PGEPHIS 1

PUNJAB GOVERNMENT EMPLOYEE’S & PENSIONERS

HEALTH INSURANCE SCHEME

THE SALIENT FEATURES OF PUNJAB GOVERNMENT EMPLOYEES AND

PENSIONERS HEALTH INSURANCE SCHEME

1. BENEFICIARIES:

All personnel of the Punjab Government including All India Service

officers, Serving, Newly Recruited, Retired and Retiring who are
covered under the existing Punjab Medical Attendant Rules [CS(MA)
Rules, 1940] shall be offered Health Insurance Scheme on
compulsory or on optional basis as indicated below:
a. PGEPHIS shall be compulsory to all serving Punjab Government Employees
and Pensioners (herein after referred to as “Serving Employees and pensioners”)
who are presently covered under the existing Punjab Medical Attendant Rules [CS
(MA) Rules, 1940].

Serving Employees and Pensioners shall have to mandatorily submit their

Enrollment Form within the duration of Enrollment Period. In an event of their failure
to get enrolled under the Scheme during the Enrollment Period, they shall be able to
get enrolled in the subsequent renewal/ policy plan period of PGEPHIS. No fresh
enrollment of the Serving Employees and Pensioners shall be allowed after the date
of expiry of Enrollment Period except for any exceptional circumstances, under
which coverage as well as payment of premium of such employees/pensioners shall
be allowed on pro-rata basis (herein after referred to as employee/pensioner under
exceptional circumstances).

b. PGEPHIS shall also be compulsory to new Punjab Government Employees who

would be joining after the date of expiry of Enrollment Period of the scheme
(hereinafter referred to as “New Employees”). The enrollment of new employees,
who join after the date of after the date of expiry of Enrollment Period, shall continue
throughout the policy plan period. The coverage as well as payment of premium of
new employees shall be on pro rata basis, for the remaining period of policy plan
period from the date of their joining in the service. In an event a new employee
avails hospitalization during the intervening period between his/her date of joining in
the service and his/her enrollment, the new employee shall be entitled to receive
treatment at the provider network on the reimbursement basis as per the package
rates defined under the Scheme, subject to submission of bills/ claim within
prescribed time period.

c. PGEPHIS would be available on voluntary/ optional basis for the following

categories:

• All IAS & IPS officers serving in the State- serving and retired who are
covered under the existing Punjab Medical Attendant Rules [CS(MA) Rules,
1940].
• Serving & Ex-MLAs,
 PGEPHIS 2

• Serving and Ex-Judicial officers including judges of Punjab & Haryana High
Court,

In order to enroll under PGEPHIS, the beneficiaries falling under the category for
which the scheme is available on optional basis, if covered under the existing
Medical Attendant Rules, will have to opt out of the current reimbursement system, if
applicable. Those who wish to opt for PGEPHIS shall exercise their option/ choice at
the time of filling the Enrollment Form within the stipulated Enrollment Period. Those
who do not opt for PGEPHIS during the duration of Enrollment Period, shall be able
to exercise their option in the subsequent renewal/ policy plan period of PGEPHIS.
No fresh enrollment of the beneficiaries falling under categories, for which the
scheme is available on optional basis, shall be allowed after the date of expiry of
Enrollment Period.

2. TARGET GROUP/ STATUS

Category Applicability Premium Liability

Serving Employees & Pensioners Compulsory State

After the closer of enrollment period Compulsory State

(On pro rata basis)
New employees and
employees/pensioners under
exceptional circumstances.

All India Service officers, Serving & Optional State

Ex-MLAs, Serving and Ex-Judicial
officers including judges of Punjab &
Haryana High Court

Note :
In case husband and wife both are in Punjab Government job or one of them is retiree
from Punjab Government, either one of them is eligible for the scheme. However, in
case any employee/pensioner is taking medical reimbursement (as a dependent of
spouse) from other source, he/she will not be eligible under the PGEPHIS.

3. INSURANCE COVERAGE:
The PGEPHIS will cover the indoor/ daycare entitlements as specified under the
State Services( Medical Attendant Rules) [CS(MA)] Rules, 1940, except for
exclusions and other things specified in PGEPHIS.
a) In-patient benefits – The Insurance Scheme shall pay all expenses incurred in
course of medical treatment availed by the beneficiaries in the empanelled hospitals/
nursing homes (24 hours admission clause) within the country, arising out of any
illness/disease/injury and or sickness.

NOTE: In case of organ transplant, the expenses incurred for the Donor are
also payable under the scheme.
 PGEPHIS 3

b) Coverage of Pre-existing diseases: All diseases under the Scheme shall be

covered from day one. A person suffering from any disease prior to the inception of
the policy shall also be covered.

c) Pre & Post hospitalization benefit: Benefits up to 7 days Pre Hospitalization & up
to 30 days Post Hospitalization respectively which would cover all expenses related
to treatment of the sickness for which hospitalization was done. The beneficiary shall
avail this benefit on cashless basis in empanelled hospitals. The pre and post
hospitalization investigations shall be covered at CGHS Rates.

Coverage of Chronic Diseases: Medical reimbursement of bills against chronic

diseases, that are covered under the existing Punjab Medical Attendant Rules [CS
(MA) Rules, 1940] shall be admissible as long as either the patient is treated as
indoor patient or as outdoor patient having valid “Complicated chronic disease
certificate”. Complicated chronic disease certificate” has to be issued by State
Government Medical Colleges, PGIMER Chandigarh, AIIMS Delhi and GMCH
Chandigarh. The beneficiary shall avail this benefit on cashless basis from
designated stores and hospitals in every district and block of Punjab and
Chandigarh.

e) Day Care Procedures: Given the advances made in the treatment techniques, many
medical treatments, formerly requiring hospitalization, can now be treated on a day
care basis. The scheme would also provide for day care facilities (less than 24 hours
hospitalization) for such identified procedures. OPD services shall not be part of Day
Care facilities.

• Eye Surgery
• Lithotripsy (kidney stone removal)
• Tonsillectomy
• D&C
• Dental surgery following an accident
• Surgery of Hydrocele
• Surgery of Prostrate
• Few Gastrointestinal Surgery
• Genital Surgery
• Surgery of Nose/Throat / Ear
• Surgery of Urinary System
• Dialysis
• Parenteral Chemotherapy
• Radiotherapy
• Treatment related to dog bite/snake bite etc.
• Treatment of fractures/dislocation, Contracture releases and minor
reconstructive procedures of limbs which otherwise require
hospitalization
• Laparoscopic therapeutic surgeries that can be done in day care
• Identified surgeries under General Anesthesia or any procedure
mutually agreed upon between Insurer/ TPA and Nodal Department.
• Coronary Angiography/ cardiac interventions done on daycare basis.
 PGEPHIS 4

g) Maternity and Newborn Benefits:

a. Maternity benefit

• This means treatment taken in Empanelled Hospital/Nursing Home arising from

childbirth including Normal Delivery/Caesarean Section including miscarriage or
abortion induced by accident or other medical emergency.

• This benefit would be limited to only first two living children in respect of
Dependent Spouse/Female Employee covered from day one under the policy,
without any waiting period.

b. Newborn benefit

Newborn child (single/twins) to an insured mother would be covered from day one up to
the expiry of the current policy plan period for the expenses incurred for treatment taken
in empanelled Hospitals/Nursing Homes/Day Care Clinics as In-patient during the
currency of the policy and will be treated as part of the mother subject to eligibility under
maternity benefit. However, next year the child could be covered as a regular member of
the family subject to the eligibility of the member as per definition of the family as defined
under Punjab Medical Attendant Rule [CS (MA) Rules, 1940].

