SERVICES AGREEMENT FOR HEALTHCARE PARTNERS

THIS Agreement (“Agreement”) is by and between HealthAssure Private Limited (“HealthAssure”) and its affiliates,
and DLABS
_______________________________________________________ *insert
Diagnostic Centre , Ground Floor , Teepeyem Plus Building , Opposite BSNL Bhavan , Kalathiparambu Road, Ernakulamaddress+
Sou (“HealthCare Partner”) and
is entered into as of _______________ (“Effective Date”).
15/10/2020

1. GENERAL
1.1 HealthAssure Private Limited (HealthAssure or We) is engaged in the business of connecting individuals and
Corporates (Customers) with diagnostic centers, hospitals, and other healthcare service providers (whether
individuals or organizations) (HealthCare Partners or You) for human health and social care services like
pathology, diagnostics, consultations, tele medicine, etc. (collectively referred to as the HealthCare Services)
1.2 HealthAssure aggregates HealthCare Services is by operating and providing access to the portal
[Link] *as well as software applications under the name “HealthPass” on mobile devices+ (each
a Platform)
1.3 HealthAssure and HealthCare Partner desire to enter into this Agreement and the use of the Platform
pursuant to the terms and conditions set forth herein;

2. SERVICES
Company will make available to its Customer’s Healthcare requirements, including access to HealthCare
Partner, including information about its specialties and services through its Platform. The HealthCare Partner
has agreed to provide details of the HealthCare Services for access to HealthAssure’ s Customers on its
Platform

3. OPERATIONAL PROTOCOL
3.1 The HealthCare Partner agrees to provide HealthCare Services to the Customers who have opted to seek such
HealthCare Services on the Platform. To enable the provision of HealthCare Services by the HealthCare
Partner, HealthAssure shall provide the Customers with information and details of the HealthCare Partner
including but not limited to: the address of the HealthCare Partner; the contact details of the HealthCare
Partner; infrastructure (including but not limited to the diagnostic apparatus) available with the HealthCare
Partner; registration details obtained by the HealthCare Partner under applicable law; HealthCare Partner's
specialities and the health care and medical services offered by the HealthCare Partner.
3.2 Pursuant to every Healthcare Service request made by a Customer on the Planform, HealthAssure shall
intimate the HealthCare Partner by electronic mail or telephonic communication (Intimation) [12] hours
before the Customer has sought an appointment to avail of HealthCare Services. Such an Intimation shall
contain details of the identity of the Customer, the time slot of the appointment for HealthCare Services
requested by the Customer, and specifics of the HealthCare Services requested.
3.3 If the HealthCare Partner is unable to render HealthCare Services at the time slot(s) requested by the
Customer specified in the Intimation, the HealthCare Partner shall intimate HealthAssure. The HealthCare
partner shall also provide details of each slot available in the 48 hours preceding (if applicable) and in the 48
hours subsequent to the time slot requested in the Intimation, to enable HealthAssure to find the Customer
another suitable time slot.
3.4 For each individual who identifies himself as a Customer, prior to rendering any HealthCare Services, the
HealthCare Partner shall verify:

(a) The identity of the Customer in line with the Intimation. A HealthCare Partner may verify the identity of
the Customer using any identification document issued by HealthAssure or using any identity document
issued by a governmental body or agency.
(b) The extent of the HealthCare Services to be rendered to the Customer, in line with the Intimation

3.5 After the completion of the HealthCare Services to be rendered to a Customer, the HealthCare Partner shall
issue to HealthAssure a confirmation of completion of HealthCare Services to a Customer (Confirmation)
through electronic mail.
3.6 HealthAssure reserves the right to modify or amend these operational protocols at its sole discretion from
time to time. Any change modifications or amendments shall be informed to the HealthCare Partner by
HealthAssure through a written notice.
3.7 HealthAssure neither provides nor does it hold itself to nor does it intend to provide any HealthCare Services.

Page | 1 HealthAssure Provider Agreement

3.8 In addition to the details set out above, the HealthCare Partner shall provide HealthAssure with [the details of
its registration obtained under the Central Goods and Services Act, 2017] and the permanent account
number. In case of any change in such details or information, the HealthCare Partner shall inform
HealthAssure within [7] days of any such change.

4. BILLING & COMMERCIALS

4.1 The HealthCare Partner agrees to provide Services to HealthAssure's Customers as per mutually agreed Price
List.
4.2 Customer will be invoiced as per the price list in Annexure -1 with an addition of convience charges
(Convenience Charges) payable to HealthAssure for facilitation of service from Healthcare Provider to
Customer
4.3 Upon receiving payment on an Invoice from a Customer after the completion of HealthCare Services,
HealthAssure shall transfer the List Price so received to the relevant HealthCare Partner, within [45] days of
receiving the full payment. The transfer of the such amount to the HealthCare Partner by HealthAssure shall
be considered full and complete payment to the HealthCare Partner for the HealthCare Services provided by
the HealthCare Partner.
4.4 After HealthAssure has received Confirmation of completion of HealthCare Services by the HealthCare
Partner, HealthAssure shall raise consolidated invoices on the relevant Customer and collect payment (List
Price plus Convenience Charge) against such invoices on behalf of the HealthCare Partner in accordance with
all applicable laws.
4.5 HealthAssure, as an e-commerce Platform, reserves the right to withhold any amounts as tax either for or on
behalf of the HealthCare Partner, in accordance with applicable law, for the supply of services by the
HealthCare Partner to the Customers.
4.6 In case of a rejection of an invoice by the Customer, and the eventual non-payment for such an invoice, due
to errors, fraud or misrepresentation by the HealthCare Partner, HealthAssure shall not be liable to transfer
any amounts to the HealthCare Partner for any such rejected amounts.
4.7 The HealthCare Partner shall have access to services rendered to HealthAssure’ s Customers in the previous
month (Statement) on its platform accessible to the Healthcare Partner. This will also include the
Convenience fees charged to the Customers for respective month.

5. INTELLECTUAL PROPERTY RIGHTS

5.1 All Trademarks owned by HealthAssure and other marks indicated on the Platforms, All Logos and designs
owned by HealthAssure indicated on the Platforms belong to HealthAssure solely. The HealthCare Partner
shall not in any manner, directly or indirectly, use any of the HealthAssure Trademarks without the express
authorization of HealthAssure.
5.2 Copyright: [The content published on the Platforms (Platform Content) are either generated by HealthAssure
or the Health Care Partner. Accordingly, HealthAssure or the Health Care Partner hold exclusive copyright
over all contents published on the Platforms, as applicable in a given case.] Any attempt to copy, modify,
delete, reproduce, distribute or otherwise use any of the Platform Content for any commercial purpose or for
the purpose of earning profit, without the express authorization of HealthAssure or the Health Care Partner,
as applicable in a given case, will amount to the violation of this Master Services Agreement in addition to all
applicable laws.
It is further clarified that all and any intellectual property rights created from the use of the Platform shall
solely belong to HealthAssure.

6. LIMITATION OF LIABILITY
6.1 The HealthCare Partner will, at its own expense maintain, adequate general and professional liability
insurance coverage in accordance with minimum industry standards. The HealthCare Partner agrees to
indemnify and hold harmless HealthAssure, (including its representatives, directors, officers, employees and
agents) and its Customers for all actions related to the HealthCare Partner's provision of medical care,
including without limitation, negligence, fraud, medical malpractice, omissions, or failure to perform, and its
compliance with relevant laws and regulations governing its practice.

Page | 2 HealthAssure & Provider Agreement

7. REPRESENTATIONS
HealthCare Partner represents that HealthCare Partner and all physicians and health personnel associated
with HealthCare Partner have obtained any and all licenses, certifications or permits required by law for
HealthCare Partner to provide the Administered Services and that the execution of this Agreement is not
prohibited by any other agreement or arrangement that HealthCare Partner is associated with. HealthCare
Partner further represents and warrants that HealthCare Partner will provide the Administered Services in
accordance with applicable laws and that the information provided to Company hereunder is true and correct
throughout the term of this Agreement.

8. TERMINATION
Either party may terminate this Master Services Agreement at any time with cause upon sixty (60) days prior
written notice.

9. NON-SOLICIT
The HealthCare Partner shall not solicit any employees or consultants of HealthAssure or any of its affiliates,
individually or on behalf of any third party, nor shall the HealthCare Partner induce any such employees or
consultants to terminate or breach an employment, contractual or other similar relationship with
HealthAssure or any of its affiliates.

10. FORCE MAJEURE

Any actions undertaken pursuant to this Master Services Agreement is subject to force majeure
circumstances including without limitation floods, natural disasters, war, acts of terror, political unrests, acts
of God or any circumstance beyond the control of HealthAssure (Force Majeure Events). HealthAssure will
not be liable for any delay or adverse effect caused to the HealthCare Partner as a result of a Force Majeure
Event.

11. CUMULATIVE REMEDIES

The remedies under this Master Services Agreement will be cumulative and not alternative and the election
of one remedy for breach will not preclude pursuit of other remedies.

12. ASSIGNMENT
Neither party may assign this Agreement, or any rights or obligations under this Agreement to anyone
without the other party’s written consent; provided, however, that the Company may assign this Agreement,
including all of its rights and obligations to its affiliates or to an entity controlling, controlled by, or under
common control with the Company, or to a purchaser of its assets, regardless of the form of the transaction,
without prior written notification to HealthCare Partner.

13. CONFIDENTIALITY
Because of this Agreement and the parties’ business dealings, each may have access to certain trade secrets
and other confidential and proprietary information (“Confidential Information”) of the other. Each party
agrees to hold such Confidential Information in confidence and will not use or disclose such information by
any means without prior written consent of the other party except as may be required: (1) by law; or (2) to
fulfill the rights and obligations set forth in this Agreement. HealthCare Partner agrees that Participant’s
medical information is confidential and subject to the protections contained within this Agreement and
imposed by applicable law. The parties will maintain such records as are required by applicable law. This
provision will survive termination of this Agreement.

14. GOVERNING LAW AND DISPUTE RESOLUTION

14.1 This Master Services Agreement and Terms and Conditions shall be governed by the provisions of Indian law,
and subject to the exclusive jurisdiction of courts situated at [Mumbai, Maharashtra, India].
14.2 In the event of any dispute, controversy or claim arising out of, relating to, or in connection with

(a) this Master Services Agreement or/and the Terms and Conditions, or
(b) the formation, existence, negotiation or interpretation of this Master Services Agreement or/and the
Terms and Conditions, or

Page | 3 HealthAssure & Provider Agreement

 (c) the breach, termination, validity or enforceability of this Master Services Agreement
(collectively referred to as Dispute) the representatives of HealthAssure and the HealthCare Partner shall
amicably resolve the resolve the Dispute in good faith, as soon as either party is apprised of the existence of a
Dispute.

14.3 In the event HealthAssure and the HealthCare Partner are unable to resolve the Dispute within 30 days of
them commencing discussions to amicably settle the dispute, the Dispute shall be referred to be resolved
through arbitration. Unless otherwise agreed to by the parties, the arbitral tribunal shall consist of a sole
arbitrator to be appointed by the mutual consent of both the parties.

14.4 The arbitration proceedings shall be conducted in accordance with provisions of the (Indian) Arbitration and
Conciliation Act, 1996 (including any statutory amendments and modifications thereto). Unless otherwise
agreed to by the parties, the arbitration proceedings will be held at [Mumbai, Maharashtra.] The arbitration
award shall be final and binding on the parties.

14.5 This Master Services Agreement and the rights and obligations of the parties shall remain in full force and
effect pending the award in such arbitration proceeding.

IN WITNESS WHEREOF, the parties hereto have executed and delivered this Agreement as of the Effective Date.

HealthAssure Private Limited HealthCare Partner

Signature: ________________________________ Signature: ___________________________________

Dr. Ushas Kumar G

Name: ___________________________________ Name: ______________________________________

Director
Title: ____________________________________ Title: _______________________________________

Page | 4 HealthAssure & Provider Agreement

 ANNEXURE 1: PRICING / PACKAGES
PRE-POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF BHARTI AXA LIFE INSURANCE COMPANY LIMITED

Sr. No. Medical Tests Amt (INR)

CAT 1 FMR 100
CAT 2 FMR, FBS, LIPIDS, ECG 495
CAT 3 FMR, ECG, FBS, LIPIDS, HbA1c 695
CAT 4 FMR, FBS, LIPIDS, HbA1c, TMT 1205
CAT 5 FMR, BLOOD PROFILE, ECG 1215
CAT 6 FMR, ECG, BLOOD PROFILE, Hba1c 1415
CAT 7 FMR, TMT, BLOOD PROFILE, HbA1c 1925
CAT 8 CAT 7 + PSA 2225
CAT 9 FMR, HbA1c, TMT 900
Urine Cotinine Test 400

Blood profile – Fasting Blood sugar, HIV-Elisa, CBC, HBsAg, BUN, Serum Creatinine, Liver function Test,
GGTP(Gamma Glutamyl Tran Peptidase), Lipid Profile.

