;

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AND WHEREAS the Hospital/Network Provider has expressed its desire to join Insurer's
network of Hospitals and has represented that it has the requisite capabilities, infrastructure
and facilities to extend medical facilities and treatment to the Beneficiaries as covered under
the Policy on the terms and conditions herein agreed;

AND WHEREAS the Hospital / Network Provider has expressed its desire to be on panel of
the Insurer for providing the necessary treatment to the beneficiaries of Insurer directly for
availing the cashless and claims adjudication service and based on the representations of
the Hospital / Network Provider, the Insurer / has agreed to empanel the Hospital / Network
provider for referring the complete health services.

NOW IT IS HEREBY AGREED BY AND BETWEEN THE PARTIES AS FOLLOWS:

ARTICLE 1: DEFINITIONS AND INTERPRETATION

1. A Definitions: In this Agreement unless inconsistent with, or otherwise indicated by the

context, the following terms shall have the meanings assigned to them hereunder, namely:

a. ‘Beneficiary (ies)’ shall mean and include the Insured Person(s) that are covered
under the Health Insurance Policy issued by the Insurer.

b. ‘Cashless Facility’ means a facility extended by the Insurer or TPA on behalf of the
insurer to the Policy Holder(s) where the payment(s) for the cost of treatment
undergone by the Policy Holder(s) in accordance with the Policy (defined
hereinafter) terms and conditions, are directly to be made to the Network Provider
by the Insurer to the extent Pre- Authorization is approved.

c. ‘Health Services’ shall mean all services necessary or required to be rendered

by the Hospital under the agreement with Insurer in connection with ‘health
insurance business’ or ‘health cover’ as defined in regulation 2(f) of the IRDAI
(Registration of Indian Insurance Companies) Regulations, 2000 and modifications
thereto but does not include the business of an insurer and or an insurance
intermediary or an insurance agent.

d. ‘Hospital / Network Provider’ shall mean the hospital enlisted by the Insurer, a TPA
or jointly by an Insurer and a TPA to provide medical services to an insured by a
cashless facility.

e. ‘Identification Card / Cashless Card’ shall mean the Identification Card for the
Beneficiaries issued to enable them to obtain cashless services wherever
applicable under the Policy.

f. ‘IRDAI / Authority’ shall mean the Insurance Regulatory and Development Authority
of India established under sub–section (1) of section 3 of the Insurance Regulatory
and Development Authority Act 1999.

g. ‘Law’ includes all statutes, enactments, acts of legislature, laws, ordinances, rules,
bye laws, clauses, regulations, notifications, Circulars, guidelines, policies and
orders of any statutory authority or court of India.

h. ‘Policy’ shall mean the Health Insurance Policy of the Insurer issued to the
Beneficiary and to be serviced by the Insurer.

i. ‘Policyholder’ shall mean the person in whose name the Policy has been issued by
the Insurer and who has paid the premium to the Insurer on behalf of the
Beneficiary(ies).

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 j. ‘Third Party Administrator’ (TPA) means a company registered with the authority and
engaged by an Insurer, for a fee by whatever name called and as may be
mentioned in the health service agreement for providing health services as
mentioned by the regulator.

1. B Interpretation: In this Agreement, unless the context otherwise requires:

a. The masculine gender includes the other two genders and vice versa;

b. The singular includes the plural and vice versa;

c. Natural persons include created entities (corporate/incorporate) and

vice versa;

d. Marginal notes or headings to clauses are for reference purposes only

and do not bear upon the interpretation of this Agreement.

e. Should any condition mentioned herein, contain a substantive

condition, then such substantive condition shall be valid and binding
on all the Parties notwithstanding the fact that it is embodied in the
Definitions clause.

ARTICLE 2: TERM

a. Unless otherwise agreed in writing signed by authorized representatives of the

Parties, or Terminated in accordance with Article-17 of the present agreement this
Agreement shall continue in perpetuity from___________.

b. Any new network provider that is or may in future be owned or managed by the
Hospital after the date of this Agreement may be added to the list of Hospitals by
way of an addendum to this agreement.

c. Insurer shall have the right to avail similar services as contemplated herein from
other Hospitals/Network Providers for the Services covered under this Agreement.

d. The hospital shall extend cashless facility to the insured members of the Insurer
either by sending pre-authorization request to Insurer directly or to the TPAs of the
Insurer with whom the insurer has agreement.

e. The list of servicing TPAs to whom the cashless requests may be sent shall be
communicated to the hospital by Insurer from time to time.

ARTICLE 3: SCOPE OF SERVICES AND GENERAL OBLIGATIONS

a. Hospital undertakes to provide the medical services in a precise, reliable and

professional manner to the satisfaction of the Insurer and in accordance with the
applicable legal, regulatory and ethical obligations and in accordance with additional
instructions issued by Insurer in writing from time to time.

b. The Hospital shall treat the beneficiaries of the Insurer according to good and
acceptable business practice. It shall equip itself with qualified and experienced
doctors, medical and Para–medical staff, nurses etc, and also other infrastructure
essential to maintain the desired quality and standard of medication at all times.
Hospital shall also ensure to possess all the requisite compliances at all the time.
The Insurer shall not be responsible for any such lapse on part of the Hospital.

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c. The Hospital shall provide medically necessary Health Services as may be required
by the Beneficiary admitted to the Hospital on Cashless basis in pursuance of terms
and conditions of this Agreement and shall follow its standard procedures for
admission of Beneficiaries and their standard protocols for providing necessary care
to the Beneficiaries.

d. The Hospital shall provide the following services as its main operations (inclusion /
exclusion may vary) for each hospital:

i. Inpatient / Outpatient treatment to general public

ii. Day care procedures
iii. Preventive health check-ups
iv. Other curative treatments
v. Pharmacy
vi. Other medical or paramedical services.
vii. Ambulance Service
viii. Any other feature mentioned in the policy
e. Hospital shall treat the Beneficiaries according to acceptable clinical protocols

f. Hospital shall extend priority admission facilities to the Beneficiaries.

g. Hospital shall not discriminate any Beneficiary in rendering or providing agreed

Health Services and offers to extend the kind or type of services, which a
Beneficiary is entitled as per the Policy terms and conditions.

h. Hospital shall not under any circumstances suggest or recommend or inform the
Beneficiary approaching the Hospital for Cashless Service, that he/she may opt for
Medical Reimbursement either in lieu of or in addition to cashless facility extended
by the Insurer without the knowledge and written consent of the Insurer.

i. The Hospital shall allow the officials of Insurer or the TPA extending cashless to visit
the Beneficiary without interfering in the line of treatment. However Insurer or TPA
Executive shall have the right to discuss the treatment plan with treating doctor,
verifying the hospital records including patient running bill and wherever possible
and feasible speak to the patient or relatives of the patients in the process of
admissibility of the liability under the policy. Further access to review/check the
medical treatment records and bills prepared in the Hospital will be allowed to
Insurer on a case to case.

j. The Hospital will convey to its medical consultants to keep the Beneficiary only for
the required number of days of treatment and carry only the required investigation
and treatment for the ailment for which he/she is admitted. Any other incidental
investigation required by the Beneficiary on his request needs to be approved
separately by Insurer and if it is not covered under the Policy it will not be paid by
Insurer and the Hospital needs to recover it from the Beneficiary. In all such cases,
the Hospital will have to inform the Beneficiary that he will have to bear the cost of
the same. Hospital shall not protest against any such payment that has been
withheld by the Insurer on this account or deny the Cash Less Access to other
policyholders.

k. The Hospital shall also endeavour to comply with future requirements of Insurer to
facilitate better services to Beneficiaries, e.g. providing for standardized billing, ICD
coding, etc. If there is any statutory requirement mandated by any
Government/authority, then all the Parties shall comply with the same.

l. The Hospital agrees to have bills and processes audited on a case to case basis as
and when necessary through the audit team of the Insurer or Insurer representative
deputed by Insurer. Such visit of the Insurer may be by giving a short notice or

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 without any prior notice or information to the hospital.

m. The Hospital shall endeavour to have an officer in the administration department

assigned for insurance/contractual requirements about the various types of medical
benefits offered under the different insurance plans.

n. The Hospital shall at all times during the course of this Agreement maintain a
dedicated Helpdesk to manage all Beneficiaries which is easily accessible to
Beneficiaries. For the ease of the Beneficiary, the Hospital shall display their
recognition as preferred Network Provider of Insurer in respect of the Policy and
promotional material, network status and the procedures for admission supplied by
the insurer at prominent location, including but not limited to outside the Hospital, at
the Helpdesk, at the reception, admission counter and Casualty/ Emergency
departments. The format for the signage outside the Hospital and at the reception
counter shall be provided by the insurer. The Helpdesk shall install dedicated staff
at their reception and admission facilities for aiding in the admission procedures for
Beneficiaries of the Policy within fifteen (15) days of execution of this Agreement.
The Helpdesk shall make available the following:

i. Registration Certificate of the Hospital from Local authority wherever

applicable
ii. Facility of telephone
iii. Personal Computer, Printer and Fax machine
iv. Internet / Any other connectivity to the insurer Server
v. Trained Staff to man the Helpdesk at all times. Training should be
imparted to atleast three of the Hospital staff who can manage the
Transaction Management Software (‘TMS’) / Helpdesk round the clock.
vi. The Hospital shall inform and provide necessary training to all its relevant
employees and medical staff, staff in the Admissions and Billing
Department on the process of obtaining Authorization for conditions not
covered under the list of Packages, the facilities being provided under this
Agreement.
vii. The Helpdesk shall make available adequate copies of Pre-Authorisation
Form of the Insurer at all times.

o. The Hospital shall render services as an independent Contractor and shall not act or
purport to act as an agent or agency of Insurer.

p. Hospital shall not make any representations associating Insurer with the treatment
regarding which Insurer shall have no liability whatsoever.

q. Hospital shall have no objection to the use of its name and other relevant material
on the websites or other printing material of the Insurer.

r. The Hospital shall ensure that no Confidential Information is shared or made

available by the Hospital or any person associated with it to any person/entity not
related to the Hospital, without prior written consent of Insurer.

s. If the Insurer at any time discovers that the Hospital, advertently, fraudulently or
negligently provided untrue, incorrect or insufficient information, the Insurer
reserves the right to refuse payment of the resulting claim.

t. The Hospital shall take Pre-authorization from the Insurer each time the period
covered by the Pre-authorization has expired, or if any aspect of the treatment has
changed or the expenses or length of stay has exceeded the initially submitted
estimations. When the cost of treatment exceeds the authorized limit, request for
enhancement of authorization limit shall be made immediately during hospitalization
using the same format as for the initial preauthorization. Whenever request is made

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 for additional Authorization (called Re-authorization), the Hospital shall request the
Insurer for such additional preauthorization not less than 4 hours before discharge.
The request for enhancement shall be evaluated based on the availability of further
limits and may require to provide valid reasons for the same like if any aspect of the
treatment has changed or the expenses or length of stay has exceeded the initially
submitted estimations. No enhancement of limit is possible after discharge of
Insured.

u. Customer Relationship: The Provider shall provide due guidance to the beneficiaries
on cashless process. The Provider shall provide prompt and accurate update of
status of cashless approval to the Beneficiary. The cashless administration process
shall be managed expeditiously.

ARTICLE 4: PAYMENT TERMS AND PACKAGE RATES (TARIFF)

4. A. Payment Terms

a. The agreement is subject to the detailed schedule of fees submitted by the Network
Provider, which has to be accepted by the Insurer – included in Schedule I as
agreed between the Parties. Tariffs may be modified only by an amendment to the
relevant Schedule executed by all the Parties in writing.

b. The Network Provider has to submit the fee schedule (specified in Schedule I) and
list package charges. Such package charges must be inclusive of stay, medicines,
consumables, surgical fees operation theatre etc. If any charges are excluded from
package, the same should be specified. No additional payment would be
entertained unless the medical team of Insurer agrees with treating consultant of
any deviation. This tariff is valid for 24 months after signing the contract which may
be renewed thereafter with mutual consent.

c. Any revision in the fee schedule will be submitted to Insurer at least 30 days prior to
the effective date. The Insurer reserves the right to accept or discontinue the
contract after assessing the revised fee schedule.

d. The Network Provider agrees to give a ______________ discount from the

prevailing tariff on the final bill to Insurer. Insurer will pay the net amount to the
Network Provider after deduction of applicable discount. The Network Provider shall
reflect the agreed discounts in the final hospitalization bill of each claim.

e. In case the Insurer is not intimated regarding the revision, Insurer will pay for the
services only as per the then existing agreed schedule of fees.

f. Provider agrees that the schedule of fee submitted is the lowest and if any other
schedule of fees during the tenure is found lower, provider will refund such
additional charges levied.

g. The Provider agrees to submit clear and unambiguous tariff and related information
as well as details/change in Provider infrastructure, staffing and management
changes to the Insurer.