• In first pregnancy, twins are born than the benefit will cease for second
pregnancy. However, in second pregnancy twins are born than both will be covered
till the expiry of the current policy.

• Congenital diseases of newborn child shall be covered.

h) The exclusions under the PGEPHIS shall be made available on reimbursement basis to
the employees / pensioners as per existing policy and State Services (Medical Attendant
Rules) [CS(MA)] Rules, 1940 as amended from time to time through Treasury route.

i) Any treatment taken abroad will not be covered under PGEPHIS. Any employee /
pensioner will have to take overseas insurance cover before going abroad. Premium of
such insurance cover will be borne by employee/pensioner. In case, any employee is
going on Government tour, premium of such overseas insurance will be borne by the
State Government.

j) Robotic Surgeries, Cochlear Implantation, liver transplantation and Stem Cell surgeries
shall not be covered on cashless basis under the scheme. The employee/ pensioner will
seek reimbursement as per the existing pattern to the extent of the State Medical
Reimbursement Policy and procedures as per his/her entitlement under State Services
(Medical Attendent Rules)[CS(MA)] rules, 1940

4. A. FAMILY SIZE:
a. The Scheme shall cover a family and dependents as defined under Punjab Medical
Attendant Rules [CS (MA) Rules, 1940]. New born shall be considered insured from
day one till the expiry of the current policy irrespective of the number of members
covered subject to eligibility under maternity benefit.

Note:
 PGEPHIS 5

i. For the policy period, new born would be provided all benefits under PGEPHIS
and will not be counted as a separate member. The child will be treated as part
of the mother.

ii. Verification for the new born could be done by any of the existing family
members who are getting the PGEPHIS benefits.

iii. Member is required to enroll new born child at the time of renewal of the policy.

b. All Members shall be insured till they are the member of the scheme unless
withdrawn from the Scheme.

B. Age limit of dependent for the purposes of PGEPHIS includes:-

Age Limit of dependents shall be as defined under existing Punjab Medical
Attendance Rules [CS (MA) Rules, 1940].

C. Income limit for dependency of family members –

Income Limit for dependency of family members shall be as defined under
existing Punjab Medical Attendance Rules [CS (MA) Rules, 1940].
NOTE:

The definition of dependent shall be as per guidelines issued by Punjab Government from
time to time.

D. Addition & Deletion of Family Members during currency of the

policy:
i) Addition to the family is allowed in following contingencies during the policy:
• Marriage of the PGEPHIS beneficiary (requiring inclusion of spouse’s
name), or
• Parents becoming dependants.

ii) Deletion from Family is allowed in following contingencies:

a) Death of covered beneficiary,

b) Divorce of the spouse,

c) Member becoming ineligible (on condition of dependency)

E. New Employees
a) As regards the new incumbents the coverage in the insurance scheme is
compulsory. The data of such employees/ pensioners will be collected
from the various departments by the Insurance Company.

b) The respective department of the new employee would provide the data
to the insurer. Each of the New Employee shall fill up the enrollment form
and submit one recent passport size photograph of each of his/her
 PGEPHIS 6

eligible family member including himself/herself to be enrolled, to the

DDO of his/her department within 7 days of joining into the service.

c) In an event a new employee avails hospitalization during the intervening

period between his/her date of joining in the service and his/her
enrollment, the new employee shall be entitled to receive treatment at
the provider network on the reimbursement basis as per the package
rates defined under the Scheme, subject to submission of bills/ claim
within prescribed time period.

c) The said employees would have to be covered in the Insurance Scheme

from the date of joining. Thus for them the inclusion in the policy will be
made by making payment of the pre defined monthly pro-rata premium
rate which would be less than the yearly premium, if their date of joining
into the service falls after the date of start of the policy.

5. IDENTIFICATION OF FAMILY:
Beneficiaries shall be identified by a "Photo ID Card" issued by the insurer/ TPA
to all the beneficiaries which would contain Unique Health Identification Number
(UHID No.) and all relevant details of the PGEPHIS members. This card would
be used at the Provider Network to access 'Health Insurance Benefits. The
photograph printed on the ID will be taken as the proof for determining the
eligibility of the beneficiaries.

6. SUM INSURED AND BUFFER / CORPORATE SUM INSURED:

A. BASE SUM INSURED:
The Scheme shall provide coverage for meeting all expenses relating to
hospitalization of beneficiary members up to Rs. 3,00,000/- per family per year in
any of the Empanelled Hospital/Nursing Home/Day Care Unit subject to
prescribed rates on cashless basis through Photo ID Cards. The benefit shall be
available to each and every member of the family on floater basis i.e. the total
cover of Rs. 3.00 lakh can be availed by one individual or collectively by all
members of the family. In an event the sum insured of Rs 3 lacs per family is
exhausted, the coverage of the family shall be met through the Buffer Sum
Insured of Rs 25 Crore available to each and every beneficiary of the group, on
group floater basis, to be maintained by the Insurance Company.

In an event the Buffer Sum Insured of Rs 25 crores gets completely exhausted,

the cashless reimbursement more than Rs 3.00 lacs will not be available to any
employee/ pensioner and the over and above expenses shall be met by the State
Government as per the extent of the medical reimbursement policy and
procedures. In such circumstances, the Insurance Company will inform the
employee/pensioner that further treatment shall not be available on cashless but
reimbursement basis as per existing pattern at PGI/ AIIMS rates and the
employee/pensioner will seek the reimbursement over and above Rs. 3.00 lacs
as per existing pattern to the extent of the medical reimbursement policy and
procedures. The concerned DDO will seek the reimbursement from concerned
Civil Surgeon/Directorate of Health & Family Welfare who will examine the bill as
 PGEPHIS 7

per the entitlement of the claimant as per State Services (Medical Attendant
Rules) [CS(MA)] Rules, 1940. If that particular bill(s) as per the entitlement(s) is
less than Rs. 3.00 lacs then no amount will be reimbursed to the employee and if
the bill(s) is more than Rs. 3.00 lacs then additional amount will be reimbursed to
the employee through Treasury Route.

B. BUFFER / CORPORATE SUM INSURED:

An additional Sum Insured of Rs. 25 Crore shall be provided by the Insurer as
Buffer/Corporate Floater. This will be used in case hospitalization expenses of a
family exceed the base sum insured of Rs 3.00 lakhs. Insurer is required to inform
the Nodal Department with the details on case to case basis electronically.

7. PAYMENT OF PREMIUM:
In case of serving employees/pensioners and mentioned as a opted category,
the premium of the main member as well as dependent(s) (as defined in the
State Services (Medical Attendant Rules) [CS(MA)] Rules, 1940) will be paid by
the State Government.

8. ENROLLMENT PERIOD:
a) The enrolment period shall start with immediate effect from the date of
notification of the Scheme and will be completed by 31-12-2015, except for i)
"new employees", who shall be eligible to get covered under PGEPHIS after
the date expiry of the enrollment period, w.e.f their date of joining into the
service and ii) "employees/pensioners under exceptional circumstances", who
shall be eligible to get covered under PGEPHIS after the expiry of the
enrollment period and policy of employees/pensioners under exceptional
circumstances" shall start after 30 days from the date of submissions of their
enrollment form to the insurance company.