PRE_POLICY HEALTH CHECK-UP PACKAGE

FOR THE PROSPECTIVE POLICY HOLDERS OF HDFC ERGO HEALTH INSURANCE COMPANY LIMITED

PPC category Tests DC Rates

Cat 1 MER, FBS, ECG 220
Cat 2 MER, FBS, ECG, TC, Sr creatinine 320
Cat 3 MER, FBS, ECG, Lipids, Sr creatinine 545
Cat 4 MER, FBS, TMT, Lipids, Sr creatinine 965
Cat 5 MER, FBS, TMT, Lipids, Sr creatinine, SGOT, Sr uric acid 1180
Cat 6 MER, FBS, TMT, Lipids, Sr creatinine, LFT, Sr uric acid, USG Abd 1760
Cat 7 MER, FBS, ECG, 2D ECHO, Lipids, Sr creatinine, LFT, Sr uric acid, USG Abd 1905
MER, TMT or ECG with 2D ECHO, Lipids, Sr creatinine, LFT, USG Abd, HbA1C, Urine
Cat 8 Microalbumin 2225
Cat 9 MER, FBS, Lipids, Sr creatinine, LFT, Sr uric acid, HbA1C 1025
Cat 10 MER, HbA1C, Urine microalbumin, TC, Total Protein, SGOT, Sr creatinine, TMT 1175
Cat 11 MER, ECG, FBS, Lipids Profile, Serum creatinine, LFT, Serum uric acid, HbA1C 1280
Cat 12 MER, FBS, ECG, Lipid Profile, HbA1c, LFT, SR Creatinine, Uric Acid, Urine Microalbumin 1445
Cat 13 MER, FBS, Lipid Profile, HbA1c, LFT, Sr. Creatinine, Uric acid, TMT 1700
Cat 14 MER, FBS, Lipid Profile, HbA1c, LFT, Sr. Creatinine, Uric acid, ECG, 2D ECHO 1790

Additional
Package DC Rate
Category
CAT 20 MER,RUA,Group 16,TMT,HbA1c 2080
CAT 21 MER,RUA,Group 16,TMT,HbA1c,USG Abdomin,2D Echo,PSA 3480
FBS,S Cholestrol,S Triglycerides,HDL,S Globulin,S Albumin,S Bilirubin Direct,S Bilirubin
Group 16 1300
Indirect,SGOT,SGPT,S Creatinine,GGT,ALP,HbsAg,S Uric Acid,HIV,CBC,ESR

Type of Process – Pre-Policy Health Check up

Payment Mode – Credit
Report Dispatch Process – Hard copy & Soft copy to be sent to HealthAssure on fax@[Link] along with
Identity Card photocopy

Page | 5 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF MAX BUPA HEALTH INSURANCE
CAT TEST DETAILS Rates
Level 1 MER, RUA 100
Level 2 MER, RUA, FBS, TCHOLESTROL, GGT 360
Level 3 MER, RUA, FBS, TCHOLESTROL, GGT, HDL, TG, [Link], SGOT, SGPT 680
Level 4 MER, RUA, FBS, TCHOLESTROL, GGT, HDL, TG, Screat, SGOT, SGPT, Hbsag, Hba1c, CBC, ECG 1040
MER, RUA, FBS, TCHOLESTROL, GGT, HDL, TG, Screat, SGOT, SGPT, Hbsag, Hba1c, TMT, HIV
Level 5 1&2 1760
Level 6 MER,RUA,Hba1c,T CHOL,HDL,GGT,S CREAT,SGOT,SGPT,ECG 450

Home Visit Charges per Family Rates

MER + Blood Collection + ECG 350
MER 200
ECG 65
Blood Collection 65

ADDITIONAL - PRE_POLICY HEALTH CHECK-UP PACKAGE

FOR THE PROSPECTIVE POLICY HOLDERS OF MAX BUPA HEALTH INSURANCE

Name of Tests Test Category Rates

Level 1 New Grid MER,RUA,TCHOL,LDL,HbA1c,ECG 410

Level 2 New Grid MER, RUA, T CHOL, LDL, HBA1C, ECG, SGPT, SGOT, S CREAT, GGT 525
MER, RUA,CBC,GGT, Total bilirubin, HBSAg, Anti HCV antibody, TCHOL,
HDL, TMT, 2 D ECHO, SCREAT, Pulmonary Function test, USG whole
HAV2 Male abdomen, CEA, PSA (Males), Serum Homocysteine 3750
MER, RUA,CBC,GGT, Total bilirubin, HBSAg, Anti HCV antibody, TCHOL,
HDL, TMT, 2 D ECHO, SCREAT, Pulmonary Function test, USG whole
HAV2 Female abdomen, CEA, PAP Smear (Females), Serum Homocysteine 3750

MER, RUA,CBC,GGT, Total bilirubin, HBSAg, Anti HCV antibody, TCHOL,

HDL, TMT, 2 D ECHO, SCREAT, Pulmonary Function test, USG whole
HAV2-1 abdomen, CEA, Serum Homocysteine 3500

Name of Tests HA Quote

CEA 350
Cervical smear 350
ENTexamination 100
IgE 720
Serum Homocysteine 1000
Ultrasound abdomen(USG) 300

Type of Process – Pre-Policy Health Check up

Payment Mode – Credit
Report Dispatch Process – Hard copy & Soft copy to be sent to HealthAssure on fax@[Link] along with
Identity Card photocopy

Page | 6 HealthAssure & Provider Agreement

 ANNUAL HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF MAX BUPA HEALTH INSURANCE

Plan Test Details HA Rate

AHC 1 CBC+ESR, RUA, FBS, Post Lunch Blood Sugar 240
AHC 2 (Silver) CBC+ESR, RUA, FBS, Post Lunch Blood Sugar, S. Cholesterol, S. Triglycerides, ECG 500
AHC 3 (Silver Package) CBC+ESR, RUA, FBS, Post Lunch Blood Sugar, Lipid Profile, ECG 600
CBC+ESR, RUA, FBS, Post Lunch Blood Sugar, S. Cholesterol, S. Triglycerides, ECG,
AHC 4 (Gold Package) HbA1C, Chest X-ray 700
CBC+ESR, RUA, FBS, Post Lunch Blood Sugar, S. Cholesterol, S. Triglycerides, HBA1C,
AHC 5 (Gold Package) ECG,CXR, Liver Function Test, Kidney Function Test 1200
AHC 6 (Platinum CBC+ESR, RUA, FBS, Post Lunch Blood Sugar, S. Cholesterol, S. Triglycerides, ECG,
Package) CXR, Kidney Function Test, PSA (Males only), Prostate Examination, Hba1c 1600
AHC 7 (Platinum CBC+ESR, RUA, FBS, Post Lunch Blood Sugar, S. Cholesterol, S. Triglycerides, ECG,
Package) CXR, Kidney Function Test, Cervical Smear, Mammography, Hba1c 1900
CBC+ESR, RUA, FBS, Post Lunch Blood Sugar, CXR, ECG, Hba1c, Serum Cholestrol and
AHC 8 (Platinum triglycerides, Liver Function Test, Kidney Function test, Hepatitis B Surface Antigen,
Package) TMT or Stress test, Abdominal Ultrasound, Mammography 2700
CBC+ESR, RUA, FBS, Post Lunch Blood Sugar, CXR, ECG, Hba1c, Serum Cholestrol and
AHC 9 (Platinum triglycerides, Liver Function Test, Kidney Function test, Hepatitis B Surface Antigen,
Package) TMT or Stress test, Abdominal Ultrasound, PSA, Prostate Examination 2600

New Additional Categories:

Tests Rates
Package Tests
(INR)
Complete Blood Count, Urine Routine, Blood Group, ESR, Fasting Blood
HcV2-Variant-1 Sugar, ECG, Serum Cholesterol, SGPT, Creatinine 560
Complete Blood Count, Urine Routine, Blood Group, ESR, Fasting Blood
Sugar, Lipid Profile, Kidney Function Test, ECG, Complete physical
HcV2-Variant-2 examination by Physician 1115
Complete Blood Count, Urine Routine, Blood Group, ESR, Fasting Blood
Sugar, Lipid Profile, Stress Test (TMT) or 2D Echo, Kidney Function Test,
HcV2-Variant-3 Complete physical examination by Physician 1500
Complete Blood Count,Urine Routine Analysis,Random Blood
Silver < = 35 years Sugar,Serum Cholestrol,Serum LDL 300
Complete Blood Count,Urine Routine Analysis,HbA1C,Serum
Silver 36 - 50 Years Cholestrol,Serum LDL,Serum Creatinine,Urea 600
Complete Blood Count,Urine Routine Analysis,ESR,HbA1C,Serum
Silver > 50 Years Cholestrol,Serum HDL,Serum LDL,Kidney Function Test 850

Physician Consultation Scope – Review of Tests done, Vitals (BP/Pulse etc.,) Systemic Examination, any specific
symptoms narrated by the customer.

Type of Process – Annual Health Check up

Payment Mode – Credit
Report Dispatch Process – Hard copy to be handed over to the client & Soft copy to be sent to HealthAssure on
fax@[Link] along with Identity Card photocopy.
*If Any client want to do any additional Individual test we would request you to kindly provide discount of 40-45%

Page | 7 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF MAX LIFE INSURANCE COMPANY LIMITED

Category Tests Rate

Cat 1 MER 100
Cat 2 MER, CBC including ESR 150
Cat 3 MER, Blood Profile 990
Cat 4 MER, Blood Profile, ECG,MSU 1100
Cat 5 MER, Blood Profile, ECG, MSU, CBC including ESR 1145
Cat 6 MER, Blood Profile, TMT, MSU, CBC including ESR 1640
Cat 7 MER, Blood Profile, TMT, MSU, CBC including ESR, CXR 1710

Reflex Test to be done :

FBS If above the normal range, then HbA1c (Glycosylated Haemoglobin) to be performed.
CBC ESR should be a part of CBC test
HbsAg If positive, then HbeAg and Anti HCV to be performed
Urine Dipstick If any abnormality is found, then MSU to be performed.
Note: If protein trace is found, no need to perform MSU

Blood profile – Fasting Blood Sugar, HIV-Elisa, HBsAg, BUN, Serum Creatinine, SGPT, SGOT,
Serum Triglycerides,HDL Cholestrol, Serum Cholestrol, GGTP, Bilirubin(Direct/Conjugated), Alkaline
Phosphatase, Serum Albumin,Bilirubin(Indirect/Unconjugated), Bilirubin(Total)

PRE_POLICY HEALTH CHECK-UP ADDITIONAL PACKAGE

FOR THE PROSPECTIVE POLICY HOLDERS OF MAX LIFE INSURANCE COMPANY LIMITED

Category Test Details HA Rate

CAT 1 MER with urine dipstick 100
CAT 2_New Grid MER, MSU, BP1 300
CAT 4 A MER, MSU, BP1, ECG 400
CAT 4 B MER, MSU, BP2, ECG 850
CAT 5_New Grid MER, BP3, ECG, MSU, CBC 1045
CAT 6 A MER, MSU, BP2, TMT 1350
CAT 6 B MER, BP3, TMT, MSU, CBC 1540

Components:-

Blood Profile 1/BP 1 Blood Profile 2 /BP2 Blood Profile 3 /BP 3

FBS FBS FBS
Serum Cholestrol HIV I & II HbsAg
High Density
Serum Cholestrol HIV I & II
Lipoprotein(HDL)
Lipids (Serum cholesterol, HDL,
HDL
Triglycerides)
Kidney Function Test ( Serum Creatinine,
Blood Urea Nitrogen, Bilirubin, Direct
TRIG
Bilirubin, Indirect Bilirubin Serum
Albumin)
Liver Function Test ( SGOT, SGPT,
Serum Creatinine
Gamma GT, ALP )
Serum Albumin
SGOT
SGPT

Page | 8 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
THE PROSPECTIVE POLICY HOLDERS OF RELIGARE HEALTH INSURANCE COMPANY LIMITED

Test Set Medical Tests Rates

Care V2 - Set 1 MER, CBC & ESR, HBA1C, RUA, SGPT, S. Creatinine 400
MER, CBC & ESR, HBA1C, RUA, ECG, USG abd/pelvis (M&F), S.
Care V2 - Set 2 Creatinine 800

Care V2 - Set 3 MER, CBC & ESR, HbA1c, [Link], ECG, SGPT, S. Creatinine,RUA 500

Care V2 - Set 4 MER, CBC & ESR, HbA1c, [Link], TMT, SGPT, S. Creatinine,RUA 1010
MER, CBC & ESR, HbA1c, Lipids, LFT with GGT, RUA, TMT, HBsAg, S.
Care V2 - Set 5 Creatinine 1395

Care V2 - Set 6 MER, CBC & ESR, HBA1C, RUA, 2DEcho with ECG, USG, S. Creatinine 1270
MER, CBC & ESR, HbA1c, Lipids, LFT with GGT, RUA, TMT, HBsAg, S.
Care V2 - Set 7 Creatinine, USG abd/pelvis (M&F) 1795

MER, CBC & ESR, HbA1c, Lipids, LFT with GGT, RUA, HBsAg,RFT, USG
Care V2 - Set 8 abd/pelvis (M&F), PSA (M), TMT, 2D ECHO with ECG 2955

MER, CBC & ESR, HbA1c, Lipids, LFT with GGT, RUA, HBsAg,RFT, USG
Care V2 - Set 9M abd/pelvis (M&F), CEA, PSA (M), TMT, 2D ECHO with ECG 3305

MER, CBC & ESR, HbA1c, Lipids, LFT with GGT, RUA, HBsAg,RFT, USG
Care V2 - Set 9F abd/pelvis (M&F), CEA, PAP(F), TMT, 2D ECHO with ECG 3355
MER, CBC & ESR, HbA1c, Lipids, LFT with GGT, RUA, HBsAg,RFT, USG
abd/pelvis (M&F), CEA, PSA (M), Chest - X Ray, PFT, TSH, TMT, 2D ECHO
Care V2 - Set 10M with ECG 3830
MER, CBC & ESR, HbA1c, Lipids, LFT with GGT, RUA, HBsAg,RFT, USG
abd/pelvis (M&F), CEA, PAP (F), Chest - X Ray, PFT, TSH, TMT, 2D ECHO
Care V2 - Set 10F with ECG 3880

RFT BUN, Uric acid, Creatinine

Total Protein, Albumin, Globulin, A/G Ratio, Total Bilirubin, Direct Bilirubin,
Indirect Bilirubin, SGOT, SGPT, Alkaline phosphatase, GGT, LACTATE
LFT with GGT DEHYDROGENASE ( LDH )
Total Cholesterol, Triglycerides, HDL Cholesterol, LDL, VLDL, Total Cholesterol
Lipid Profile /HDL Ratio, HDL / LDL Ratio

Type of Process – Pre-Policy Health Check up

Payment Mode – Credit
Report Dispatch Process – Hard copy & Soft copy to be sent to HealthAssure on fax@[Link] along with
Identity Card photocopy

Page | 9 HealthAssure & Provider Agreement

ANNUAL HEALTH CHECK-UP PACKAGE FOR THE EMPLOYEES OF DEUTSCHE BANK
Test Package Package 1 (M/F > 35) Package 2 (M > 40) Package 3 (F > 40)
Diabetes Screen x x x
Liver Profile x x x
Cholesterol Profile x x x
Renal Profile x x x
Complete Haemogram x x x
Urinogram x x x
Stool Routine x x x
Thyroid Profile x x x
Chest X-ray x x x
ECG x x x
Physical Examination x x x
Stress Test / Echocardiogram / Mammography x x
PAP Smear x
Package Rate 2400 3200 3500

Test Break up
Fasting Blood Sugar Total Count
HbA1C Differential Count
Average Blood Glucose ESR
Diabetes Screen PPBS Platelet Count
Platelet Distribution
Width
Mean Platelet Volume
Total RBC Count
Red Cell Distribution
Bilirubin (direct/conjugated) Width
Bilirubin (indirect/un-conjugated) PCV
Bilirubin (Total) Complete MCV
GGT (Gamma Glutamyl Haemogram
TransPeptidase) MCH
Liver Profile SGPT/ ALT MCH Concentration
SGOT/ AST Lymphocytes
Alkaline Phosphatase (ALP) Monocytes
Serum Albumin Basophile
Total Protein Eosinophils
Globulin Neutrophils
Total Cholesterol/ Serum Cholesterol Total Leucocytes
HDL Cholesterol Haemoglobin
VLDL Cholesterol Morphology of cells
Cholesterol Profile LDL Cholesterol Urine Routine
HDL Ratio Urinary Bilirubin
LDL Ratio Urinary Ketone
Serum Triglycerides Specific Gravity
Blood Urea Nitrogen Urine Blood
Urinogram
Uric Acid pH
Renal Profile Serum Creatinine Urinary Protein
Calcium Urobilinogen
BUN/ Creatinine Ratio Nitrate
Stool routine Stool routine Urinary Leucocytes
Page | 10 HealthAssure & Provider Agreement
 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF HDFC ERGO HEALTH INSURANCE CASHLESS – ENERGY AND CITIBANK
PRODUCT LIMITED

HealthAssure
Category New Revised Test Categories Rates
Pre Screening Test HbA1C, Urine Microalbumin 500
MER, TMT or ECG with 2D ECHO, Lipids, Sr creatinine, LFT, USG Abd, HbA1C, Urine
Cat 8 microalbumin 2225
MER, HbA1C, Urine microalbumin, Total Cholestrol, Total Protein, SGOT, Sr
Cat 10 creatinine, TMT 1175
Cat 8 - Pre
Screening Test MER, TMT or ECG with 2D ECHO, Lipids, Sr creatinine, LFT, USG Abd 1725
Cat 10 - Pre
Screening Test MER, Total Cholestrol, Total Protein, SGOT, Sr creatinine, TMT 750
Wellness Pack 1 HbA1c, Blood pressure Monitoring, BMI, MER with Urine Dipstick 300
HbA1c, Blood Pressure, FBS, BMI, Total Cholesterol, Creatinine, High-density
lipoprotein (HDL), Low-density lipoprotein (LDL), Triglyceride (TG), Total Protein,
Serum Albumin, Gamma-glutamyltransferase (GGT), SGOT, SGPT, Billirubin, ECG,
Total Cholesterol : HDL Cholesterol ratio, MER with Urine Dipstick, Eye & Foot
Wellness Pack 2 exam (diabetic) 800

Type of Process – Pre-Policy Health Check up

Payment Mode – Credit
Report Dispatch Process – Hard copy & Soft copy to be sent to HealthAssure on fax@[Link] along with
Identity Card photocopy

Page | 11 HealthAssure & Provider Agreement

 PRE-EMPLOYMENT AND ANNUAL HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE EMPLOYEES OF MARSH INDIA INSURANCE BROKERS
Pre Employment Test Grid Annual Health Check Test Grid
Pre employment Health Check up Master Health Check up Heart Health Check
Pathology Pathology Pathology
Complete Haemogram Complete Haemogram Complete Haemogram
Haemoglobin Haemoglobin Haemoglobin
Packed Cell Volume Packed Cell Volume Packed Cell Volume
MCHC, MCV, MCH MCHC, MCV, MCH MCHC, MCV, MCH
WBC, Differential Count WBC, Differential Count WBC, Differential Count
Peripheral Smear Peripheral Smear Peripheral Smear
RBC,ESR RBC,ESR RBC,ESR
Platelet Count Platelet Count Platelet Count
Blood Sugar Blood Sugar Blood Sugar
Blood Sugar Fasting Blood Sugar Fasting & PP Blood Sugar Fasting & PP
Lipid Profile Lipid Profile Lipid Profile
Total Cholesterol Total Cholesterol Total Cholesterol
Liver Function Test HDL HDL
SGOT LDL LDL
Kidney Assessment VLDL VLDL
Serum Creatinine Triglycerides Triglycerides
HIV(Rapid) Total Cholesterol/HDL Ratio Total Cholesterol/HDL Ratio
Blood Grouping & Rh typing Liver Function Test Liver Function Test
Urine Routine Total Proteins, Albumin, Globulin Total Proteins, Albumin, Globulin
Diagnostic Tests AG ratio AG ratio
Chest X-Ray Alkaline Phosphates Alkaline Phosphates
ECG SGPT SGPT
Consultations GGTP GGTP
Physical Examination by MD
Physician SGOT SGOT
Questionnaire Bilirubin – Total & Indirect Bilirubin – Total & Indirect
Kidney Assessment Kidney Assessment
Package Rate - Rs. 900/- Serum Urea Serum Urea
Serum Creatinine Serum Creatinine
Serum Uric Acid Serum Uric Acid
HIV (Rapid) Blood Grouping & Rh typing
Urine Routine Urine Routine
Stool Routine Stool Routine
Diagnostic Tests Diagnostic Tests
Chest X-Ray Chest X-Ray
ECG ECG
Ultrasound screening of whole Ultrasound screening of whole
Abdomen Abdomen
Pap Smear (for women) / PSA (for
Men) Treadmill test (TMT)
Consultations Echocardiography (ECHO)
Physical Examination by MD Pap Smear (for women) / PSA (for
Physician Men)
Pulmonary Function Test (PFT)
Package Rate - Rs. 1955/- Consultations
Physical Examination by MD Physician
Diet Counseling
Cardiologist consultation

Package Rate - Rs. 4085/-

Page | 12 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF MANIPAL CIGNATTK HEALTH INSURANCE PVT LTD

SET TEST DETAILS HA Rates

Set I MER 125

Set II MER, CBC-ESR, Hba1c, ECG, Total Cholestrol, SGPT, Serum Creatinine, Urine Routine 635
MER, CBC-ESR, HbA1c, ECG, Lipid Profile, SGOT, SGPT, GGTP, Serum Creatinine, Uric acid,
Set III Urine Routine 960
MER, CBC-ESR, HbA1c, Lipid Profile, SGOT, SGPT, GGTP, Serum Creatinine, Uric acid, Urine
Set IV Routine, FBS, TMT, USG Abdomen & Pelvic, CEA, HIV 2320
MER, CBC-ESR, HbA1c, Lipid Profile, USG Abdomen & Pelvic, X RAY CHEST, FBS,TMT, CEA,
Set V HIV, LFT, RFT, Urine Routine, PSA, PAP SMEAR 3480
Set VI MER, 2D Echo, CBC-ESR, Lipid Profile, Kidney Profile, LFT, TMT 1920
Set VII MER, HBA1C, 2D Echo, CBC-ESR, Lipid Profile, Kidney Function Test 1360
MER, CBC-ESR, Lipid Profile, HbA1c, Sr. Creatinine, Urine Routine, SGOT, SGPT, GGT, TMT,
Set VIII Uric acid 1560
MER, Urine Routine, FBS, CBC - ESR, Peripheral Blood Smear, Sr Creatinine, Lipid Profile,
Set IX TMT, USG Abdomen & Pelvis, HbA1c, X-Ray Chest, SGOT, SGPT, GGT, HBsAg, Uric acid 2320
MER, Urine Routine, FBS, CBC-ESR, Peripheral Blood Smear, Lipid Profile, TMT, USG Abd and
Set X Pelvis, HbA1c, X-Ray Chest, LFT, RFT, HBsAg, PAP smear(Female), PSA(Males), CEA, HIV 3600
Set XI MER, CBC-ESR, FBS, Lipid profile, SGOT, SGPT, GGT, Sr. Creatinine, ECG 750

Set XII MER, FBS, ECG. CBC, ESR 280

Set XIII MER, FBS, LIPIDS, ECG 500

Set XIV MER, CBC-ESR, FBS, Lipid Profile, Sr. Creatinine, ECG 650

Individual CEA - Cancer Marker (Formal name: Carcinoembryonic Antigen) 350

Individual X- ray Abdomen 125
Individual USG Abdomen & Pelvis 500
Individual CRP (Formal name: C-Reactive Protein) 300

Type of Process – Pre-Policy Health Check up

Payment Mode – Credit
Report Dispatch Process – Hard copy & Soft copy to be sent to HealthAssure on fax@[Link] along with
Identity Card photocopy

Page | 13 HealthAssure & Provider Agreement

 ANNUAL HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF MANIPAL CIGNATTK HEALTH INSURANCE PVT LTD

Package Name New Test details Rate

Protect above 18 ECG, Total Cholesterol, FBS, Sr. Creatinine, CBC, SGPT 400
ECG, FBS, Sr. Creatinine, CBC-ESR, Lipid Profile,
Plus 18 – 40 SGOT,SGPT, GGT 745

ECG, FBS, Sr. Creatinine, CBC-ESR, Lipid Profile,

Plus 40 + Female SGOT,SGPT, GGT,For females only - TSH 920
ECG, FBS, Sr. Creatinine, CBC-ESR, Lipid Profile,
Plus 40 + Male SGOT,SGPT, GGT 745
Preferred and Premier 18 - ECG, FBS, Sr. Creatinine, CBC-ESR, Lipid Profile,
40 Female SGOT,SGPT, GGT ,For females: TSH 920
Preferred and Premier 18 - ECG, FBS, Sr. Creatinine, CBC-ESR, Lipid Profile,
40 Male SGOT,SGPT, GGT 745
Preferred and Premier 40 ECG, FBS, Sr. Creatinine, CBC-ESR, Lipid Profile,
+ Male SGOT,SGPT, GGT,TMT 1345
Preferred and Premier 40 + ECG, FBS, Sr. Creatinine, CBC-ESR, Lipid Profile,
Female SGOT,SGPT, GGT,TSH, TMT 1520

Accumulate below 18 ECG, Total Cholesterol,FBS, Sr. Creatinine, CBC, SGPT 400
ECG, FBS, Sr. Creatinine, CBC-ESR, Lipid Profile,
Accumulate 18 - 40 SGOT,SGPT, GGT 745

ECG, FBS, Sr. Creatinine, CBC-ESR, Lipid Profile,

Accumulate 40 + Female SGOT,SGPT, GGT,For females only - TSH 920
ECG, FBS, Sr. Creatinine, CBC-ESR, Lipid Profile,
Accumulate 40 + Male SGOT,SGPT, GGT 745

Additional Categories

Plan Name Test Details Rates

AHC - 1 MER, ECG, Total Cholesterol, FBS, Sr. Creatinine, CBC, Urine 540
Routine, SGPT

AHC – 2 MER, ECG,CBC-ESR, Lipid Profile, HbA1c, Sr. Creatinine, RUA, SGOT, 960
SGPT, GGT, Uric Acid

AHC – 3 MER, ECG,CBC-ESR, Lipid Profile, HbA1c, Sr. Creatinine, RUA, SGOT, 2200
SGPT, GGT, Uric Acid, TSH, Pap smear, Mammogram

AHC – 4 MER, ECG,CBC-ESR, Lipid Profile, HbA1c, Sr. Creatinine, RUA, SGOT, 1200
SGPT, GGT, Uric Acid, PSA

AHC – 5 MER, ECG,CBC-ESR, Lipid Profile, HbA1c, Sr. Creatinine, RUA, SGOT, 2200
SGPT, GGT, Uric Acid, TSH, Pap smear, Mammogram
MER, ECG,CBC-ESR, Lipid Profile, HbA1c, Sr. Creatinine, RUA, SGOT,
AHC – 6 1200
SGPT, GGT, Uric Acid, PSA

AHC – 7 MER, CBC-ESR, Lipid Profile, HbA1c, Sr. Creatinine, RUA, SGOT, 2250
SGPT, GGT, Uric acid, TMT, USG Abdomen & Pelvis, PSA
MER, CBC-ESR, Lipid Profile, HbA1c, Sr. Creatinine, RUA, SGOT,
AHC – 8 SGPT, GGT, TMT, Uric acid, USG Abdomen & Pelvis, Pap smear, 3000
Mammogram, TSH

Type of Process – Annual Health Check up

Payment Mode – Credit
Report Dispatch Process – Hard copy to be handed over to the client & Soft copy to be sent to HealthAssure on
fax@[Link] along with Identity Card photocopy.

Page | 14 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF BIRLA SUNLIFE INSURANCE CO LTD

SET TEST DETAILS HA Rates

Set I FMR with Urine Dispstick 100
Set II FMR with Urine Dispstick, BSL 13, ECG 990
Set III FMR with Urine Dispstick, BSL 13, ECG, CBC with ESR 1060
Set IV FMR with Urine Dispstick, BSL 13, TM - ECG 1500
Set V FMR with Urine Dispstick, BSL 13, TM - ECG, CBC with ESR 1570
Set VI FMR with Urine Dispstick, BSL 7, ECG 640
Set VII FMR with Urine Dispstick, BSL 11, ECG 690

BSL- 13 - Fasting BSL- 13 Non - Fasting BSL 11 BSL 7

RBS (Random Blood
FBS ( Fasting Blood Sugar) Sugar ) FBS FBS
SGOT / AST SGOT / AST Urea / BUN SGOT
GGTP GGTP Serum Creatinine SGPT
SGPT / ALT SGPT / ALT Total Bilirubin GGT
Serum Cholestrol Serum Cholestrol SGOT Cholesterol
Alkaline Phosphate Alkaline Phosphate SGPT HBsAG
Trglycerides Trglycerides GGT HIV test
Total Protein Total Protein Total Proteins
Serum Albumin Serum Albumin Cholesterol
Serum Globulin Serum Globulin Triglycerides
Total Biliburin Total Biliburin Alkaline Phosphatase
Direct Bilirubin Direct Bilirubin
Indirect Bilirubin Indirect Bilirubin
BUN BUN
Serum Creatinine Serum Creatinine
HBSAG HBSAG
HIV (1&2) HIV (1&2)
HbA1C HbA1C
CBC with ESR CBC with ESR

Page | 15 HealthAssure & Provider Agreement

*INDIVIDUAL RATES OF BIRLA SUNLIFE INSURANCE CO.