4. B. Package Rates

a. As agreed between the Parties, the Rates are as per attached Schedule I

b. Unless otherwise stated, the above package prices are fully inclusive of all costs,
including (without limitation): accommodation charges, critical care (including ICU,
ITU, HDU, CCU, NICU, PICU etc), laboratory, blood handling and phlebotomy,

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 imaging, theatre fees, surgeon's fees, anaesthetist's fees, surgeon's follow-up visits
in Provider, equipment usage, recovery, nursing, theatre consumables,
prosthesis/implants, theatre drugs (including anaesthesia), physiotherapy,
occupational therapy, hydrotherapy and dietician's fees.

c. The above package prices are valid regardless of the length of the stay in the
Provider, except in exceptional circumstances (where an unexpected medical
complication arises during Treatment which is not due to the mistake or negligence
of the Provider and/or treating doctor). In such circumstances, Pre-Authorisation
must be obtained from the Insurer for any additional costs above the package price.

d. Package Rates (in case of surgical) or fixed/flat Per Day rate (in case of medical) will
include:

i. Registration Charges
ii. Bed charges
iii. Nursing and Boarding charges
iv. Surgeons, Anaesthetists, Medical Practitioner, Consultants fees etc.
v. Anaesthesia, Blood, Oxygen, OT Charges, Surgical Appliances costs,
etc,
vi. Medicines and Drugs
vii. Cost of Prosthetic Devices, Implants, X-Ray, other Diagnostic Tests,
etc.
viii. Any other expenses related to the treatment of the patient in the
Hospital
e. Insurer will process the claim on receipt of complete medical documents.

f. However if required, Insurer or TPAs extending cashless can visit the Hospital to
gather further documents related to the treatment to process the case.

g. Insurer shall make direct payments to the Network provider and to the policyholders
by integrating their banking system platform with the Network Provider or the
insured, as the case may be. Payment shall be done to Hospital through direct
Electronic Fund Transfer, subject to applicable deduction of tax at source directly by
insurer. TDS will be deductible at an applicable higher rate in the event of non-
availability of the PAN details of the Hospital.

h. Only Insurer shall have a right to reject the payment of the claim that is not in
accordance with the terms of the Policy. The Insurer reserves the right not to pay
any such bill which as per the understanding of the Insurer is fraudulent or involves
misrepresentation of facts.

i. Notwithstanding anything above, it is clearly understood by all parties that in case of

a fixed benefit policies the payment to Providers will be done as per the policy
coverage / authorised amount at the cashless stage.

j. That, dispute and/or difference, if any, qua settlement of bill, is not raised/ addressed
by the hospital within 15 days from the date of settlement, it will be deemed that the
Provider is fully and finally satisfied with the settlement of such bill by the Insurer

ARTICLE 5: DISPLAY OF INFORMATION

a. For the ease of the Beneficiary, the Hospital shall display their recognition as
preferred Network Provider of Insurer in respect of the Policy and promotional
material, network status and the procedures for admission supplied by the insurer at
prominent location, including but not limited to outside the Hospital, at the Helpdesk,
at the reception, admission counter and Casualty/ Emergency departments.

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 b. Provider also needs to inform their reception and admissions facilities regarding the
procedures of admission and obtaining Pre-authorisation and discharge as per the
procedures laid down in Schedule II.

ARTICLE 6: HOSPITAL SERVICES

6. A. Identification of Beneficiaries

a. The beneficiaries will be identified by the Provider on the basis of a Smart card/ ID
card issued by the Insurer – which would bear the logo and name of the Insurer
along with basic details of the beneficiary¸. The Smart card/ ID card may have the
photograph or signature or thumb impression of the beneficiary.

b. The Provider shall also ask for additional identity proof such as a voter's identity
card, PAN Card, passport or driving license to verify the beneficiary’s identity (in the
event that the beneficiary is a minor, the principal policy holder's proof of identity will
be required).

c. In certain cases where Smart card/ ID cards are not yet issued by [Insurer or its
representative], Beneficiary may have only the policy document issued by the
Insurer. In such cases, the Provider would be required to extend services to the
beneficiary.

d. The Provider is required to take a photocopy of the Smart card/ ID card, to be

submitted later with the bill or to keep as proof of the beneficiary being treated.

6. B. Admission Procedure

The Admission Procedures for the Hospital Services are segregated into the
following: (i) Planned Admission; and (ii) Emergency Admission. The Procedures for
Planned Admission and Emergency Admission are set out in Schedule II.

ARTICLE 6.C: DISCHARGE PROCEDURE

The Discharge Procedures for the Hospital Services are set out in Schedule II, IV
and V.

At the time of discharge of the Beneficiary from the Hospital in whose case Insurer had
sanctioned Cashless facility for Medical Treatment, the Hospital shall ensure the
following factual documents for its records in accordance with Indian law and medical
ethics:

a. Original Discharge Card/Discharge Summary and billing format as stipulated in

Schedules IV and V respectively, counterfoil generated at the time of discharge,
original investigation reports, original prescriptions and pharmacy receipts, any other
documentary evidence statutorily required under the law. These original documents
must not be given to the Beneficiary and should be retained/preserved by the Billing
Department of the Insurer. Hospital should submit the original documents to insurer
or representative TPA for payment of claim in the case of Cashless authorisation.
Patient/member is entitled to collect copies of all documents. However in the case of
a Reimbursement Hospitalisation, where Cashless facility has not been extended to
the Beneficiary, all the above said original documents can be handed over to the
Beneficiary

b. The Discharge Card/Discharge Summary shall mention the summary of the

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 symptoms with the duration of ailment, clinical findings, investigations, overall
treatments, diagnosis and follow-up treatments, duration of other disorders like
hypertension or diabetes and operative notes in case of surgeries. The Discharge
Card / Discharge Summary shall be signed by the treating doctor(s).Standard Claim
form duly filled in shall be presented to the insured for signing and identity of the
insured shall be confirmed by the Hospital.

ARTICLE 8: BILLING & PAYMENT TERMS

a. The Provider will submit all the original medical bills, discharge summary,
investigation reports along with all the documents of hospitalization and the
treatment carried on in the Provider along with the final preauthorization request.

b. The Provider will submit the final docket to the corporate office or designated local
office of the Insurer or representative TPA within 2 days of discharge of patient from
hospital. Any claim submitted after 30 days from the date of discharge will be further
investigated by the insurer or representative TPA and the Insurer or representative
may ask for further documents and also to furnish reasons for such delay.

c. The final docket must contain the following:

i. Preauthorization letter, beneficiary acceptance letter and duly signed claim

form, refund receipt, if any,

ii. Original final bill with detailed break up of miscellaneous, consumables and
other charges.

iii. Original and complete discharge card/ summary mentioning the duration of
ailment and duration of other disorders like Hypertension or Diabetes if any.

iv. Original investigation reports with corresponding prescription/ request.

v. Pharmacy bill if supplied by Provider with corresponding request.

vi. Any other statutory documentary evidence required under law or policy
terms and conditions

vii. Status of deposit paid if any by policyholder.

d. All the payments shall be made by direct electronic fund transfer to the extent
possible within 21 days of submission of completed set of claim documents.
However, if required, the Insurer or representative TPA can:

i. Call for further document related to treatment to process the case, in which
case the Provider acknowledges that payment may be delayed.
ii. Visit Provider to gather further documents related to treatment to process
the case.

e. All payments made by the Insurer shall be subject to deduction of tax at source as
applicable under the relevant laws.

f. Provided that the Insurer shall have a right to reject the payment of the claims that
are not in accordance with the terms and conditions of the insurance policy. The
Insurer shall also not be liable to pay the due bills to the Provider if the sufficient
documents and the further information as may be required is not provided.

g. Provider shall approach to the Insurer for the recovery of any such denied payment.

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h. The Insurer shall have a right to deduct such items from the final bills as are not
correlated with corresponding report. However, the Provider may send these reports
within 30 days of receiving the payment to get the amount so deducted. Due reason
for deductions if any will be given at the time of settlement of the bills by the insurer.

i. The Provider shall be liable to refund any such amounts which have been paid to
them due to concealment of material facts or misleading information, or difference
in the information in the discharge summary/ documents from the Pre authorization.

j. If the Provider submits an invoice for Charges that are not in accordance with
Schedule I (on tariffs) or as set out in this Agreement, such invoices may be
rejected or will be paid with deductions by Insurer.

k. The Insurer shall not be obliged to pay any invoice issued by the Network Provider
for a claim for Treatment that was provided more than 6 months prior to the date of
issue of the invoice.

l. Payment Reconciliation process

i. On a regular basis – but at least quarterly, the Insurer would provide a list
of all outstanding payments to the Provider.
ii. This report would be provided in a standard format as agreed between the
parties.
iii. The parties shall meet regularly, but at least once in two months – to
review all such pending claims to discuss a suitable solution.

m. Network Rejections

i. A “Network Rejection” is defined as a situation where part or whole of an

Authorization Letter (AL) is revoked by the Insurer on account of further
information which comes to light when the Provider submits the claims to the
Insurer for payment.
ii. Reauthorizations are an essential control to ensure that network rejections –
and the consequent disputes between Insurer and Providers are minimized.
iii. Where the preauthorization / reauthorization was wrongly given by the
Insurer to the Provider, the Provider would have full recourse upto the
amount of the preauthorization to the Insurer.
iv. Where there was a change in the clinical line of treatment after admission,
and a reauthorization was obtained, the reauthorization limits and decision
would apply.
v. Where there was a change in the clinical line of treatment after admission,
and no reauthorization was obtained, the Provider would have recourse to
the patient only, for the entire amount of the preauthorization.
vi. Where the case papers provided at claims stage show the existence of pre-
existing diseases which are not disclosed under the policy, the Insurer would
not be liable to pay the claim – and the preauthorization or reauthorization
would stand void.

n. Where the case has been investigated by the clinical team of the Insurer and found
to be fraudulent – the preauthorization / reauthorization would stand void and the
Provider would not have recourse to the Insurer for the amounts.

o. Where the claim amount includes a secondary or subsequent ailment for which no
AL has been obtained the Insurer would not be liable to pay for costs linked to the
secondary ailment.

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ARTICLE 9: PROCEDURE FOR DE-EMPANELMENT

a. The Insurer reserves the right to de-empanel the Hospital from its network of
Hospitals if there is a change of control affecting that Hospital. The Hospital shall
notify the Insurer in writing within 15 working days of a change of control.

b. In the event of De-empanelment of Hospital, the Parties shall comply with the
Process for de-empanelment of Hospitals set out in Schedule III to this Agreement.

c. Where a policyholder has been issued a pre-authorisation for the conduct of given
procedure in a given hospital or if the policyholder is already undergoing such
treatment at hospital, and such hospital is proposed to be removed from the list of
Network providers then Insurer shall provide the benefits of cashless facility to such
policyholder as if such hospital continues to be on network provider list.

d. The reason for de-empanelment may include but not be limited to the following;

i. Conduct of the Hospital is such that the policyholders of the insurers are facing
regular problems and are complaining about the professional conduct of the
hospital.
ii. Hospital has been found to be indulged into malpractices, fraudulent activities
while dealing with the policyholders of the Insurer,
iii. At the discretion of Tata AIG, without any reason.

ARTICLE 10: RELATIONSHIP OF THE PARTIES

a. Nothing contained herein shall be deemed to create between the Parties, any
partnership, joint venture or relationship of principal and agent or master and
servant or employer and employee or any affiliate or subsidiaries thereof. Each of
the Parties hereto agree not to hold itself or allow its directors, employees, agents,
representatives to hold out to be a principal or an agent, employee or any
subsidiary or affiliate of the other.

