<Stamp Paper of appropriate value>
SUPPLEMENTARY AGREEMENT TO THE AGREEMENT
BETWEEN
GOVT. OF [NAME OF THE STATE]
AND
[NAME OF THE INSURANCE COMPANY]
UNDER RASHTRIYA SWASTHYA BIMA YOJANA (RSBY)
This Agreement made at ______day of ______2014.
BETWEEN
(1) THE GOVERNMENT OF THE STATE OF [Name of the State], represented by the Secretary to the Department ______, Government of [Name of the State], having its principal office at [insert address] (being represented by the State Nodal Agency having its principal office at [insert address] (here and after referred to as SNA or 1st party which expression shall, unless repugnant to the context or meaning thereof, be deemed to mean and include its successors and permitted assigns);
AND
(2) [Name of the Insurance Company], an insurance company registered with the Insurance Regulatory & Development Authority having registration number [insert number] and having its registered office at [insert address] (hereinafter referred to as the Insurer or 2nd Party which expression shall, unless repugnant to the context or meaning thereof, be deemed to mean and include its successors and permitted assigns).
The State Nodal Agency and the Insurer shall collectively be referred to as the Parties and individually as the Party.
There is a clear understanding between the parties to this supplementary agreement issued as a part of the “Main (existing) Agreement” and that this supplementary agreement shall be considered an integral part of “Main Agreement” between both parties (i.e. State Nodal Agency and Insurer).
WHEREAS
A. The "Rashtriya Swasthya Bima Yojana" (the RSBY), a Central Sponsored Scheme (CSS) of the Government of India, requires Insurance Companies to provide health insurance cover to the extent of Rs. 30,000 on a floater and cashless basis through an established network of health care providers to the RSBY Beneficiary Family Units (RSBY will be known as the Scheme).
B. The scheme funded by the Government of India, i.e. 75% of premium is paid by central government, while remaining 25% of premium is paid by state government (applicable changes to the above to 90% & 10% in case of north eastern states and Jammu and Kashmir, respectively).
C. The Government of [Name of the State] is implementing RSBY in [Number of Districts] districts namely [Name of the Districts] through the [Name of the Insurance Company].
D. The Government of [Name of the State] has decided to include additional clauses to measure and monitor the performance of the insurance companies and include other measures under the RSBY scheme;
E. There is a clear understanding between the parties to this supplementary agreement issued as a part of the “Main (existing) Agreement” and that this supplementary agreement shall be considered an integral part of the “Main Agreement” between both parties (i.e. State Nodal Agency and Insurer).
NOW THEREFORE this supplementary agreement sets out the parameters to monitor the performance of the insurance company, and also related to penalties and premium refund.
General Conditions
1. Definitions & Interpretation
1.1. The definitions and interpretations mentioned in the Main Agreement shall also be applicable to this Supplementary agreement. In addition to those, the following terms and expressions shall have the meaning, for purposes of this Supplementary Agreement, as indicated below:
A. “Monitoring Parameters” shall mean the performance parameters to monitor the performance of the insurance company for the Insurance Companies as set out in para 2.2 and 2.3 herein below.
B. “Premium Refund” shall mean the amount of premium that will be refunded by the Insurance Company as per defined guidelines, as defined in para 2.2 herein below.
2. Performance Evaluation
2.1. THAT the parties hereby agree that the Government shall monitor the performance of the Insurance Company based on the defined parameters and impose such conditions as outlined in this document.
2.2. Monitoring parameters
2.2.1. That the performance of Insurance Company shall be monitored on the parameters provided in Annexure I of this supplementary agreement.
2.2.2. That for the purpose of evaluation MoLE may make use of the information collected as part of implementation or monitoring of RSBY. Where there is a variance between facts as claimed by insurance company and as revealed from the data available with MoLE, decisions shall be based on the data available with MoLE, SNAs and reports from SNAs, Grievance Redressal Mechanism etc.