Every employee/ pensioner will ensure his/her enrolment along with

dependants before 15-12-2015 enabling the Insurance Company to deliver the
enrolled insurance cards upto 31.12.15.

b) The insurance policy coverage/ Policy Plan Period shall commence from 1st
January 2016 and will expire on midnight 12.00 am of 31-12-2016.

c) Beneficiaries under optional category as well as serving employees and

pensioners, shall have to submit their enrollment forms through their DDOs
within the enrollment period. Enrollment of such beneficiaries shall not be
allowed after the expiry of the enrollment period.

d) The Scheme shall provide health insurance coverage to all the beneficiaries
who submit their enrollment form within the enrollment period for a Policy Plan
Period of twelve months initially.

e) In the case of new employees (employees joining after the expiry of enrollment
period) and Employees/Pensioner under exceptional circumstances, the
enrolment will continue throughout the policy plan period. In this case, coverage
as well as payment of premium shall be allowed on pro-rata basis.
 PGEPHIS 8

9. PERIOD OF INSURANCE AND PERIOD OF CONTRACT:

The Scheme will be introduced from the date agreed by the Punjab Government/
PHSC. The period of Insurance Contract will be effective from the date/ date of
signing of SLA and shall expire three months after the date of expiry of policy plan
period or at completion of all the obligations of the insurance company, whichever
is later; subject to renewal of policy on yearly basis based on parameters fixed by
the Punjab Government/ PHSC at its absolute discretion. Without prejudice to the
unconditional and independent right of the Punjab government/ PHSC to take any
suitable legal or other remedial measure, the Punjab Government/ / PHSC
reserves the right to terminate the contract if the policy is not renewed in the
subsequent year with the same Insurance Company, for any reasons whatsoever.

In case the contract is terminated after the expiry of the Policy Plan Period, the
Insurer shall continue to remain liable for making payments in respect of all the
claims lodged with it or the TPA in respect of all the claims/ invoices of Provider
Network and Beneficiaries on or before the date of expiry of the policy plan
period.

10. PROVIDER NETWORK:

10.1 The hospitals in Punjab, Chandigarh and NCR area (Gurgaon, Noida and
Delhi), that shall be included for providing medical facilities to the
Beneficiaries under the Scheme shall be identified by the Insurer or by the
TPA appointed by the Insurer, as per the prescribed minimum qualifying
criteria of the hospitals and shall be empanelled by the TPA after seeking
prior approval from the State Government/ PHSC. The Government
Hospitals, Government Medical College, / Research Institutes located in
Punjab, Chandigarh and NCR area (Gurgaon, Noida and Delhi) shall be
automatically included in the Provider Network.

10.2 Modus Operandi to be followed for treatment at various Network Hospitals

for all types of treatment shall be as under:

i) For private hospitals in Punjab, Chandigarh &Panchkula :

Rates shall be determined in accordance with the PGEPHIS
Schedule of Rates. For treatments that have not been mentioned in
the PGEPHIS rates, the rates applicable shall be either CGHS Rates
or negotiated rates with the hospital whichever is less.

ii) For Govt. hospitals in Punjab & Chandigarh : Rates shall be

determined in accordance with the PGEPHIS Schedule of Rates,
fixed by the Nodal Department/ State Government. For treatments
that have not been mentioned in the PGEPHIS rates, the rates shall
be internal rates of the respective Govt. Hospital. The treatment
provided shall be essentially on cashless basis, however in cases
where cashless services has not been rendered by the hospital, due
to any reasons whatsoever; the beneficiary shall be eligible for
reimbursement, subject to submission of the claim to the TPA within
30 days from the date of discharge from the hospital. The
 PGEPHIS 9

reimbursement shall be made at Govt Hospital rates or PGEPHIS

Rates, whichever is less.

iii) For PGIMER, GMCH-32 and State Medical Colleges: The

Internal rates of respective hospital/institution shall be applicable.
The treatment availed by the beneficiary shall be on reimbursement
basis, subject to submission of the claim to the TPA within 30 days
from the date of discharge from the hospital. The reimbursement
shall be made at respective Govt Hospital rates, where treatment is
taken or PGEPHIS Rates, whichever is less.

iv) For private hospitals in NCR area (Gurgaon, Noida and

Delhi): The CGHS-New Delhi rate shall be applicable. The
treatment availed by the beneficiary shall be on reimbursement
basis, subject to submission of the claim to the TPA within 30 days
from the date of discharge from the hospital.

The treatment provided shall be essentially on cashless basis,

however in cases where cashless services has not been rendered by
the hospital, due to any reasons whatsoever; the beneficiary shall be
eligible for reimbursement at the CGHS rates or the hospital rates,
whichever is less, subject to submission of the claim to the TPA
within 30 days from the date of discharge from the hospital.

v) For Govt. hospitals in NCR area (Gurgaon, Noida and

Delhi): The internal rates of the respective Govt. hospital shall be
applicable. The treatment availed by the beneficiary shall be on
reimbursement basis, subject to submission of the claim to the TPA
within 30 days from the date of discharge from the hospital. . The
reimbursement shall be made at the respective Govt Hospital rates,
where treatment is taken or PGEPHIS Rates, whichever is less.

vi) For Private Hospitals in remaining parts of the country:

The reimbursement to the beneficiary against the claim of the
treatment availed in the private hospital located anywhere in India
except Punjab, Chandigarh and NCR area (Gurgaon, Noida and
Delhi), shall be made in accordance with the PGEPHIS rates,
irrespective of the actual expenditure incurred by the beneficiary. For
treatments that have not been mentioned in the PGEPHIS rate list,
the reimbursement shall be made in accordance with the PGIMER
Rates, Chandigarh.

vii) For Govt Hospitals in remaining parts of the country: The

reimbursement to the beneficiary against the claim of the treatment
availed in the Govt hospital located anywhere in India except Punjab,
Chandigarh and NCR area (Gurgaon, Noida and Delhi), shall be
made in accordance with the internal rates of the respective Govt.
hospital OR PGEPHIS rates, whichever is lower.

10.3 A) Both Public and Private Health Providers which provide

hospitalization and/or a Day Care Services would be eligible for
 PGEPHIS 10

inclusion under the PGEPHIS, subject to such requirements for

empanelment as agreed between the Punjab Government/ PHSC
and Insurers. PGEPHIS aspires to provide to all its beneficiaries high
quality medical care services that are affordable. The private
hospitals shall be empanelled by the TPA/ Insurer, for providing
cashless treatment, in Punjab, Chandigarh and NCR area
(Gurgaon, Noida and Delhi). The Hospitals/Nursing Homes/Day
Care Clinics interested to join the PGEPHIS should be preferably
accredited with NABH/JCI (Joint Commission International)/ACHS
(Australia) or by any other accreditation body approved by
International Society for Quality in Health Care (ISQua) as minimum
eligibility criteria for empanelment of hospitals. Such
Hospitals/Nursing Homes/Day Care Clinics should comply with the
following minimum qualifying criteria:

• Should have at least 25-bed indoor treatment capacity along with full
fledged Operation Theatre and Intensive Care Unit. Eye Hospitals
catering to OPD procedures such as cataract and other eye
surgeries, which are covered under the Scheme, may have less than
25 beds.

• Should have atleast three permanent M.B.B.S doctors and at least

one postgraduate doctor (M.D/M.S) on its roll. The Hospital should
also have atleast one DM/ MCh Doctor for the each super speciality
catered to by the Hospital.

• Should have atleast three permanent trained nurses, who are

registered with nursing council of India, on its roll.

• Should have facility of in-house pharmacy and pathological lab or tie-

ups for pathological tests/pharmacies to ensure completely cashless
treatment of the Beneficiaries.

• Should have the facility of 24 hrs nursing staff/medical staff

consisting of fully qualified doctor(s), round the clock and 24hrs
admission facility.

• Shall agree to the rates/duration of stay for various procedures as

mentioned in PGEPHIS Schedule of Rates.

• Shall install necessary infrastructure such as computer, fax machine,

software, hardware at its own cost etc for implementing e-
preauthorization and facilitating online transmission of radiological
images/ modalities and identify minimum two coordinators to
coordinate with patient, treating doctor, TPA and billing department
of the hospital.