Sr No Medical Test HA Rates

1 FMR with Urine Dispstick 100
2 BSL 13 800
3 ECG 90
4 TM – ECG 600
5 CBC 50
6 PSA 270
7 HbA1c 200
8 Anti HCV 340
9 HbeAG 375
10 Microalbumin 120
11 CBC with ESR 70
12 X-ray 90
13 2 D Echo (Plain) 600
14 USG (Full Abdomen) 350
15 PFT 180
16 HDL 65
17 Urine Cotinine 400
18 Cholesterol/HDL Ratio 65
19 ESR 20
20 RUA 30
21 Free PSA 850
22 Total PSA 270
23 HIV 1 & 2 with Elisa Method 175
24 HIV with Western Blot 2300
25 LDL 65
26 VLDL 100
27 BSL 11 500
28 BSL 7 450
29 Home Visit Rates for MBBS 125
30 Home Visit Rates for Technician 65

Type of Process – Pre-policy Health Checkup.

Payment Mode – Credit
Report Dispatch Process – Hard copy & Soft copy to be sent to HealthAssure on fax@[Link] along with
Identity Card photocopy

Page | 16 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF ROYAL SUNDARAM ALLIANCE INSURANCE CO

PPHC List of Tests HA Rate

Category (INR)
RSA Set 1 –
CBC, ESR, URA, MER, FBS, S Cholesterol, ECG, SGPT, S. Creatinine 465
FBS
RSA Set 1 -
CBC, ESR, URA, MER, HbA1C, S Cholesterol, ECG, SGPT, S. Creatinine 570
HbA1c
CBC, ESR, URA, MER, HbA1C, Lipid Profile, TMT or 2D Echo, LFT with GGT,
1600
RSA Set 2 RFT, HBsAg

ANNUAL HEALTH CHECK-UP PACKAGE

FOR THE PROSPECTIVE POLICY HOLDERS OF ROYAL SUNDARAM ALLIANCE INSURANCE CO

AHC List of Tests HA Rate

Category (INR)
RSA AHC I
CBC, URA, Blood Group, ESR, FBS, ECG, S Cholesterol, SGPT, Creatinine 465
RSA AHC II CBC, URA, Blood Group, ESR, FBS, Lipid Profile, KFT, ECG, Complete
935
physical examination by Physician
RSA AHC III CBC, URA, Blood Group, ESR, FBS, Lipid Profile, Stress Test (TMT) or 2D
1435
Echo, KFT, Complete physical examination by Physician

Type of Process – Annual Health Checkup.

Payment Mode – Credit
Report Dispatch Process – Hard copy to be handed over to the client & Soft copy to be sent to HealthAssure on
fax@[Link] along with Identity Card photocopy

PRE-EMPLOYMENT HEALTH CHECK-UP PACKAGE

FOR THE PROSPECTIVE POLICY HOLDERS OF MYLAN PHARMACEUTICALS

Test Details
Haemogram
Erythrocyte Sedimentation Rate
Blood Grouping & RH Type
Fasting Blood Sugar
Lipid Profile
Serum Creatinine
Blood Urea
Liver Function Tests
Complete Urine Analysis
ECG
Chest X-Ray PA View
Physical Examination
Complete Eye Examination (With Colour Vision)
Package Rate - INR 1350/-

Page | 17 HealthAssure & Provider Agreement

 PRE-EMPLOYMENT HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF MYLAN LABORATORIES LIMITED

Mylan Lab - Pre Employment

(i) Complete blood picture (CBP)
(ii) ESR (Erythrocyte Sedimentation Rate)
(iii) Blood group and typing
(iv) FBS (Fasting Blood Sugar) & PLBS (Post
Prandial Blood Sugar) – in case of Diabetic
patient OR RBS (Random Blood Sugar) – in case
of Non-Diabetic patient
(v) Lipid profile (includes Total Cholesterol, HDL
Cholesterol, LDL Cholesterol, Triglycerides, VLDL
Cholesterol and corresponding ratios)
(vi) HBsAg (Screening for Hepatitis B)
(vii) Anti HCV (Anti- Hepatitis C Virus)
(viii) Complete urine analysis (CUE)
(ix) ECG (Electro Cardio Gram)
(x) Serum Creatinine
(xi) Liver Function Test (LFT- including Total
Bilirubin- Direct & Indirect; SGPT/ALT; SGOT/AST;
Alkaline Phosphatase; GGTP; Total Protein;
Albumin; Globulin & Ratios )
(xii) Audiometry (Pure Tone Audiometry or PTA)

(xiii) Pulmonary Function Test (PFT)

(xiv) Eye Checkup – Includes Ophthalmologist
evaluation with Visual Acuity, Far & Near Vision
and Colour Vision
(xv) Chest X Ray PA view (Not to be done for
Pregnant women for risk of radiation to the baby)
(xvi) Ultrasound Abdomen & Pelvis
(xvii) Physician Evaluation includes (a) Physical
Examination of Height, Weight, BP, etc and (b)
Systemic Examination of Cardiovascular System,
Respiratory System, Gastrointestinal System,
Central Nervous System, Musculoskeletal system,
Genitourinary system, so on and so forth
including Allergies & Epilepsy history, etc

(xviii) ENT examination

(xix) Dermatological Examination by Skin
Specialist
INR 1900/-

Type of Process – Pre-employment Health Checkup.

Payment Mode – Credit
Report Dispatch Process – Soft copy of Fitness Status & Blood Group to be sent to HealthAssure on
fax@[Link] along with Identity Card photocopy. Hard Copy of Report to be dispatched to HealthAssure
Mumbai Office

Page | 18 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF ICICI PRUDENTIAL LIFE INSURANCE CO.

Category Tests HA Rate

Set 1 MER, HbA1c 275
Set 2 MER,ECG,RUA,LIPID,FBS,HbA1c 620
Set 3 MER,ECG,RUA,SMA12,HbA1c 1050
Set 4 MER,ECG,RUA,SMA12,CBC,HbA1c 1095
Set 5 MER,ECG,RUA,SMA12,CBC,HIV,AUS,HbA1c 1405
Set 6 MER,ECG,RUA,SMA12,HIV,AUS,HbA1c 1360
Set 7 MER,TMT,RUA,SMA12,CBC,HIV,AUS,HbA1c 1905
Set 8 MER,TMT,RUA,SMA12,CBC,HIV,AUS,CXR,HbA1c 2005
Set 9 MER,TMT,RUA,S12,HIV,AUS,HbA1c 1860
Set 10 SMA12,HbA1c 825

AUS - Australia Antigen Test

Abbreviations SMA12 - FBS, [Link], S. Triglycerides, HDL, LDL, S. Proteins, S. Albumin,
S. Bilirubin (Direct & Indirect), SGOT, SGPT, S. Creatinine, GGT

PRE_POLICY HEALTH CHECK-UP PACKAGE

FOR THE PROSPECTIVE POLICY HOLDERS OF EXIDE LIFE INSURANCE CO.

Category Codes Details of Tests HA Rate

CAT C MER, RUA, FBS, LIP 425
CAT D MER, RUA, FBS, LIP, BIO, HIV 930
CAT E MER, RUA, ECG, FBS, LIP, BIO, HIV, HBsAg 1115
CAT F MER, RUA, TMT, FBS, LIP, BIO, HIV, CBC, HBsAg, HbA1c 1750
CAT H MER, RUA, FBS, LIP, BIO, HIV, HbsAg 1025
CAT I MER, RUA, FBS, LIP, BIO, HIV, HbsAg, CBC,ECG,HbA1c 1285
CAT A MER 100
CAT B MER, RUA, CBC 170

LIP - Serum Cholesterol, HDL, Triglycerides

Abbreviations BIO - S. Creatinine, SGOT, SGPT, Bilirubin (Direct + Indirect), Total Proteins
(Albumin + Globulin), GGTP

Type of Process – Pre-Policy Health Check up

Payment Mode – Credit
Report Dispatch Process – Hard copy & Soft copy to be sent to HealthAssure on fax@[Link] along
with Identity Card photocopy

Page | 19 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF FUTURE GENERALI LIFE INSURANCE CO.

Category Test Details HA Rates

Cat 1 MER, Blood Profile, Urine Cotinine 1410
Cat 2 MER, RUA, Blood Profile, ECG, Urine Cotinine 1510
Cat 3 MER, RUA, Blood Profile,HbA1c, ECG, Urine Cotinine 1725
Cat 4 MER, RUA, Blood Profile,HbA1c, TMT, Urine Cotinine 2160
Cat 5 MER, RUA, Blood Profile,HbA1c, TMT,CXR, Urine Cotinine 2235
Cat A MRF,FBS,CBC,ESR 260
Cat B MRF,FBS,CBC,ESR RUA, ECG, Lipid Profile 600
Cat C MRF,FBS, RUA,FGI-15,HIV 1160
Cat D MRF,FBS, RUA,FGI-15,HIV,ECG 1255
Cat E MRF,FBS, RUA,FGI-15,HIV,TMT 1830
Cat F MRF,FBS, RUA,FGI-15,HIV,TMT CXR 1930
Cat G JME 100
Cat H MRF 100

Blood LFT with GGTP, Lipid Profile, RFT(Including Bun Report), HbsAg, HBA1C, FBS,
Profile CBC & ESR, Total Proteins, HIV 1025
LFT with GGTP, Lipid Profile, RFT(Including Bun Report), HbsAg, HbA1c, CBC
FGI-15 & ESR, Total Proteins 1025

MRF Medical Report Form ( meaning MER - Medical Examination Report)

JME Juvenile Medical Examination

Type of Process – Pre-Policy Health Check up

Payment Mode – Credit/Cash
Report Dispatch Process – Hard copy & Soft copy to be sent to HealthAssure on fax@[Link] along
with Identity Card & client photocopy

Page | 20 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF Future Generali India General Insurance

Package Component Rates

Series 1 MER 100
Series 2 MER, ECG, LAB 1 530
Series 3 MER, ECG, LAB 2 955
Series 4 MER, ECG, LAB 3 1485
Series 5 MER, ECG, LAB 3, Chest X-Ray 1600
Series 6 MER, ECG, LAB 3, Chest X-Ray, CTMT 2200
Series 7 MER, ECG, LAB 3, CTMT 2085
Series 8 MER, ECG, LAB 3, 2D Echo with ECG 2085
Series 9 MER, ECG, LAB 4 1200
Series 10 MER, ECG, LAB 5 1530
Series 11 MER, ECG, LAB 5, 2D Echo with ECG 2130
Series 12 MER, ECG, LAB 4, 2D Echo with ECG 1800
Series 13 MER, ECG, LAB 6 570
Series 14 MER, ECG, RUA, Lipid Profile, LFT with GGT, RFT, Hba1c 1130
MER, RUA, Lipid Profile, LFT with GGT, RFT, Hba1c, Chest X-
Series 15 Ray, TMT 1765

Series 16 MER, RUA, Lipid Profile, LFT with GGT, RFT, Hba1c, Chest X-
Ray, TMT, CEA 2055
Female
Series 17 MER, RUA, Lipid Profile, LFT with GGT, RFT, Hba1c, Chest X-
Ray, TMT, CEA, PSA 2355
Male

LAB 1 FBS, PPBS, CBC + ESR, Serum Cholestrol, Sr Creatinine, RUA 330
FBS, PPBS, CBC + ESR, Serum Cholestrol, Sr Creatinine, RUA,
LAB 2 Lipid Profile, LFT with GGT, RFT 755

FBS, PPBS, CBC + ESR, Serum Cholestrol, Sr Creatinine, RUA,

LAB 3 Lipid Profile, LFT with GGT, RFT, Hba1c, HbsAg, HIV 1285

LAB 4 Hba1c, CBC+ESR, Lipid Profile, RUA, LFT with GGT, RFT 1000
Hba1c, CBC+ESR, Lipid Profile, RUA, LFT with GGT, RFT,
LAB 5 HbsAg, HIV 1330

LAB 6 Hba1c, CBC+ESR, RUA, Creatinine 370

MER,ECG, CBC +ESR,RUA, FBS, PPBS, Lipid Profile, Creatinine,

Series A SGOT, SGPT, GGT 955

Series B CBC+ESR, RUA, RBS 140

Series C CBC+ESR, RUA, FBS, PPBS, ECG, Creatinine 350
Series D MER,CBC +ESR, FBS, PPBS, ECG, Creatinine 420

RFT Urea and Serum Electrolytes(Na & K)

Bilirubin- Total, Indirect Bilirubin, SGOT, SGTP, Alkaline
LFT Phosphatase, GGTP, Total Proteins, Albumin

Type of Process – Pre-Policy Health Check up

Payment Mode – Credit/Cash
Report Dispatch Process – Hard copy & Soft copy to be sent to HealthAssure on fax@[Link] along
with Identity Card & client photocopy

Page | 21 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF Kotak Life Insurance.

HA
Packages Tests
Rates
P1 FMR 100
P2 FMR, ECG, FBS 210
P3 FMR, FBS, HIV,CHOL 340
P4 FMR,ECG, SMA-15, HIV,RUA 1095
P5 FMR, SMA-15, HIV, HbA1c, RUA, ECG 1295
P6 FMR, ECG, CBC (HEMOGRAM)/ESR, RUA, SMA-15, HIV,HbA1c 1395
P7 FMR, CTMT, CBC (HEMOGRAM)/ESR, SMA-15, HIV, HbA1c, RUA 1810
FMR, CTMT, CBC (HEMOGRAM)/ESR, SMA-15, HIV, HBsAg, HbA1c,
P8
RUA 1905

FBS, Serum Cholesterol, HDL Cholesterol, Serum Triglycerides, TC /

HDL Ratio, Serum Creatinine, Serum Uric Acid, Serum Calcium,
SGOT, SGPT, Alkaline Phosphatase, Total Proteins, Albumin, Total
SMA-15 Bilirubin, GGTP 700
Plain X-ray of KUB (2 plates) 160
X-ray Dorsal Spine (AP & Lateral) 250
Sonography of KUB 235
Others Sonography of whole abdomen 400

PRE_POLICY HEALTH CHECK-UP PACKAGE

FOR THE PROSPECTIVE POLICY HOLDERS OF Magma.