ARTICLE 11: REGISTRY OF HOSPITAL (ROHINI).

Network Provider shall meet with the following minimum requirements:

a. They shall be registered in the Hospital Registry ROHINI maintained by Insurance

Information Bureau (IIB) [https://rohini.iib.gov.in/]. Hospital shall complete the
registration within thirty days of the date of entry into agreement or within such
period as may be specified by the Authority.

b. Hospital providing allopathic treatment shall meet with the pre-accreditation entry
level standards laid down by National Accreditation Board for Hospitals (NABH) or
such other standards or requirements as may be specified by the Authority from time
to time within a period of two years from the date of agreement. (Explanatory Note:
Network Providers are to visit NABH website for details regarding procedure for
obtaining the necessary accreditation).

ARTICLE 12: DECLARATIONS, UNDERTAKINGS AND WARRANTIES BY HOSPITAL

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a. Hospital declares that it has full power, capacity and authority to execute, deliver and
perform this Agreement and has taken all necessary actions (corporate, statutory,
contractual or otherwise) to authorize the execution, delivery and performance of
this Agreement.

b. Hospital declares that it has and shall maintain at all times, valid registrations,
licenses, approvals required by Law in order to provide the Services pursuant to this
Agreement. The Hospital undertakes to uphold all requirements of the Law in so far
as these apply to it in accordance with the provisions of applicable Law and the
regulations enacted from to time, by the local bodies or by the Central or the state
government. Hospital declares that it shall maintain the required standards,
benchmarks and protocols for Network Providers as required by the law from time to
time.

c. Hospital declares and warrants the maintenance at all times of required manpower,
qualified, experienced and skilled medical staff (doctors, staff and employees etc),
up-to-date infrastructure and facilities for treatment of the Beneficiaries and provision
of desired quality and standard of Services.

d. Hospital declares that it or its medical staff have never committed a criminal offence
which prevents it/them from practicing medicine and no criminal charge has been
established or are pending against it by a court of competent jurisdiction.

e. The Hospital undertakes to designate specific employees/staff to provide assistance

to, and fully cooperate with the Policyholders.

f. Hospital declares that it has procured and shall at all times ensure during the tenure
of the Agreement, that its facility is covered by adequate insurances including but
not limited to Employers’ Liability Insurance policy, Public Liability Insurance,
Professional Indemnity Policy and such other insurances as required by law or as
specified by the Insurer. The premiums for such Policies shall be borne solely by the
Hospital.

g. Hospital undertakes to continue to provide the Services to the Insurer as outlined in

the Scope of Services even in the event the Agreement of the Insurer with the
Hospital or TPA is changed or terminated or expired.

h. The Hospital undertakes to provide the Services to the Beneficiaries as per the
Package Rates and shall not inflate the Package Rates or indulge in excess billing
and any violation in this regard would be treated as an irregularity.

i. The Hospital undertakes not to take any deposit from the Beneficiary if pre
authorization is received to the extent of approved amount under the insurance
policy.

j. The Hospital warrants that its consultants, doctors, surgeons, medical staff of the
Hospital shall follow ethical medical practices and clinical protocols established by
the Hospital and prevalent norms in the medical world in conducting diagnostic tests,
prescribing medical procedures, providing treatment at all points of time.

k. The Hospital warrants that it shall not disclose to any external persons or agencies
any Confidential Information regarding the Beneficiary or Insurer, whether marked
‘confidential’ or not, unless authorized to do so by Insurer.

l. The Hospital undertakes to inform the Insurer via e-mail of any changes in the
following, with the registration proofs of the changes brought about by the Hospital,
failing which, only the details/facilities present at the time of signing of this
Agreement will be considered for claim settlement:

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 i. Infrastructure of the Hospital
ii. Its Name and/or Address,
iii. Ownership structure
iv. Hospital Registration Number (Local authority)
v. Contact details
vi. Bank Details
vii. PAN Card details
viii. Specialities being offered by the Hospital
ix. Any other information or details as required by Tata AIG in compliance
with the regulations and its internal policies.

m. Closure of the Hospital for any number of days owing to any reason,
internal/restructuring which would bring about a change in the number of beds in
general ward/ICU/OT.

ARTICLE 13: REPORTING

a. In the first week of each month, beginning from the first month of the
commencement of this Agreement, the Hospital and the insurer shall exchange
information on their experiences during the month and review the functioning of the
process and make suitable changes whenever required. However, all such changes
have to be in writing and by way of suitable Supplementary/Addendum to this
Agreement. All official correspondence, reporting, etc, pertaining to this
Agreement shall be conducted with the insurer at the address specified by the
insurer.

ARTICLE 15: NON-EXCLUSIVITY

a. Insurer reserves the right to appoint other Network provider for implementing the
packages to which the Hospital shall have no objection.

ARTICLE 16: FORCE MAJEURE

a. Neither Party shall be liable for any failure or delay in the performance of its
obligations under this Agreement to the extent such failure or delay or both is
caused, directly or indirectly, without fault by such Party, by any reason beyond its
reasonable control, including but not limited to, by fire, flood, explosion, earthquake,
elements of nature, drought or bad weather, lightning or acts of God, acts of state,
strikes, acts of war (whether declared or not), hostilities, terrorism, riots, civil
disorders or commotion, lockouts, industrial disputes, rebellions or revolutions,
blockages; quarantines, epidemics, pandemics whether declared or not and
impacting the geographical region of any party, embargoes and other similar
governmental action or any central or state government action or notification or
circular affecting the ability of a party to perform its obligations or such other action
which is beyond the reasonable control of the affected party (each a "Force Majeure
Event").

b. Any Party so delayed in its performance will immediately notify the other by
telephone or by the most timely means otherwise available (to be confirmed in
writing within two (2) Business Days of the inception of such delay) and describe in
reasonable detail the circumstances causing such delay with relevant documentary
supporting. However, the party claiming such event shall take all necessary steps to
mitigate the delay so caused in spite of such Force Majeure Event.

Page 13 of 50
 c. If a Force Majeure Event occurs the affected party will be excused from the
performance or observance of its obligations till such time the Force Majeure Event
subsists or continues. Parties further agree that during such Force Majeure Event,
Tata AIG shall be liable to pay only for the services actually provided prior to the
occurrence of the Force Majeure Event and for the services actually availed by Tata
AIG during the subsistence of the Force Majeure Event.

d. If under this clause either party is excused performance of any obligations for a
continuous period of thirty (30) days, then the other party may at any time hereafter
while such performance continues to be excused, terminate this Agreement without
liability, by notice in writing to the other party.

ARTICLE 17: TERMINATION

a. This Agreement may be terminated by either of the Parties, without assigning any
reason, by giving two Month’s prior written notice to the other Parties, provided that
this Agreement shall remain effective thereafter with respect to all rights and
obligations incurred or committed by the Parties hereto prior to such termination.

b. Insurer in consultation, reserve the right to terminate this Agreement by giving thirty
(30) days’ notice if:

i. The Hospital breaches any representation/warranty under this Agreement.

ii. The Hospital violates any of the terms and conditions of this Agreement;
or
iii. Insurer observes cases of overstay and over-provisioning without
adequate explanation.

c. Insurer shall be entitled to terminate the Agreement forthwith without any prior
notice, in case of:

i. Any wrongful act, fraud, misrepresentation, inadequacy of service or other

non-compliance or default by the Hospital, subject to the Insurer providing
Hospital an opportunity of being heard.
ii. Suspension or revocation of the License of the Hospital
iii. Any legal proceeding concerning a criminal offence or negligence is
initiated against the Hospital.

In the above cases, Insurer shall also have the right to modify this agreement.
Provided that such termination or modification shall be made after giving the
Network Provider an opportunity of being heard.

d. In the event, IRDAI cancels the Policy/Product for any reason, the cashless
services related to that Policy/Product shall be ceased or withdrawn without prior
notice to the Hospital

e. Network Provider shall have the option to opt out of the Insurer network due to
reasons of inadequacy of service rendered by insurer to the Hospital by providing a
notice of one month and hospital can continue to serve the insurer. One month
notice may be waived by mutual consent between the parties.

f. Insurer reserves the right not to pay any such bill which as per the understanding of
the Insurer is fraudulent and on the basis of which the termination notice is being
served.

g. The Parties reserve the right to inform the public at large along with the reasons of
termination of the Agreement by the method which they deem fit.

Page 14 of 50
 h. Any patient who is already availing the treatment under the policy of the insurer,
parties shall ensure the continuity of the treatment to the beneficiary in all such
circumstances until the completion of treatment of the exhausting of the sum insured
and therefore the Hospital shall continue to provide the services to the Insurer even
if the Agreement with the Insurer is terminated.

ARTICLE 18: CONFIDENTIALITY

a. ‘Confidential Information’ shall include

i. policyholders data, claims data pertaining to the business of the others

parties however the same has been received by the receiving party for the
purpose of discharging their obligations under this contract and
ii. all information (whether proprietary or not and whether or not marked
as ‘Confidential’) pertaining to the business of the Insurer or any of their
affiliates, employees or business associates to which the Hospital or its
employees have access to, in any manner whatsoever.

Provided that Confidential Information shall not include, for the any information
which is;

i. already in the custody of the receiving party or

ii. available in public domain.

b. Each Party shall maintain confidentiality relating to all matters and issues dealt with
by the Parties in the course of the business contemplated by and relating to this
agreement. The Hospital shall not disclose to any third party, and shall use its best
efforts to ensure that its officers, employees, keep secret all information disclosed,
including without limitation, document marked confidential, medical reports, personal
information relating to Insured Persons/Beneficiaries and other unpublished
information except as maybe authorized in writing by insurer. The insurer shall not
disclose to any third party and shall use its best efforts to ensure that its directors,
officers, employees, sub-contractors and affiliates keep secret all information relating
to this agreement and hospitalization of the policyholders of the insured in the
Hospital including without limitation to the Hospital’s proprietary information, process
flows, and other required details.

c. In particular the Hospital agrees to:

i. Maintain confidentiality and endeavour to maintain confidentiality of any

persons directly employed or associated with health services under this
agreement of all information received by the Hospital or such other
medical practitioner or such other person by virtue of this agreement or
otherwise, including insurer’s proprietary information, confidential
information relating to insured, medicals test reports whether created/
handled /delivered by the Hospital. Any personal information relating to a
Insured received by the Hospital shall be used only for the purpose of
inclusion, preparation, finalisation of medical reports/test reports for
transmission to the insurer only and shall not give or make available
such information/any documents to any third party whatsoever.

ii. Keep confidential and endeavour to maintain confidentiality by its

medical officer, employees, medical staff, or such other persons, of
medical reports relating to Insured, and that the information contained in
these reports remains confidential and the reports or any part of report is

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 not disclosed/informed to the Insurance Agent/Advisor under any
circumstances.

iii. Keep confidential and endeavour to maintain confidentiality of any

information relating to Insured and shall not use the said confidential
information for research, creating comparative database, statistical
analysis or any other studies without appropriate previous authorization
from insurer.

d. The contents of this Clause shall not derogate from the duty of the Hospital to report
to insurer any data, information or medical background which is brought to its
attention in the framework of its work for Insurer and which is likely to be relevant to
Insurer. The transfer of information shall be done subject to the work procedures of
Insurer to be established from time to time.

e. This clause shall revise the termination / expiry of this Agreement.

ARTICLE 19: DATA SECURITY, SAFEGUARDS AND MONITORING

a. The Hospital represents compliance with security best practices which may be
monitored by periodic computer security audits performed by or on behalf of Tata
AIG. The periodicity of these audits will be decided at the reasonable discretion of
Tata AIG. These audits may include, but shall not be limited to, a review of: access
and authorization procedures, physical security controls, backup and recovery
procedures, network security controls and program change controls.

b. To the extent that Tata AIG deems it necessary to carry out a program of inspection
and audit to safeguard against threats and hazards to the confidentiality, integrity,
and availability of data, the Hospital shall afford Tata AIG's representatives access to
the Hospital's facilities, installations, technical resources, operations, documentation,
records, databases and personnel.

c. The Hospital shall provide Tata AIG access to various monitoring and performance
measurement systems (both manual and automated). Tata AIG has the right to get
the monitoring and performance measurement systems (both manual and
automated) audited. The Hospital shall remedy all discrepancies observed by the
auditors at no additional cost to Tata AIG within 15 days from receipt of intimation
from Tata AIG.

d. Hospital shall not publish or disclose in any manner, without Tata AIG's prior written
consent, the details of any security safeguards designed, developed, or
implemented by Hospital under this Agreement or existing at any Tata AIG location.
Hospital shall develop procedures and implementation plans to ensure that
Information Technology (‘IT’) resources leaving the control of the assigned user
(such as being reassigned, removed for repair, replaced, or upgraded) are cleared of
all Tata AIGs data and sensitive application software. Hospital shall also ensure that
all employees who are involved in providing such security safeguards or part of it
shall not publish or disclose in any manner, without Tata AIG's prior written consent,
the details of any security safeguards designed, developed, or implemented by
Hospital under this Agreement or existing at any Tata AIG location.

e. Hospital shall ensure compliance with the all applicable laws including but not limited
to Information Technology Act 2000 and Information Technology (Reasonable
security practices and procedures and sensitive personal data or information) Rules,
2011 (“Rules”).

f. The Hospital represents compliance with security best practices and have put in

Page 16 of 50
 place security control measures to prevent, detect and react to breaches including
data leakage. All such controls and measure may be monitored by periodic
computer security audits performed by or on behalf of Tata AIG. The periodicity of
these audits will be decided at the reasonable discretion of Tata AIG. These audits
may include, but shall not be limited to, a review of: access and authorization
procedures, physical security controls, backup and recovery procedures, network
security controls and program change controls.

g. To the extent that Tata AIG deems it necessary to carry out a program of inspection
and audit to safeguard against threats and hazards to the confidentiality, integrity,
and availability of data, the Hospital shall afford Tata AIG's representatives access to
the Hospital's facilities, installations, technical resources, operations, documentation,
records, databases and personnel.

h. The Hospital shall provide Tata AIG access to various monitoring and performance
measurement systems (both manual and automated). Tata AIG has the right to get
the monitoring and performance measurement systems (both manual and
automated) audited. The Hospital shall remedy all discrepancies observed by the
auditors at no additional cost to Tata AIG within 15 days from receipt of intimation
from Tata AIG.

i. Hospital shall ensure that for all services to be provided as per any SOWs executed
under this MSA, the data centres and servers on which the applications are hosted
shall be located in India only.

j. Hospital shall ensure adherence to a stringent policy of Data Security and shall
ensure that there is no disclosure of information whatsoever failing which will result
into further course of action as envisaged in this Agreement.

k. The Hospital will ensure its applications are protected against unauthorized access,
alteration, destruction, disclosure or dissemination of records and data.

l. Hospital shall be responsible for purging all Tata AIG data from their system or
storage device (with the intent that the data cannot be reconstructed by any known
technique) as per the turnaround time mutually agreed between the Hospital and
Tata AIG.

m. Hospital shall update all data using information technology and shall have systems,
firewalls and all paraphernalia to avoid jeopardizing the data.

n. The Hospital shall, in relation to Tata AIG Personal Data:

i. process such Personal Data only on the written instructions of Tata AIG, and
shall not in any manner share, transfer or disclose Tata AIG Personal Data to
any third party, other than as expressly permitted in writing by Tata AIG;

ii. implement appropriate technical and organizational measures to protect

against unauthorised or unlawful processing of Tata AIG Personal Data and
against its accidental loss, damage or destruction, including inter alia as
appropriate:

 the pseudonymisation and encryption of Personal Data;

 the ability to ensure the ongoing confidentiality, integrity, availability

and resilience of processing systems and services;

 the ability to restore the availability and access to Personal Data in a

timely manner in the event of a physical or technical incident; and

Page 17 of 50
  process for regularly testing, assessing and evaluating the
effectiveness of technical and organisational measures for ensuring
the security of the processing.

 ensure that all personnel who have access to and/or process

Personal Data are obliged to keep the same confidential;

o. promptly notify Tata AIG if it receives any complaint, notice or communication

(whether from any data subject, supervisory authority or other third party) which
relates to processing of Customer Personal Data and promptly assist Tata AIG [at
the Hospital's expense] in responding to any request from a data subject and in
ensuring compliance with Tata AIG 's obligations under Applicable Data Protection
Laws such as those relating to security, breach notifications, impact assessments,
consultation with supervisory authorities/regulators, etc.;

p. notify Tata AIG without undue delay and no later than [please specify a timeline] after
becoming aware of a data breach or on suspecting the same, the Hospital shall
promptly conduct an initial assessment to determine, with a reasonable degree of
certainty, whether the event or incident qualifies for notification to Tata AIG and shall
provide a copy of this initial assessment along with such notification;

q. delete or return to Tata AIG all Customer Personal Data on termination or expiry of
the Agreement [at the written direction of the Customer] and certify to Tata AIG in
writing it has done so, unless the Hospital is required by Applicable Law to continue
to process any Personal Data, in which case the Hospital shall promptly notify Tata
AIG, in writing, of the relevant Applicable Law and shall only be permitted to process
Customer Personal Data for the specific purpose so-notified, and all other
requirements set out in this Agreement shall continue to apply to such Personal
Data; and

r. maintain adequate records, and, on Tata AIG 's request, make available such
information as Tata AIG may reasonably request, and allow for and submit its
premises and operations to audits, including inspections, by Tata AIG or Tata AIG 's
designated auditor, to demonstrate its compliance with Applicable Data Protection
Laws.

s. For the purposes of this agreement, Personal Data means any personal data
(including sensitive personal data or information), which the Hospital receives and
processes in connection with this Agreement.

ARTICLE 20: DATA PURGING /ARCHIVAL:

a. On completion of service or termination of the Agreement, whichever is earlier, the

Hospital shall:

i. promptly return to Tata AIG, of all the records/data pertaining to Tata AIG,
for such period as may be demanded by Tata AIG, which is in the
Custody, possession or control (including any copies or reproductions
thereof) of Service Provide under this Agreement, whether such data is in
maintained by Hospital in physical or electronic form; and

ii. not keep any copy of such data with it; and

iii. securely purge / erase / destroy all such data form its systems, at its own
costs and in such a manner that the data such purged is not traceable /
recoverable from its systems and shall also carry disposal of the physical
records.

Page 18 of 50
 iv. Hospital shall promptly thereafter certify (“Data Purging Certificate”) in
writing to Tata AIG that it has returned or destroyed (as the case may be)
the Personal Information and has not kept copies of any Personal
Information. “Destroy” means, with respect to the subject Personal
Information, destruction of such information through shredding,
pulverizing, burning, destruction or erasure (in the case of electronic
media), or other methods such that it cannot practicably be read or
reconstructed.

ARTICLE 21: PRIVACY AND SECURITY SAFEGUARDS

a. Hospital shall not publish or disclose in any manner, without Tata AIG's prior written
consent, the details of any security safeguards designed, developed, or
implemented by Hospital under this Agreement or existing at any Tata AIG location.
Hospital shall develop procedures and implementation plans to ensure that
Information Technology (‘IT’) resources leaving the control of the assigned user
(such as being reassigned, removed for repair, replaced, or upgraded) are cleared of
all Tata AIGs data and sensitive application software. Hospital shall also ensure that
all employees who are involved in providing such security safeguards or part of it
shall not publish or disclose in any manner, without Tata AIG's prior written consent,
the details of any security safeguards designed, developed, or implemented by
Hospital under this Agreement or existing at any Tata AIG location.

b. The Hospital shall comply with reasonable instructions, policies, directives, code of
conduct, guidelines of Tata AIG as communicated by Tata AIG from time to time [to
the extent relevant to the provision of the services by the Hospital].

c. The Hospital shall process all Customer Personal Data strictly in accordance with
this Agreement and its privacy policy (“Privacy Policy”) [as approved by Tata AIG,]
and shall not amend the Privacy Policy without Tata AIG 's prior written consent.

d. The Hospital shall promptly comply with all reasonable instructions of Tata AIG
including those in connection with the Privacy Policy of the Hospital, and shall
promptly provide copies of the same to Tata AIG on request in a commonly available
electronic format, and hereby consents to Tata AIG making the same available to
any applicable data subject, supervisory authority or other third party.

e. The Hospital represents that the Privacy Policy will at all times comply with
Applicable Data Protection Laws and that it will not make any amendments to the
Privacy Policy where this would be in contravention of Applicable Data Protection
Laws.

ARTICLE 22: INSPECTION OF RECORDS AND AUDIT

a. Tata AIG or TPA extending cashless benefit reserves the right to visit any of the
Hospital's premises without prior notice to ensure that the data provided by Tata AIG
is not misused; Provided that Tata AIG’s access should be limited to verification of
Tata AIG’s data alone and the Hospital shall not provide to Tata AIG data of third
parties.

b. Tata AIG and IRDAI shall be authorized to make reasonable inquiries and audit the
Hospital's compliance with the provisions of this Agreement and the Hospital agrees
to provide Tata AIG with such information and access for audit as requested for by
Tata AIG. At all times, after prior notice to the Hospital, Tata AIG shall have the right
to inspect the premises of the Hospital directly or through its representatives (Audit
firm or Consultants) to, ensure compliance with the terms of the Agreement.
Hospital’s records with respect to any matters covered by this Agreement shall be

Page 19 of 50
 made available to Tata AIG or its designees at any time during normal business
hours, as often as Tata AIG deems necessary, to audit, examine, and make excerpts
or transcripts of all relevant data.

c. The Insurance Regulatory and Development Authority of India and any other
regulatory authority shall also have the right to conduct audit of Hospital with respect
to the terms of this agreement.

d. Hospital shall at its own expense, have an external ISO27001 or equivalent

certification on Security Management systems and should share the complete report
of the audit with customer on an annual basis.

e. To conduct an inspection of the Hospital from time to time in connection with:

i. Quality assuring specific Services;
ii. Reasonable concerns about the Hospital expressed by anyone; and/or
iii. Audit of the Hospital's compliance with the management of care and
quality standards as agreed;
iv. Any other matter as required under this Agreement

f. If any material issue of quality and/or any issue of safety is identified as a result of
any such inspection, the Insurer shall immediately notify the Hospital of the issue
and the remedial action required. The Hospital undertakes to take such remedial
action forthwith as may be advised by the Insurer.

g. The Insurer may conduct an audit of the Hospital's billing or clinical data in order to
satisfy itself of the appropriateness of decisions made or charges billed and/or paid.

h. To the extent permitted by applicable Laws, the Hospital will allow the Insurer's staff
to inspect and if requested will provide a copy of medical records of any Beneficiary,
relevant to the respective claims or pre-authorization.

i. The Hospital shall allow the Insurer's staff or appointed representatives access to
the Hospital to visit any Beneficiary, to facilitate Pre-Authorisation, case
management, discuss aspects of the Treatment, discharge management, disease
management, post-operative care and/or post-discharge care, utilisation
management, quality assurance reviews, utilisation reviews, and grievance
procedures with the Beneficiary and treating consultant where appropriate.

j. In the event that any non-compliance with any term of this Agreement (including,
without limitation, any overcharges) is discovered as a result of any such audit, the
Insurer shall have the right to:

i. Recover from the Hospital the amount of any monies overcharged;

ii. Widen the scope of audit and/or size of the audit sample;
iii. Caution the Hospital against carrying on or indulging in such practices
and seek undertaking from the Hospital;
iv. Cause the Hospital to take corrective action in order to rectify non-
compliances within a reasonable time-frame; and/or
v. Terminate the Agreement.

ARTICLE 23: DEFICIENCY IN SERVICES

a. In the event the Hospital does not provide or fail to provide the Services or provide
inadequate Services, the Insurer shall have the right to withhold the payments to the
Hospital. The Insurer shall also have the right to claim the financial loss arising from
the deficiency in Services provided or deduct the costs charged for inferior Services
rendered. The Insurer shall have the right to discontinue the Services if it so deems

Page 20 of 50
 necessary.

ARTICLE 24: INDEMNITIES

a. Insurer will not interfere in the treatment and medical care provided to its
Beneficiaries. Insurer will not be in any way held responsible / liable for the outcome
of treatment or quality of care provided by the Hospital nor shall the Insurer be liable
to pay any costs, damages, compensation demanded by Beneficiary for poor/wrong
quality of test reports or treatment given by Hospital or for deficiency/wrong
treatment by Doctors/nursing staff.

b. Insurer shall not be liable or responsible for any acts, omission or commission of the
Doctors and other medical staff of the Hospital and the Hospital shall obtain
professional indemnity policy at its own cost for this purpose. The Hospital agrees
that it shall be responsible in any manner whatsoever for the claims arising from any
deficiency in the Services or any failure to provide identified Service.

c. Notwithstanding anything to the contrary contained in this Agreement, neither of the

Parties shall be liable by reason of failure or delay in the performance of its duties
and obligations under this Agreement, if such failure or delay is caused by acts of
God, strikes, lock-outs, embargos, war, riots civil commotion, any orders of
governmental, quasi-governmental or local authorities, or any other similar cause
beyond its control and without its fault or negligence.

d. The Hospital shall indemnify, defend and hold harmless the Insurer against
any claims, demands, proceedings, actions, damages, costs (including legal costs),
and expenses suffered or incurred by/taken against the Insurer due to and arising
out of:

i. Negligence of Hospital/Doctors in fulfilling the obligations under this

Agreement;
ii. Gross negligence and/or wilful misconduct by it and/or its staff, officers,
directors, employees agents or affiliates;
iii. Breach of the terms, warranty, representation, covenant of this
Agreement by the Hospital or any of its employees, doctors, consultants
or medical staff;
iv. Non-fulfilment of its obligations under law or to any third party(ies);
v. Any liability arising out of wrongful denial/rejection of a Service and
consequent action taken by the Government against the Insurer;
vi. Any amount charged by the Hospital in excess of the agreed charges;
vii. Any claim arising out of the loss of medical records/documents that are
submitted by Beneficiary to Hospital or lost while in the custody of
Hospital.

ARTICLE 25: GOVERNING LAW AND ARBITRATION

a. The provisions of this Agreement shall be governed by, and construed in accordance
with Indian law and shall be subject to the exclusive jurisdiction of the courts at
Mumbai.

b. Any dispute, controversy or claims arising out of or relation to this Agreement or the
breach, termination or invalidity thereof, shall be settled by arbitration in accordance
with the provisions of the (Indian) Arbitration and Conciliation Act, 1996. The arbitral
tribunal shall be composed of three arbitrators, one arbitrator appointed by each
Party and one another arbitrator appointed by the mutual consent of the arbitrators

Page 21 of 50
 so appointed.

c. The place of arbitration shall be Mumbai and any award whether interim or final,
shall be made, and shall be deemed for all purposes between the Parties to be
made, in Mumbai.

d. The arbitral procedure shall be conducted in the English language and any award or
awards shall be rendered in English. The procedural law of the arbitration shall be
Indian law.

e. The award of the arbitrator shall be final and conclusive and binding upon the
Parties.

f. The rights and obligations of the Parties under, or pursuant to, this Clause including
the arbitration agreement in this clause, shall be governed by and subject to Indian
law.

g. Cost of the arbitration proceeding shall be borne by the Parties on a pro-rata basis.

ARTICLE 26: NOTICES

a. All notices, demands or other communications to be given or delivered under or by

reason of the provisions of this Agreement will be in writing and delivered to the
other Parties by registered mail, by courier or by facsimile. In the absence of
evidence of earlier receipt, a demand/other communication to the other Parties is
deemed given:

 If sent by registered mail, seven working days after posting it; and
 If sent by courier, seven working days after posting it; and
 If sent by facsimile, two working days after transmission. In this case, further
confirmation has to be done via telephone and e-mail.

The Notices shall be sent to the other Party to the registered office addresses /
branch office address as mentioned in this agreement.

ARTICLE 27: ETHICAL STANDARDS

a. Tata AIG is a Tata Group company and abides by the Tata AIG Code of Conduct
which has been created in spirit with the Tata Code of Conduct. By virtue of abiding
with the Tata AIG Code of Conduct, no employee (on-roll or off-roll) will indulge in
fraudulent activities in relation to bribery or corruption. While doing business with
you, any such incident if being observed by you, please escalate the matter
immediately and raise a concern. For raising a concern/complaint kindly reach out to
us -

 By Electronic Mail :-
Chief Ethics Counselor: conduct@tataaig.com
 By Post:-
Head of Department - Secretarial and Legal
Tata AIG General Insurance Company Limited
Peninsula Business Park, Tower A,
15th Floor, G.K. Marg, Lower Parel,
Mumbai - 400013

Page 22 of 50
ARTICLE 28: GENERAL PROVISIONS

a. This Agreement together with any Annexures attached hereto constitutes the entire
Agreement between the Parties and supersedes, with respect to the matters
regulated herein, and all other mutual understandings, accord and agreements,
irrespective of their form between the parties. All Annexures shall constitute an
integral part of the Agreement.

b. Except as otherwise provided herein, no modification, amendment or waiver of any

provision of this Agreement will be effective unless such modification, amendment or
waiver is approved in writing by the parties hereto.

c. Should specific provision of this Agreement be wholly or partially not legally effective
or unenforceable or later lose their legal effectiveness or enforceability, the validity of
the remaining provisions of this Agreement shall not be affected thereby.

d. The Hospital may not assign, transfer, encumber or otherwise dispose of this
Agreement or any interest herein without the prior written consent of Insurer.
Provided that the Insurer may assign this Agreement or any rights, title or interest
herein to an Affiliate without requiring the consent of the Hospital.

e. The failure of any of the Parties to insist, in any one or more instances, upon a strict
performance of any of the provisions of this Agreement or to exercise any option
herein contained, shall not be construed as a waiver or relinquishment of such
provision, but the same shall continue and remain in full force and effect.

f. The invalidity or unenforceability of any provisions of this Agreement shall not affect
the validity, legality or enforceability of the remainder of this Agreement or the
validity, legality or enforceability of this Agreement, including any such provision, it
being intended that all rights and obligations of the Parties hereunder shall be
enforceable to the fullest extent permitted by law.

g. The captions herein are included for convenience of reference only and shall be
ignored in the construction or interpretation hereof.

h. Electronic Signature: Each party agrees that this Agreement and any other
documents to be delivered in connection herewith may be electronically signed, and
that any electronic signatures appearing on this Agreement or such other documents
are the same as handwritten signatures for the purposes of validity, enforceability,
and admissibility.

i. Electronic Record: This document is an electronic record in terms of the Information

Technology Act, 2000 (“IT Act”) and rules made thereunder as may be applicable,
and the amended provisions pertaining to electronic records in various statutes as
amended by the IT Act.

j. Execution Date: The “Execution Date” of this Agreement shall be the date on which
all parties have signed this Agreement. If the parties do not sign this Agreement on
the same date, the Execution Date shall be the date that the last party signs this
Agreement. In case the agreement is signed digitally, the execution date shall be the
date this agreement was electronically signed by last Party.

Page 23 of 50
NOW THEREFORE this Agreement is signed by each party’s authorised
representative:

Signed and delivered by Signed and delivered by Tata AIG General

_________________________________ Insurance Company Limited

Name
Name Designation
Designation

Page 24 of 50
 SCHEDULE - I
(Rates to be included as agreed upon with the hospitals)
PACKAGE RATES - TARIFFS AND FEES
Explanatory notes

1. Tariff rates are attached in the tables below. The following serve to provide
explanations for the same
Accommodation The above accommodation charges are inclusive of: room, bed, all in-
charges room furniture, equipment and facilities, ward equipment usage,
nursing, resident medical officers, ward dressings/consumables, ward
drugs, patient housekeeping, cleaning, and removal of sutures.

Theatre charges, The charges are inclusive of: operating room costs including all
surgeon's and equipment and facilities, nursing and support staff, instrumentation,
anaesthetist fees theatre dressings and consumables (excluding drugs, prosthesis /
implants unless stated). Where more than one procedure is performed
at the same time the Provider may charge 100% of the charge for the
most complex procedure and 75% of the charge for any other
procedure performed.-the surgeries will be billed as per the tariff
approved separately and not as per the % mentioned above if it is 2
different incisions

2 Accommodation

Beneficiaries are entitled to stay in accommodation up to a certain standard, depending on

their scale of cover, as notified by Insurer to the Provider from time-to-time. If a Beneficiary is
accommodated in a room categorized and charged at a higher rate than that Beneficiary's
entitlement the Provider will only be reimbursed by the Insurer for the room for which the
Beneficiary is entitled to. The Provider may only recover any additional Charge for a higher
standard room from the Beneficiary if the Beneficiary's entitled room standard is available
but the Beneficiary chooses to be accommodated in a higher standard room and the
Provider has obtained the prior written consent of the Beneficiary. In the event that the
Beneficiary is accommodated in a higher standard room due to lack of room availability, then
neither the Insurer nor the Beneficiary shall be obliged to pay for any additional Charges.

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 SCHEDULE – II
HOSPITAL SERVICES - ADMISSION PROCEDURE

A. PROCEDURE FOR PLANNED ADMISSION

The process to be followed by the Hospital on receipt of request for hospitalization on

behalf of the Beneficiary is prescribed as follows:

1. Hospital Services - Cashless Facility Admission Procedure

The insured shall be provided treatment free of cost for all such ailments covered under
the policy within the limits / sub-limits and the sum insured, i.e., not specifically excluded
under the policy. The Provider shall be reimbursed as per the tariff agreed under the
service level agreement for different treatments or procedures. The procedure to be
followed for providing cashless facility shall be:

A. Preauthorization Procedure - Planned Admissions:

1. Request for hospitalization shall be forwarded by the Hospital immediately after

obtaining due details from the treating doctor in the preauthorization form
prescribed by the Authority (IRDA) i.e. Request for Authorization Letter (‘RAL’).
The RAL shall be sent electronically along with all the relevant details in the
electronic form to the 24-hour authorization/cashless department of the Insurer or
its representative TPA along with contact details of treating physician and the
insured. The Insurer’s or its representative TPA medical team may consult the
treating physician or the insured, if necessary.
2. If the treating physician of the Hospital identifies any disease or ailment as pre-
existing, the treating physician shall record it and also inform the Insured
immediately.
3. In the cases where the symptoms appear vague / no effective diagnosis is arrived
at, the medical team of the insurer or its representative TPA may consult with
treating physician /insured, if necessary.
4. The RAL shall reach the authorization department of insurer or its representative
TPA seven (7) days prior to the expected date of admission, in case of planned
admission.
5. If Clause 3 above is not followed, the clarification for the delay needs to be
forwarded along with the request for authorization.
6. The RAL form shall be dully filled with clearly mentioning Yes or No and/or the
details as required. The form shall not be sent with nil or blanks replies.
7. The guarantee of payment shall be given only for the medically necessary
treatment cost of the ailment covered and mentioned in the request for
hospitalization. Non covered items i.e. non-medical items which are specifically
excluded in the Policy like telephone usage, food provided to relatives/attendants,
Hospital registration fees, etc, shall be collected directly from the Insured.
8. The Authorization Letter by the Insurer or its representative TPA shall clearly
indicate the amount agreed for providing cashless facility for hospitalization.
9. In event of the cost of treatment increasing, the Hospital may check the
availability of further limit with the insurer or its representative TPA.
10. When the cost of treatment exceeds the authorized limit, request for
enhancement of authorization limit shall be made immediately during
hospitalization using the same format as for the initial preauthorization. The
request for enhancement shall be evaluated based on the availability of further
limits and may require to provide valid reasons for the same. No enhancement of
limit is possible after discharge of Insured.
11. Further the insurer shall accept or decline such additional expenses within a
maximum of 24 hours of receiving the request for enhancement. Absence of
receiving the reply from the Insurer within 24 hours shall be construed as denial