• Shall provide preferred and priority admission to the beneficiaries

and ensure that hospitalization of the members is completely
cashless i.e. arrange for funds for the medicines/investigations not
available with the hospital or have necessary tie-up with the
diagnostic centers/pharmacies for the facilities not available in the
hospitals.
 PGEPHIS 11

B) General purpose hospital having 25 or more beds with the following

specialties : General Medicine, General Surgery, Obstetrics and Gynecology,
Paediatrics, Orthopedics (excluding Joint Replacement), ICU and Critical
Care units ,ENT and Ophthalmology, Imaging facilities , in house laboratory
facilities and Blood Bank.

C) Specialty hospitals (specialties list given below) Hospitals having less than
50 beds can apply as a specialty hospital -provided they have at least 10
beds earmarked for the specialty applied for with at least 15 additional beds –
Thus under this category a single specialty hospital would have at least 25
beds. However, under this category a maximum of three specialties is
allowed.

• Cardiology , Cardiovascular and Cardiothoracic surgery

• Urology - including Dialysis and Lithotripsy
• Orthopedic- Surgery - including arthroscopic surgery and Joint
Replacement
• Endoscopic surgery
• Neurosurgery
• Gynaecology and Obstetrics
D) Super-specialty Hospitals- with 150 or more beds with treatment facilities in
at least three of following Super Specialties in addition to Cardiology& Cardio-
thoracic Surgery and Specialized Orthopaedic Treatment facilities that include
Joint Replacement surgery:

· Nephrology & Urology incl. Renal Transplantation

· Endocrinology
· Neurosurgery
· Gastro-enterology & GI –Surgery incl. Liver Transplantation
· Oncology – ( Surgery, Chemotherapy & Radiotherapy)

These hospitals shall provide treatment /services in all disciplines available in

the hospital.

E) Cancer hospitals having minimum of 50 beds and all treatment facilities for
cancer including radiotherapy (approved by BARC / AERB). Already
empanelled hospitals for Cancer treatment in the State will continue to be
empanelled hospitals.

NOTE - A:
a) Such Hospitals/Nursing Homes/Day Care Clinics that obtained entry level pre
accreditation certificate from NABH would also be eligible for empanelment under
PGEPHIS.

b) The Hospitals/Nursing Homes/Day Care Clinics which are already empanelled

under CGHS in Punjab, if, desires to be get empanelled under PHEPHIS shall be
eligible for empanelment under the Scheme.

c) In addition, the empanelled Hospitals/Nursing Homes/Day Care Clinics having

in-house diagnostic Laboratories or using the linked diagnostic laboratories shall
also apply for National Accreditation Board for Testing & Calibration Laboratories
(NABL) certification of the Laboratory.
 PGEPHIS 12

d) The diagnostic labs setup in the district hospitals under PPP mode shall be
covered under the scheme.

Note - B:
1) Hospitals/Nursing Homes/Day Care Clinics that have already applied for
accredited under NABH/JCI/NABL shall inform the office of Insurer with
supportive document.

2) Those applying to NABH/JCI for accreditation to join the PGEPHIS shall also
agree to the PGEPHIS package rates and to the clause 10.4-A and 10.4-B
mentioned below.

10.4 (A) Criteria for Empanelment of Hospitals/Nursing Homes/Day Care

Clinics in addition to the NABH /JCI / ACHS / ISQua/ NABL
criteria.
i) Fully equipped and engaged in providing Medical and/ or Surgical facilities. The
facility should have an operational pharmacy and diagnostic services. In case
health provider does not have an operational pharmacy and diagnostic services,
they should be able to ltie-up with the same in close vicinity so as to provide
‘cash less’ service to the patient.

ii) Those Hospitals/Nursing Homes/Day Care Clinics undertaking surgical operations

should have a fully equipped Operating Theatre of their own.

iii) Fully qualified doctors and nursing staff under its employment round the clock.

iv) Agreeing to the cost of packages for each identified procedures as approved
under the PGEPHIS scheme.
a) These package rates shall mean and include lump sum cost of inpatient
treatment/day care/diagnostic procedures for which PGEPHIS beneficiary is
admitted from the time of admission to discharge including (but not limited to)
Registration charges, Admission charges, Accommodation charges including
Patients diet, Operation Charges, Injection charges, dressing charges, Doctors/
Consultant visit charges, ICU/ICCU charges, Monitoring charges, Transfusion
charges, IRC charges of listed investigations, Anesthesia charges, Preanesthetic
checkups, Operation Theater charges, Procedural Charges/Surgeon charges,
Cost of surgical disposables and sundries used during hospitalization, Cost of
Medicines and Drugs, Blood, Oxygen etc, Related routine and essential
diagnostic investigations, Physiotherapy charges etc, Nursing care and charges
for its services. The list is an illustrative one only.

b) In order to remove the scope of any ambiguity on the point of package rates, it is
reiterated that the package rate for a particular procedure is inclusive of all sub-
procedures and all related procedures to complete the treatment procedure. The
patient shall not be asked to bear the cost of any such procedure/item.

c) No additional charge on account of extended period of stay shall be allowed, if,

the extension is due to infection on the consequences of surgical procedure or
due to any improper procedure.
 PGEPHIS 13

d) Cost of implants is payable in addition to package rates as per Punjab Medical

Attendance Rules for defined implants or as per actual, in case there is no
prescribed ceiling rates.

e) Cost of External Equipments required for treatment as permissible under PMA

Rules is payable in addition to package rates subject to ceiling rates for defined
External Equipments under Punjab Medical Attendance Rules or as per actual, in
case there is no prescribed ceiling rates.

f) Expenses incurred for treatment of new born baby are separately payable in
addition to delivery charges to mother.

g) Package rates envisage duration of indoor treatment as follows:

• Upto 12 days: for Specialized (super specialty) Treatment.

• Upto 7 days: for other Major surgeries.
• Upto 3 days: for Laparoscopic surgeries/ Normal delivery.
• ·1 day: for Day Care/ Minor surgeries

h) Entitlements for various types of wards: Beneficiaries shall be entitled to

facilities of private, semi-private or general ward depending on their pay drawn in
pay band/ pension. These entitlements are amended from time to time and the
latest order in this regards needs to be followed. The entitlement is as follows:-

[Link]. Group of Employee Entitlement

1 Group-D General Ward
2 Group-B&C Semi-Private Ward
3 Group-A Private Ward

NOTE:
a) Treatment in higher Category of accommodation than the entitled category is
not permissible.

b) The package would cover the entire cost of treatment of the patient from date
of admission to his/ her discharge from hospital and any complication while
in hospital, making the transaction truly cashless to the patient as per
PGEPHIS package rates.

c) The applicable PGEPHIS rates under the Scheme would be for the policy
period and shall not be amended during the currency of the policy. Rates for
such procedures which are not in the PGEPHIS list, can only be considered,
if, finalized during the policy period.

d) Procedures will be subject to Cashless services and a preauthorization

procedure, as per Clause – 12.

v) Maintaining the necessary records as required and the Insurer or its

representative/State Government/Nodal Department will have an access to the
records of the insured patient.
 PGEPHIS 14

vi) Allowing the Insurer or its representative / State Government / Nodal Department
to visit, carry out the inspection as and deemed fit.

vii) The Private Empanelled Hospitals/Nursing Homes/Day Care Clinics be legally

responsible for user authentication.

viii) Has to display its status of being a preferred provider of PGEPHIS at the
reception/admission desks and to keep the displays and other materials supplied
by the Insurer for the ease of beneficiaries, State Government and Insurer.

ix) Agrees to provide a separate help desk headed by paramedical for providing the
necessary assistance round the clock to the PGEPHIS beneficiary.

x) These empanelled Hospitals/Nursing Homes must have the capacity to submit all
claims / bills in electronic format to the Insurance Company, and must also have/
should be ready to establish at its own cost, the dedicated equipment, software
and connectivity for such electronic submission.

xi) The provider should have suitable backup arrangements, so that in the event of
any unforeseen situations, the affected portion of the data should be retrievable
in totality.

xii) In case the PGEPHIS approved rates are more than what is being charged for
same procedure from other (non- PGEPHIS) patients or institutions, then the
hospital has to offer the same reduced rates for the said procedure by allowing
appropriate discount to PGEPHIS.

xiii) The Hospital agrees that any liability arising due to any default or negligence in
providing or performance of the medical services shall be borne exclusively by
the hospital that shall alone be responsible for the defect and / or deficiencies in
rendering such services.

10.5 (B) Additional Benefits to be Provided by Empanelled

Hospitals/Nursing Homes /Day Care Clinics
In addition to the benefits mentioned above, both Empanelled Public and Private
Hospitals/Nursing Homes/Day Care Clinics should be in a position to provide
following additional benefits to the PGEPHIS beneficiaries:

i) Free pre and post hospitalization consultation under pre and post
hospitalization cover period.

ii) PGEPHIS rates for diagnostic tests done under under pre and post
hospitalization cover period.

11. DELISTING OF HOSPITALS:

Empanelled Hospitals/Nursing Homes/Day Care Clinics would be delisted by the
Insurer from the PGEPHIS network after the approval for the same has been
accorded by the State Govt./ PHSC, if, it is found that guidelines of the Scheme
are not followed by them and services offered are not satisfactory as per laid
 PGEPHIS 15

down standards. Based on recommendation of the Insurer, the Nodal

Department shall initiate disciplinary proceedings against erring NWHs for the
following reasons: (i) Infrastructure deficiencies (ii) Equipment deficiencies (iii)
Man power deficiencies (iv) Service deficiencies (v) Violation of service contract
agreement vi) Misconduct/ fraudulent activity. Nodal Department shall have the
rights to approve one or more of the following disciplinary actions at its sole
discretion:

(i) Withholding of payments: Cashless treatment is the bedrock and the primary
non-negotiable of this Scheme. Any violation of this condition shall result in
immediate withholding of entire payments of the hospital. Payments shall
be released only after the hospital repays the patient and takes corrective
measures.

A particular claim may also be withheld in case of any service deficiency in

management of any case and the payment may be released based on the
expert opinion obtained by the Govt. or after rectification.

(ii) Levy of penalty: In cases where all the payments have been released to the
NWHs, a penalty shall be levied on the NWH for violations attracting
disciplinary action.

(iii) Suspension: The NWH shall be liable to be suspended in all cases of

violations of agreement.

(iv) De-empanelment of specialities: The NWH can be de- empanelled for

a particular speciality in case of service deficiencies in that particular
speciality or completely as per the discretion of the State Govt/ Nodal
Department.

(v) Delisting: The NWH shall be delisted for repeated violation of service contract
agreement and other service deficiencies for a period of not less than one
year.

12. CASHLESS ACCESS SERVICE:

The TPA/ Insurer has to ensure that all PGEPHIS members are provided with
adequate facilities so that they do not have to pay any deposits at the
commencement of the treatment or at the end of treatment to the extent of the
Services as covered under the Scheme. The service provided by the Insurer
along with the responsibilities of the Insurer as detailed in this clause is
collectively referred to as the “Cashless Access Service.”

The services have to be provided by the Empanelled Hospitals/Nursing

Homes/Day Care Clinics to the beneficiary based on Photo ID Card
authentication only without any delay. The beneficiaries shall be provided
treatment free of cost for all such ailments covered under the Scheme within the
limits/sub-limits of defined package rates and sum insured, i.e., not specifically
excluded under the scheme.
 PGEPHIS 16

A. Pre-Authorization for Cashless Access in case of

Emergency/Planned Hospitalization for Listed /Non Listed
packaged procedures:
Packaged procedures would mean the rates for various procedures
approved by the State Govt. for PGEPHIS. It would be the responsibility
of the TPA/ Insurer to have all empanelled hospitals/nursing homes/ day
care clinics agreed to the same. Request for Authorization shall be
forwarded by the Empanelled Hospitals/Nursing Homes/Day Care Clinics
after obtaining due details from the treating doctor in the prescribed
format i.e. “Request for Authorization Letter” (RAL). The RAL needs to
electronically send to the 24-hour Authorization /Cashless department of
the TPA along with contact details of treating physician, through e-
preauthorization mode. The medical team of TPA would get in touch with
treating physician, if necessary.
a. The RAL (Request for Authorization Letter) should reach the Authorization
Department of TPA from the time of admission to not later than 24 hrs of
admission, in case of emergency or within 3 days prior to the expected date of
admission, to within 6 hrs of admission and not later than 12 hrs of admission
incase of planned admission. The RAL form should be dully filled in all cases.
There should be No Nil, or Blanks, which will help in providing the outcome at the
earliest. Along with RAL copies of diagnostic test reports and radiological images
should also be forwarded electronically.

b. Upon failure of compliance of the provisions of the above “clause a”, the
clarification for the delay needs to be forwarded along with RAL by the
Empanelled Hospitals/Nursing Homes/Day Care Clinics.

c. If, given medical data is not sufficient for the medical team of Authorization
Department to confirm the eligibility, it will be responsibility of the Empanelled
Hospitals/Nursing Homes/Day Care Clinics, upon receipt of any query/ demand
of any additional information from the TPA, to provide the complete details
without any further delay, failing which it would be treated as violation of the
norms.

d. In case of non listed procedure, the Empanelled Hospitals/Nursing Homes/Day

Care Clinics and Insurer shall negotiate the cost of package based on the type of
treatment required; the agreed amount shall become a package rate of that
procedure.

e. i) Insurer guarantees payment only after receipt of RAL and the necessary
medical details. Only after TPA has ascertained the rates as per PGEPHIS
prescribed rates and or negotiated the packages (if no rates are fixed by
PGEPHIS), with provider, TPA shall issue the Authorization Letter (AL)/
Additional Information/ request/ Denial Letter/ Query Letter, as the case may
be.

ii) The TPA shall process the RAL within 2 hours of its receipt at its end and
shall send to the Provider Hospital, either an Authorization Letter or a Denial
Letter or any other letter seeking additional information as required for
concluding the admissibility of the case, not later than 2 hours from the time of
the receipt of the RAL at its end.
 PGEPHIS 17

iii) In the event of asking for some additional information and no response being
received from the Provider Hospital, the TPA/Insurer shall ensure that the
required information is obtained from the treating doctor or the Beneficiary or
the Network Hospital through any other mode of communication including
those other than e-RAL for enabling it to take the final decision. The report of
the IRC shall be mandatorily taken by the TPA in Cardiac cases and Joint
Replacement cases in case of the admissions taking place in Network
Hospitals. However under no circumstances, in emergency cardiac cases, the
issuance of authorization shall be withheld for want of IRC Report, which can
be obtained later to rule out any discrepancy in cardiac angiogram or any
other report received from the Network Hospital , for which an explanation
may be sought from the Network Hospital In cases of planned admissions in
Network Hospitals, where any radiological investigation/ diagnostic modality
that can be reported by IRC is conducted, the report of the IRC may be taken
on case to case basis. The report of IRC shall not be taken by the TPA in
cases of admissions taking place in Government Hospitals.