Package 1 Rates Package 2 Rates Package 3 Rates

Medical Examination Report Medical Examination Report Medical Examination Report
CBC + ESR CBC + ESR CBC + ESR
FBS HbA1c HbA1c
Serum Cholesterol Lipid Profile Lipid Profile
550 960 1800
SGOT and SGPT Liver Function Test Liver Function Test
Routine Urine Analysis Routine Urine Analysis Routine Urine Analysis
ECG ECG 2D Echocardiography
Serum Creatinine Serum Creatinine Kindey Profile

Lipid Profile Cholestrol, Triglycerides, HDL, LDL, VLDL

LFT Proteins, Albumin, Globulin, Bilirubin(Direct & Indirect), SGOT, SGPT,

GGT, Alkaline Phophatase, Bilirubin Direct , Bilirubin Indirect
Kidney Profile Uric Acid, Serum Creatinine, BUN

Important Instructions :

• These are all HNI Customers for this product. Kindly ensure 100% Customer Focus
• Please complete the medicals smoothly and ensure all tests are conducted in a single visit
• Please ensure the report is complete on all criteria
• These are Credit businesses and please ensure No-Cash is collected from the Customers

Page | 22 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF HDFC ERGO HEALTH INSURANCE – Combi Product.

Categories Tests Rate

HC Cat 1 MER,Urine Cotinine,FBS, CHOL, BIO, HIV 1070
HC Cat 2 MER, Urine Cotinine,FBS, CHOL, HAEM, BIO, HIV 1130

HC Cat 3 MER, ECG, MSU, FBS, CHOL, HAEM,BIO, HIV 1005

HC Cat 4 MER, ECG, Urine Cotinine, FBS, CHOL, BIO, HIV 1175

HC Cat 5 MER, ECG, Urine Cotinine,FBS, CHOL, HAEM, BIO, HIV 1235

HC Cat 6 MER, MSU, Urine Cotinine, FBS, HbA1c, CHOL, BIO, HIV, HBsAg 1455

HC Cat 7 MER, ECG, MSU, Urine Cotinine, FBS, Lipid Profile, HAEM, BIO, HIV 1510

HC Cat 8 MER, ECG, MSU, Urine Cotinine, FBS, HbA1c, CHOL,BIO, HIV, HBsAg 1575
MER, MSU, Urine Cotinine, FBS, Lipid Profile, HAEM, BIO, HIV, TMT, Uric acid,
HC Cat 9 USG A & P 2360

HC Cat 10 MER, MSU, Urine Cotinine, FBS, HbA1c, CHOL, HAEM, BIO, HIV, HBsAg 1530

HC Cat 11 MER, ECG, MSU, Urine Cotinine,FBS, HbA1c, CHOL, HAEM, BIO, HIV, HBsAg 1630

HC Cat 12 MER, ECG, MSU, Urine Cotinine, FBS,HbA1c, Lipid Profile, HAEM, BIO, HIV 1690

HC Cat 13 MER, FBS,TMT,Lipids,[Link], LFT, Uric Acid, USG A & P 1640

HC Cat 14 MER, TMT, MSU, FBS, HbA1c, Lipid,Profile, HAEM, BIO 1790

HC Cat 15 MER, TMT, MSU, FBS, HbA1c, Lipid Profile, HAEM, BIO, Creatinine 1790

HC Cat 16 MER, Urine Cotinine, FBS, HAEM, BIO, HIV, TMT,Lipids,Uric acid, USG A & P 2245
MER, TMT, MSU, Urine Cotinine, FBS, HbA1c, Lipid Profile, HAEM, BIO, HIV,
HC Cat 17 HBsAg 2310
MER, TMT, MSU, Urine Cotinine, FBS, HbA1c, Lipid Profile, HAEM, BIO, HIV,
HC Cat 18 HBsAg, Creatinine 2310

HC Cat 19 MER,Urine Cotinine, FBS, BIO, HIV, TMT, Lipids, Uric acid, USG A & P 2190

HC Cat 20 MER, MSU, FBS, HAEM, BIO, HIV, TMT, Lipids, Uric acid, USG A & P 1965
MER, TMT, MSU, FBS, HbA1c, Lipid Profile, HAEM, BIO, Uric acid, 2D ECHO,
HC Cat 21 USG A & P 2625
MER, TMT, MSU, Urine Cotinine, FBS, HbA1c, Lipid Profile, HAEM, BIO, HIV,
HC Cat 22 HBsAg, Uric acid, USG A & P 2605
MER, MSU, Urine Cotinine, FBS, HbA1c, BIO, HIV, HBsAg, TMT,Lipids,Uric acid,
HC Cat 23 USG A & P 2550
MER, MSU, Urine Cotinine, FBS, HbA1c, Lipid Profile, HAEM, BIO, HIV, TMT,
HC Cat 24 Uric acid, USG A & P 2485
MER, MSU, Urine Cotinine, FBS, HbA1c, HAEM, BIO, HIV, HBsAg,
HC Cat 25 TMT,Lipids,Uric acid, USG A & P 2525

Page | 23 HealthAssure & Provider Agreement

 HC Cat 26 MER, TMT, MSU, FBS, HbA1c, Lipid Profile, HAEM, BIO,Uric acid, USG A & P 1985
MER, TMT, MSU, Urine Cotinine, FBS,HbA1c, Lipid Profile, HAEM, BIO, HIV,
HC Cat 27 HBsAg, Uric acid, 2D ECHO, USG A & P 3030
MER, TMT, 2D Echocardiogram, MSU, Urine Microalbumin, Urine Cotinine,
FBS, HbA1c, CHOL, HAEM, BIO, HIV, HBsAg, USG A & P & , Pulmonary
HC Cat 28 Function Test 3260
MER, TMT, 2D Echocardiogram, MSU, Urine Microalbumin, Urine Cotinine,
FBS, HbA1c, Lipid Profile, HAEM, BIO, HIV, HBsAg, USG A & P, Pulmonary
HC Cat 29 Function Test, Uric acid 3540
MER, TMT, 2D Echocardiogram, MSU, Urine Microalbumin, UrineCotinine,
FBS, HbA1c, CHOL, HAEM, BIO, HIV, HBsAg, USG A & P, Pulmonary Function
HC Cat 30 Test, Lipids, Uric acid 3610
MER, TMT, 2D Echocardiogram, MSU, Urine Microalbumin, Urine Cotinine,
FBS, HbA1c, CHOL, HAEM, BIO, HIV, HBsAg, Anti HCV, USG A & P, Pulmonary
HC Cat 31 Function Test 3540
MER, TMT, 2D Echocardiogram, MSU, Urine Microalbumin, Urine Cotinine,
FBS, HbA1c, Lipid Profile, HAEM, BIO, HIV, HBsAg, Anti HCV, USG A & P,
HC Cat 32 M Pulmonary Function Test, PSA, Uric acid 4085
MER, TMT, 2D Echocardiogram, MSU, Urine Microalbumin, Urine Cotinine,
FBS, HbA1c, Lipid Profile, HAEM, BIO, HIV, HBsAg, Anti HCV, USG A & P,
HC Cat 32 F Pulmonary Function Test, Uric acid 3825
MER, TMT, 2D Echocardiogram, MSU,Urine Microalbumin, Urine
Cotinine,FBS, HbA1c, Lipid Profile, HAEM, BIO,HIV, HBsAg, USG A & P,
HC Cat 33 Pulmonary Function Test 3475
MER, TMT, 2D Echocardiogram, MSU,Urine Microalbumin, Urine
Cotinine,FBS, HbA1c, Lipid Profile, HAEM, BIO,HIV, HBsAg, Anti HCV, USG A &
HC Cat 34 P, Pulmonary Function Test 3750
MER, TMT, 2D Echocardiogram, MSU,Urine Microalbumin, Urine Cotinine,
FBS,HbA1c, Lipid Profile, HAEM, BIO, HIV,HBsAg, Anti HCV, USG A & P,
HC Cat 35M Pulmonary Function Test, PSA 4015
MER, TMT, 2D Echocardiogram, MSU,Urine Microalbumin, Urine Cotinine,
FBS,HbA1c, Lipid Profile, HAEM, BIO, HIV,HBsAg, Anti HCV, USG A & P &
HC Cat 35F ,Pulmonary Function Test, 3750
MER, TMT, 2D Echocardiogram, MSU,Urine Microalbumin, Urine
Cotinine,FBS, HbA1c, Lipid Profile, HAEM, BIO,HIV, HBsAg, Anti HCV, USG A &
HC Cat 36 P, Pulmonary Function Test, Uric acid 3825
MER, TMT, 2D Echocardiogram,MSU, Urine Microalbumin, UrineCotinine,
FBS, HbA1c, CHOL, HAEM,BIO, HIV, HBsAg, Anti HCV, USG A & P,
HC Cat 37 PulmonaryFunction Test, Lipids, Uric acid 3890

RBC, WBC, Hb, Hematocrit, Platelets, MCV, MCH,

Haem MCHC, ESR
MSU Midstream Urinanalysis
Lipid
Profile Cholestrol, Triglycerides, HDL, LDL, VLDL
Proteins, Albumin, Globulin, Bilirubin(Direct &
Indirect), SGOT, SGPT, GGT, Alkaline Phophatase,
LFT Bilirubin Direct , Bilirubin Indirect
Protein, Albumin, Creatinine, Bilirubin (Direct &
Indirect), SGOT, SGPT,ALP,GGT, Bilirubin Direct ,
BIO Bilirubin Indirect
Important Instructions :

• These are all HNI Customers for this product. Kindly ensure 100% Customer Focus
• Please complete the medicals smoothly and ensure all tests are conducted in a single visit
• Please ensure the report is complete on all criteria
• These are Credit businesses and please ensure No-Cash is collected from the Customers

Page | 24 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF TATA AIA.

Category Test Names Rate

Cat 1 ME 100
Cat 2 BPB,ME 850
Cat 3 BPB,ME,HBA1c 1050
Cat 4 COTININE,BPB,ME 1100
Cat 5 BPB,ECGR,HBA1C,ME 1225
Cat 6 COTININE,BPB,ECGR,HBA1C,ME 1450
Cat 7 BPC,TMT,HBA1C,ME 1560
Cat 8 BPC,TMT,HBA1C,ME,Cotinine 1890
Cat 9 BPC,ECG-R ,HBA1C,ME 1215
Cat 10 BPC,ECG-R ,HBA1C,ME,Cotinine 1540
Cat 11 ME, BPC, Cotinine 1340
Cat 12 TMT 600
Cat 13 ME, HBA1c,ECG-R 400
Cat 14 ME,BPB,HBA1c,TMT 1590
Cat 15 ME,BPB,HBA1c,TMT,Cotinine 1800

FBS, TC, TG, HDL, Serum Creatinine, Serum

Bilirubin, SGOT, SGPT, GGT,
BPB ALP,[Link],Hbsag 1130
CBP with ESR, HDL, HIV, TC, TG, FBS, Serum
Creatinine, Urea, Serum Bilirubin,Hbsag,
BPC SGOT, SGPT, ALP, GGT, Albumin 1280

Individual Rates - TATA AIA

Tests Rates
MER 100
BPE (Blood Profile - E, this includes HIV test) 170
Chest X-Ray 100
X-ray KUB 150
USG - Whole Abdomen 350
USG – Thyroid 350
USG – Pelvis 300
PFT 150
Microscopic Urine Analysis 30
ECG-Resting 100
ECG-Exercise 600
Anti HCV (IgG) (HCV Antibodies) 340
APTT (Activated Partial Thromboplastin Time) 120
Bilirubin (Direct/Conjugated) 65
Bilirubin (Indirect/Unconjugated) 65
Bilirubin (Total) 65
BST(Blood Sugar Tolerance) 60
BT(Bleeding Time) 30
Calcium 50
ECG(Stress) 600
Echocardiography 700
Page | 25 HealthAssure & Provider Agreement
 ESR (Erythrocyte Sedimentation rate) 15
FSH(Follicle Stimulating Hormone) 275
GTT(Glucose Tolerance Test-5 samples) 175
Haemogram (without peripheral smear) 75
Hb% (Haemoglobin) 20
HbA1c (Glycosylated Haemoglobin) 200
HBDH(Hydroxy Butyrate DeHydrogenase) 180
HbeAg 350
HCV(Hepatitis C Virus) 340
HDL(High Density Lipids Cholesterol) 60
MCH (Mean Corpuscular Haemoglobin) 25
MCH (Mean Corpuscular Haemoglobin Concentration) 25
MCV (Mean Corpuscular Volume) 25
Mg(Magnesium) 140
Microalbumin(Urine) 120
PCV(Haematocrit) 35
Peripheral Blood Smear (without blood profile) 100
Platelets 35
Proteins(Globulin) 50
Proteins(Total) 50
PSA(Prostate Specific Antigen) 270
PTT(Partial Thromboplastin Time) 170
RBC (Red Blood Cells) 35
Serum Acid Phosphates 125
Serum Amylase 110
Serum CPK (Creatinine Phosphokinase) 75
Serum LH (Luetenizing Hormone) 240
Serum Lipase 240
Serum Uric Acid 35
Sodium 40
Sputum Routine 55
Stool Routine 30
T3(Free) 80
T3(Triiodothyronine) 80
T4(Free) 80
T4 (Thyroxine) 80
TMT(Tread Mill Test) 600
Total Leucocyte Count(TLC) 35
Total Lipids 70
TSH (Thyroid Stimulating Hormone) 80
Vision Testing 100
VLDL(Very Low Density Lipids) 85
WBC(White Blood Cells) 30
X-Ray (Barium Enema) 680
X-Ray (Barium Swallow) 410
X-Ray (Cholecystography) 550
X-ray (IVP-Intravenous Pylegraphy) 550
X-ray (Lumbo-Sacral) 125
*Renal / Kidney Function Test 300
*Lipid Profile 255
Page | 26 HealthAssure & Provider Agreement
 Hypertension Profile 400
Diabetic Profile 300
*Liver Function Test 260
*Thyroid Profile 240
*CBP (cbc) 60
HIV 170
Cholesterol 55
HDL Cholesterol 60
Triglycerides 60
Glucose 30
Creatinine 50
Urea(BUN) 40
HbsAg 110
SGOT 50
SGPT 50
Alk Phosphates 60
GGTP 65
AFP 220
Albumin 40
FBS 30
PG2 40
2 Urine dipstick 20
3BP Reading 30
JMR 100
*BPB 1130
*BPC 1280
Stress Echo 800
2D ECHO 700
Stress Thalium At actual
Blood Cotinine 650
Urine Cotinine 250

Important Instructions :

• These are all HNI Customers for this product. Kindly ensure 100% Customer Focus
• Please complete the medicals smoothly and ensure all tests are conducted in a single visit
• Please ensure the report is complete on all criteria
• These are Credit businesses and please ensure No-Cash is collected from the Customers

Page | 27 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF Bajaj Allianz General Insurance Co.