Page 26 of 50
 of the additional amount.
12. In case the Beneficiary has opted for a higher accommodation / facility than the
one eligible under the policy, the Hospital shall explain orally the effect of such
option and also take a written consent from the insured at the time of admission
as regard to owing the responsibility of such expenses by the Beneficiary
including the proportionate expenses which have a direct bearing due to up
gradation of room accommodation/facility. In all such cases the Insurer shall pay
for the expenses which are based on the eligibility limits of the Beneficiary.
However the Hospital may charge any advance amount/deposit from the
Beneficiary only in such cases where the insured has opted for an upgraded
facility to the extent of the amounts to be collected from the Beneficiary.
13. Insurance company guarantees payment only after receipt of RAL and the
necessary medical details. The Authorization Letter (‘AL’) shall be issued within
48hours of receiving the RAL.
14. In case the ailment is not covered or given medical data is not sufficient for the
medical team of authorization department to confirm the eligibility, insurer or its
representative TPA shall seek further clarification/ information immediately.
15. Authorization letter [AL] shall mention the authorization number and the amount
guaranteed for the procedure.
16. In case the balance sum available is considerably less than the cost of treatment,
the Hospital shall follow their norms of deposit/running bills etc. However,
Hospital shall only charge the balance amount over and above the amount
authorized under the health insurance policy against the package or treatment
from the insured.
17. Once the insured is to be discharged, the Hospital shall make a final request for
the preauthorization for any residual amount along with the standard discharge
summary and the standard billing format. Once the Hospital receives final pre-
authorization for a specific amount, the insured shall be allowed to get discharged
by paying the difference between the pre-authorized amount and actual bill, if
any. Insurer, upon receipt of the complete bills and documents, shall make
payments of the guaranteed amount to the Hospital directly.
18. Due to any reason if the insured does not avail treatment at the Provider after the
preauthorization and the amount is released the Provider shall return the amount
to the insurer immediately.
19. All the payments in respect of pre-authorized amounts shall be made
electronically by the insurer to the Hospital as early as possible as but not later
than a week from the date of submission of complete set of claim documents
from hospital.
20. Denial of authorization (DAL) for cashless is by no means denial of treatment by
the health facility. The Hospital shall deal with such case as per their normal rules
and regulations.
21. Insurer shall not be liable for payments to the Hospital’s in case the information
provided in the “request for authorization letter” and subsequent documents
during the course of authorization, is found incorrect or not disclosed.
22. Provider, Insurer and its representative TPA shall ensure that the procedure
specified is strictly complied in all respects.

I. Preauthorization Procedure - Emergency Admissions:

1. In case of emergencies also, the procedure specified in I (1), (2) and (3) shall be
followed.
2. The insurer or its representative TPA may continue to discuss with treating doctor till
conclusion of eligibility of coverage is arrived at. However, any lifesaving, limb saving,
sight saving, emergency medical attention cannot be withheld or delayed for the purpose
of waiting for pre-authorization. Provider meanwhile may consider treating him by taking
a token deposit or as per their norms.

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 3. Once a pre-authorisation is issued after ascertaining the coverage, the Hospital shall
refund the deposit amount to the insured if taken barring a token amount to take care of
non-covered expenses. Once the patient is medically stable, he must be transferred to
the room which he is eligible for as his health plan, which would be mentioned in the pre-
authorisation certificate.
a. The Parties agree that the Provider shall admit the Beneficiary in the case of
emergency but pre-authorization request will need to made within 24 hours of the
admission.
b. Provider upon deciding to admit the Beneficiary should inform/ intimate over
phone immediately to the 24 hours Insurer’s helpdesk or the local/ nearest
Insurer office or its representative TPA
d. On receipt of the preauthorization form for the Provider giving the details of
the ailments for admission and the estimated treatment cost, which is to be
forwarded within 12 hours of admission, Insurer directly or through its
representative TPA undertakes to issue the confirmation letter for the admissible
amount within 4 hours of the receipt of the preauthorization form subject to policy
terms & conditions.
e. In case the ailment is not covered or given medical data is not sufficient for
the medical team to confirm the eligibility, Insurer can deny the guarantee of
payment, which shall be addressed, to the Insured under intimation to the
Provider. The Provider will have to follow their normal practice in such cases.
f. Denial of Authorization/ guarantee of payment in no way means denial of
treatment. The Provider shall deal with each case as per their normal rules and
regulations.
g. Pre-Authorization certificate will mention the amount guaranteed class of
admission, eligibility of beneficiary or various sub limits for rooms and board,
surgical fees etc. wherever applicable. Provider must take care to ensure
compliance.
h. The guarantee of payment is given only for the necessary treatment cost of
the ailment covered and mentioned in the request for authorization. Any
investigation carried out at the request of the patient but not forming the
necessary part of the treatment also must be collected from the patient.
i. In case the sum available is considerably less than the estimated treatment
cost, Provider should follow their normal norms of deposit/ running bills etc., to
ensure that they realize any excess sum payable by the policyholders/insured
under the health insurance policy, not provided for by indemnity.

II. Preauthorization Procedure - RTA / MLCs:

a.i.1. If requesting a pre-authorisation for any potential medico-legal case including

Road Traffic Accidents, the Provider shall indicate the same in the relevant section of the
standard form.
a.i.2. In case of a road traffic accident and or a medico legal case, if the victim was
under the influence of alcohol or inebriating drugs or any other addictive substance or
does intentional self-injury, it is mandatory for the Provider to inform this circumstance of
emergency to the insurer or its representative TPA.

IV. Authorization letter (AL):

1. Authorization letter shall mention the amount, guaranteed class of admission, eligibility, of
the patient or various sub limits for rooms and board, surgical fees etc. wherever
applicable, as per the insurance policy of the patient.
2. The Pre-Authorization letter will also mention validity of dates for admission and number
of days allowed for hospitalization, if any. The Provider shall see that these rules are
strictly followed; else the AL will be considered null and void.

Page 28 of 50
3. In the event the room category, if any, is not available the same shall be informed to the
insurer or its representative TPA and the insured. For such cases, if the insured is
admitted to a class of accommodation higher than what he is eligible for, the Hospital
shall collect the necessary difference, if any, in charges from the insured.
4. The AL has a limited period of validity - which is 15 days from the date of pre-auth
document.
5. AL is not an unconditional guarantee of payment. It is conditional on facts presented –
when the facts change the guarantee changes.

V. Reauthorization:

a.i.1. Where there is a change in the line of treatment - a fresh authorization shall be
obtained from the insurer immediately - this is called a reauthorization.
a.i.2. The same pre-authorization form shall be used for the re-authorization, and the
same turnaround times as specified shall apply.
a.i.3. In case of any change after the preauthorisation – the Provider is required to obtain
a reauthorisation 8 hours prior to discharge.

VI. Discharge:

1. The following documents shall be included in the list of documents to be sent along with
the claim form to the insurer or its representative TPA. These shall not be given to the
insured.
a. Original pre authorization request form,
b. Original authorization letter,
c. Original discharge card,
d. Original bill with break up
e. Original investigation reports,
f. All original prescription & pharmacy receipt etc
But copies should be given to insured.
2. Where the insured requires the discharge card/reports he or she can be asked to take
photocopies of the same at his or her own expenses and these have to be clearly
stamped as "Duplicate & originals are submitted to insurer".
3. The discharge card/Summary shall mention the duration of ailment and duration of other
disorders like hypertension or diabetes and operative notes in case of surgeries. The
clinical detail shall be sufficiently and justifiably informative. In addition, the Provider shall
provide all the relevant details pertaining to past treatment availed by the insured in the
Provider.
4. Signature of the insured on final Provider bill shall be obtained.
5. In the event of death or incapacitation of the insured, the signature of the nominee or any
of insured’s of the family who represents the insured as such subject to reasonable
satisfaction of Provider shall be sufficient for the insurer to consider the claim.
6. Standard Claim form duly filled in shall be presented to the insured for signing and
identity of the insured shall be confirmed by the Hospital.

VII. Discharge Summary and Bills

1. The Provider shall submit directly to Insurer or its representative TPA the discharge
summary and bills as per the format given by IRDA as given in Annexure IV and V
attached to this agreement and also original invoices and such invoices shall contain, at
the minimum, the following information:
a. The insured’s full name and date of birth,
b. The policy number,
c. The insured’s address;
d. The admitting consultant,
e. The date of admission and discharge,

Page 29 of 50
 f. The procedure performed and procedure code according to ICD-10 PCS or any other
code as specified by the Authority from time to time,
g. The diagnosis at the time treatment and diagnosis code according to ICD-10 or any
other code as specified by the Authority from time to time,
h. Whether this is an interim or final bill /account,
i. The description of each service performed, together with associated Charges,
j. The agreed standard billing codes associated with each Service performed and dates
on which items of Service were provided; and
k. The insured’s signature ( in original)

2. The Provider shall submit the following documents which the final invoice:
a. Copy of pre-authorization letter,
a. Fully completed claim form or the relevant claim section of the pre-authorization
letter, signed by the insured and the treating consultant for the treatment
performed,
b. Original and complete discharge summary in standard form and billing form in the
standard form, including the treating Consultant’s operative notes,
c. Original investigation reports with corresponding prescription / request;
d. Pharmacy bill with corresponding prescription / request,
e. Any other statutory documentary evidence required under law or by the Insured’s
policy; and
f. Photocopy of the Insured’s photo identification (e.g. voter’s smart card / ID card,
passport or driving licence etc)

3. The Provider shall submit the final invoice and all supporting documentation required
within 2 days of discharge date.

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 SCHEDULE - III

PROCESS FOR DE-EMPANELMENT OF NETWORK PROVIDERS

Step 1 - Putting the Provider on “Watch-list”

a.i.1. Based on the claims data analysis and/ or the Hospital visits, if there is any doubt
on the performance of a Hospital, the Insurer can put that Hospital on the watch list.

a.i.2. The data of such Hospital shall be analysed very closely on a daily basis by the
Insurer for patterns, trends and anomalies.

a.i.3. The Insurer will immediately inform the Health Insurance Forum about the
Provider which have been put in the watch list within 24 hours of this action.

Step 2 - Suspension of the Hospital

1. The Hospital can be temporarily suspended in the following cases:

a. For the Hospital which is on the “Watch-list” of the Insurer observes continuous
patterns or strong evidence of irregularity based on either claims data or field visit of
Hospitals, the Hospitals shall be suspended from providing services to Beneficiaries
and a formal investigation shall be instituted.
b. If a Hospital is not in the “Watch-list”, but the Insurer observes at any stage that it has
data/evidence that suggests that the Hospital is involved in any unethical practice/ is
not adhering to the major clauses of the contract with the Insurer involved in financial
fraud related to health insurance patients, it may immediately suspend the Hospital
from providing services to Beneficiaries and a formal investigation shall be instituted.

2. The Health Insurance Forum should be informed of the decision of suspension of

Provider within 24 hours of this action.

3. A formal letter shall be send to the Hospital regarding its suspension with mentioning the
timeframe within which the formal investigation will be completed.

Step 3 - Detailed Investigation

1. The Insurer can launch a detailed investigation into the activities of a Hospital in the
following conditions:
a. For the Hospitals which have been suspended.
b. Receipt of complaint of a serious nature from any of the stakeholders.

2. The detailed investigation may include field visits to the Hospitals, examination of case
papers, talking with the Beneficiaries (if needed), examination of Hospital records, etc.

3. If the investigation reveals that the report/complaint/allegation against the Hospital is not
substantiated, the Insurer would immediately revoke the suspension (in case it is
suspended) and inform the same to the Health Insurance Forum. A letter regarding
revocation of suspension shall be sent to the Hospital within 24 hours of that decision.

Step 4 - Action by the Insurer

1. If the investigation reveals that the complaint/allegation against the Hospital is correct then
the following procedure shall be followed:
a. The Hospital must be issued a “show-cause” notice seeking an explanation
for the aberration.

Page 31 of 50
 b. After receipt of the explanation and its examination, the charges may be
dropped or an action can be taken.
c. The action could entail one of the following based on the seriousness of the issue
and other factors involved:
I. A warning to the concerned Hospital
II. De-empanelment of the Hospital

2. The process should be completed within 30 days from the date of suspension.

Step 5 - Actions to be taken after De-empanelment

1. Insurer shall take the following action once a Hospital has been de-empanelled:
a. A letter shall be sent to the Hospital regarding this decision.
b. This information shall be sent to all other Insurers which are doing health insurance
business.
c. An FIR shall be lodged against the Hospital by the Insurer at the earliest in case the
de-empanelment is on account of fraud or a fraudulent activity.
d. The Insurer which had de-empanelled the Hospital may be advised to notify the
same in the local media, informing all Beneficiaries about the de-empanelment, so
that the Beneficiaries do not utilize the services of that particular Hospital.
e. If the Hospital appeals against the Insurer’s decision, the above actions shall be
subject to the dispute resolution process agreed in the Agreement. Grievance by the
Provider.

