Rashtriya Swasthya Bima Yojna: 2010 Guidebook - Health Systems ...

Rashtriya SwasthyaBima Yojna2010 GuidebookA Joint initiative of USAID and Mission Convergence, GNCTD

2010 RSBY Guidebook

Table of ContentsThe Concept of Health Insurance ................................................................. 1Rashtriya Swasthya Bima Yojna ................................................................... 3RSBY Coverage ............................................................................................. 5Expenses not covered under RSBY ............................................................... 7RSBY Processes ............................................................................................. 9Enrollment ................................................................................................... 9Use of Smart Card ...................................................................................... 11Role of TPA’s District Kiosks ....................................................................... 13Role of TPA’s District Kiosks ....................................................................... 13Utilisation of Benefits ................................................................................. 15Who to call when there is a question ........................................................... 17Glossary of Terms ....................................................................................... 19Annex I: Indicative List of Package Rates under RSBY ............................. 23Annex II: Indicative List of Day Care/Procedures under RSBY ................. 25Annex III: List of Empanelled Hospitals under RSBY in NCT .................... 27Annex IV: Important Contact Information ................................................. 36Annex V: List & Contact information about TPA’s District Kiosks ........... 36Annex VI: References .................................................................................. 36Annex VII: Photo Credits ............................................................................ 362010 RSBY Guidebook Page i

List of FiguresRSBY Stakeholder Inter-Relationship .............................................................. 8Role of Gender Resource Centres (GRCs) in RSBY Enrollment ......................... 9Changes in the BPL/Vulnerable household list.............................................. 11RSBY Enrollment Process ............................................................................. 14Role of GRCs in Benefit Utilisation ................................................................ 15RSBY Utilisation of Benefits Process Flow...................................................... 18List of Empanelled Hospitals - Central District .............................................. 27List of Empanelled Hospitals -East District.................................................... 28List of Empanelled Hospitals -North District .................................................. 30List of Empanelled Hospitals - North-East District ......................................... 31List of Empanelled Hospitals - North-West District ........................................ 32List of Empanelled Hospitals - South District ................................................ 33List of Empanelled Hospitals - South-West District........................................ 34List of Empanelled Hospitals - West District .................................................. 35Page ii

The Concept of Health InsuranceHealth Insurance works by spreading the risk ofhealthcare expenses over a number of people so that thefinancial burden of unfortunate few who need healthcare isshared by the many fortunate who remain healthy.Most of us, at some point in our lives, will need to seek expensive healthcareservices e.g. hospitalisation or surgery. With the present day stress, sedentarylife-styles and pollution, an increasing number of persons are being diagnosedwith heart ailment, cancer and other critical illnesses that are expensive totreat. A few days of hospitalisation, major surgery or chemotherapy can costlakhs of rupees.In India, many of uspay directly to thedoctor, the chemist andthe laboratory for day today ailments, sincetreatment of these isgenerally low-cost.However, the cost ofhospitalisation isexpensive and most ofus find it unaffordable.Health Insuranceprotects us againstunexpected financialloss. It empowers us to access and afford needed healthcare services. Let ussee an example: Rajiv has fallen ill and requires hospitalisation, which will costRs. 10,000. There are two different ways to cover this cost:1. Collect, or pool, a small amount of money from each person in thecommunity to cover the cost of Rajiv’s hospitalisation, or2. Make Rajiv cover the cost on his own – which could potentially push himinto poverty – and set the precedent that everyone must pay their ownhealthcare costs, regardless of how high they may be.The first option is an example of how health insurance works. Each person inthe community makes a small contribution and eventually the communityshares the burden of the large expense incurred for hospitalisation of one.2010 RSBY Guidebook Page 1

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Rashtriya Swasthya Bima YojnaHouseholds pay for the majority of healthcare costs in India. Coveringhealthcare expenses is a primary cause of indebtedness in India, and can pushpeople deeper into poverty. It is known that many people, including the poor,prefer to access services in the private sector. This preference can intensify thefinancial pressure faced by many, as the private sector is more costly.Health Insurance is a way to help lessen the burden of paying for healthcare byspreading the costs of health across a group of people.Rashtriya Swasthya Bima Yojna (RSBY) is a health insurance scheme that waslaunched on 1st April 2008 by the Ministry of Labour and Employment (MoLE).The goal of RSBY is to provide health insurance coverage to individuals andhouseholds below-the-poverty-line (BPL). RSBY plans to cover the entire BPLpopulation in the country (approx 30crore) by 2012-13.Status of RSBY ImplementationRSBY provides the BPL beneficiaries:in the Country• Financial protection againsthospitalisation expenses• Improved access and choice of qualityhospitals (public and private)• Cashless utilisation of benefitsthrough use of a smart card 26 States have launched RSBY No. of lives coveredapproximately 5.5 crore Pan-India network of 3.717empanelled hospitals Over 3,50,000 hospitalisationcases treated2010 RSBY Guidebook Page 3

Facts & Figures of RSBY Coveragein NCT of Delhi 1‣ Covers BPL/Vulnerable Families of 9 Districts‣ No. of Families Enrolled – 2,12,058‣ No. of Empanelled Hospitals in the Network –78‣ No. of Claims Paid – 8,665‣ Total Amount of Claims – Rs. 2.77 crore‣ Total Amount Paid – Rs. 45 lakh‣ Insurance Company: Oriental InsuranceCompany‣ RSBY Coverage Period: 1st August 2009 to31st July 2010‣ Third Party Administrator: Alankit HealthcareTPA Ltd.‣ Implementing Organization: MissionConvergence/Samajik Suvidha Sangam1 Data Source: Alankit Healthcare TPA Limited. Figures shown are up to March 31, 2010Page 4

RSBY COVERAGEWho is eligible?• BPL/Vulnerable households, identified by the State GovernmentWhat is covered?• Hospitalisation expensesfor medical and/orsurgical proceduresincluding maternitybenefit up to Rs 30,000per family per year on afloater basis. To accessthe benefits under RSBY,a beneficiary should behospitalized in anempanelled hospital for24 hours or more. Inaddition, beneficiariescan also access day care surgeries/procedures that do not require stay ofmore than 24 hours in an empanelled hospital.• Cashless treatment in any of the empanelled hospitals. This means thatwhen a family accesses treatment, they do not pay the hospital anything.• Day Care Surgeries/Procedures in some circumstances. For an indicativelist of covered day care surgical procedures, please refer Annex II of thisGuidebook.• Pre-existing conditions/diseases are covered from day one. Pre-existingdisease relate to a disease that was present at any time in the past(including any disease, which the insured person may not have beenaware of) and prior to the enrollment of the beneficiary under RSBY• Pre- hospitalisation up to 1 day before hospitalisation.• Post-hospitalisation up to 5 days from the date of discharge.2010 RSBY Guidebook Page 5

• Maternity and NewbornChildren covered, subjectto conditions. See box.• Transportation costs arecovered with a maximumof Rs. 100 per visit andan annual limit ofRs.1,000.• Family size: up to fivemembers of a householdcan be covered. If thereare more than threechildren, the head of thehousehold must decidewhich three to beinsured. Extended familycannot be included in thefamily even if thebeneficiary familyconsists of less than fivepersons. Enrollment ofthe head of thehousehold and thespouse is compulsory.Maternity & Child Coverage under RSBY• All expenses related to the delivery ofthe baby (normal or cesarean) in thehospital/nursing home are covered• Coverage up to Rs 2,500 for normaldelivery• Coverage up to Rs 4,500 for caesareansection or complicated delivery• Involuntary termination of pregnancy orother medical emergency• Newborn coverage from day one up tothe end of the policy, even if thenewborn is the sixth member of theenrolled family. (Upon renewal, thehead of household must decide whichdependents are to be enrolled; only 5family members are covered)• Normal hospitalisation period for bothmother and child should not be lessthan 48 hours post delivery• Benefit is on a familyfloater basis, whichmeans that the totalbenefit amount (Rs.30,000) can be used byone person or jointly withother members of thefamily.• Age Limit: There is nolower or upper age limitfor coverage.• Maximum benefit for maternity coverageis Rs. 4.500/- including transportationcharge of Rs. 100/- per hospitalisationExclusions under Maternity Benefit• Abortion: Voluntary termination ofpregnancy, except for medicalemergency to save the life of themother• Hospitalisation Period: If less than 48hours from the time ofdelivery/operation• Payment by beneficiaries: Beneficiaries are required to pay Rs. 30 perfamily as registration charge, at the time of enrollment and upon renewal.Page 6