Category Test Details Rates

FMR, ECG, FBS, CBC with ESR, Serum Cholesterol, HDL
Cholesterol, Triglycerides, Serum Creatinine, GGTP, SGOT,
Vital Health checkup SGPT,Hba1c,Urinalysis,Total Protein, Serum Albumin, 950
Serum Globulin, A:G Ratio
FMR, CBC with ESR, FBS, Serum Cholesterol, Urine Routine,
Tax Gain Chest X Ray 450

Set 1 FMR 100

FMR, ECG, FBS, CBC with ESR, Serum Cholesterol, Serum
Set 2 Creatinine, Urinalysis (Chemical & Microscopic) 420

FMR, ECG, FBS, CBC with ESR, Serum Cholesterol, Serum

Creatinine, Urinalysis (Chemical & Microscopic), PPBS, HDL
Set 3 1020
Cholesterol, Serum Triglycerides, GGTP, SGOT,SGPT,Hba1c,
HbsAg
FMR, ECG, FBS, CBC with ESR, Serum Cholesterol, Serum
Set 4 Creatinine, Urinalysis (Chemical & Microscopic), PPBS, HDL 820
Cholesterol, Serum Triglycerides, GGTP, SGOT,SGPT
FMR, TMT, FBS, CBC with ESR, Serum Cholesterol, Serum
Set 5 Creatinine, Urinalysis (Chemical & Microscopic), PPBS, HDL 1240
Cholesterol, Serum Triglycerides, GGTP, SGOT,SGPT
FMR, TMT, FBS, CBC with ESR, Serum Cholesterol, Serum
Creatinine, Urinalysis (Chemical & Microscopic), PPBS, HDL
Set 6 1525
Cholesterol, Serum Triglycerides, GGTP, SGOT,SGPT,Hba1c,
HbsAg
FMR, ECG, FBS, CBC with ESR, Serum Cholesterol, Serum
Set 7 Creatinine, Urinalysis (Chemical & Microscopic), Chest X- 550
Ray
FBS, CBC with ESR, Serum Cholesterol, Serum Creatinine,
Lab I Urinalysis (Chemical & Microscopic) 200

FBS, CBC with ESR, Serum Cholesterol, Serum Creatinine,

Lab II Urinalysis (Chemical & Microscopic),PPBS, HDL Cholesterol, 515
Serum Triglycerides, GGTP, SGOT,SGPT
FBS, CBC with ESR, Serum Cholesterol, Serum Creatinine,
Lab III Urinalysis (Chemical & Microscopic),PPBS, HDL Cholesterol, 800
Serum Triglycerides, GGTP, SGOT,SGPT,Hba1c, HbsAg
FMR, ECG, FBS, CBC with ESR, Serum Cholesterol, HDL
Cholesterol, Triglycerides, Serum Creatinine, GGTP, SGOT,
HCS Above 1 Crore 2050
SGPT,Hba1c,Urinalysis,Total Protein, Serum Albumin,
Serum Globulin, A:G Ratio, USG Abdomen & Pelvis,2D Echo
FMR, Renal Function Test, USG Abdomen, CBC with
Comprehensive Care Plan ESR,FBS, PPBS, Lipid Profile, Liver Function test, Hba1c, 2600
Urine Routine, ECG, Chest X-Ray, TMT, PSA for Men

FMR, ECG,CBC with ESR, FBS, Lipid Profile, Serum

Health Guard_Individual Creatinine, SGOT,SGPT, Urine Routine 720

FMR, ECG,CBC with ESR, FBS, Lipid Profile, Serum

Health Guard_Floater Creatinine, SGOT,SGPT, Urine Routine 720

FMR, ECG,CBC with ESR, Serum Cholesterol, Urine Routine,

Silver Health Chest X-Ray 500

FMR, ECG,CBC with ESR, FBS, Lipid Profile, Serum

Star Package Creatinine, SGOT, SGPT, Urine Routine, PPBS,GGTP, Chest 895
X-Ray
FMR, ECG, CBC with ESR, Urine Routine
Health Ensure 300

Page | 28 HealthAssure & Provider Agreement

 FMR, CBC with ESR,FBS, Serum Creatinine, ECG, Serum
HCS Annual >25 Male Cholesterol, USG Abdomen & Pelvis 950

FMR, CBC with ESR,FBS, Serum Creatinine, ECG,PAP Smear,

HCS Annual >25 Female Serum Cholesterol, USG Abdomen & Pelvis 1375

FMR, CBC with ESR, Chest X-Ray, Blood Group, Urine

HCS Annual 5-25 Yrs Routine 275

Renal Function test - BUN, Uric acid, Creatinine

Test Components Lipid Profile - Total Cholesterol, HDL, LDL, Triglycerides,
HDL/LDL Ratio, VLDL

Important Instructions :
• These are all HNI Customers for this product. Kindly ensure 100% Customer Focus
• Please complete the medicals smoothly and ensure all tests are conducted in a single visit
• Please ensure the report is complete on all criteria
• These are Credit businesses and please ensure No-Cash is collected from the Customers

ADDITIONAL - PRE_POLICY HEALTH CHECK-UP PACKAGE

FOR THE PROSPECTIVE POLICY HOLDERS OF Bajaj Allianz Life Insurance Co.

Package Name TEST Details HA Rate

Bajaj Allianz Life - Package 1 MER 100
Bajaj Allianz Life - Package 2 MER + ECG 160
Bajaj Allianz Life - Package 3 MER + A1 545
Bajaj Allianz Life - Package 4 MER + A1+ B1 1045
Bajaj Allianz Life - Package 5 MER + A1+ B1 + C + D 1300
Bajaj Allianz Life - Package 6 MER + A1 + ECG 625
Bajaj Allianz Life - Package 7 MER + A1+ B1+ECG 1125
Bajaj Allianz Life - Package 8 MER +A+B+C+D 1200
Bajaj Allianz Life - Package 9 MER +A+B+C+D+Urine Cotinine 1500
Bajaj Allianz Life - Package 10 MER + A1+ B1 + C + D + ECG 1380
Bajaj Allianz Life - Package 11 MER + A1+ B1 + C + D + CTMT 1940
Bajaj Allianz Life - Package 12 MER + A1 + B1+ C+D+Urine Cotinine+ ECG 1620
Bajaj Allianz Life - Package 13 MER + A1 + B1+ C+D+Urine Cotinine+ CTMT 2180
Bajaj Allianz Life - Package 14 MER + A1 + C+Urine Cotinine+ECG 940
Bajaj Allianz Life - Package 15 MER + A1 + B1+C+Urine Cotinine+ECG 1440

PATHOLOGY HA Rate
A1 = FBS+HBA1c+Lipid Profile( Serum Cholesterol, HDL, Triglycerides, LDL, 465
VLDL)+ RUA + Serum Creatinine
B 1= LFT{SGPT,SGOT, GGTP, ALP, Total Proteins – Albumin & Globulin)
Serum Bilirubin (Total Direct and Indirect)} +CBC (HB, WBC, RBC, 500
LYMPHOCYTES, NEUTROPHILS, EOSINOPHILS, MONOCYTES, BASOPHILS,
PLATELET COUNT, MCV , MCHC,MCH ,ESR)+Blood Urea+ Uric Acid
A = FBS+HBA1c+Lipid Profile(Serum Cholesterol, HDL, Triglycerides, LDL,
VLDL)+ RUA+ CBC (HB, WBC, RBC, LYMPHOCYTES, NEUTROPHILS, 465
EOSINOPHILS, MONOCYTES, BASOPHILS, PLATELET COUNT, MCV ,
MCHC,MCH ,ESR)
B =LFT {SGPT,SGOT, GGTP, ALP, Total Proteins – Albumin & Globulin) Serum 400
Bilirubin (Total Direct and Indirect)}+[Link]
C = HbsAG 100
D = HIV 180
Urine Cotinine test As per our agreement
Page | 29 HealthAssure & Provider Agreement
 HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF Bajaj Allianz Annual Health Check Up.

HA
Package Name Package Details
Rate
FMR, ECG with reporting, FBG, CBC, [Link], HDL Cholesterol,
BAGIC -Health Triglycerides, Creatinine, GGTP, SGOT , SGPT, HbA1c, Urinalysis,
1125
Guard Package 1 Total Protein, Sr. Albumin, Sr. Globulin, A:G Ratio, Blood Group &
Rh Type.
FMR, ECG with reporting, FBG, CBC, [Link], HDL Cholesterol,
BAGIC -Health Triglycerides, Creatinine, GGTP, SGOT , SGPT, HbA1c, Urinalysis,
1225
Guard Package 2 Total Protein, Sr. Albumin, Sr. Globulin, A:G Ratio, Blood Group &
Rh Type, TSH.

FMR, ECG with reporting, FBG, CBC, [Link], HDL Cholesterol,

BAGIC -Health Triglycerides, Creatinine, GGTP, SGOT , SGPT, HbA1c, Urinalysis,
1900
Guard Package 3 Total Protein, Sr. Albumin, Sr. Globulin, A:G Ratio, Blood Group &
Rh Type, TSH, USG Abdomen.

FMR, ECG with reporting, FBG, CBC, [Link], HDL Cholesterol,

BAGIC -Health Triglycerides, Creatinine, GGTP, SGOT , SGPT, HbA1c, Urinalysis,
2000
Guard Package 4 Total Protein, Sr. Albumin, Sr. Globulin, A:G Ratio, Blood Group &
Rh Type, TSH, USG Abdomen, Chest X-Ray.
FMR, ECG with reporting, FBG, CBC, [Link], HDL Cholesterol,
BAGIC -Health Triglycerides, Creatinine, GGTP, SGOT , SGPT, HbA1c, Urinalysis,
2100
Guard Package 5 Total Protein, Sr. Albumin, Sr. Globulin, A:G Ratio, Blood Group &
Rh Type, TSH, USG Abdomen, Chest X-Ray, ENT Check up.
FMR, ECG with reporting, FBG, CBC, [Link], HDL Cholesterol,
BAGIC -Health Triglycerides, Creatinine, GGTP, SGOT , SGPT, HbA1c, Urinalysis,
2775
Guard Package 6 Total Protein, Sr. Albumin, Sr. Globulin, A:G Ratio, TSH, T3 and T4,
USG Abdomen, Chest X-Ray, ENT Check up, Stress Test.
FMR, ECG with reporting, FBG, CBC, [Link], HDL Cholesterol,
BAGIC -Health Triglycerides, Creatinine, GGTP, SGOT , SGPT, HbA1c, Urinalysis,
3215
Guard Package 7 Total Protein, Sr. Albumin, Sr. Globulin, A:G Ratio, TSH, T3 and T4,
USG Abdomen, Chest X-Ray, ENT Check up, Stress Test, PSA.
FMR, ECG with reporting, FBG, CBC, [Link], HDL Cholesterol,
BAGIC -Health Triglycerides, Creatinine, GGTP, SGOT , SGPT, HbA1c, Urinalysis,
3215
Guard Package 8 Total Protein, Sr. Albumin, Sr. Globulin, A:G Ratio, TSH, T3 and T4,
USG Abdomen, Chest X-Ray, ENT Check up, Stress Test, PAP smear.
FMR, ECG with reporting, FBG, CBC, [Link], HDL Cholesterol,
Triglycerides, Creatinine, GGTP, SGOT , SGPT, HbA1c, Urinalysis,
BAGIC -Health
Total Protein, Sr. Albumin, Sr. Globulin, A:G Ratio, TSH, T3 and T4, 3365
Guard Package 9
USG Abdomen, Chest X-Ray, ENT Check up, Stress Test, PSA, Dental
check up.
FMR, ECG with reporting, FBG, CBC, [Link], HDL Cholesterol,
Triglycerides, Creatinine, GGTP, SGOT , SGPT, HbA1c, Urinalysis,
BAGIC -Health
Total Protein, Sr. Albumin, Sr. Globulin, A:G Ratio, TSH, T3 and T4, 4015
Guard Package 10
USG Abdomen, Chest X-Ray, ENT Check up, Stress Test, PAP smear,
Dental Check up,mammography.
BAGIC -Health
CBC+ESR, T. Cholesterol, S. Creatinine, Fasting Blood Sugar. 300
Ensure Package 1
BAGIC -Health CBC+ESR, T. Cholesterol, S. Creatinine, Fasting Blood Sugar, SGOT,
500
Ensure Package 2 SGPT, BUN.
BAGIC -Health CBC+ESR, Fasting Blood Sugar, LIPID PROFILE, S. Creatinine, SGOT,
700
Ensure Package 3 SGPT, BUN.
BAGIC FYCF -Silver Physician Consultation, ECG, Complete Blood Count, Fasting Blood
540
Health Sugar, Serum Cholesterol, Urine Routine, Chest X Ray.

Page | 30 HealthAssure & Provider Agreement

 Physician Consultation (Height, Weight and B.P.), ECG with
BAGIC HCS AHC reporting, FBG, CBC, [Link], HDL Cholesterol, Triglycerides,
1225
Package 1 Creatinine, GGTP, SGOT, SGPT, HbA1c, Urinalysis, Total Protein, Sr.
Albumin, Sr. Globulin, A:G Ratio, Blood Group & Rh Type, TSH.
Physician Consultation (Height, Weight and B.P.), ECG with
reporting, FBG, CBC, [Link], HDL Cholesterol, Triglycerides,
BAGIC HCS AHC
Creatinine, GGTP, SGOT, SGPT, HbA1c, Urinalysis, Total Protein, Sr. 2000
Package 2
Albumin, Sr. Globulin, A:G Ratio, Blood Group & Rh Type, TSH, T3
and T4, USG Abdomen, Chest X-Ray.
Physician Consultation (Height, Weight and B.P.), ECG with
reporting, FBG, CBC, [Link], HDL Cholesterol, Triglycerides,
BAGIC HCS AHC
Creatinine, GGTP, SGOT, SGPT, HbA1c, Urinalysis, Total Protein, Sr.
Package 3 2760
Albumin, Sr. Globulin, A:G Ratio, TSH, T3 and T4, USG Abdomen,
Chest X-Ray, ENT Checkup, Stress Test.