2. The Provider can approach the Grievance Redressal Committee constituted by the
Health Insurance Forum for the Redressal. The Grievance Redressal Committee will
take a final view within 30 days of the receipt of representation. However, the
Provider will continue to be de-empanelled till the time a final view by the Grievance
Redressal Committee.

3. Special Cases for De-empanelment

In the case where at the end of the Insurance policy if an insurance company does
not want to continue with the particular provider in district, it can de-empanel that
particular provider. However, it should be ensured that adequate numbers of
Providers are available in that area for the policyholders / insured.

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 SCHEDULE - IV

STANDARD DISCHARGE SUMMARY:

1. Components of standardization:
a. List of standard contents in the discharge summary.
b. Standard guidelines for preparing a discharge summary so that the interpretation of
the terms in the document and the information provided is uniform.

2. Standard Contents of Discharge Summary Format:

a. Patient’s Name*:
b. Telephone No / Mobile No*:
c. IPD No:
d. Admission No:
e. Treating Consultant/s Name, contact numbers and Department/Specialty :
f. Date of Admission with Time:
g. Date of Discharge with Time:
h. MLC No/FIR No*:
i. Provisional Diagnosis at the time of Admission:
j. Final Diagnosis at the time of Discharge:
k. ICD-10 code(s) or any other codes, as recommended by the Authority, for Final
diagnosis*:
l. Presenting Complaints with Duration and Reason for Admission:
m. Summary of Presenting Illness:
n. Key findings, on physical examination at the time of admission:
o. History of alcoholism, tobacco or substance abuse, if any:
p. Significant Past Medical and Surgical History, if any*:
q. Family History if significant/relevant to diagnosis or treatment:
r. Summary of key investigations during Hospitalization*:
s. Course in the Hospital including complications if any*:
t. Advice on Discharge*:
u. Name & Signature of treating Consultant/ Authorized Team Doctor:
v. Name & Signature of Patient / Attendant*:
* refer to guide notes below:

3. GUIDE NOTES FOR FILLING DISCHARGE SUMMARY FORMAT:

a. The patient’s name shall be the official name as appearing in the insurance policy
document and the attendants should be made aware that it cannot be changed
subsequently, because in some cases the attendants give the nick names which are
different from documented names. As a matter of abundant precaution, all personal
information should be shown to the patient/attendant and validated with their
signatures.
b. The contact numbers shall be specifically those of the patient and if pertaining to
attendant, the same should be mentioned.
c. Where applicable, copy of MLC/FIR needs to be attached
d. Desirable not mandatory.
e. Significant past medical and surgical history shall be relevant to present ailment and
shall provide the summary of treatment previously taken, reports of relevant tests
conducted during that period. In case history is not given by patient, it should be
specified as to who provided the same.
f. Summary of key investigations shall appear chronologically consolidated for each type
of investigation. If an investigation does not seem to be a logical requirement for the
main disease/line of treatment, the admitting consultant should justify the reason for
carrying out such test/investigation.
g. The course in the hospital shall specify the line of treatment, medications

Page 33 of 50
 administered, operative procedure carried out and if any complications arise during
course in the hospital, the same should be specified. If opinion from another doctor
from outside hospital is obtained, reason for same should be mentioned and also
who decided to take opinion i.e. whether the admitting and treating consultant wanted
the opinion as additional expertise or the patient relatives wanted the opinion for their
reassurance.
h. Discharge medication, precautions, diet regime, follow up consultation etc should be
specified. If patient suffers from any allergy, the same shall be mentioned.
i. The signatures/Thumb impression in the Discharge Summary and final hospital bill
shall be that of the patient because generally the patient is discharged after having
improved. In other cases like Death or incapacitation summary or transfer notes in
case of terminal illness, the attendant can sign, the inability of the patient to sign
should be recorded by the attending doctor.

Page 34 of 50
 SCHEDULE-V

PROCEDURE TO FURNISH THE STANDARD BILLING

STANDARD FORMAT FOR PROVIDER BILLS

1. Components of standardization: Standardization involves three components:
I. Bill Format.
II. Codes for billing items and nomenclature.
III. Standard guidelines for preparing the bills.
2. Format specified: The bill is expected to be in two formats.
i. The summary bill and
ii. The detailed breakup of the bills.
3. Explanation and Guidelines – Summary Bill
i. The summary format is annexed in the Schedule-IV A
ii. The Bill shall be generated on the letter head of the provider and in A4 size to
aid scanning.
iii. The summary bill shall not have any additional items (only 9)
iv. The provider has to mention the service tax number in case they charge
service tax to the insurance company.
v. The payer mentioned in the bill has to be necessarily the insurance company
and not the TPA
vi. In case of package charged for any procedure/treatment, the provider is
expected to mention the amount in serial no 9 only. Items beyond the
package are to be mentioned in serial numbers 1 to 8
vii. The patient/attendant signature is mandatory on the summary bill.
viii. The additional guidelines to fill the summary format shall be as below:

Field Name Remarks

Provider Name Legal entity name and not the trade name

Registration number of the provider with local authorities. Once the

Provider Registration
clinical establishments. (registration and regulation) bill, 2007 is
Number
passed, then registration number under this act

Address of the Facility where number is admitted. A provider can

Address
have more than one facility.

Unique number identifying the particular hospitalization of the

IP No
member

Patient Name Full name of the patient

Page 35 of 50
 Name of the Insurance company with whom the member is
insured. In case of cash patient then the field is to be left blank. If
Payer Name the bill is raised to more than one insurer then the primary insurer
who has given cashless is to be mentioned. The name of
insurance company needs to be mentioned.

Member address Full address of the member

Bill Number Bill number of the provider

Bill Date Date on which the bill is generated

PAN Number PAN Number - Mandatory

Registration number from service tax authorities. Mandatory in

Service Tax Regn No.
case service tax is charged in the bill

Date of admission of the member in case of IPD cases. In case of

Date of admission
Day care procedures, this is the date of procedure

Date of discharge of the member in case of IPD cases. In case of

Date of discharge Day care procedures, this is the date of procedure (same as date
of admission)

Bed number in which the patient is admitted. In case the member

Bed Number is admitted under more than one bed number, all the numbers
have to be mentioned.

All items under the primary head Rs.’100000’in the detailed bill
SL.No.1 of billing have to be summarized into this. In case the procedure is
Summary packages, then only bills amount beyond the package needs to be
mentioned here.

All items under the primary head Rs.’200000’ in the detailed bill
SL No.2 of billing
have to be summarized into this. In case the procedure is
Summary
packages, then only bills amount beyond the package need to be
mentioned here.

All items under the primary head Rs.’300000’ in the detailed bill
SL No.3 of billing have to be summarized into this. In case the procedure is
Summary packages, then only bills amount beyond the package needs to be
mentioned here.

All items under the primary head Rs.’400000’ in the detailed bill
SL No 4 of billing have to be summarized into this. In case the procedure is
Summary packages, then only bills amount beyond the package needs to be
mentioned here.

Page 36 of 50
 All items under the primary head Rs.’500000’ in the detailed bill
SL No 5 of billing have to be summarized into this. In case the procedure is
Summary packages, then only bills amount beyond the package needs to be
mentioned here.

All items under the primary head Rs.’600000’ in the detailed bill
SL No 6 of billing have to be summarized into this. In case the procedure is
Summary packages, then only bills amount beyond the package needs to be
mentioned here.

All items under the primary head Rs.’700000’ in the detailed bill
SL No 7 of billing have to be summarized into this. In case the procedure is
Summary packages, then only bills amount beyond the package needs to be
mentioned here

All items under the primary head Rs.’800000’ in the detailed bill
SL No 8 of billing have to be summarized into this. In case the procedure is
Summary packages, then only bills amount beyond the package needs to be
mentioned here

All items under the primary head Rs.’900000’ in the detailed bill
SL No 8 of billing have to be summarized into this. If more than one procedure is
Summary done. The total amount of the two procedures needs to be
summarized.

Total Bill amount Sum total of all items 1 to 9 in the bill

Amount paid by the Amount of bill paid by the member including co-pay, deductible,
member non-medical items etc including discount offered to member, if any.

Amount charged to
Amount payable by Insurance company
Payer

Discount Amount Amount offered as discount to the insurance company

Service Tax Service Tax chargeable to insurance company.

Amount Payable Total amount payable by insurance company including service tax.

Amount in Words Above amount in words for the sake of clarity

Signature of the patient or the attendant of the patient needs to be

Patients signature
mandatorily taken

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 Authorized signatory The signature of the authorized signatory at the provider

4. Explanation and Guidelines- Detailed Breakup of the Bill

i. The summary format is annexed in Schedule-IV-B

ii. The Bill shall be generated on the letter head of the provider and in A4 size paper to
aid scanning.

iii. The billing has to be done at lever 2 or 3

iv. In case of medicines/consumables. The relevant level code has to be mentioned

(40100, 401002) and the text should indicate the actual medicine used.
v. If providers have outsourced the pharmacy to external vendors, in such cases the
providers can attach the original bills separately; however, the summary
of this original bill has to be mentioned in the Summary bill.
vi. In case of pharmacy returns the same code originally used is to be used with a
negative sign in the units.
vii. In case of cancellation of any service the same code originally used is to be used with
a negative sign indicating reversal.
viii. The date on which the service is rendered is to be mentioned in the bill. This would be
a. the date of requisition in case of investigations.

b. date of consultation for professional fees

c. date of requisition in case of pharmacy/consumables irrespective of when

they were used.

d. date of return of pharmacy items for pharmacy returns.

ix. The additional guidelines to fill the summary format shall be as below, expect that the
first section of the bill is same as the bill summary referred in 3 above.

Field Name Remarks

Date on which service is rendered. For example, this is the date of

Date
investigation, date of procedure etc.

Code Level 2 or 3 code of the billing item as per the codes ( Part II )

Particulars Text explanation of the item charged

Rate Per unit price ( per day room rent, per consultation charges)

Unit No of units charged(hours, days, number as appropriate)

Amount Rate*unit(s)

Page 38 of 50
 Schedule-VA

SUMMARY BILL FORMAT

Provider Name …………………………….. Bill Number ………………………..

Provider
Bill Date
Registration No

Address PAN Number

Service Tax
IP No
Regn. No.

Date of
Patient Name
admission

XXXX Insurance Company Date of

Payer Name
Ltd Discharge

Member Address Bed Number

Billing Summary

Sl No Primary Code Particulars Amount

1 100000 Room& Nursing Charges

2 200000 ICU Charges

3 300000 OT Charges

4 400000 Medicine & Consumables

5 500000 Professional Fees’

6 600000 Investigation Charges

7 700000 Ambulance Charges

8 800000 Miscellaneous charges

9 900000 Package Charges

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Total Bill Amount 0

Amount paid by Member 0

Amount charged to Payer 0

Discount Amount 0

Service Tax 0

Amount Payable 0

Amount in words Rupees _______ only

Patients Signature Authorized

Signatory

Page 40 of 50
 Schedule-V B

DETAILED BREAKUP FORMAT

PART–I

Provider Name ........................ Bill Number ..............................

Provider registration No.