2.2.3. That there may be cases where condition at Sr. No 2,3 & 4 of Annexure-I related to hospital empanelment may not be fulfilled due to limited availability of the hospitals for the empanelment. In all such cases, the Insurance Company shall obtain a certificate from the District Administration regarding non-availability of the hospitals and in such a case, if Insurance Company is able to submit the certificate, then value attached to these parameters shall not be considered while calculating the threshold limits under Annexure 1.
2.2.4. That failure to meet the minimum performance criteria of marks would render the insurance company
2.2.4.1. Liable to such deduction of premium as stipulated Annexure 1 of this document
2.2.4.2. Liable for its de-empanelment from “Empaneled List of Insurers” by MOLE when exceeding the threshold limit set in Annexure 1 of the document.
2.3. That the conditions of the Supplementary Agreement shall apply to the period of starting ______and ending on midnight of ______.
2.4. That the performance evaluation of insurance company, on parameters of Annexure I of this Supplementary Agreement shall be conducted by SNA on a bi-annual basis.
3. Premium Refund
3.1. THAT the Insurance Company shall be required to refund premium as stipulated below if they fail to reach the claim ratio specified below at the full period of insurance Policy.
3.2. THAT the Premium Refund shall be as per the formula below:
3.2.1. In case the claim ratio [(Claims paid / Premium received)] is less than 70% then the Insurance Company will return the difference between actual claim ratio and 70% to SNA.
3.2.2. The claims data shall be updated by the insurance company within 30 days of submission of claims by the hospital.
3.2.3. This refund amount will be returned within 90 days of end of the policy.
3.2.4. SNA shall return back proportionate central share to MoLE once the premium is refunded by the Insurance Company.
4. Other conditions
4.1. That the insurer specifically agrees that it would abide by all the changes in operations and would deliver all its obligations as per revised guidelines/manuals issued by the MoLE.
4.2. That the insurer will provide a copy of all MIS reports as per the revised guidelines/manuals, to SNA as well as to MoLE on a monthly basis or any other information as may be requested by SNA/MoLE.
IN WITNESS WHEREOF, the Parties have caused this Agreement to be signed sealed and delivered by their duly authorized representatives on the day month and year first hereinabove written.
1. 2.
SIGNED, SEALED and DELIVERED / SIGNED, SEALED and DELIVEREDfor & on behalf of
the First Party / for & on behalf of
the Second Party
Government of ______/
______
9
Annexure-I – Monitoring Parameters to Measure the Performance of the Insurance Company
S. No / SLA’s / Source of data / Monitoring method / Periodicity / Points criteriaSettlement of Claims
1. / Settlement of claims within 30 days / Computed from the claim settlement data in RSBY Central Server / The ratio of claims amount which have not been paid or rejected within 30 days (from the date of claims raised to the insurance company) to the total claims amount made to the insurance company. / Based on the claim made within 12 months of the policy period. / If 10% of claims remain unpaid at the end of 30 days – 5 Points
If between 10% and 25% of the claims remain unpaid after 30 days – 10 Points
If between 25% - 40% of the claims remain unpaid after 30 days – 15 Points
Empanelment and De-Empanelment of Heath Care Service Providers or Hospitals
2. / At least 2 hospitals to be empanelled in each block. / List of empanelled hospitals to be provided by the Insurance Company to SNA clearly identifying hospitals in each block. The claim regarding non availability of hospitals for enrolment to be verified by SNA / Number of blocks with less than two empanelled hospitals. Blocks where district authorities or SNA certify that two hospitals are not available for empanelment shall be excluded from assessment. / Assessed 15 days prior to the commencement of policy / Every block where less than 1 hospitals have been empanelled – 5 Points
[Will not apply if no hospitals are available for empanelment as per certificate produced]
Every block where more than 1 and less than 2 hospitals have been empanelled – 3 Points
[Will not apply if only 1 hospitals is available for empanelment as per certificate produced]
There should be at least one hospital for every 8000 families enrolled in the scheme / List of empanelled hospitals to be provided by the insurance company to the SNA / Number if beneficiaries in the cluster of districts divided by the number of empanelled hospitals
Districts where district authorities or SNA certify that required numbers of hospitals are not available for empanelment shall be excluded from assessment. / Assessed 15 days prior to the commencement of policy / If atleast 1 healthcare provider is empanelled in each district on every 8000 - 9000 families enrolled till the start of policy – 1 Point
If atleast 1 healthcare provider is empanelled in each district on every 9000 - 10000 families enrolled till the start of policy – 3 Point
If atleast 1 healthcare provider is empanelled in each district for more than 10000 families enrolled till the start of policy – 5 Point
Districts where district authorities or SNA certify that required numbers of hospitals are not available for empanelment shall be excluded from assessment.