iv) The TPA after receipt of RAL from the Network Hospital on its web portal shall
immediately send Requisition Letter to the IRC, not later than 60 minutes after
the receipt of the RAL, intimating the name, card number and CCN Number of
the beneficiary, to seek report of the IRC as per the format contained in the
SLA.

v) In case of payment of expenses by the Beneficiary to the hospital because of

non resolution of query of the hospital or delay in issuance of authorization
letter to the hospital, the Insurer shall unconditionally and without any demur
make the reimbursement of the hospitalization expenses incurred by the
Beneficiary at the actual rates charged by the hospital, irrespective of the
package rates, not exceeding the maximum limit of Rs. 3 lacs of the Sum
Insured.

vi) In an event a Member goes to a Provider Hospital and inspite of showing

his/her ID card to the hospital authorities within stipulated time period, is
denied cashless hospitalization by the hospital, for any reason whatsoever,
including but not limited to, denial by the Hospital at its own end without
receiving any denial from the TPA or the wrongful denial by the TPA or delay
in issuance of authorization by the TPA for any reasons or any other
circumstances whatsoever and no fault lies with the Member, he/ she may
submit his/ her claim to the TPA as per the check list for reimbursement within
60 days of date of discharge from the hospital. In such cases, the TPA/Insurer
shall extend full cooperation to the Beneficiary and depending upon merit/
genuineness of the case, determine the admissibility of the claim within the
purview of the Scheme and settle the claim within 15 days of receipt of the
claim, in accordance with terms and conditions of the Scheme.

f. In case the ailment is not covered, TPA can deny the authorization. In such case
it would be the responsibility of the Empanelled Hospitals/Nursing Homes/Day
Care Clinics to inform the beneficiary accordingly. The TPA shall clearly mention
explicit and justifiable reasons for the denial of cashless access in the Denial
Letter issued to the Network Hospital or to the Beneficiary. The TPA shall deny
the cashless treatment to any Beneficiary, only if the respective treatment/
procedure is not admissible as per the terms and conditions laid in the Scheme.
The TPA shall not, under any circumstances whatsoever, deny cashless
treatment to the Beneficiary on account of non receipt/ delayed receipt of the
query response from the Provider Hospital. The TPA shall exercise its own
independent discretion, taking into account all clinical parameters/ conditions/
 PGEPHIS 18

eligibility terms and conditions, along with the report of IRC, wherever applicable,
to decide upon the admissibility of the case. No case shall be rejected by the
TPA/ Insurer, solely based upon the reporting of the IRC. IRC shall not be
allowed to decide upon the rejection or admissibility of any RAL received from
the Network Hospital. IRC shall only provide interpretations/ findings on
radiological image/ modality sent to it by the Insurer/ Network Hospital, establish
radiological extent of disease, point out discrepancies, if any, between its own
report and report of the Network hospital and provide grading on the extent of the
disease as interpreted radiologically.

g. The TPA/ Insurer needs to file a report to Nodal Department explaining reasons for
denial of every such claim on day to day basis.

h. Authorization letter [AL] shall be numbered, signed and stamped by the Doctor of
the TPA. It shall mention the name of the treatment or medical procedure for
which the amount has been authorized and the amount guaranteed as a
PGEPHIS package rates and negotiated rates for such procedure for which
package has not been fixed earlier. Empanelled Hospitals/Nursing Homes/Day
Care Clinics must see that these rules are strictly followed.

i. The guarantee of payment is given only for the necessary treatment cost of the
ailment covered and mentioned in the request for Authorization letter (RAL) for
hospitalization.

J. In case of non listed procedure, the Empanelled Hospitals/Nursing Homes and

Insurer shall negotiate the cost of package based on the type of treatment
required; the agreed amount shall become a package rate of that procedure

Note:

In cases where the beneficiary is admitted in a hospital during the current policy period
but is discharged after the end of the policy period, the claim shall be paid under
operating policy in which beneficiary was admitted.

13. CLAIM SETTLEMENT:

The Empanelled Hospital/Nursing Home shall be reimbursed the cost of treatment
as per PGEPHIS Package Rates with hospitals. The Insurance Company shall
settle the claims of the Hospitals/Nursing Homes within 15 days of receipt of the
complete bills along with the discharge summary of the patient. The claim
settlement progress will be scrutinized and reviewed by the State Government/
PHSC .

14. REPUDIATION OF CLAIMS:

In case of any claim is found untenable, the TPA/ Insurer shall communicate
reasons to the Health provider and Designated Authority of the State / Nodal
Department for this purpose with a copy to the Beneficiary. All such claims shall
be reviewed by the State Government/ PHSC on monthly /quarterly basis

15. RIGHT OF APPEAL AND REOPENING OF CLAIM:

The Empanelled Hospitals/Nursing Homes shall have a right of appeal to Nodal
Department against the TPA/ Insurer, if, the Health Care Provider feels that the
 PGEPHIS 19

claim is payable. The Nodal Department can direct the Insurer/ TPA to re-open
the claim, if, proper and relevant documents as required are submitted.

16. REVIEW OF PAID CLAIMS:

The Nodal Department will have the right to reopen a settled claim and to direct
the TPA/ Insurer to settle for an appropriate amount within a period of 3 months of
payment of the claim. The TPA and insurer further agree to provide access to the
PHSC their records for this purpose. All the claims settled by the Insurer to the
Empanelled Hospitals/Nursing Homes based on the bills received from the
hospitals in conformity with the PGEPHIS package rate arrived at and also based
on the pre-authorization given by the Insurer/ TPA will be reckoned as final and
will not be subject to any reopening by any authority except the Nodal Department

17. ENROLMENT:
The enrolment of the beneficiaries would be undertaken by the Insurance
Company selected by State Government/Nodal Department. The Insurer shall
enroll the beneficiaries as per procedure laid down below and shall issue Photo
ID cards to all the PGEPHIS beneficiaries.
(a) No fresh enrollment of serving employees or pensioners will take place after the
date of expiry of Enrollment Period. However, in the case of new employees,
whose date of joining falls after the date of the expiry of the enrollment period
and Employees/Pensioner under exceptional circumstances, the enrolment will
continue throughout the year. Beneficiaries falling under optional category who
did not opt for the Scheme in the first year, shall be eligible to opt in the
subsequent renewals.

The Scheme shall provide health insurance coverage for a Policy Plan Period
of twelve months to all the beneficiaries who have got enrolled under the
Scheme within the Enrollment Period. Though the date of start of policy of the
new employees and Employees/Pensioner under exceptional circumstances
shall, vary from member to member, depending upon the date of joining of
such member/ date of enrolling under the scheme. The date of expiry of policy
shall be co-terminus for all the beneficiaries.

(b) Insured will have the option to change the details regarding dependent
beneficiary in the ID card; however the total number of dependents cannot be
more than the number fixed at the time of next renewal of the Scheme,

(c) The Insurer will arrange for preparation of the Photo ID Card as per the
Guidelines provided.

(d) At the time of delivering the card, the Insurer shall provide a booklet/ Guide
Book along with Photo ID Card to the PGEPHIS beneficiary indicating the list of
the Networked Hospitals, the availability of benefits and the names and details
of the contact person/persons, and toll-free number. The insurer shall also
make available the soft copy of guide book on its website, that can be
downloaded by the beneficiary, in case required.

(e) To address the problems of incorrectness, functionality of cards etc and if

enrolment of the beneficiary could not be done for any reason, inspite of
submission of the Enrollment Form to the Insurance Company; the same would
be done at by the TPA within 15 days of receipt of any such complaint.
 PGEPHIS 20

(f) Photo ID Cards along with the Guide Book shall be handed over by the
Insurance Company to the DDOs for onward delivery to the employee/
pensioner.

