Common use of EXTENT OF COVERAGE Clause in Contracts

EXTENT OF COVERAGE. i) The Provider Hospital shall extend only in-patient hospitalization to the Members under this Agreement and claims will be settled directly by the University under „Direct Payment System‟. For the „Out- Patient treatment‟, the University employee shall take such treatment on the agreed rates on cash basis and the University shall not be responsible for any such medical expenditure on this account under „Direct Payment System‟. ii) The Provider Hospital will extend services as per the rates prescribed in the Central Government Health Scheme (hereinafter referred as „CGHS‟) for both IPD & OPD treatment. In case there are no CGHS/DGEHS prescribed rates for any test/procedure, then AIIMS rates are applicable. If there are no CGHS/DGEHS/AIIMS rates, then reimbursement is to be arrived at by calculating admissible amount item-wise as per approved rates/actual whichever is less, in case of investigation. iii) If the Provider Hospital normally charges rates for various procedures which are lower than the rates given by CGHS, the reimbursement would be at the actual rates charged by the Provider Hospital. iv) The Provider Hospital shall ensure that each time a Member avails service envisaged in this Agreement, the expenses are regulated strictly with reference to the eligibility and monetary limits fixed with reference to the entitlements status of such Member. v) The Provider Hospital shall ensure that the benefits are made available to the Member(s) strictly as per terms of this Agreement and no benefits outside the terms of this agreement shall be allowed without prior approval, unless the same is essential for the recovery of member(s). vi) The University shall not be liable to make any payment on account of claims which are in the opinion of the University fraudulent or are a result of fabricated claims.

EXTENT OF COVERAGE. (i) The Provider Hospital shall extend only in-patient inpatient hospitalization to the Members Pensioners/Family Pensioners/dependent under this Agreement agreement and claims will be settled directly by the University UGC under „Direct Payment System‟. ‘CASHLESS FACILITY’. For the „Out- Patient treatment‟, out patient treatment’ the University UGC retired employee shall take such treatment on the agreed rates on cash basis and the University UGC shall not be responsible for any such medical expenditure on this account under „Direct Payment System‟.‘CASHLESS FACILITY’. (ii) The Provider Hospital will extend services as per the service on prevailing CGHS rates prescribed in the Central Government Health Scheme (hereinafter referred as „CGHS‟) only both for both IPD & and OPD treatment. In case there are no CGHS/DGEHS prescribed rates for any test/procedure, then AIIMS rates are applicable. If there are no CGHS/DGEHS/AIIMS rates, then reimbursement is to be arrived at by calculating admissible amount item-wise as per approved rates/actual whichever is less, in case of investigation. (iii) If the Provider Hospital normally charges rates for various procedures which are lower than the rates given by CGHSnegotiated rates, the reimbursement would be at the actual rates charged by the Provider Hospital. (iv) The Provider Hospital shall ensure that each time a Member avails Pensioners/Family Pensioners/dependents avail service envisaged in this Agreementagreement, the expenses are regulated strictly with reference to the eligibility and monetary limits fixed with reference to the entitlements status of such Memberentitlement status, as indicated in O.M. No.S.11011/2/2008-CGHS(P) dated 20th May, 2009. (v) The Provider Hospital shall ensure that the benefits are made available to the Member(s) member strictly as per terms of this Agreement agreement and no benefits benefit outside the terms of this agreement shall be allowed without prior approval, approval unless the same is essential for the recovery of member(s)Pensioners/Family Pensioners/dependents. (vi) The University UGC shall not be liable to make any payment on account of claims which are in the opinion of the University UGC fraudulent or are as a result of fabricated claims.