<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)
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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.
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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 nonavailability 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.
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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 DELIVERED
FOR & ON BEHALF OF
THE FIRST PARTY
FOR & ON BEHALF OF
THE SECOND PARTY
Government of ___________
____________________
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Annexure-I – Monitoring Parameters to Measure the Performance of the Insurance Company
S.
No
1.
SLA’s
Source of data
Monitoring method
Settlement of Claims
Settlement of claims within 30 Computed from the claim The ratio of claims amount
days
settlement data in RSBY which have not been paid or
Central Server
rejected within 30 days (from the
date of claims raised to the
insurance company) to the total
claims amount made to the
insurance company.
Periodicity
Points criteria
Based on the claim If 10% of claims remain
made within 12 unpaid at the end of 30 days –
months of the policy 5 Points
period.
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
2.
Empanelment and De-Empanelment of Heath Care Service Providers or Hospitals
At least 2 hospitals to be List
of
empanelled Number of blocks with less than
empanelled in each block.
hospitals to be provided two
empanelled
hospitals.
by
the
Insurance Blocks where district authorities
Company to SNA clearly or SNA certify that two hospitals
identifying hospitals in are
not
available
for
each block. The claim empanelment shall be excluded
regarding non availability from assessment.
of hospitals for enrolment
to be verified by SNA
Assessed 15 days Every block where less than 1
prior
to
the hospitals
have
been
commencement of empanelled – 5 Points
policy
[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
There should be at least one List
of
[Will not apply if only 1
hospitals is available for
empanelment as per certificate
produced]
empanelled Number if beneficiaries in the Assessed 15 days If atleast 1 healthcare provider
5
hospital for every 8000 hospitals to be provided cluster of districts divided by the prior
to
the is empanelled in each district
families enrolled in the scheme by the insurance company number of empanelled hospitals commencement of on every 8000 - 9000 families
to the SNA
policy
enrolled till the start of policy
Districts
where
district
– 1 Point
authorities or SNA certify that
required numbers of hospitals
If atleast 1 healthcare provider
are
not
available
for
is empanelled in each district
empanelment shall be excluded
on every 9000 - 10000
from assessment.
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
3
There shall be at least 5 List
of
empanelled
hospitals in the district hospitals to be provided
headquarters.
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
Districts where district
authorities or SNA certify that
required numbers of hospitals
are not available for
empanelment shall be
excluded from assessment.
For number of districts with less Assessed 15 days Every district headquarters
than five empanelled hospitals, prior
to
the where less than 3 hospitals
where district authorities or SNA commencement of have been empanelled – 5
certify that five hospitals are not policy
Points
available for empanelment shall
be excluded from assessment
[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
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4.
5.
6.
The following specialties’ shall List of specialties in the
be
available
through empanelled hospital to be
empanelled hospitals in each provided by the insurance
district.
company to SNA
a. General Medicine
b. General surgery
c. Obstetrics
and
Gynaecology
d. Paediatrics
e. Ophthalmology
f. ENT
g. Orthopaedic
Other Issues Related to Enrolment
Preparation of brochures to be A printed brochure with a
given to the beneficiaries.
certificate from the printer
showing the number of
copies printed is produced
before SNA.
Setting up of District Kiosk by insurance company
Set up and operationalize Report
from
district
RSBY kiosks according to the officers that kiosks as per
guidelines.
Concession
agreement
have been set up
7.
Manpower requirements
Human resources as per the Report from
guidelines of the scheme
company
8.
Organizing workshops
Organizing of all workshops as Report from
per the guidelines
company
Total number of specialties Assessed 15 days
available across all hospitals for prior
to
the
each district.
commencement of
policy
Districts
where
district
authorities or SNA certify that
required numbers of hospitals
are
not
available
for
empanelment shall be excluded
from assessment.
produced]
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
Brochures at least equal to the 15 days before the IF brochure not shared with
number of beneficiaries is commencement of the SNA till the start of the
printed and distributed to insured enrolment
enrolment – 6 Points
families at all enrolment stations.
IF brochure not share with the
SNA at all – 10 Points
Kiosks as per the Concession 7
days
Before
agreement are set up and commencement of
available for use by eligible enrolment
beneficiaries
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
insurance Details of the manpower on the At least 15 days If not appointed till the start of
letterhead of the insurance before start of policy policy – 3
company to be given to SNA
If not appointed till 15 days
policy 5
insurance Report by insurance company to At least 7 days If not conducted till the start
SNA within 7 days of workshop before start of policy of policy – 3
period
If not conducted till 1 month
7
9.
from the start of policy -5
District office set up by insurer
District office in all districts List of offices with their District offices are established Within 15 days from If not set up within 1 month
being served
contact details provided to and staffed
signing of contract
from signing of the contract –
SNA
by
insurance
5 points
company
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Performance severity:
Threshold limit
Severity
5-7 points
1% of total annual Premium amount for the concerned Insurance Company
8-13 points
3% of total annual Premium amount for the concerned Insurance Company
14- 21 points
5% of the total annual Premium amount for the concerned Insurance Company and cancellation of Renewal and
insurance company debarred for one year
5% of total annual premium and Insurance Company debarred from bidding for three years
More than 21 points
False intimations on any of the Investigations to be called against the insurance company
above parameters
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