EXPENSES NOT COVERED UNDER RSBY• Conditions that do not require hospitalisation• Outpatient Diagnostic, Medical and Surgicalprocedures or treatments• Expenses for evaluation/diagnostic purposes• Expenses on vitamins and tonics etc.• Dental treatment or surgery unless arising from disease or injury andwhich requires hospitalisation• Congenital external diseases• Drug and Alcohol Induced illness• Sterilization and Fertility related procedures• Vaccination• Plastic surgery• Circumcision• Suicide• Traditional medicine,including Unani, Siddha, andAyurveda2010 RSBY Guidebook Page 7

Government of IndiaMinistry of Labour & EmploymentRSBY Stakeholder Inter-RelationshipRSBY Premium SubsidvImplementation SupportGovernment of DelhiDepartment of Labour(RSBY Policyholder)Mission ConvergenceSamajik Suvidha Sangam(RSBY Implementation Agency)Community OutreachEnrollment FacilitationEntitlement Holders /BeneficiariesThird Party AdministratorCashless Hospital ServicesEnrollment of beneficiariesSmart cardsList of empanelled hospitals24 hour helplineNetwork of EmpanelledHospitalsHospital Service FeesPage 82010 RSBY Guidebook

RSBY ProcessesENROLLMENTEnrollment is the addition of a newmember/family in the records ofRSBY. An electronic list of eligibleBPL households is provided to theinsurance company/Third PartyAdministrator (TPA) by theGovernment Departmentimplementing the scheme. Anenrollment schedule for eachlocation/village is then prepared bythe insurance company/TPA to beginsigning families up into the scheme.RSBY Publicity Banner in NCT of Delhi• An electronic list of eligible BPL/Vulnerable households is provided to theInsurance Company orTPA.• An enrollmentschedule for each GRCalong with dates isprepared by theInsurance Company/TPA with the help ofMission Convergenceofficials.• Mobile enrollmentstations are set up atlocal centers (e.g., GRCcenters) in each GRCRole of Gender Resource Centres (GRCs) inRSBY EnrollmentCoordinate & plan with TPA in advance to receive listof beneficiaries and enrollment camp datesMap their catchment area and identify thebeneficiariesDisseminate information on RSBY benefits andutilizationPlan and publicize the schedule of enrollment campamong the beneficiariesDistribute Yellow Slips among the beneficiaries priorto enrollment datearea. The stations are equipped by the TPA with the hardware required tocollect biometric information (fingerprints) and photographs of themembers of the household covered.2010 RSBY Guidebook Page 9