(g) Insurance Company will also provide a web-based enrollment application/

employees registration platform/e-enrollment module. The enrollment forms
for the employees/pensioners and option/enrollment form for the employees/
pensioners under optional category will be available after the designated date,
on the website "[Link]" along with the procedure to fill such
forms. A copy of the forms will be made available to all the DDOs. The forms
can be filled online as well as offline but have to be submitted in hardcopy
through DDO to Insurance Company. The Insurance Company will collect the
filled forms from DDO and handover the Insurance Cards of the main member
and dependent(s) to the DDO for onward delivery to the employee/pensioner.
The insurance Company shall provide right to print ID Card to the DDO of the
department. DDO, however won't have any rights to make any amendments/
modifications/ alterations in the enrollment database of the employees. Every
employee/pensioner will be notified regarding enrollment with Unique Health
Identification Numbers. In case of misplacement of the card/non availability of
the card, this Unique Health Identification Numbers can be used for taking
treatment in the designated hospitals.

The empanelled Hospitals/Nursing Homes/Day Care Clinics and the

beneficiaries shall have the access to the dedicated website to see their
relevant information.

(h) Nodal Department at the State Health Department will also monitor data related
to Insurance plan like enrolment etc through this website.

(j) The beneficiaries falling under the category of compulsory enrollment shall
remain the member of the scheme with future renewals automatically awarded.
The beneficiaries falling under the category of optional enrollment, if wish to opt
out of the scheme, shall be required to submit the declaration to the Department
of Health & Family Welfare Punjab for discontinuation from the Scheme at the
time of next renewal of the Scheme . In such cases the benefits shall cease on
the expiry of the policy.

18. ENROLMENT PROCESS:

The process of enrolment shall be as under:

A. Serving Employees:
1. Departments and offices will notify the employees to join compulsory
PGEPHIS without existing Medical reimbursement under PMA rules.

2. DDO would be the contact point for the Insurance Companies and shall be
responsible for validating the enrollment forms filled by the employees and
forwarding it to the Insurance Company.

3. Enrolment forms giving details about self and family and options given by
employees/ pensioners falling under optional category would be consolidated
by the Administrative Department/ respective Department. The data of the
beneficiary and dependent members to be covered along with 1 recent
passport size colored photo of each member , has to be provided in the
 PGEPHIS 21

enrolment form, which will be collected by the Insurance Company from the
DDOs of various departments on weekly/monthly basis during the enrollment
period.

4. Insurance Company will issue Photo ID Cards on the basis of information

received in the Enrolment Form filled by the beneficiaries, received through
DDOs.

5. Such Photo Id Cards along with the guide book shall be handed over to the
respective DDO of the employee for onward delivery to the employees within
15 days of receipt of filled Enrollment Form and not later than 5 days prior to
the commencement date of the Policy Plan Period, by the Insurance
Company.

B. Pensioners
1. In case of pensioners, wide publicity of the Scheme should be given through
various media sources like advertisement in local newspapers, Cable network
etc.

2. The notification of the Scheme will be available on the website

"[Link]" giving details of the proposed Scheme.

3. Information can also be disseminated through pensioners associations and

other related agencies.

4. Enrolment forms, along with the procedure to fill such forms, could be
downloaded/ filled online through the website "[Link]" along
with the procedure to fill such forms.

5. Pensioners would fill up the enrolment form giving details relating to self and
dependent members along with 1 recent passport size photos of each
member. The forms can be filled online as well as offline but have to be
submitted in hardcopy through DDO to Insurance Company. The Insurance
Company will collect the filled forms from the DDOs.

6. Photo Id Cards of the pensioners along with the guide book shall be handed
over to the respective DDO, where he/ she was last serving, for onward
delivery to the pensioner, within 15 days of receipt of filled Enrollment Form
and not later than 5 days prior to the commencement date of the Policy Plan
Period, by the Insurance Company.

C. For New Employees:

a. All New Employees shall be compulsorily covered under PGEPHIS.

b. At the time of their entry into service they are required to carry out required
documentary formalities related to enrolment under the Scheme at their
respective places of posting.
 PGEPHIS 22

c. `Employee shall fill up form enrolment form, providing 1 resent passport size
photographs of the family each (individual) and submit the filled Enrolment Form
to the DDO of his/ her Department within 7 days of joining into the service.

e. Insurer shall arrange to collect the enrolment form & family photograph from the
respective DDOs under acknowledgement, after receiving intimation from the
DDO.

f. After required processing of the Enrolment Form at the Insurer's/ TPA's end, ID
card shall be issued by the insurer and handed over to the to the DDO for
onward delivery to the new employee.

g. The insurance cover shall be effective from the date of joining of an employee.

Note: The Insurer will have to complete the following activities before the start
of the Policy Plan Period:

• ·Empanelment of the Hospitals/Nursing Homes/Day Care Clinics.

• Setting up of Project Office/ District Offices ·
• Setting up of adequate infrastructure required for the implementation of
the Scheme.

19. EXCLUSIONS:
The Insurer shall not be liable to make any payment under this Scheme in
respect of any expenses whatsoever incurred in connection with or in respect of:

A. Hospitalization Benefits:

1) Conditions that do not require hospitalization:

a) Condition that do not require hospitalization. Outpatient Diagnostic, Medical and
Surgical procedures or treatments unless necessary for treatment of a disease
covered under Day Care procedures or Inpatient hospitalization.

b) Expenses incurred at Hospital or Nursing Home primarily for evaluation /

diagnostic purposes only, during the hospitalized period. Expenses on vitamins and
tonics etc unless forming part of treatment for injury or disease as certified by the
attending physician. Expenses on telephone, tonics, cosmetics / toiletries, etc.

2) Any dental treatment or surgery which is corrective, cosmetic or of aesthetic

procedure, including wears and tears etc. unless arising from disease or accident
which requires hospitalization for treatment.

3) Congenital external diseases etc: Congenital External Diseases or defects or

Anomalies.

4) Sex change or treatment which results from or is in any way related to sex change.
 PGEPHIS 23

5) Vaccination/Cosmetic or of aesthetic treatment: Vaccination: Inoculation

or change of life or cosmetic or of aesthetic treatment of any description and Plastic
Surgery other than as may be necessitated due to an accident or as a part of any
illness. Cost of Spectacles / Contact Lens.

6) Suicide etc: Intentional self-injury/Suicide/Self manmade injuries.

7) Naturopathy, Homeopathy, Unani, Siddha, Ayurveda:
a) Homeopathy, Unani, Siddha, Ayurveda treatment unless taken as inpatient in a
network hospital.

b) Naturopathy, unproven procedure or treatment, experimental or alternative

medicine including acupressure, acupuncture, magnetic and such other therapies
etc. Any treatment received in convalescent home, convalescent hospital, health
hydro, nature care clinic or similar establishments.

8) External and/or durable Medical/Non-medical equipment of any kind used

for diagnosis and/or treatment except covered under PGEPHIS scheme.
B. Maternity Benefit Exclusion Clauses:
1. Those insured persons who are already having two or more living children will not be
eligible for this benefit. Claim in respect of only first two living children will be
considered in respect of any one insured person covered under the policy or any
renewal thereof. In such situation any such child born during the policy period, the
same shall be covered as an additional member at the time of renewal only.

2. Expenses incurred in connection with voluntary medical termination of pregnancy

during the first twelve weeks from the date of conception are not covered except
induced by accident or other medical emergency to save the life of mother.

3. Pre-natal and post-natal expenses are not covered unless admitted in

Hospital/nursing home and treatment is taken there.