Additional BAGIC AHC Package.

Package Test Grid Rates

Physician Consultation including Height, Weight and B.P, ECG with
BAGIC AHC 1 reporting, CBC, ESR, FBS, Creatinine, Lipid profile, Liver function 931
test, HbA1c, Urinalysis
Physician Consultation including Height, Weight and B.P, ECG with
BAGIC AHC 2 reporting, CBC+ ESR, FBS, Creatinine, Lipid profile, Liver function 1260
test, HbA1c, Urinalysis, USG A & P
Physician Consultation including Height, Weight and B.P, ECG with
BAGIC AHC 3 reporting, CBC, ESR, FBS, Creatinine, Lipid profile, Liver function 1381
test, HbA1c, Urinalysis, USG A & P, Uric Acid, TSH
Physician Consultation including Height, Weight and B.P, ECG with
BAGIC AHC 4 reporting, CBC, ESR, FBS, Creatinine, Lipid profile, Liver function 1516
test, HbA1c, Urinalysis, USG A & P, Uric Acid, TFT, Urea
Physician Consultation including Height, Weight and B.P, ECG with
reporting, CBC, ESR, FBS, Creatinine, Lipid profile, Liver function
BAGIC AHC 5 test, HbA1c, Urinalysis, USG A & P, Uric Acid, TFT, Urea, Chest X- 1525
Ray
Physician Consultation including Height, Weight and B.P, ECG with
reporting, CBC, ESR, FBS, Creatinine, Lipid profile, Liver function
BAGIC AHC 6 test, HbA1c, Urinalysis, USG A & P, Uric Acid, TFT, Urea, Chest X- 2061
Ray, Vitamin B 12
Physician Consultation including Height, Weight and B.P, ECG with
reporting, CBC, ESR, FBS, Creatinine, Lipid profile, Liver function
BAGIC AHC 7 test, HbA1c, Urinalysis, USG A & P, Uric Acid, TFT, Urea, Chest X- 2115
Ray, Vitamin B 12, Total Protein
Physician Consultation including Height, Weight and B.P, ECG with
reporting, CBC,ESR, FBS, Creatinine, Lipid profile, Liver function
BAGIC AHC 8 test, HbA1c, Urinalysis, USG A & P, Uric Acid, TFT, Urea, Chest X- 2421
Ray, Vitamin B 12, Vitamin D3
Physician Consultation including Height, Weight and B.P, CBC, ESR,
BAGIC AHC 9 Male FBS, Creatinine, ECG with reporting, Lipid profile, USG A & P, PSA , 1251
HbA1c
Physician Consultation including Height, Weight and B.P, CBC, ESR,
BAGIC AHC 10 FBS, Creatinine, ECG with reporting, Lipid profile, USG A & P, PAP 1251
Female Smear , HbA1c
Physician Consultation including Height, Weight and B.P, CBC, ESR,
BAGIC AHC 11 FBS, Creatinine, ECG with reporting, Lipid profile, USG A & P, PSA , 1480
Male HbA1c, TFT, Chest X-Ray

Page | 31 HealthAssure & Provider Agreement

 Physician Consultation including Height, Weight and B.P, CBC, ESR,
BAGIC AHC 12 FBS, Creatinine, ECG with reporting, Lipid profile, USG A & P, PAP 1480
Female Smear , HbA1c, TFT, Chest X-Ray
Physician Consultation including Height, Weight and B.P, CBC, ESR,
BAGIC AHC 13 FBS, Creatinine, ECG with reporting, Lipid profile, USG A & P, PSA , 1962
Male HbA1c, TFT, X-RAY, Vitamin B12
Physician Consultation including Height, Weight and B.P, CBC, ESR,
BAGIC AHC 14 FBS, Creatinine, ECG with reporting, Lipid profile, USG A & P, PAP 1962
Female Smear , HbA1c, TFT, Chest X-Ray, Vitamin B12

Important Instructions :

• These are all HNI Customers for this product. Kindly ensure 100% Customer Focus
• Please complete the medicals smoothly and ensure all tests are conducted in a single visit
• Please ensure the report is complete on all criteria
• These are Credit businesses and please ensure No-Cash is collected from the Customers

Page | 32 HealthAssure & Provider Agreement

 POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF SBI Life Insurance.

Package Name Rate

Category A- ( CBC+ ESR + Lipid profile) 250
Category B- (RFT (S. creatinine, BUN, Serum uric acid) + LFT
(GGTP+SGOT+SGPT., Alkaline phosphate)+BILIRUBIN(Direct + 600
Indirect + Total)+ + Serum protein +S. albumin, Hbsag
Category C- (FBS + RUA) 60
Category D- (HIV) 150

Test Name Rate

FMR 100
AEC (Absolute Eosinophil Count) 45
AFP (Alpha FetoProtein) 250
APTT (Activated Partial Thromboplastin Time) 145
BST (Blood Sugar Tolerance) 50
BT (Bleeding Time) 25
Calcium 60
Copper 290
CT (Clotting Time) 25
Diabetic Profile 150
DLC (Differential Leucocyte Count) 35
Electrolytes ([Link]+K+CL-) 100
Free PSA 350
FSH (Follicle Stimulating Hormone) 290
G6PD -Quatitative (G-6 Phosphatedehydrogenase) 175
GTT (Glucose Tolerance Test-5 samples) 160
HBDH (Hydroxy Butyrate DeHydrogenase) 175
HYPERTENSION PROFILE 450
Iron / TIBC 160
LDH 90
Mantoux Test / Tuberculin Test 50
MCH (Mean Corpuscular Haemoglobin) 20
MCHC (Mean Corpuscular Haemoglobin
20
Concentration)
MCV (Mean Corpuscular Volume) 20
Mg (Magnesium) 145
PCV (Haematocrit) 25
Peripheral Blood Smear 100
Phosphorus 60
Platelets 45
Potassium 45
PTT (Partial Thromboplastin Time) 175
PG2 25
RA Factor 60
RBC (Red Blood Cells) 35
Serum Acid Phosphatase 145
Serum Amylase 145
Serum CPK (Creatinine PhosphoKinase) 90
Serum LH (Luetenizing Hormone) 250
Serum Lipase 250
Sodium 40
Sputum Routine 50
Page | 33 HealthAssure & Provider Agreement
 TLC (Total Leucocyte Count) 35
VDRL (Venereal Disease Research Laboratory) 45
Vision Testing 100
WBC (White Blood Cells) 25
Widal (Tube Method) 60
X-Ray (Barium Enema) 700
X-Ray (Barium Meal Follow Through) 700
X-Ray (Barium Swallow) 400
X-Ray (Cholecystography) 500
X-Ray (IVP - Intravenous Pyleography) 550
X-Ray (Kidney Urinary Bladder) 175

PRE_POLICY HEALTH CHECK-UP PACKAGE

FOR THE PROSPECTIVE POLICY HOLDERS OF Reliance General Health Insurance.

Category Package Rate

CAT 1 MER 100
CAT 2 MER,CBC with ESR,FBS,RUA,S Creatinine 300
MER,CBC with ESR,FBS,HbA1c,Lipid , SGOT, SGPT, GGT,RUA,ECG, HbsAg, S
CAT 3 Creatinine 1170
MER,CBC with ESR,FBS,HbA1c,Lipid , SGOT, SGPT, GGT,RUA, TMT, HbsAg,
CAT 4 HIV,S Creatinine 1785
MER,CBC with ESR,FBS,HbA1c,Lipid , SGOT, SGPT, GGT,RUA,TMT, HbsAg, S
CAT 5 Creatinine 1590
MER,CBC with ESR,HbA1c,Lipid , SGOT, SGPT, GGT,RUA,TMT,2 D
CAT 6 M echo,HbsAg,HIV,S Creatinine, USG A& P, PSA 2928
MER,CBC with ESR,HbA1c,Lipid , SGOT, SGPT, GGT,RUA,TMT,2 D echo,
CAT 6 F HbsAg, HIV,S Creatinine, USG A& P, PAP Smear 2928

Important Instructions :
• These are all HNI Customers for this product. Kindly ensure 100% Customer Focus
• Please complete the medicals smoothly and ensure all tests are conducted in a single visit
• Please ensure the report is complete on all criteria
• These are Credit businesses and please ensure No-Cash is collected from the Customers
• Hard copy and soft copy of reports to HealthAssure at fax@[Link]

Page | 34 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF Aditya Birla Health Insurance

Category Test Details Rate

Cat 1 MER, FBS,ECG, RUA, CBC + ESR 350

Cat 2 - Revised MER, ECG, RUA, CBC + ESR,Sr. Cholestrol, Triglyceride, Sr. 835
Creatinine, Hba1c, Urine Microalbumin

Cat 3 - Revised MER, ECG, RUA, CBC + ESR,Sr. Cholestrol, Triglyceride, Sr. 595
Creatinine, Hba1c

Cat 4 - Revised MER, ECG, RUA, CBC + ESR,Sr. Cholestrol, Triglyceride, Sr. 915
Creatinine, Hba1c, SGPT, Microalbumin

Cat 5 - Revised MER, ECG, RUA, CBC + ESR,Microalbumin,Hba1c,Lipid Profile, 1085

LFT with GGT, RFT
Cat 10 MER, Hba1c, [Link], Microalbumin, Lipid Profile 800
Cat 11 PFT 175
Cat 12 MER, FBS, Total Cholestrol 130

Cat 16 - Revised MER, RUA, CBC with Smear + ESR, LFT with GGT, RFT, Lipid 2325
Profile, TMT, USG A & P, FBS, Hba1c, X Ray, Hbsag, HCV

Cat 17M - Revised MER, RUA, CBC with Smear + ESR, LFT with GGT, RFT, Lipid 2435
Profile, TMT, USG A & P, FBS, Hba1c, X-Ray, Hbsag, HCV, PSA
MER, RUA, CBC with Smear + ESR, LFT with GGT, RFT, Lipid
Cat 17F - Revised Profile, TMT, USG A & P, FBS, Hba1c, X Ray, Hbsag, HCV, PAP 2435
Smear

Cat 18M - Revised MER, RUA, CBC with Smear + ESR, Lipid Profile, USG A & P, 1650
Hba1c, SGPT, GGTP, [Link], ECG, FBS, PSA

Cat 18F - Revised MER, RUA, CBC with Smear + ESR, Lipid Profile, USG A & P, 1650
Hba1c, SGPT, GGTP, [Link], ECG, FBS, PAP Smear

Cat 19M - Revised MER, RUA, CBC with Smear + ESR, LFT with GGT, RFT, Lipid 2435
Profile, TMT, USG A & P, FBS, Hba1c, X-Ray, Hbsag, HCV, PSA
MER, RUA, CBC with Smear + ESR, LFT with GGT, RFT, Lipid
Cat 19F - Revised Profile, TMT, USG A & P, FBS, Hba1c, X-Ray, Hbsag, HCV, PAP 2435
Smear

Cat 20 MER, CBC with Smear + ESR , USG A & P, X-Ray, Hbsag, HCV, 1400
SGPT, GGT

Cat 21M MER, CBC with Smear + ESR , USG A & P, X-Ray, Hbsag, HCV, PSA 1350
, SGPT, GGT

Cat 21F MER, CBC with Smear + ESR , USG A & P, X-Ray, Hbsag, HCV, PAP 1350
Smear, SGPT, GGT

Cat 22M MER, CBC with Smear + ESR , USG A & P, X-Ray, Hbsag, SGPT, 1025
GGT, PSA

Cat 22F MER, CBC with Smear + ESR , USG A & P, X-Ray, Hbsag, SGPT, 1025
GGT, PAP Smear

Cat 23 M - Revised MER, CBC with Smear + ESR , USG A & P, X-Ray, Hbsag, HCV, PSA, 1550
SGPT, GGT

Cat 23 F - Revised MER, CBC with Smear + ESR , USG A & P, X-Ray, Hbsag, HCV, PAP 1550
Smear, SGPT, GGT

Cat 24 - Revised MER, Hba1c, RUA, CBC + ESR, ECG, Serum Cholestrol, SGPT, 555
[Link]

Cat 26 - Revised MER, Hba1c, ECG, RUA, CBC + ESR, [Link], Lipid Profile, 795
SGPT

Cat 32 - Revised MER, CBC + ESR , RUA, Blood Group, FBS, Serum Cholestrol, 520
SGPT, [Link], ECG

Cat 33 - Revised 875

MER, CBC + ESR , RUA, Blood Group, FBS, Lipid Profile, RFT, ECG

Page | 35 HealthAssure & Provider Agreement

 Cat 34 - Revised 1315
MER, CBC + ESR , RUA, Blood Group, FBS, Lipid Profile, RFT, TMT
MER, CBC + ESR , Blood Group & RH Factor, RUA, Stool Routine,
Total Bilirubin, Direct Bilirubin,SGOT, SGPT,GGT,Alkaline
Cat 35 - Revised Phosphate, Total Protein, Albumin, Globulin,TMT,ECG, Serum 2260
Cholestrol,HDL,LDL,[Link],VLDL,[Link],BUN,Uric
acid,Hba1c, X-Ray, USG A & P
Cat 37 (Below 18 MER, Eye Examination, Dental Examination and Scoring, Growth 100
years) - Revised Charting, Dr Consultation, Urine Examination

Cat 13 - Revised MER, FBS, Serum Cholestrol, RUA, CBC + ESR, Sr Creatinine, 860
Albumin, SGPT, TSH, ECG

Cat 14M - Revised MER, FBS, Serum Cholestrol, RUA, CBC + ESR, Sr Creatinine, 1770
Albumin, SGPT, TSH, TMT or 2D Echo, PSA

Cat 14F - Revised MER, FBS, Serum Cholestrol, RUA, CBC + ESR, Sr Creatinine, 1770
Albumin, SGPT, TSH, TMT or 2D Echo, PAP Smear

PRE_POLICY HEALTH CHECK-UP PACKAGE

FOR THE PROSPECTIVE POLICY HOLDERS OF CHOLAMANDALAM MS GENERAL INSURANCE COMPANY LTD .

Category Test Details HA Rates

MER, CBC with ESR, ECG, HbA1C, T Cholesterol,
Package 1 SGPT, RUA 615

MER, CBC with ESR, RUA, HbA1C, Lipid profile, LFT

Package 2 with GGT, RFT, CXR, USG A & P, TMT 2080

MER, CBC with ESR, ECG, CUE, FBS, LFT with GGT,
Health Check-up Package 1 RFT 720

MER, CBC with ESR, ECG, CUE, FBS, LFT with GGT,
Health Check-up Package 2 RFT, CXR, Lipid Profile, USG A & P, TMT 2080

Components:

LFT Lipid Profile RFT

T. Bilirubin Se. Cholesterol Se. Uric Acid
I - Direct Se. Triglyceride Se. Creatinine
II - Indirect Se. HDL BUN
SGOT (AST) Se. LDL
SGPT( ALP) Se. VLDL
Se. T. Protein T. Chole/HDL Ratio
I - Albumin
II - Globulin
III - A/G Ratio
Se. ALP
GGT

Important Instructions :

· These are all HNI Customers, Kindly ensure 100% Customer Focus.
. Please complete the medicals smoothly and ensure all tests are conducted in a single
visit
· Please ensure the report is complete on all criteria
· These are Credit businesses and please ensure No-Cash is collected from theCustomers
· Softcopy and Hardcopy of medical reports to HealthAssure at fax@[Link]

Page | 36 HealthAssure & Provider Agreement

 PRE_POLICY HEALTH CHECK-UP PACKAGE
FOR THE PROSPECTIVE POLICY HOLDERS OF Canara HSBC Life Insurance(CHSBC)

Category Test Details Rate

CAT-1 MER 80
CAT-2 MER,FBS,Lipid Profile,RUA 300
CAT-3 MER,FBS,Lipid Profile,HIV 430
CAT-4 MER,FBS,Lipid Profile,RUA,ECG 385
CAT-5 MER,FBS,Lipid Profile,RUA,HIV,ECG,LFT 720
MER,RUA,BIO(Fasting Blood Sugar, Fasting S. Cholesterol, HDL,
Triglycerides, SGOT, SGPT, GGTP, Total Bilirubin, Direct Bilirubin,
CAT-6 Indirect Bilirubin, Total Proteins, Albumin, Globulin, 895
Creatinine),HbsAg, HIV,ECG

MER,RUA,BIO(Fasting Blood Sugar, Fasting S. Cholesterol,

HDL,Triglycerides, SGOT, SGPT, GGTP, Total Bilirubin, Direct Bilirubin,
CAT-7 Indirect Bilirubin, Total Proteins, Albumin, Globulin, 1510
Creatinine),HbsAg, CBC & ESR,HIV,TMT
MER,RUA,BIO(Fasting Blood Sugar, Fasting S. Cholesterol, HDL,
CAT-7 Triglycerides, SGOT, SGPT, GGTP, Total Bilirubin, Direct Bilirubin,
Indirect Bilirubin, Total Proteins, Albumin, Globulin, Creatinine), 870
(without TMT)
HbsAg, CBC & ESR,HIV

MER,RUA,BIO(Fasting Blood Sugar, Fasting S. Cholesterol, HDL,

Triglycerides, SGOT, SGPT, GGTP, Total Bilirubin, Direct Bilirubin,
CAT-8 Indirect Bilirubin, Total Proteins, Albumin, Globulin, 1680
Creatinine),HbsAg, CBC & ESR,HIV,TMT,HbA1C
MER,RUA,BIO(Fasting Blood Sugar, Fasting S. Cholesterol, HDL,
Triglycerides, SGOT, SGPT, GGTP, Total Bilirubin, Direct Bilirubin,
CAT-9 Indirect Bilirubin, Total Proteins, Albumin, Globulin, Creatinine), 1765
HbsAg, CBC & ESR,HIV,TMT,HbA1C,CXR
Cat-10 JMER 80
Cat-11 JMER,FBS,CBC & ESR,HIV,ECG 420
Cat-12 MER,FBS,Lipid Profile,RUA,HIV,LFT 635
Fasting Blood Sugar, Fasting S. Cholesterol, HDL,Triglycerides,
BIO SGOT, SGPT, GGTP, Total Bilirubin, Direct Bilirubin, Indirect 420
Bilirubin,Total Proteins, Albumin, Globulin, Creatinine

LIPID PROFILE Fasting S. Cholesterol, HDL, LDL, Triglycerides

LIVER SGOT, SGPT, GGTP, Total Bilirubin, Direct, Indirect, Total Proteins,
FUNCTION TEST Albumin, Globulin

Important Instructions :

• These are all HNI Customers for this product. Kindly ensure 100% Customer Focus
• Please complete the medicals smoothly and ensure all tests are conducted
in a single visit
• Please ensure the report is complete on all criteria
• These are Credit businesses and please ensure No-Cash is collected from
the Customers
• Hard copy and soft copy of reports to HealthAssure at fax@[Link]

Page | 37 HealthAssure & Provider Agreement

 Individual Pricing for All Insurer’s
Services Rate
Medical Examination Report 100
Fasting Blood Sugar 25
HIV-Elisa 160
CBC 50
HBsAg 95
BUN 40
ESR 20
Serum Creatinine 35
HbA1c 175
SGPT 50
SGOT 50
HbeAg 340
Microalbumin 140
Anti-HCV 300
Serum Triglycerides 60
HDL Cholesterol 60
Serum Cholesterol 50
ECG 85
TMT 550
PFT (Pulmonary Function Test) 150
Liver Function Test 320
GGTP (Gamma Glutamyl Tran Peptidase) 65
Serum Uric Acid 40
Renal Function Test 300
Bilirubin (Direct/ Conjugated) 65
PPBS 25
Urine Routine Analysis 25
Mammography / Sono Mammo 600
B P Reading 20
Alkaline Phosphatase 50
Blood Group & RH Factor 40
Calcium 50
Chlorides 45
Phosphorus 50
Platelets 35
Potassium 35
Serum Amylase 110
Sodium 40
StoolRoutine 30
Vision Test 85
X-Ray Barium Meal follow through 700
Home Visit by Physician 125
Home Visit by Technician 65
Haemoglobin 20
Proteins – Total 50
Proteins (Albumin) 40
Iron/TIBC 140
Peripheral Blood Smear 105
Height and Weight 20
Cotinine Test / Nicotin (Processing -
250
Dipstick)
Page | 38 HealthAssure & Provider Agreement
 APTT (Activated Partial Thromboplastin Time) 120
FSH (Follicle Stimulating Hormone) 275
LDL 60
RA Factor 60
Serum CPK 85
Sputum Routine 60
Thyroid Function Test 300
AFP (AlphaFetoProtein) 240
AEC (Absolute Eosinophil Count) 50
Bilirubin (Indirect / Unconjugated) 65
Bilirubin (Total) 60
Chest X-Ray 85
Copper 275
CT (Clotting Time) 30
DLC (Differential Leucocyte Count) 35
GTT (Glucose Tolerance Test - 5 samples) 140
Haemogram 100
LDH 80
Lipid Profile 200
Prostrate Specific Antigen 255
Serum Lipase 240
UltraSonography (Pelvic) 280
VLDL (Very Low Density Lipids ) 85
Cotinine Test / Nicotin (Urine Sample
75
Collection)
Thyroid Stimulating Hormone (TSH) 150
Echocardiography 500
X-Ray Kidney 150
VDRL 60
UltraSonography(Abdomin) 300
PAP Smear 300
Serum Insulin 450
Serum LH 260
Serum FSH 290
Serum Estradiol 350
Serum Progesterone 350
Serum Free Testosterone 975
Serum IgE 500
RA test 60
CEA - CARCINOEMBRYONIC ANTIGEN 290
Vitamin B12 550
Vitamin D 800
Serum homocysteine 1000
Anti CCP Antibody test 1000
Ferritin 375
Serum Prolactin 220
Iron Study 450
Vidal test 110
Glucose Tolerance Test 220
2D-Echo Colour Doppler 600
Audiometry 300
X ray Knees 350
X ray LS Spine 350

Page | 39 HealthAssure & Provider Agreement

Note:- Individual test shall be only 2% out of the total cases routed to the centre.

HealthAssure Product Package : Annexure 1: PRICING / PACKAGES

A) Package Rates Agreed with Preferred Provider

HealthAssure Titanium HealthAssure Platinum HealthAssure Sapphire HealthAssure Ruby

Physician Consultation Physician Consultation Physician Consultation Physician Consultation

FBS FBS FBS FBS
HbA1c HbA1c CBC CBC
CBC CBC ESR ESR
ESR ESR Urine Analysis Urine Analysis
Urine Analysis Urine Analysis Lipid Profile Lipid Profile
Lipid Profile Lipid Profile TMT TMT
2D Echo 2D Echo Liver Function Test Liver Function Test
Liver Function Test Liver Function Test Kidney Function Test Kidney Function Test
Kidney Function Test Kidney Function Test Chest X Ray Chest X Ray
Chest X Ray Chest X Ray PSA / Pap Smear PSA / Pap Smear
PSA / Pap Smear PSA / Pap Smear USG – Abdomen USG - Abdomen
USG – Abdomen USG - Abdomen Thyroid Profile Package Cost - 2035/-
Vitamin D Vitamin D Blood Group
Vitamin B Package Cost - 2650/- Package Cost - 2350/-
Package Cost - 2950/-

HealthAssure Pearl HealthAssure Topaz HealthAssure Moonstone HealthAssure Jasper

Physician Consultation Physician Consultation Physician Consultation Physician Consultation

FBS FBS FBS FBS
CBC CBC CBC CBC
ESR ESR ESR ESR
Urine Analysis HbA1c Urine Analysis Urine Analysis
Lipid Profile Urine Analysis Lipid Profile Lipid Profile
ECG Lipid Profile ECG ECG
Liver Function Test ECG Liver Function Test Liver Function Test
Kidney Function Test Liver Function Test Kidney Function Test Kidney Function Test
Chest X Ray Kidney Function Test Thyroid Profile Chest X Ray
PSA / Pap Smear USG - Abdomen HbA1c Package Cost - 1340/-
USG – Abdomen Thyroid Profile Package Cost - 1565/-
HbA1c Package Cost - 1905/-
Blood Group
Package Cost -2080/-

Page | 40 HealthAssure & Provider Agreement

 HealthAssure Ivory HealthAssure Opal HealthAssure Emerald HealthAssure Diamond

Physician Consultation Physician Consultation Physician Consultation Physician Consultation

FBS FBS FBS FBS
CBC CBC CBC CBC
ESR ESR ESR ESR
Urine Analysis Urine Analysis Urine Analysis Urine Analysis
Serum Cholesterol Serum Cholesterol Serum Cholesterol Serum Cholesterol
HDL HDL HDL HDL
LDL LDL Triglycerides Triglycerides
Triglycerides Triglycerides ECG ECG
ECG ECG SGOT SGOT
SGOT SGOT Creatinine Creatinine
SGPT SGPT Chest X Ray Package Cost - 785/-
ALP ALP Package Cost - 905/-
BUN Creatinine
Creatinine Chest X Ray
Uric Acid Package Cost - 1050/-
Chest X Ray
Package Cost - 1150/-

HealthAssure Healthy HealthAssure Healthy

HealthAssure Coral HealthAssure Amber
Heart Package Liver Package
Physician Consultation Physician Consultation HbA1c HbA1c
FBS FBS Lipid Profile Liver Function Test
CBC CBC - Cholestrol - SGPT
ESR ESR - HDL - SGOT
Urine Analysis Urine Analysis - LDL - Alkaline Phosphatase
Serum Cholesterol Serum Cholesterol - VLDL - Bilirubin : Total
ECG SGOT - Triglycerides - Bilirubin : Indirect
SGOT Creatinine - Ratios - Bilirubin : Direct
Creatinine Package Cost - 490/- ECG - Serum Proteins
Package Cost - 600/- Package Cost - 680/- - Serum Albumin
- Serum Globulin
Urine Routine Analysis
Package Cost - 660/-

HealthAssure Healthy HealthAssure Diabetes HealthAssure HealthAssure Lipid

Kidney Package Package Hypertension
Package Profile
HbA1c FBS HbA1c Cholestrol
Renal Function Test PPBS Lipid Profile HDL
- BUN HbA1c - Cholestrol LDL
- Serum Creatinine Lipid Profile - HDL VLDL
- Serum Uric Acid - Cholestrol - LDL Triglycerides
Serum Electrolytes - HDL - VLDL Ratios
- Pottasium - LDL - Triglycerides Package Cost - 275/-
- Sodium - VLDL - Ratios
- Chloride - Triglycerides Serum Electrolytes
Urine Microalbumin - Ratios - Potassium
Creatinine Clearance Package Cost - 650/- - Sodium
Package Cost - 990/- - Chloride
ECG
Package Cost - 760/-

Page | 41 HealthAssure & Provider Agreement

 HealthAssure Liver HealthAssure Renal HealthAssure Basic
Profile Profile Profile
SGPT BUN Physician Consultation
SGOT Serum Creatinine FBS
Alkaline Phosphatase Serum Uric Acid CBC
Bilirubin : Total Potassium ESR
Bilirubin : Indirect Sodium Urine Analysis
Bilirubin : Direct Chloride Package Cost - 230/-
Serum Proteins Package Cost - 350/-
Serum Albumin
Serum Globulin
Package Cost - 320/-

B) Other Individual Test Rates with Preferred Provider

Test Rates
BMD 1100
CA 19-9 520
CA-125 475
CA-Breast 520
CA-GI 650
Vitamin B 550
Vitamin D 800
Serum Electrolytes 200
Audiometry 270
CEA 290

C) Consultation with Preferred Partner

General Physician Consultation – INR 125 per Consultation

Specialty Consultation – INR 175 per Consultation

(i) Please fill in the below details as per the availability at your center.

Speciality Consultation Yes / No Timings

Physician Consul (GP)

yes 8.00 am 5.00 pm
Gynaecologist
yes on request
Paediatrician
yes on request
Ophthalmology
yes on request
Dental
yes on request
Dietician/Nutritionist
yes on request
Physiotherapist
yes on request

Page | 42 HealthAssure & Provider Agreement