• Based on the list, BPL/Vulnerable households areidentified by the GRC staffthrough a door to door survey.After that the yellow slips 2 ,provided by the TPA, are issuedto the identified families andthey are informed about thedate for enrollment. Families arealso informed about the RSBYspecifics and enrollmentcriteria. If the family isinterested in enrolling, they areadvised to bring their surveyslip or Ration Card along with Rs. 30/- when they come for enrollment.• At the time of enrollment, the first step is to match the identity of theBPL/Vulnerable family with BPL/Vulnerable Household data carried bythe TPA operator. Once the data is matched, the TPA operator collectsbiometric information (fingerprints) and photographs of the members ofthe beneficiary household. Theregistration fee of Rs.30/- perhousehold is also collected by the TPAoperator at this stage. Subsequently,the concerned Field Key Officer (FKO)authenticates the smart card.• The smart card is normally deliveredwithin 15 days to the GRCs for onwarddistribution to the beneficiaries. Thesmart card is delivered along with aninformation pamphlet, describing thescheme and the list of empanelledhospitals.A RSBY Enrollment Camp in National Capital Territory (NCT)Beneficiaries should bringthe following when theycome for Enrollment:• Identification proof i.e.,ration card, voter IDcard etc.• Yellow slip given by theThird PartyAdministrator (TPA)• Rs. 30/- towardsRegistration Fees2 Yellow Slip – an identification slip for enrollment provided to the identified BPL/Vulnerable householdsPage 102010 RSBY Guidebook

USE OF SMART CARD• The smart card identifies each family and allows cashless access to thenetwork of participating hospitals in India.Photograph on the Smart Card• The photo of the head ofhousehold is printed onthe smart card. Thephotograph of all familymembers is stored in thechip embedded in thecard. The purpose ofthese photos is to be ableto identify the enrolledbeneficiaries when theyseek health services.Role of Field Key Officer (FKO)• FKO is a representative of the Government. However, in the NCT of Delhi,the GRC coordinators have been designated as FKOs.• Each enrollment team at the GRC has an FKO who identifies thebeneficiaries at the time of enrollment. The FKO uses his own smart cardto authenticate the beneficiaries’ smart card. Without FKO’sauthentication thebeneficiary’s smartChanges in the BPL/Vulnerable household listcard will not work.• The detail of eachfamily is copied in theFKO card. Theinsurance company ispaid based on thenumber ofbeneficiaries obtainedfrom the FKO card.• RSBY mandates the presence of FKOs at the enrollment station.Registration feesEnrollment team is allowed to do some modificationsin the existing list with respect to the dependentsName, Age and Gender of the dependents can berevised in the BPL/Vulnerable list if requested by thehead of the householdHowever, the relationship code with the head of thehousehold cannot be changed• Registration Fees of Rs.30/- is aimed at meeting part of the administrativeexpenses of the TPA. The registration fee is to be paid when the beneficiaryenrolls in RSBY, including at the time of renewal.2010 RSBY Guidebook Page 11

Splitting Smart Cards• Smart cards can be split to allow a family member to use the RSBYservices when traveling in a district/city different than the family.• The smart card cannot be split in more than two.• The total combined benefit limit of both the cards remains Rs. 30,000/-per beneficiary family. The benefit limit of each split card is decided by theHead of the family at the time of the split.• Splitting will be done at the district kiosk of the TPA. The cost for splittinga card is Rs.125/- in the NCT of Delhi and it has to be paid for by thebeneficiary.• The FKO does not need to be present to split cards.Issuing Duplicate Cards• A new card can be issued at the district kiosk for Rs.125/- if the originalsmart card is lost or damaged.Addition/Deletion of Beneficiaries in the Smart Card during the year• If there is a death of one of the beneficiaries on the card, another memberof the family can be added as a beneficiary under the scheme. However,any addition would only be done if the family member forms part of theBPL/Vulnerable household list.Replacing the Head of the Family in case of Death• The second person listed as a beneficiary will be considered the head offamily. He/she would be entitled to decide who else from the family wouldbe covered. This ―second person‖ could be the widowed spouse, orsomeone else in the family.Presence of Head of Family at the time of enrollment• The presence of either the Head of the family or the second person isnecessary at the time of enrollment. If both are absent, the card cannot beissued. But, if one of them is present the card can be issued even if someother listed members are absent. The details of other members can beadded subsequently at the district kiosk.Page 122010 RSBY Guidebook

ROLE OF TPA’S DISTRICT KIOSKSDistrict Kiosks are assistancecenters set up by the TPA to helpRSBY beneficiaries for smart cardissues. The range of services theyprovide include the following:Modifying the existing Smart Card• Smart cards can be modifiedto delete or add familymembers in the case ofdeath, births, marriage ofdependent, etc.• Any addition of a member in the smart card can only be from within theBPL/Vulnerable household list.• Presence of FKO is not necessary for any addition in the abovecircumstances.Issuing new Smart Card• Eligible beneficiaries may have been left out during the round ofenrollment at the GRC. The beneficiary will be required to come with allthe family members that need to be enrolled.• Presence of FKO is necessary for issuing new smart card.Splitting of the existing Smart Card• Smart cards can be split to allow a family member to use the RSBYservices when traveling in a district/city different than the family.• Presence of FKO is not necessary to perform this role.Issuing a duplicate Smart Card• A duplicate smart card is issued in lieu of missing, damaged or lost card.On issue of the duplicate card, the earlier one is hot-listed to preventmisuse. Presence of FKO is not necessary for issuing new smart card.2010 RSBY Guidebook Page 13

Government of DelhiDepartment of Labour(RSBY Policyholder)RSBY Enrollment ProcessImplementation of RSBYMission ConvergenceSamajik Suvidha Sangam(RSBY Implementation Agency) Technical support to GRCs Defining role of GRCs in the enrollment process Supply of Pre-enrollment IEC material IEC activity in the communityThird Party Administrator Setting up Enrollment camps Biometric & photo of beneficiaries Printing of Smart cards Delivery of smart cards to GRCGender Resource CentersSuvidha KendraEnrollment Facilitation: Community Mobilization Awareness generation Identification of BPL/Vulnerable Distribution of yellow slips Field Key Officers Distribution of Smart CardsRegistration FeesEntitlement Holders /BeneficiariesPage 142010 RSBY Guidebook

UTILISATION OF BENEFITSHospitalisation Process• The beneficiary should first approach the RSBY counter at the empanelledhospital for assistance and guidance if seeking medical care.• The beneficiary must take his/her smart card to the hospital since thatalone allows him/hercashless treatment at the Role of GRCs in Benefit Utilisationhospital.• If the provider or hospitalseeks any payment from thebeneficiary for the healthcareservices, he shouldimmediately inform theinsurance company or theTPA through the toll freenumber provided to him/her.Network of Empanelled Hospitals• Public and private hospitalsare part of the network ofempanelled hospitals. Eachbeneficiary receives a list ofempanelled hospitals. Thisprovides the beneficiary with an option to choose the hospital where hedesires to seek healthcare. A list of empanelled hospitals in the NCT ofDelhi is provided as Annex III of this Guidebook.Smart Card Usage• Only the Operator at the hospital can verify the smart card and can tellthe balance remaining on the card. This is done on a smart card readermachine.Biometric/Finger Print Verification• The purpose of fingerprint verification at the time of admission at thehospital is to prevent fraud and misuse of the smart card. Fingerprint ofany enrolled member of the family can be provided.Pre hospitalisation and Post hospitalisation expensesIdentify empanelled hospitals in catchmentarea and educate communityVisit the empanelled hospitals to verifywhether RSBY helpdesk and other provisionsfor beneficiaries are in placeEducate community about the cashlesstreatment and use of smart cardAssist beneficiaries in case of non-acceptanceor misuse of smart card by empanelledhospitalHandle grievances through cross-checkingcard balances and status of treatment forbeneficiariesInform TPA/Insurance Co. in case of any fraud• Pre-hospitalisation expenses are costs of care incurred before it isdetermined that hospitalisation is necessary. Examples include tests and2010 RSBY Guidebook Page 15

medicines that lead to hospitalisation. Expenses incurred one day beforeadmission at the hospital are covered under RSBY• Post-hospitalisation expenses are costs of care incurred after dischargefrom the hospital. Expenses incurred up to five days after discharge arecovered under RSBY.• Reimbursement of pre and post hospitalisation expense is subject toproduction of proof.Package Rates/Charges• RSBY has negotiated a packagerate/charge for all expenses (e.g.medicine, tests, bed charges,other materials, food etc.) relatedto the treatment of coveredservices. An empanelled hospitalshould not charge anything fromthe patient for treating somethingwhich is part of the list ofdiseases under package rates.• Under RSBY, a list of 725package rates has beendeveloped. An indicative list ofpackage rates under RSBY is provided in Annex I of this Guidebook.Process of Payment of Transportation Charges• Rs.100 will be paid to the beneficiary per hospitalisation (up to amaximum of Rs.1,000/- per year) at the time of discharge by the hospitalwhere he/she had been hospitalized. There is no proof (tickets/receiptsetc.) required to claim transportation charges.Coverage of Food Expenses of Family Members• Food only for the person who is hospitalized is covered in the package rate.Family members accompanying the patient have to pay for their food andrelated expenses.Coverage of OPD Expenses• Out-Patient Department (OPD) expenses e.g., medicines or tests, orexpenses in hospitals which do not lead to hospitalisation are not coveredunder RSBY and are therefore the responsibility of the individual.Page 162010 RSBY Guidebook

WHO TO CALL WHEN THERE IS A QUESTION• The TPA Call centre provides, through a State Toll free telephone number,telephonic guidance to the beneficiaries on various issues of coverage,utilisation of benefits or grievances, if any.• The Call Centre is functional for 24 hours a day, 7 days a week andthroughout the year.Call Center InformationBeneficiaries can receive information on the following areas from the TPA CallCentre:• Benefit details under the policy andthe balance available with thebeneficiaries• Information on Insurer’s office,procedures etc.• General guidance on the Services• Information about the process ofcashless treatment• Information on Empanelled Providers and contact numbers• Claim status information• Data of calls received and response on the system.• Any other relevant information/related service to the beneficiaries• Any of the required information available at the call centre to theGovernment/Nodal Agency• Any related service to the Government/Nodal Agency.2010 RSBY Guidebook Page 17

RSBY Utilisation of Benefits Process FlowEntitlement Holders /BeneficiariesBeneficiary visits networkhospital with smart cardEmpanelled HospitalHospital verifies: Smart card Available benefit balanceOn discharge: Hospital bills TPA throughSmart cardThird Party AdministratorTPA pays claims to hospitalProvides Claims Fund to TPASubmits ClaimsPayment Status andSeeks Claims FundGovernment of DelhiDepartment of Labour& Mission ConvergenceBenefit utilisation dataInsurance CompanyPage 182010 RSBY Guidebook

Glossary of Terms• Beneficiary/Insured – a person who is covered to receive benefits under ahealth insurance policy• Benefit limit/Amount – amount payable by an insurer to a beneficiaryunder a health insurance policy• Benefit Limits – the maximum amount of benefits payable under a healthinsurance policy• Cashless Treatment/Service – means that the patient will not have tospend any amount (subject to the available limit of coverage) for takingtreatment or hospitalisation. The expenses incurred on the hospitalisationshall be claimed by the hospital from the insurance company• Congenital external disease – is an abnormality of the structure of a bodypart by birth• Coverage – benefits provided by a health insurance policy for which abeneficiary is covered• Covered Charges – expenses eligible for payment for medical care orsupplies, when incurred by a beneficiary under the health insurancepolicy• Covered Person – any beneficiary eligible for benefits under a healthinsurance policy• Day care Surgery – procedures that require surgical intervention that canbe performed on a beneficiary on a out-patient care basis• District Kiosk – facilitation centres established by the third partyadministrator (TPA) to assist covered beneficiaries after smart card hasbeen issued. Assistance provided by a district kiosk pertains tomodification in the existing cards, splitting of cards and issue of new cardsin lieu of lost or damaged cards• Eligibility – provisions of the health insurance policy, upon satisfying ofwhich, beneficiaries become eligible to avail benefits under the policy• Eligibility Date – the date from which the beneficiaries under a healthinsurance policy stand covered for availing the benefits covered under it2010 RSBY Guidebook Page 19