20. CALL CENTER SERVICES:

I. Toll Free Number
State wide toll free medical helpline number "104" shall be available to all the
beneficiaries for taking any information/ clarification regarding enrollment,
benefits available under the Scheme, exclusions, list of enrolled private as well
as government hospitals, process to be followed for lodging claim with Insurance
Company or with State Government and for redressal of any complaint regarding
enrollment, treatment, exclusions, benefits etc available under the Scheme. The
complaint will be redressed in a time bound manner.

21. DISPUTE RESOLUTION AND GRIEVANCE REDRESSAL:

If any dispute arises between the parties during the subsistence of the policy
period or thereafter, in connection with the validity, interpretation, implementation
or alleged breach of any provision of the scheme, it will be settled in the following
way:
 PGEPHIS 24

a. Dispute between Beneficiary and Health Care Provider/Care Provider

and the TPA/ Insurance Company:
1) District level Grievance Redressal committee
Grievance Redressal committee shall be set up in each District for all possible
Redressal of grievance of beneficiaries/Health provider by the Insurer. The
committee will constitute following members:

i. Deputy Commissioner,

ii Civil Surgeon

iii Deputy Medical Commissioner

iv Representative of Insurance Company

The Committee will resolve the Grievance with in 30 days from the date of receiving
the application. Any Party, if not satisfied with the decision of the committee, can
reached to the State Level Committee.

• State level Grievance Redressal committee:

The next level of Grievance Redressal will be State Level SGRC

consisting having following members.
I Principal Secretary, Health & Family Welfare Punjab

ii Managing Director, PHSC

iii Director Health Services, Punjab

iv State Representative of Insurance Company

v Nodal Officer, PGEPHIS

The Committee will resolve the Grievance with in 30 days from the date of
receiving the application. The Decision of the Committee Shall be final & binding
to all the parties.

b. Dispute between TPA/ Insurance Company and the State Government

A dispute between the State Government /Nodal Department and Insurance TPA/
Company shall be referred to the respective Chairmen/ CEO’s/CMD’s of the Nodal
Department for resolution. In the event that the Chairmen/ CEO’s / CMD’s are unable
to resolve the dispute within {60 } days of it being referred to them, then either Party
may refer the dispute for resolution to a sole arbitrator who shall be jointly appointed
by both parties, or, in the event that the parties are unable to agree on the person to
act as the sole arbitrator within {30 } days after any party has claimed for an
arbitration in written form, by three arbitrators, one to be appointed by each party
with power to the two arbitrators so appointed, to appoint a third arbitrator.
 PGEPHIS 25

• The law governing the arbitration shall be the Arbitration and Conciliation Act, 1996
as amended or re-enacted from time to time.
• The proceedings of arbitration shall be conducted in the English Language.
• The arbitration shall be held in Chandigarh, Punjab.

22. NODAL DEPARTMENT:

a) The Punjab health System Corporation would be the Nodal Department for
the implementation of PGEPHIS.

b) A Coordination Committee having the representatives from The Department

of Health & Family Welfare, Punjab, Finance, Planning, Pensioner Welfare
and Department of Administrative Reforms & Public Grievances for
monitoring the implementation of the Scheme on a regular basis.

c) The Punjab health System Corporation will monitor data related plan like
enrolment, empanelment of hospitals, authorization status, claims status,

Note: Any liability arising due to any default or negligence in providing or

performance of the Insurance Services shall be borne exclusively by the Insurer
who shall alone be responsible for the defect and / or deficiencies in rendering
such services. The complete financial and legal liabilities, if any, arising
consequent to the operationalization of the Scheme or the Policy, shall rest
exclusively and unconditionally with the Insurance Company.

23. OPERATIONAL TERMS AND CONDITIONS APPLICABLE TO THE

REIMBURSEMENT CLAIMS.
• All hospitals of the Punjab Health Systems Corporation (PHSC), Civil Hospitals,
Government Hospitals and Government Medical Colleges/ Research Institutes
located in the State of Punjab and Chandigarh and Govt Hospitals in New Delhi
shall be automatically included in the list of Provider Hospitals where the
beneficiaries can avail medical services as covered under the terms and
conditions of the Scheme. In an event, the aforesaid hospitals fail to provide
cashless treatment, beneficiary shall be entitled to avail reimbursement of his/her
claim, subject to the submission of claim within 30 days from the date of
discharge from the hospital.

• The reimbursement to the beneficiary against the claim of the treatment availed
in the private hospital located anywhere in India except Punjab, Chandigarh and
NCR area (Gurgaon, Noida and Delhi), shall be made in accordance with the
PGEPHIS rates, irrespective of the actual expenditure incurred by the
beneficiary, subject to the submission of claim within 30 days from the date of
discharge from the hospital. For treatments that have not been mentioned in the
PGEPHIS rate list, the reimbursement shall be made in accordance with the
PGIMER Rates, Chandigarh.
 PGEPHIS 26

• The treatment in PGIMER, GMCH-32 and State Medical Colleges of Punjab and
Government Hospitals in NCR area (Gurgaon, Noida and Delhi) will be covered
at Govt. Hospital rates as applicable in such Govt. Hospitals or PGEPHIS Rates,
whichever is less. The consumables, medicines/investigations that are not
available in Govt. Hospital and are purchased by the beneficiary from outside
shall also be reimbursed by the TPA to the Beneficiary, at the PGEPHIS Rates or
the rates as billed by outside source, whichever is less.

• The beneficiaries shall bear all the expenses incurred on

treatment/hospitalization in the Govt. Hospitals, where the treatment is not
available on cashless basis and shall later claim for reimbursement from the
TPA, within 30 days from the date of discharge from the Govt. Hospital.

• Benefits up to 7 days Pre Hospitalization & up to 30 days Post Hospitalization

respectively which would cover all expenses related to treatment of the sickness
for which hospitalization was done shall be covered on cashless basis at
PGEPHIS Rates, in empanelled private hospitals in Chandigarh, Punjab and
Panchkula; on reimbursement basis in Government Hospitals at respective Govt
Hospital rates or PGEPHIS Rates, whichever is less; on reimbursement basis in
the private hospitals in remaining parts of the country at PGEPHIS rates or the
rates as billed by the private hospital, whichever is less, subject to the
submission of bills to the TPA within 60 days of the date of discharge from the
hospital.

• Medical reimbursement of bills against chronic diseases, that are covered under
the existing Punjab Medical Attendance Rules, shall be admissible as long as
either the patient is treated as indoor patient or as out door patient having valid
“Complicated chronic disease certificate”. Treatment can be had from any
hospital/Nursing Home/clinic located anywhere in India. Complicated chronic
disease certificate” has to be issued by State Government Medical Colleges,
PGIMER Chandigarh, AIIMS Delhi and GMCH Chandigarh. The beneficiary shall
avail this benefit on cashless basis in designated stores and empanelled
hospitals in all the districts of Punjab and Chandigarh.

24. CHECKLIST FOR REIMBURSEMENT CLAIMS:

1 Copy of Photo I.D. Card.

2 Original Hospital bill with bill breakup details, Pharmacy bills with prescriptions.

3 Original reports with Laboratory Bills, and prescription for investigations.

4 Original Radiological Investigation reports with images,

 PGEPHIS 27

5 Original or attested Discharge summary of the hospital with Date and Time of
admission & discharge mentioned in it.

6 Claim form signed by the patient or the claimant.

7 Death certificate in death cases.

8 For the medicines purchased, the bills in original and prescription by the treating
doctor/ hospital.

9 FIR or MLC report in accident, if the case has been registered with Local police
station.

10 Bar codes, Batch Number and Invoices for the stents, implants, catheters etc.

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