3 / There shall be at least 5 hospitals in the district headquarters. / List of empanelled hospitals to be provided by the Insurance Company to SNA clearly identifying hospitals in each district. The claim regarding non availability of hospitals for enrolment to be verified by SNA / For number of districts with less than five empanelled hospitals, where district authorities or SNA certify that five hospitals are not available for empanelment shall be excluded from assessment / Assessed 15 days prior to the commencement of policy / Every district headquarters where less than 3 hospitals have been empanelled – 5 Points
[Will not apply if no hospitals are available for empanelment as per certificate produced]
Every district headquarters where 3 to 5 hospitals have been empanelled – 3 Points
[Will not apply if only 1 hospital is available for empanelment as per certificate produced]
4. / The following specialties’ shall be available through empanelled hospitals in each district.
a. General Medicine
b. General surgery
c. Obstetrics and Gynaecology
d. Paediatrics
e. Ophthalmology
f. ENT
g. Orthopaedic / List of specialties in the empanelled hospital to be provided by the insurance company to SNA / Total number of specialties available across all hospitals for each district.
Districts where district authorities or SNA certify that required numbers of hospitals are not available for empanelment shall be excluded from assessment. / Assessed 15 days prior to the commencement of policy / If 5 specialties available in each district till the start of policy – 3 Points
If 3-4 specialties available in each district till the start of policy – 5 Points
Other Issues Related to Enrolment
5. / Preparation of brochures to be given to the beneficiaries. / A printed brochure with a certificate from the printer showing the number of copies printed is produced before SNA. / Brochures at least equal to the number of beneficiaries is printed and distributed to insured families at all enrolment stations. / 15 days before the commencement of enrolment / IF brochure not shared with the SNA till the start of the enrolment – 6 Points
IF brochure not share with the SNA at all – 10 Points
Setting up of District Kiosk by insurance company
6. / Set up and operationalize RSBY kiosks according to the guidelines. / Report from district officers that kiosks as per Concession agreement have been set up / Kiosks as per the Concession agreement are set up and available for use by eligible beneficiaries / 7 days Before commencement of enrolment / IF not set up 7 days prior to the commencement of enrolment – 3 Points.
IF not set up till one month from the commencement of enrolment – 5 Points
Manpower requirements
7. / Human resources as per the guidelines of the scheme / Report from insurance company / Details of the manpower on the letterhead of the insurance company to be given to SNA / At least 15 days before start of policy / If not appointed till the start of policy – 3
If not appointed till 15 days policy 5
Organizing workshops
8. / Organizing of all workshops as per the guidelines / Report from insurance company / Report by insurance company to SNA within 7 days of workshop / At least 7 days before start of policy period / If not conducted till the start of policy – 3
If not conducted till 1 month from the start of policy -5
District office set up by insurer
9. / District office in all districts being served / List of offices with their contact details provided to SNA by insurance company / District offices are established and staffed / Within 15 days from signing of contract / If not set up within 1 month from signing of the contract – 5 points
Performance severity: