Common use of Benefit Package Clause in Contracts

Benefit Package. The Benefits within this scheme, to be provided on a cashless basis to the Beneficiaries up to the limit of their annual coverage, package charges on specific procedures and subject to other terms and conditions outlined herein, are the following: a. The scheme shall provide coverage for meeting expenses of hospitalization for medical and/or surgical procedures including maternity benefit, to the enrolled families for up to Rs.30,000 per family per year subject to limits, in any of the empanelled hospitals across India. The benefit to the family will be on floater basis, i.e., the total reimbursement of Rs.30,000 can be availed individually or collectively by members of the family per year. b. Pre-existing conditions/diseases are to be covered from the first day of the start of policy, subject to the exclusions given in Appendix 1. c. Coverage of health services related to surgical nature for defined procedures shall also be provided on a day care basis. The Insurance Company shall provide coverage for the defined day care treatments/ procedures as given in Appendix 2. d. Provision for transport allowance of Rs. 100 per hospitalization subject to an annual ceiling of Rs. 1000 shall be a part of the package. This will be provided by the hospital to the beneficiary at the time of discharge in cash. e. Pre and post hospitalization costs up to 1 day prior to hospitalization and up to 5 days from the date of discharge from the hospital shall be part of the package rates. f. Maternity and Newborn Child will be covered as indicated below: I. It shall include treatment taken in hospital/nursing home arising out of childbirth, including normal delivery / caesarean section and/ or miscarriage or abortion induced by accident or other medical emergency subject to exclusions given in Appendix 1. II. Newborn child shall be automatically covered from birth upto the expiry of the policy for that year for all the expenses incurred in taking treatment at the hospital as in-patient. This benefit shall be a part of basic sum insured and new born will be considered as a part of insured family member till the expiry of the policy subject to exclusions given in Appendix 1. III. The coverage shall be from day one of the inception of the policy. However, normal hospitalisation period for both mother and child should not be less than 48 hours post delivery. i. For the ongoing policy period until its renewal, new born will be provided all benefits under RSBY and will NOT be counted as a separate member even if five members of the family are already enrolled . ii. Verification for the new born can be done by any of the existing family members who are enrolled in RSBY through the same smart card as that of the mother. g. Domiciliary treatment: Not Covered

Benefit Package. The Benefits within this scheme, to be provided on a cashless basis to the Beneficiaries up to the limit of their annual coverage, package charges on specific procedures and subject to other terms and conditions outlined herein, are the following: a. The scheme shall provide coverage for meeting expenses of hospitalization for medical and/or surgical procedures including maternity benefit, to the enrolled families for up to Rs.30,000 per family per year subject to limits, in any of the empanelled hospitals across India. The benefit to the family will be on floater basis, i.e., the total reimbursement of Rs.30,000 can be availed individually or collectively by members of the family per year. b. Pre-existing conditions/diseases are to be covered from the first day of the start of policy, subject to the exclusions given in Appendix 1. c. Coverage of health services related to surgical nature for defined procedures shall also be provided on a day care basis. The Insurance Company shall provide coverage for the defined day care treatments/ procedures as given in Appendix 2. d. Provision for transport allowance of Rs. 100 per hospitalization subject to an annual ceiling of Rs. 1000 shall be a part of the package. This will be provided by the hospital to the beneficiary at the time of discharge in cash. e. Pre and post hospitalization costs hospitalizationcosts up to 1 day prior to hospitalization and up to 5 days from the date of discharge from the hospital shall be part of the package rates. f. Maternity and Newborn Child will be covered as indicated below: I. It shall include treatment taken in hospital/nursing home arising out of childbirth, including normal delivery / caesarean section and/ sectionand/ or miscarriage or abortion induced by accident or other medical emergency subject to exclusions given in Appendix 1. II. Newborn child shall be automatically covered from birth upto the expiry of the policy for that year for all the expenses incurred in taking treatment at the hospital as in-patient. This benefit shall be a part of basic sum insured and new born will be considered as a part of insured family member till the expiry of the policy subject to exclusions given in Appendix 1. III. The coverage shall be from day one of the inception of the policy. However, normal hospitalisation period for both mother and child should not be less than 48 hours post delivery. i. For the ongoing policy period until its renewal, new born will be provided all benefits under RSBY and will NOT be counted as a separate member even if five members of the family are already enrolled . ii. Verification for the new born can be done by any of the existing family members who are enrolled in RSBY through the same smart card as that of the mother. g. Domiciliary treatment: :Not Covered

Benefit Package. AB-PMJAY Cover The Benefits benefits within this scheme, Scheme under the Risk Cover are to be provided on a cashless basis to the AB-PMJAY Beneficiaries up to the limit of their annual coverage, package charges on specific procedures coverage and subject to other terms includes: Hospitalization expense benefits Day care treatment benefits (as applicable) Follow-up care benefits Pre- and conditions outlined herein, post-hospitalization expense benefits Newborn child/ children benefits The details of benefit packages are the following: a. The scheme shall provide coverage for meeting expenses of hospitalization for medical and/or surgical procedures including maternity benefit, furnished in Schedule 3: ‘Packages and Rates’ and exclusions are furnished in Schedule 2: ‘Exclusions to the enrolled families Policy’. For availing select treatment in any empanelled hospitals, preauthorisation is required to be taken for defined cases. Except for exclusions listed in Schedule 2, treatment/procedures will also be allowed, in addition to the procedures listed in Schedule 3, of up to Rs.30,000 per family per year subject a limit of Rs. 1,00,000 to limits, in any AB-PMJAY Beneficiary (called ‘Unspecified Procedure’) within the overall limit of the empanelled hospitals across IndiaRs. The benefit 5,00,000. Operations pertaining to the family will be on floater basis, i.e., the total reimbursement of Rs.30,000 can be availed individually or collectively by members of the family per year. b. Pre-existing conditions/diseases Unspecified Procedure are to be covered from governed as per Unspecified Packages Guidelines provided under Schedule 3 (b). The SHA shall reimburse claims of Empanelled Health Care Provider under the first AB-PMJAY based on Package Rates determined as follows: If the package rate for a medical treatment or surgical procedure requiring Hospitalization or Day Care Treatment (as applicable) is fixed in Schedule 3, then the Package Rate so fixed shall apply for the Policy Cover Period. If the package rate for a surgical procedure requiring Hospitalization or Day Care Treatment (as applicable) is not listed in Schedule 3, then the ISA may pre-authorise an appropriate amount based on rates for similar procedures defined in Schedule 3 or based on other applicable national or state health insurance schemes such as CGHS. In case of medical care, the rate will be calculated on per day basis as specified in schedule 3 except for special inputs like High end radiological diagnostic and High-end histopathology (Biopsies) and advanced serology investigations packages or some other special inputs existing in the HBP (or are released by NHA in future) which can be clubbed with medical packages PM-▇▇▇ is a cashless scheme where no beneficiary should be made to pay for availing treatment in any empanelled hospitals. However, upon exhaustion of the beneficiary PM-▇▇▇ ▇▇▇▇▇▇ of Rs. 5.00 Lakhs, or if the treatment cost exceeds the benefit coverage amount available with the beneficiary families then the Beneficiary and SHA (through ISA/TPA) will need to be clearly communicated in advance about the additional payment at the start of policysuch treatment. In case an AB-PMJAY Beneficiary is required to undertake multiple surgical procedures in one OT session, then the procedure with highest rate shall be considered as the primary package and reimbursed at 100%, thereupon the 2nd surgical procedure shall be reimbursed at 50% of package rate, 3rd and subsequent surgical procedures shall be reimbursed at 25% of the package rate. Surgical and Medical packages will not be allowed to be availed at the same time (Except for certain add on procedures as defined in Schedule 3 and configured in NTMS). In exceptional circumstances, hospital may raise a request for such pre-auth which will be decided by ▇▇▇ with the help of concerned medical specialist. Certain packages as mentioned in Schedule 3 will only be reserved for Public EHCPs as decided by the SHA (instructions to the state: categorically mention such procedures in schedule 3). The state may permit availing of these packages in Private EHCPs only after a referral from a Public EHCP is made. Some modifications (in not more than 10% of total number of packages) may be done by SHA in this regard. Incentivization will be provided to certain hospitals {as defined in schedule 3 (c)} which will be over and above the rates defined in Schedule 3. For the purpose of Hospitalization expenses as package rates shall include all the costs associated with the treatment, amongst other things: Registration charges. Bed charges Nursing and boarding charges. Surgeons, Anaesthetists, Medical Practitioner, Consultants fees etc. Anaesthesia, Blood Transfusion, Oxygen, O.T. Charges, Cost of Surgical Appliances etc. Medicines and drugs. Cost of prosthetic devices, implants etc. Pathology and radiology tests: Medical procedures include basic Radiological imaging and diagnostic tests such as X-ray, USG, Haematology, pathology etc. However, High end radiological diagnostic and High-end histopathology (Biopsies) and advanced serology investigations packages can be booked as a separate add-on procedure if required. Surgical packages are all inclusive and do not permit addition of other diagnostic packages. Food to patient. Pre and Post Hospitalization expenses: Expenses incurred for consultation, diagnostic tests and medicines prior to admission of the patient in the same hospital and cost of diagnostic tests and medicines up to 15 days after discharge from the hospital for the same ailment / surgery. Any other expenses related to the treatment of the patient in the hospital. For the purpose of Day Care Treatment expenses shall include, amongst other things: Registration charges; Surgeons, anaesthetists, Medical Practitioners, consultants’ fees, etc.; Anaesthesia, blood transfusion, oxygen, operation theatre charges, cost of surgical appliances, etc.; Medicines and drugs; Cost of prosthetic devices, implants, organs, etc. Pathology and radiology tests: Medical procedures include basic Radiological imaging and diagnostic tests such as X-ray, USG, Haematology, pathology etc. However, High end radiological diagnostic and High-end histopathology (Biopsies) and advanced serology investigations packages can be booked as a separate add-on procedure if required. Surgical packages are all inclusive and do not permit addition of other diagnostic packages. Pre and Post Hospitalization expenses: Expenses incurred for consultation, diagnostic tests and medicines prior to admission of the patient in the same hospital and cost of diagnostic tests and medicines up to 15 days after discharge from the hospital for the same ailment / surgery. Any other expenses related to the Day Care Treatment provided to the Beneficiary by an Empanelled Health Care Provider. Revision/Stratification of Package Rates during Term of the contract: In case of any revision / stratification of package rates, ISA shall not claim any additional financial implication due to the same. The SHA agrees to publish the Package Rates on its website in advance of each Policy Cover Period. In case of addition of new packages or revision/stratification of existing packages during the policy cover, SHA will add these to the list available on website. As part of the regular review process, the Parties (the ISA and EHCP) shall review information on incidence of common medical treatments or surgical procedures that are not listed in Schedule 3 and that require hospitalization or day care treatments (as applicable). No claim processing of package rate for a medical treatment or surgical procedure or day care treatment (as applicable) that is determined or revised shall exceed the sum total of Risk Cover for a AB-PMJAY Beneficiary Family Unit. However, upon exhaustion of the beneficiary PM-▇▇▇ ▇▇▇▇▇▇ of Rs. 5.00 Lakhs, or if the treatment cost exceeds the benefit coverage amount available with the beneficiary families then the Beneficiary and SHA (through ISA/TPA) will need to be clearly communicated in advance about the additional payment at the start of such treatment Benefits Available only through Empanelled Health Care Providers The benefits under the AB-PMJAY Risk Cover shall only be available to a AB-PMJAY Beneficiary through an EHCP after Aadhaar based identification as far as possible. In case Aadhaar is not available then other defined Government recognised ID will be used for this purpose. State Government shall share with the ISA within 7 days of signing the agreement a list of defined Government IDs. The benefits under the AB-PMJAY Cover shall, subject to the exclusions given available AB-PMJAY Sum Insured, be available to the AB-PMJAY Beneficiary on a cashless and paperless basis at any EHCP. Specialized tertiary level services shall be available and offered only by the EHCP empanelled for that particular service. Not all EHCPs can offer all tertiary level services, unless they are specifically designated by the SHA for offering such tertiary level services. Identification of AB-PMJAY Beneficiary Family Units Identification of AB-NHPM Beneficiary Family Units is based on the deprivation criteria of D1, D2, D3, D4, D5 and D7, Automatically Included category and 11 broadly defined occupational un-organised workers (in Appendix 1Urban Sector) of the Socio-Economic Caste Census (SECC) database of the State/ UT along with the existing enrolled RSBY Beneficiary Families not figuring in the SECC Database. The beneficiaries will be verified using Aadhaar(or an alternative government ID) and Ration Card (or an alternative family ID)/ produced by the beneficiary from empanelled hospitals. Once successfully verified, the beneficiary will be provided with a print of AB-PMJAY e-card which can be used as reference while availing benefits. Beneficiary Identification and Verification will be carried out by ▇▇▇ and who will issue an ‘e-card’ to the verified AB-PMJAY Beneficiary as per BIS Guidelines provided under Schedule 4. The role of ISA is only for approval of e-cards based upon the documents provided. In case of any issue, the ISA shall only recommend for rejection for e-card request to the SHA. Decision to reject an E-card shall rest only with SHA based on the SHA’s due dilligence. Brief process flow of Beneficiary Identification System The operator searches through the AB PM-▇▇▇ list to determine if the person is covered. Search can be performed by Name and Location, Ration Card No or Mobile number (collected during data drive) or ID printed on the letter sent to family or RSBY URN If the beneficiary’s name is found in the AB PM-▇▇▇ list, Aadhaar (or an alternative government ID) and Ration Card (or an alternative family ID) is collected against the Name / Family. Other family IDs include the following options: • Government certified list of members • RSBY Card: Document image (RSBY Card) to be uploaded • PM Letter: Document image (PM Letter) to be uploaded • State Specific Requirement (Instructions to the state: In case of unavailability of either of the abovementioned family IDs, the state can decide to accept an Individual ID mentioning at least father/ mother/ spouse’s name as a family ID. This will be accepted only in such cases where both individual’s name and father/ mother/ ▇▇▇▇▇▇’s name match as that in SECC/ RSBY/ State Scheme data) The operator sends the linked record for approval to the ISA / Trust. The beneficiary will be advised to wait for approval from the ISA/ trust. The ISA / Trust will setup a Beneficiary approval team that works on fixed service level agreements on turnaround time. The AB PM-▇▇▇ details and the information from the ID is presented to the verifier. The ISA / Trust can either approve or recommend a case for rejection with reason. All cases recommended for rejection will be scrutinized by a State team that works on fixed service level agreements on turnaround time. The state team will either accept rejection or approve with reason. The e-card will be printed with the unique ID under AB PM-▇▇▇ and handed over to the beneficiay to serve as a proof for verification for future reference Empanelment of Health Care Providers All public hospitals with inpatient facilities (Community Health Centre and above) shall deemed to be empanelled. Private healthcare providers (both for profit and not for profit) which provide hospitalization and/or day care services (as applicable) would be eligible for empanelment under AB-PMJAY, subject to their meeting of certain requirements (empanelment criteria) in the areas of infrastructure, manpower, equipment (IT, help desk etc. c. Coverage ) and services (for e.g. liaison officers to facilitate beneficiary management) offered, refer to Schedule 5 of this document. At the time of empanelment, those Hospitals that have the capacity and which fulfil the minimum criteria for offering tertiary treatment services as prescribed by the SHA would be specifically designated for providing such tertiary care packages. The SHA shall be responsible for empanelment and periodic renewal of empanelment of health care providers for offering services under the AB-PMJAY. The SHA may undertake this function either directly or through the selected ISA. However, the final decision regarding empanelment of hospital will rest with SHA. Under circumstances of any dispute, final decision related to surgical nature empanelment of health care providers shall vest exclusively with the SHA. Detailed guidelines regarding empanelment of health care providers are provided at Schedule 5. Agreement with Empanelled Health Care Providers Once a health care provider is found to be eligible for defined procedures shall also be provided on a day care basis. The empanelment and if the empanelment is approved by SHA, then SHA and the selected Insurance Company shall enter into a tripartite Provider Service Agreement with such health care provider to provide coverage for the defined medical treatments, surgical procedures, day care treatments/ procedures treatments (as given in Appendix 2. d. Provision applicable), and follow-up care for transport allowance of Rswhich such health care provider meets the infrastructure and personnel requirements. 100 per hospitalization subject to an annual ceiling of Rs. 1000 This Provider Service Agreement shall be a tripartite agreement where the ISA shall be the third party. Format for this Agreement is provided at Schedule 6. The Agreement of an EHCP shall continue for a period as per duration of three years from the date of the execution of the tripartite Provider Services Agreement, unless the EHCP is de-empanelled in accordance with De-empanelment guidelines provided under Schedule 5 and its agreement terminated in accordance with its terms. The ISA agrees that neither it nor its outsourced agency will enter into any understanding with the EHCP that are in contradiction to or that deviates from or breaches the terms of the Implementation Support Contract between the SHA and the ISA or tripartite Provider Service Agreement with the EHCP. If the ISA or its outsourced agency or any if its representatives violates the provisions of Clause 6.d. above, it shall be deemed as a material breach and the SHA shall have the right to initiate appropriate action against the ISA or the EHCP or both. As a part of the packageAgreement, the ISA shall ensure that each EHCP has within its premises the required IT infrastructure (hardware and software) as per the AB-PMJAY guidelines. This will All Private EHCPs shall be provided responsible for all costs related to hardware and maintenance of the IT infrastructure. For all Public EHCPs the costs related to hardware and maintenance of the IT infrastructure shall be borne by the hospital to ISA. The EHCPS may take ISA’s support may be sought for procurement of such hardware by the beneficiary at EHCPs, however the time ownership of discharge in cash. e. Pre all such assets, hardware and post hospitalization costs up to 1 day prior to hospitalization and up to 5 days software along with its licenses, shall irrevocably vest with the EHCP. De-empanelment of Health Care Providers The SHA, either on its own or through Insuance Company, shall suspend or de-empanel an EHCP from the date AB-PMJAY, as per the guidelines mentioned in Schedule 5 and/or as per applicable laws and/or rules. Notwithstanding a suspension or de-empanelment of discharge from an EHCP, the hospital ISA shall ensure that it shall honour all Claims for any expenses that have been pre-authorised or are legitimately due before the effectiveness of such suspension or de-empanelment as if such de-empanelled EHCP continues to be an EHCP. Term and Performance Bank Guarantee Term Term of the Implementation Support Contract with the ISA This ISA Contract shall be part for a period of maximum 3 (three) years with starting date (insert date) Though the package rates. f. Maternity and Newborn Child will Contract period is for 3 (three) years, it is to be covered as indicated below: I. It shall include treatment taken in hospital/nursing home arising out of childbirth, including normal delivery / caesarean section and/ or miscarriage or abortion induced by accident or other medical emergency subject to exclusions given in Appendix 1. II. Newborn child shall be automatically covered reviewed for renewal after every 12 months from birth upto the expiry start date of the policy for that year for all with reference to the expenses incurred performance criteria laid out in taking treatment at the hospital as in-patient. This benefit shall be a part of basic sum insured and new born will be considered as a part of insured family member till the expiry of the policy subject to exclusions given in Appendix 1. III. The coverage shall be from day one of the inception of the policySchedule 12. However, normal hospitalisation period for not withstanding provisions under clause 8.1.b, renewal of ISA Contract shall be mututally agreed between both mother and child should not be less than 48 hours post delivery. i. the parties. Start of Policy For the ongoing purpose of start of a policy, all eligible beneficiary family units in the entire State of ______________ shall be covered under one policy. This issue of policy period until its renewal, new born will shall be provided all benefits under RSBY and will NOT be counted as a separate member even if five members of the family are already enrolled . ii. Verification for the new born can be done by any of the existing family members who are enrolled in RSBY through the same smart card as that of the mother. g. Domiciliary treatment: Not Coveredsup

Benefit Package. The Benefits within this scheme, to be provided on a cashless basis to the Beneficiaries up to the limit of their annual coverage, package charges on specific procedures and subject to other terms and conditions outlined herein, are the following: a. The scheme shall provide coverage for meeting expenses of hospitalization for medical and/or surgical procedures including maternity benefit, to the enrolled families for up to Rs.30,000 per family per year subject to limits, in any of the empanelled hospitals across India. The benefit to the family will be on floater basis, i.e., the total reimbursement of Rs.30,000 can be availed individually or collectively by members of the family per year. b. Pre-existing conditions/diseases are to be covered from the first day of the start of policy, subject to the exclusions given in Appendix 1. c. Coverage of health services related to surgical nature for defined procedures shall also be provided on a day care basis. The Insurance Company shall provide coverage for the defined day care treatments/ procedures as given in Appendix 2. d. Provision for transport allowance of Rs. 100 per hospitalization subject to an annual ceiling of Rs. 1000 shall be a part of the package. This will be provided by the hospital to the beneficiary at the time of discharge in cash. e. Pre and post hospitalization costs up to 1 day prior to hospitalization and up to 5 days from the date of discharge from the hospital shall be part of the package rates. f. Maternity and Newborn Child will be covered as indicated below: I. It shall include treatment taken in hospital/nursing home arising out of childbirth, including normal delivery / caesarean section and/ or miscarriage or abortion induced by accident or other medical emergency subject to exclusions given in Appendix 1. II. Newborn child shall be automatically covered from birth upto the expiry of the policy for that year for all the expenses incurred in taking treatment at the hospital as in-patient. This benefit shall be a part of basic sum insured and new born will be considered as a part of insured family member till the expiry of the policy subject to exclusions given in Appendix 1. III. The coverage shall be from day one of the inception of the policy. However, normal hospitalisation period for both mother and child should not be less than 48 hours post delivery.. Note: i. For the ongoing policy period until its renewal, new born will be provided all benefits under RSBY and will NOT be counted as a separate member even if five members of the family are already enrolled enrolled. ii. Verification for the new born can be done by any of the existing family members who are enrolled in RSBY through the same smart card as that of the mother. g. Domiciliary treatment: Not Covered

Benefit Package. AB PM-▇▇▇ - ▇▇▇▇ Cover‌ a. The Benefits benefits within this scheme, Scheme under the Risk Cover are to be provided on a cashless basis to the AB PM-▇▇▇ – KASP Beneficiaries up to the limit of their annual coverage, package charges on specific procedures coverage and subject to other terms and conditions outlined herein, are the followingincludes: a. i. Hospitalization expense benefits ii. Day care treatment benefits (as applicable) iii. Follow-up care benefits iv. Pre- and post-hospitalization expense benefits v. Newborn child/ children benefits b. The scheme shall provide coverage for meeting expenses details of hospitalization for medical and/or surgical procedures including maternity benefit, benefit packages are furnished in Schedule 3: ‘HBP and Quality’ and exclusions are furnished in Schedule 2: ‘Exclusions to the enrolled families Policy’. c. For availing select treatment in Private empanelled hospitals, preauthorisation is required to be taken for defined cases. d. Except for exclusions listed in Schedule 2, treatment/procedures will also be allowed, in addition to the procedures listed in Schedule 3, of up to Rs.30,000 per family per year subject a limit fixed by SHA to limits, in any AB PM- ▇▇▇ – KASP Beneficiary (called ‘Unspecified Procedure’) within the overall limit of the empanelled hospitals across IndiaRs. The benefit 5,00,000. Operations pertaining to the family will be on floater basis, i.e., the total reimbursement of Rs.30,000 can be availed individually or collectively by members of the family per year. b. Pre-existing conditions/diseases Unspecified Procedure are to be covered governed as per Unspecified Packages Guidelines provided under Schedule 3 (b). e. The TPA/ISA shall recommend to pay claims of Empanelled Health Care Provider under the AB PM-▇▇▇ – KASP based on Package Rates determined as follows: i. If the package rate for a medical treatment or surgical procedure requiring Hospitalization or Day Care Treatment (as applicable) is fixed in Schedule 3, then the Package Rate so fixed shall apply for the Policy Cover Period. ii. AB PM-▇▇▇ – KASP is a cashless scheme where no payment from a beneficiary should be accepted by the first day hospital. However, upon exhaustion of the beneficiary AB PM-▇▇▇ – KASP wallet, or if the treatment cost exceeds the benefit coverage amount available with the beneficiary families then the remaining treatment cost will be borne by the AB PM-▇▇▇ – KASP Beneficiary family as per the package rates defined in this document. Beneficiary and SHA (through ISA/TPA) will need to be clearly communicated in advance about the additional payment at the start of policy, subject to the exclusions given in Appendix 1such treatment. c. Coverage iii. In case an AB PM-▇▇▇ – KASP Beneficiary is required to undertake multiple surgical procedures in one OT session, then the procedure with highest rate shall be considered as the primary package and reimbursed at 100%, thereupon the 2nd surgical procedure shall be reimbursed at 50% of health services related to package rate, 3rd and subsequent surgical nature for defined procedures shall also be provided reimbursed at 25% of the package rate. iv. Surgical and Medical packages will not be allowed to be availed at the same time (Except for certain add on procedures as defined in Schedule 3 and configured in portability transaction system). In exceptional circumstances, hospital may raise a day care basisrequest for such pre-auth which will be decided by ▇▇▇ with the help of concerned medical specialist. v. Certain packages as mentioned in Schedule 3 will only be reserved for Public EHCPs as decided by the SHA. The Insurance Company shall provide coverage for the defined day care treatments/ procedures as given State may permit availing of these packages in Appendix 2Private EHCPs only after a referral from a Public EHCP is made. d. Provision for transport allowance of Rsvi. 100 per hospitalization subject to an annual ceiling of Rs. 1000 shall be a part of the package. This Incentivization will be provided by to certain hospitals {as defined in schedule 3 (c)} which will be over and above the hospital to the beneficiary at the time of discharge rates defined in cashSchedule 3. e. f. For the purpose of Hospitalization expenses as package rates shall include all the costs associated with the treatment, amongst other things: i. Registration charges. ii. Bed charges iii. Nursing and boarding charges. iv. Surgeons, Anaesthetists, Medical Practitioner, Consultants fees etc. v. Anaesthesia, Blood Transfusion, Oxygen, O.T. Charges, Cost of Surgical Appliances etc. vi. Medicines and drugs. vii. Cost of prosthetic devices, implants etc. viii. Pathology and radiology tests: Medical procedures include basic Radiological imaging and diagnostic tests such as X-ray, USG, Haematology, pathology etc. However, High end radiological diagnostic and High-end histopathology (Biopsies) and advanced serology investigations packages can be booked as a separate add-on procedure if required. Surgical packages are all inclusive and do not permit addition of other diagnostic packages. ix. Pre and post hospitalization costs Post Hospitalization expenses: Expenses incurred for consultation, diagnostic tests and medicines upto 3 days prior to admission of the patient in the same hospital and cost of diagnostic tests and medicines up to 1 day prior to hospitalization and up to 5 15 days from the date of after discharge from the hospital for the same ailment/ surgery. x. Any other expenses related to the treatment of the patient in the hospital. g. For the purpose of Day Care Treatment expenses shall include, amongst other things: i. Registration charges; ii. Surgeons, anaesthetists, Medical Practitioners, consultants’ fees, etc.; iii. Anaesthesia, blood transfusion, oxygen, operation theatre charges, cost of surgical appliances, etc.; iv. Medicines and drugs; v. Cost of prosthetic devices, implants, organs, etc. vi. Pathology and radiology tests: Medical procedures include basic Radiological imaging and diagnostic tests such as X-ray, USG, Haematology, pathology etc. However, High end radiological diagnostic and High-end histopathology (Biopsies) and advanced serology investigations packages can be booked as a separate add-on procedure if required. Surgical packages are all inclusive and do not permit addition of other diagnostic packages. vii. Pre and Post Hospitalization expenses: Expenses incurred for consultation, diagnostic tests and medicines prior to admission of the patient in the samehospital and cost of diagnostic tests and medicines up to 15 days after discharge from the hospital for the same ailment / surgery. viii. Any other expenses related to the Day Care Treatment provided to the Beneficiary by an Empanelled Health Care Provider. h. As part of the package rates. f. Maternity regular review process, the Parties (the TPA/ISA and Newborn Child will be covered EHCP) shall review information on incidence of common medical treatments or surgical procedures that are not listed in Schedule 3 and that require hospitalization or day care treatments (as indicated below: I. It shall include treatment taken in hospital/nursing home arising out of childbirth, including normal delivery / caesarean section and/ or miscarriage or abortion induced by accident or other medical emergency subject to exclusions given in Appendix 1. II. Newborn child shall be automatically covered from birth upto the expiry of the policy for that year for all the expenses incurred in taking treatment at the hospital as in-patient. This benefit shall be a part of basic sum insured and new born will be considered as a part of insured family member till the expiry of the policy subject to exclusions given in Appendix 1. III. The coverage shall be from day one of the inception of the policy. However, normal hospitalisation period for both mother and child should not be less than 48 hours post deliveryapplicable). i. For If NHA / SHA during the ongoing policy period until its renewalcurrency of contract, new born find that a treatment is being booked under unspecified category repeatedly, or some treatment is required to be included within the list to address a pressing health problem which is or have become widely prevalent, then NHA / SHA may add such treatments in the HBP list. This will be provided all benefits under RSBY and will NOT be counted not entail any additional financial burden on the part of SHA i. No claim processing of package rate for a medical treatment or surgical procedure or day care treatment (as a separate member even if five members applicable) that is determined or revised shall exceed the total of the family are already enrolled Risk Cover for an AB PM-▇▇▇ – KASP Beneficiary Family Unit. ii. Verification for the new born can be done by any of the existing family members who are enrolled in RSBY through the same smart card as that of the mother. g. Domiciliary treatment: Not Covered