Punjab State Power Corporation Limited

DRAFT AGREEMENT

BETWEEN

PUNJAB STATE POWER CORPORATION LIMITED

AND

……………………

(Empanelled hospital)

on a non-judicial stamp paper of Rs. 100/-

This Agreement is made on the ______day of ______, 2015 between the Punjab State Power Corporation Limited having its registered office at PSEB Head office Building, The Mall, Patiala (hereinafter called PSPCL, which expression shall, unless repugnant to the context or meaning thereof, be deemed to mean and include its successors and assigns) of the First Part

AND

………………………………………..

(Name of the Hospital with Address) of the Second Part.

WHEREAS, the PSPCL is providing comprehensive medical care facilities to PSPCL Employees / Pensioners.

NOW, THEREFORE, IT IS HEREBY AGREED between the Parties as follows:

1)DEFINITIONS & INTERPRETATIONS

1.1.The following terms and expressions shall have the following meanings for purposes of this Agreement:

1.1.1.“Agreement” shall mean this Agreement and all Schedules, supplements, appendices, appendages and modifications thereof made in accordance with the terms of this Agreement.

1.1.2.“Benefit” shall mean the extent or degree of service the beneficiaries are entitled to receive as per the rules on the subject.

1.1.3.“Family Health Identity Card” shall mean the Family Health Identity Card, issued by any competent authority, of PSPCL.

1.1.4.“Members/beneficiary” shall meanemployees (Regular including the employees appointed under New Pension Scheme and work charged) of the PSPCL, their dependents and retired employees including dependents eligible to the benefits of this scheme. The definition of the family is as per instructions issued by the PSPCL from time to time.

1.1.5.“Coverage” shall mean the types of persons to be eligible as the beneficiaries of the Scheme to health services provided under the Scheme, subject to the terms, conditions and limitations.

1.1.6.“Emergency” shall mean any condition or symptom resulting from any cause, arising suddenly and if not treated at the earliest opportunity would be detrimental to the health of the patient or shall jeopardize the life of the patient.

1.1.7.“Hospital” shall mean the (Name of the Hospital) while performing under this Agreement providing medical investigation, treatment and the healthcare of human beings.

1.1.8.“De-recognition of Hospital” shall mean debarring the hospital on account of adopting unethical practices or fraudulent means in providing medical treatment to or not following the good industry practices of the health care for the PSPCL beneficiaries after following certain procedure of inquiry.

1.1.9.“Package rate” shall means and include Lump sum cost of inpatient treatment /day care/diagnostic procedure for which a beneficiary has been permitted by the competent authority or for treatment under emergency from the time to time of admission to the time of discharge including (but not limited to ) – Registration charges, Admission charges, Accommodation charges including patient’s diet, Operation charges, Injection charges, dressing charges, Doctors /consultants’ visit charges, ICU/ICCU charges, Monitoring charges, transfusing charges, Anesthesia charges, Operation Theatre Charges, Procedural charges/ Surgeon’s fee, Cost of Surgical disposables and all sundries used during hospitalization, Cost of Medicines and Drugs, Related routine and essential investigations, Physiotherapy charges etc., Pre-anestheticcheck-up, Nursing care and charges for its services during stay under package days duration.

The package rate, however, does not include expenses on telephone, tonics, cosmetics / toiletries, etc. These are not part of the treatment regimen. Cost of these additional items, if provided with the prior consent of the patient, has to be settled with the patient, for which no reimbursement shall be admissible.

The rate quoted for a particular procedure shall be inclusive of all sub-procedures and all related procedures to complete the treatment procedure. The patient shall not bear the cost of any such procedure/item.

The cost of Implant/stents/grafts is reimbursable in addition to package rates as per CGHS ceiling rates for implants/stents/grafts or as per actual, whichever is less, or if the patient wants to have better & Higher quality Coronary Stent /implant and as per existing policy, the patient /beneficiary may opt for the same after paying the difference in Cost over and above the ceiling rates.

The treatment charges for a new born baby are separately reimbursable in addition to delivery charges for mother.

The package rates envisage up to a maximum duration of indoor treatment as follows;-

12 days for Specialized (Super Specialties) Treatment;

27 days for other Major Surgeries;

3 days for Laparoscopic surgeries / normal deliveries;

1 day for day care / minor (OPD) surgeries

There are certain procedures where there is no proscribed package rate under CGHS. Similarly there are medical emergencies where the treatment is mainly conservative. The admissible amount in such cases is calculated item wise; room rent, procedure, investigation, etc

The package rates prescribed are for semi private ward. If beneficiary is entitled for general ward there will be a decrease of 10% in the rates; for private ward entitlement there will be an increase of 15% but shall not be more than hospital normal rates; However the rates shall be same for investigation irrespective of entitlement, whether the patient is admitted or not.

1.1.10“Specialized treatment” shall mean the treatment in a particular specialty.

1.1.11“Rate” – Charges for approved procedures / services as may be notified by CGHS from time to time and rebate/discount given by the provider/hospital on CGHS rates and the rates negotiated by the standing Committee with the hospitals .

1.1.12“Medical benefits”shallmeans the hospitalization relating to the ailments mentioned in the authorization letter issued by Punjab State Power Corporation Limited and providing treatment and any outdoor/day care treatment taken by the PSPCL beneficiaries and their dependents.

APPROVED RATES TO BE CHARGED

The Hospital agrees that it shall charge from the PSPCL beneficiary as per the rates for a particular procedure / package deal as prescribed by the CGHS and attached as Annexure (rate list) amended from time to time, minus rebate/discount negotiated(if any)and other rates negotiated (if any) by the standing committee with the hospital which shall be an integral part of this Agreement.

PERIOD OF EMPANELMENT

This Agreement shall remain in force for a period of 2 years or till it is modified or revoked, whichever is earlier subject to renewal on yearly basis on such terms and conditions as may be mutually agreed. The Agreement may be extended for another year subject to fulfilment of all the terms and conditions of this Agreement and with mutual consent.However, PSPCL patients should not be admitted on PSPCL account even in emergencies after expiry of the period of the Agreement, except in case the treatment is started before the expiry period. In case of any violation of this clause, PSPCL shall not in any case be responsible to settle such claims.

TREATMENT IN EMERGENCY

In emergency the hospital shall not refuse admission or demand an advance payment from the beneficiary or his family member on production of a valid PSPCL Family Health Identity card. The refusal to provide the treatment to bonafide PSPCL beneficiaries in emergency cases without valid ground would attract disqualification for continuation of empanelment.

EXTENT OF COVERAGE
The Provider hospital shall extend coverage only in-patient hospitalization for General and /or Specialized purpose or as notified by the Ministry of Health and Family Welfare Department of Health and Family Welfare under Central Government Health Scheme for that hospital to member under the agreement and claims will be settled directly by the Punjab State Power Corporation Limited under ' Cashless Medical Treatment under Direct Payment System'.

(a) The Provider hospital in respect of the packages/procedures/treatments covered under CGHS will charge CGHS rates minus negotiated discount/rebate if any.

(b) However in cases where

(1)an hospital is not agreeing to cover any specific disease/procedure/ treatment although that exist in the CGHS rate list;

(2)in respect of rent for different types of rooms available in the hospitals not covered under CGHS(applicable where the cost of procedure remains the same with the change in class of room) ;

(3)in respect of procedures/diseases with reference to the entitled class not provided in the CGHS e.g. Deluxe room, super deluxe room, presidential suit etc(applicable where the cost of procedure changes with the change in class of room) ;

the provider hospital will be entitled to charge the amount from PSPCL to the extent of CGHS rates and difference between the Hospital rates or negotiated rates(if any)& CGHS rates will be recovered from the beneficiary on cash basis. However the amount recovered from the beneficiary will be specifically mentioned in the bills raised to the PSPCL.

(c) The Provider hospital in respect of the packages/procedures/treatments not covered under CGHS and for out-patient treatments (OPD) including diagnostics will recover the cost of treatment at the Hospital rates or negotiated rates(if any)directlyfrom the beneficiary on cash basis and PSPCL shall not be responsible for any such medical expenditure on this account under ' Cashless Medical Treatment under Direct Payment System 'until the same is covered under the scheme i.e. Cashless Medical Treatment under Direct Payment System.

5.3The Provider hospital shall extend only in-patient hospitalization for General and /or Specialized purpose or as notified by the Ministry of Health and family welfare Deptt. of Health and family welfare under CGHS for the hospital to member under this agreement and claims will be settled directly by the Punjab State Power Corporation Limited under ' Cashless Medical Treatment under Direct Payment System'. For the 'outpatient treatment' the Corporation employee shall take such treatment on the agreed rates on cash basis and PSPCL shall not be responsible for any such medical expenditure on this account under ' Cashless Medical Treatment under Direct Payment System '.

5.4No advance payment will be made to the hospital under Cashless Medical Treatment under Direct Payment System.

5.5The member shall be entitled of room accommodation for IPD treatment in the empanelled hospitals as per his Group as defined by PSPCL and mentioned in the family health identity card and authorization letter :

Sr.no / Group / Grade pay / Entitlement
1 / Group 'D' / Grade pay less than Rs.2200/- / General Ward
2 / Group 'C &B' / Grade pay ranging from Rs.2200/- to Rs.5499/- / Semi- Private Ward
3 / Group ‘A’ / Grade pay 5500/- and above / Private Ward/Room

The entitlement shall be calculated on the basis of the grade pay of the post occupied by the employee in regular scale by appointment/promotion and not on the Grade pay granted on account of time bound promotional scales or otherwise.

The entitlement of the pensioner will be calculated on the corresponding grade pay of the post occupied in the regular scale on which he was retired.

The room rent will include diet charges, specialist, consultation /visiting fee up to two visit, Nursing Charges, heater/cooler /AC charges etc. as applicable.

a.Private ward is defined as a hospital room where single patient is accommodated and which has an attached toilet (lavatory and bath). The room will have furnishings like wardrobe, dressing table, bed-side table, sofa set, carpet, etc. as well as a bed for attendant. The room has to be air- conditioned.

b. Semi Private Ward is defined as a hospital room where two to three patients are accommodated and which has attached toilet facilities and necessary furnishings.

c. General ward is defined as a hall that accommodates four to ten patients.

5.6The First Admission Report/Pre authorization (Appendix-1) duly signed by the Competent Authority of the empanelled hospital is acceptable subject to the fulfillment of other terms and conditions by the PSPCL Authority competent to issue Authorization letter in various offices of PSPCL. All the Dy. CEs/Addl SEs/ Sr. XENs /AOs/ Officers maintaining the service book (i.e. DDO) or officers of equivalent and higher rank and the Nodal Officers declared by the Committee are authorized to issue Authorization Letter ( Appendix-2)

5.7The hard copy of the claim bill along with copies of investigation reports, first admission report/pre authorization letter, copy of authorization letter, original cash memos and discharge summary report will be submitted by the Hospital to the Accounts Officer/Centralized Payment cell (Medical reimbursement) PSPCL Patiala within the stipulated period as per agreed terms and conditions. The bills submitted should contain the CGHS Rate list serial number applicable against each procedure charged to facilitate processing of the bill at the earliest.

5.8The Provider Hospital shall ensure that each time a member/dependent avails service envisaged in this agreement, the expenses are regulated strictly with reference to the eligibility and monetary limits fixed with reference to the entitled status.

5.9The Hospital shall ensure that the benefits are made available to the member strictly as per terms of this agreement and no benefit outside the terms of this agreement shall be allowed without prior approval unless the same is essential for the recovery of members.

5.10PSPCL shall not be liable to make any payment on account of claims which are in the opinion of PSPCL fraudulent or are as a result of fabricated claims. Corporation would have the right to blacklist the hospital if the hospital is found to have facilitated the lodging of false claims, without prejudice to any other right that the Corporation may have under the law.

6DUTIES AND RESPONSIBILITIES OF HOSPITALS

It shall be the duty and responsibility of the Hospital , at all times, to obtain, maintain and sustain the valid NABH Accreditation , recognition and high quality and standard of its services and healthcare and to have all statutory / mandatory licenses, permits or approvals of the concerned authorities under or as per the existing laws”.

7NON ASSIGNMENT

The Hospital shall not assign, in whole or in part, its obligations to perform under this Agreement, except with the PSPCL’s prior written consent at its sole discretion and on such terms and conditions as deemed fit by the PSPCL. Any such assignment shall not relieve the Hospital from any liability or obligation under this agreement

8HOSPITAL’S INTEGRITY AND OBLIGAITONS DURING AGREEMENT PERIOD

8.1The Hospital is responsible for and obliged to conduct all contracted activities in accordance with this agreement using state-of-the-art methods and economic principles and exercising all means available to achieve the performance specified in this agreement. The Hospital is obliged to act within its own authority. The Hospital is responsible for managing the activities of its personnel and shall hold itself responsible for their mis-demeanors, negligence, misconduct or deficiency in services, if any.

8.2The Provider Hospital shall ensure that all members are admitted and treated in the Institution/Hospital on priority basis. Priority basis in this context means making available to the member services like on the spot admission/treatment, beds on an urgent basis and the like. In case there is no accommodation either in the ward or in the operation theatre or the patient requires specialized treatment which is not available in the Hospital, the provider Hospital shall make all attempts through its good offices to accommodate and admit the member to other PSPCL empanelled/super specialty Hospital subject to concurrence from the concerned member and an intimation as to the cross reference shall be made to the PSPCL within 24 hours of such referral.

8.3The Provider Hospital shall ensure that best and timely medical treatment/medical facility is extended to the member(s) and provides best of services to them at all times.

8.4It is mandatory for the Provider Hospital to maintain and adhere to the standards and quality of medical services as prescribed by Medical Council of India. The provider must represent that it has all the prescribed standards and shall maintain the same throughout.

8.5The hospital shall comply with the provisions of Law as applicable from time to time. In case, any mishap occurs to the member(s) due to the deficiency in service or medical negligence of the hospital in any manner whatsoever, the hospital shall be responsible and liable for making compensation to the affected persons/legal heirs, if so, directed by any Court/Consumer Court.

8.6PSPCL's Standing Committee/ Medical officers/designated officers will have the right to visit the Provider Hospital to check the quality, standards, review and discuss treatment provided to the members. During such visits and inquiries, the provider Hospital shall extend full co-operation to the PSPCL officials including access to the patients' medical and billing records and make available the information they request about the patient for the purposes of their investigation/inspection.

8.7The Provider Hospital shall also arrange to obtain medicines, injections, disposables as prescribed by the Doctors from authorized chemists/druggists.