Bill Date

Address PAN Number

Service Tax Regn. No

IP No

Date of admission
Patient Name

Date of Discharge
Payer Name

Member Address Bed Number

Billing Details

Sl No Date Code Particulars Rate Nos(Unit) Amount

1 101001 General Ward 500 1 500-00

Charges

2 401001 XXX medicine 50 2 100-00

3 401001 XXX Medicine-return 50 -1 -50-00

PART-II:

Level Level
Level3 Remark
1 Level 1 2 Level 2 Level 3
Code s
Code Code
Room &
10000
Nursing
0
Charges
Room &
10000 10100 Room
Nursing 101001 General Ward charges
0 0 Charges
Charges
10000 Room & 10100 Room Semi-Private room
101002
0 Nursing 0 Charges charges

Page 41 of 50
 Charges
Room &
10000 10100 Room
Nursing 101003 Single room Charges
0 0 Charges
Charges
Room &
10000 10100 Room Single Deluxe room
Nursing 101004
0 0 Charges Charges
Charges
Room &
10000 10100 Room
Nursing 101005 Deluxe room Charges
0 0 Charges
Charges
Room &
10000 10100 Room
Nursing 101006 Suite Charges
0 0 Charges
Charges
Room &
10000 10100 Room
Nursing 101007 Electricity charges
0 0 Charges
Charges
Room &
10000 10100 Room
Nursing 101008 Bed Sheet charges
0 0 Charges
Charges
Room &
10000 10100 Room
Nursing 101009 Hot water charges
0 0 Charges
Charges
Room &
10000 10100 Room Establishment
Nursing 101010
0 0 Charges Charges
Charges
Room &
10000 10100 Room Alpha/Water Bed
Nursing 101011
0 0 Charges Charges
Charges
Room &
10000 10100 Room Attendant Bed
Nursing 101012
0 0 Charges Charges
Charges
Room &
10000 10200 Nursing
Nursing
0 0 Charges
Charges
Room &
10000 10200 Nursing
Nursing 102001 Nursing fees
0 0 Charges
Charges
Room &
10000 10200 Nursing
Nursing 102002 Dressing
0 0 Charges
Charges
Room &
10000 10200 Nursing
Nursing 102003 Nebulisation
0 0 Charges
Charges
Room &
10000 10200 Nursing
Nursing 102004 Injection charges
0 0 Charges
Charges
10000 Room & 10200 Nursing
102005 Infusion Pump charges
0 Nursing 0 Charges

Page 42 of 50
 Charges
Room &
10000 10200 Nursing
Nursing 102006 Aya Charges
0 0 Charges
Charges
Room &
10000 10200 Nursing Blood Transfusion
Nursing 102007
0 0 Charges Charges
Charges
Room &
10000 10300 Duty Doctor
Nursing
0 0 fee
Charges
Room &
10000 10300 Duty Doctor
Nursing 103001 Duty Doctor fee
0 0 fee
Charges
Room &
10000 10300 Duty Doctor
Nursing 103002 RMO Fees
0 0 fee
Charges
Room &
10000 10400 Monitor
Nursing
0 0 Charges
Charges
If used
Room &
10000 10400 Monitor Pulse Oxymeter in
Nursing 104001
0 0 Charges charges Normal
Charges
Room
20000 ICU
0 Charges
20000 ICU 20000
ICU Charges
0 Charges 0
20000 ICU 20000
ICU Charges 201001 Burns Ward
0 Charges 0
20000 ICU 20000
ICU Charges 201002 HDU charges
0 Charges 0
20000 ICU 20000
ICU Charges 201003 ICCU charges
0 Charges 0
20000 ICU 20000
ICU Charges 201004 Isolation ward charges
0 Charges 0
20000 ICU 20000
ICU Charges 201005 Neuro ICU charges
0 Charges 0
20000 ICU 20000 Paediatric/neonatal
ICU Charges 201006
0 Charges 0 ICU charges
20000 ICU 20000
ICU Charges 201007 Post-Operative ICU
0 Charges 0
20000 ICU 20000
ICU Charges 201008
0 Charges 0
20000 ICU 20000
ICU Charges 201009
0 Charges 0
20000 ICU 20100 ICU Nursing If ICU
0 Charges 0 charges nursing

Page 43 of 50
 charged
separat
ely
30000 OT
0 Charges
OT
30000 OT 30200
Equipment 302001 C-arm charges
0 Charges 0
charges
OT
30000 OT 30200
Equipment 302002 Endoscopy charges
0 Charges 0
charges
OT
30000 OT 30200
Equipment 302003 Laparoscope charges
0 Charges 0
charges
OT If not
30000 OT 30200
Equipment 302004 Equipment charges specifie
0 Charges 0
charges d
OT For OT
30000 OT 30200
Equipment 302005 Monitor charges monitori
0 Charges 0
charges ng
OT for OT
30000 OT 30200
Equipment 302006 Instrument charges Instrum
0 Charges 0
charges ents
30000 OT 30300 OT Drugs &
0 Charges 0 Consumables
30000 OT 30300 OT Drugs &
303001 OT Drugs
0 Charges 0 Consumables
30000 OT 30300 OT Drugs &
303002 Implants
0 Charges 0 Consumables
Include
d guide
30000 OT 30300 OT Drugs &
303003 OT Consumables wires,
0 Charges 0 Consumables
catheter
etc.
30000 OT 30300 OT Drugs &
303004 OT Materials
0 Charges 0 Consumables
30000 OT 30300 OT Drugs &
303005 OT Gases
0 Charges 0 Consumables
30000 OT 30300 OT Drugs &
303006 Anaesthetic drugs
0 Charges 0 Consumables
30000 OT 30400 OT
0 Charges 0 Sterilization
30000 OT 30400 OT
304001 CSSD Charges
0 Charges 0 Sterilization
Medicine &
40000 Consumabl
0 es
Charges

Page 44 of 50
 Medicine & Medicine &
40000 40100
Consumabl Consumables
0 0
es charges charges
OT
Medicine &
Medicine & drugs
40000 Consumabl 40100
Consumables 401001 Ward Medicines under,
0 es 0
charges OT
Charges
charges
Medicine &
Medicine &
40000 Consumabl 40100
Consumables 401002 Ward Consumables
0 es 0
charges
Charges
Medicine &
Medicine &
40000 Consumabl 40100
Consumables 401003 Ward disposables
0 es 0
charges
Charges
Medicine &
Medicine &
40000 Consumabl 40100
Consumables 401004 Ward Materials
0 es 0
charges
Charges
Medicine &
Medicine &
40000 Consumabl 40100
Consumables 401005 Vaccination drugs
0 es 0
charges
Charges
Profession
50000
al fees
0
charges
Profession
50000 50100
al fees Visit charges
0 0
charges
Profession
50000 50100
al fees Visit charges 501001 Consultation charges
0 0
charges
Profession
50000 50100 Medical Supervision
al fees Visit charges 501002
0 0 Charges
charges
Profession
50000 50100
al fees Visit charges 501003 Professional fees
0 0
charges
Profession
50000 50200 Surgery
al fees
0 0 charges
charges
Profession
50000 50200 Surgery
al fees 502001 Surgeons Charges
0 0 charges
charges
Would
Profession also
50000 50200 Surgery Assistant Surgeons
al fees 502002 include
0 0 charges Fee
charges standby
Surgeo

Page 45 of 50
 n
Profession
50000 50300 Anaesthetists
al fees
0 0 Fee
charges
Profession
50000 50300 Anaesthetists
al fees 503001 Anaesthetists fee
0 0 Fee
charges
Provider
Profession
50000 50300 Anaesthetists s
al fees 503002 OT standby charges
0 0 Fee charges
charges
for
Profession
50000 50400 Intensivist
al fees 504000
0 0 charges
charges
Cathete
rization,
Central
Profession
50000 50400 Procedure IV Line,
al fees 504001 Beside procedures
0 0 charges Tracheo
charges
s tomy,
Venese
ction
Profession
50000 50400 Procedure
al fees 504002 Suture charges
0 0 charges
charges
Profession
50000 50500
al fees Physiotherapy 501001
0 0
charges
Profession
50000 50500 Technician OT/Cath Lab
al fees 505000
0 0 charges Technician
charges
60000 Investigatio
0 n charges
Serum
60000 Investigatio 60100 Sodium
Bio Chemistry
0 n charges 0 ueres
etc
Chroso
60000 Investigatio 60100 Medical mal
0 n Charges 0 Genetics Analysis
etc
for
procedu
60000 Investigatio 60200 Cardiology res like
0 n charges 0 charges echo,
ECG
etc
Cross
60000 Investigatio 60300 Haematology
matchin
0 n charges 0 charges
g etc

Page 46 of 50
 Blood
60000 Investigatio 60400 Microbiology
culture
0 n charges 0 charges
C&S
For
60000 Investigatio 60500
Neurology EMG,E
0 n charges 0
EG etc
PET
CT,
60000 Investigatio 60600 Nuclear
Bone
0 n Charges 0 medicine
Scan
etc.
60000 Investigatio 60700 Pathology
0 n Charges 0 charges
X-ray,
60000 Investigatio 60800 Radiology
CT, MRI
0 n Charges 0 services
etc.
60000 Investigatio 60900 Serology
0 n Charges 0 charges
Profiles
instead
of
60000 Investigatio 61100 individu
profiles
0 n Charges 0 al tests
(Lipid
profile,
LFT etc)
70000 Ambulance
0 Charges
70000 Ambulance 70100 Ambulance
0 Charges 0 Charges
Miscellane
80000
ous
0
Charges
Miscellane
80000 80100 Admission
ous
0 0 charges
Charges
Miscellane
80000 80200 Attendant
ous
0 0 food charges
Charges
Miscellane
80000 80300 Patient food
ous
0 0 charges
Charges
Miscellane
80000 80400 Registration
ous
0 0 charges
Charges
Miscellane
80000 80500
ous MRD Charges
0 0
Charges
80000 Miscellane 80600 Documentatio

Page 47 of 50
0 ous 0 n charges
Charges
Miscellane
80000 80700 Telephone
ous
0 0 Charges
Charges
Miscellane Bio Medical
80000 80800
ous Waste
0 0
Charges charges
Excludi
Miscellane Luxury ng VAT
80000 80900
ous Taxes Tax/Surcharge/Service &
0 0
Charges Charges Service
Tax
To be
used
90000 Package only in
0 Charges case of
packag
es
To be
used
ICD -
90000 Package 90100 Cardiac only in
10- CABG
0 Charges 0 Surgery case of
PCS
packag
es
To be
used
ICD-
90000 Package 90200 Cardiology only in
10- PTCA
0 Charges 0 packages case of
PCS
packag
es
To be
used
ICD-
90000 Package 90300 only in
Cath Lab 10- CAG
0 Charges 0 case of
PCS
packag
es
To be
used
ICD-
90000 Package 90400 Dental only in
10- Root Canal Treatment
0 Charges 0 Procedures case of
PCS
packag
es
To be
used
ICD-
90000 Package 90500 only in
ENT 10- FESS
0 Charges 0 case of
PCS
packag
es
90000 Package 90600 Gastroenterol ICD- To be
Gastrectomy-Partial
0 Charges 0 ogy 10- used

Page 48 of 50
 PCS only in
case of
packag
es
To be
used
ICD-
90000 Package 90700 General only in
10- Inguinal hernia
0 Charges 0 Surgery case of
PCS
packag
es
To be
used
ICD-
90000 Package 90800 only in
Gynaecology 10- LSCS
0 Charges 0 case of
PCS
packag
es
To be
used
ICD-
90000 Package 90900 only in
Nephrology 10- Nephrectomy
0 Charges 0 case of
PCS
packag
es
To be
used
ICD-
90000 Package 91000 Neuro only in
10- Craniotomy
0 Charges 0 Surgery case of
PCS
packag
es
To be
used
ICD-
90000 Package 91100 Oncology only in
10- IMRT
0 Charges 0 Procedures case of
PCS
packag
es
To be
used
ICD-
90000 Package 91200 Ophthalmolog only in
10- Cataract
0 Charges 0 y Procedures case of
PCS
packag
es
To be
used
ICD-
90000 Package 91300 only in
Orthopaedic 10- Bilateral TKR
0 Charges 0 case of
PCS
packag
es
To be
used
ICD-
90000 Package 91400 Plastic only in
10- Skin Grafting
0 Charges 0 Surgery case of
PCS
packag
es

Page 49 of 50
 To be
used
ICD-
90000 Package 91500 only in
Pulmonology 10- Pleural Tapping
0 Charges 0 case of
PCS
packag
es
To be
used
ICD-
90000 Package 91600 only in
Urology 10- ERCP
0 Charges 0 case of
PCS
packag
es
To be
used
ICD-
90000 Package 91700 Vascular only in
10- Embolectomy
0 Charges 0 Surgery case of
PCS
packag
es

Page 50 of 50