• Enrollment Period – the period in which smart cards are issued to thebeneficiaries which entitles them to the coverage under a health insurancepolicy• Enrolment Process – the process under which eligible beneficiaries areidentified, informed about the covered benefits, charged registration fees,issued smart cards and enrolled as covered beneficiaries under a healthinsurance policy• Exclusions – expenses or specified diseases, conditions and services notcovered under a health insurance policy• FKO – (Field Key Officer) are officials either from the Government or theGRCs who have been delegated the function of identifying the beneficiariesand authenticating their smart card by his FKO card and finger print• Floater basis – total amount of benefit (Rs.30,000 per family in case ofRSBY) that can be used by any one person or jointly with other membersof the family• Hospitalisation – admission of a patient into a hospital for availing ofhealth services on an in-patient basis• IEC Activities – Information, Education, and Communication (IEC)activities relate to the publicity and marketing by the insurancecompany/TPA to prior to enrollment to educate the beneficiaries regardingenrollment and benefits of the scheme• Inpatient Care – health services given to a patient admitted to a hospital,nursing home or other such facility• Insurer – an insurance company which under a contract ofinsurance/health insurance policy promises to pay benefits that arecovered under the policy to the insured beneficiary• Maternity Benefit – expenses related to child birth that are payable to thebeneficiary under a health insurance policy• Network/Empanelled Hospitals – hospitals under a health insurancepolicy that have contracted with the insurance company or its third partyadministrator to provide healthcare services to the beneficiaries on acashless basis, subject to conditions as laid down under the policy• Out-patient Care – any healthcare service provided to a beneficiary who isnot admitted to a hospital, nursing home or other such facility. Outpatientcare may include health services such as doctor consultation, laboratory &radiological investigation and dispensation of medicinesPage 202010 RSBY Guidebook

• Out-patient Diagnostic – laboratory and radiological investigations availedby a beneficiary on an outpatient basis• Package Rates – are negotiated rates between an insurance company/TPAand empanelled hospitals for specified surgeries/health services, whichinclude all the expenses related to the treatment like medicine, tests, bedcharges, other materials, food etc.. Empanelled hospitals are not expectedto charge anything from the patient for these• Post-hospitalisation Expenses – post -hospitalisation expenses are suchexpenses as incurred by the hospitals on beneficiaries after their dischargefrom the hospital• Pre-existing conditions/Diseases – any disease/physical condition thatexists prior to the effective date of coverage under a health insurancepolicy• Pre-hospitalisation Expenses – pre-hospitalisation expenses are suchexpenses that are incurred by the hospitals on beneficiaries before takinga view with regards to their hospitalisation• Smart Card – a biometric enabled card which contains the fingerprintsand photograph of a beneficiary. The electronic chip in the card alsocontains the benefit limit/amount that a beneficiary is eligible for underthe health insurance policy.• Third Party Administrator (TPA) – is an agency/firm appointed by aninsurance company to undertake functions relating to administration ofbenefits covered under a health insurance policy. The functions delegatedto a TPA under RSBY include enrollment of beneficiaries, maintainingrecords of beneficiaries, establishing a network of empanelled hospitalsand enabling cashless treatment of beneficiaries at the empanelledhospitals2010 RSBY Guidebook Page 21

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Annex I: Indicative List of Package Rates underRSBYPackage rates means that all the expenses related to the treatment likemedicine, tests, bed charges, other materials, food etc. and the hospital shouldnot charge anything from the patient for these. Package rates are inclusive of 1day pre-hospitalisation and 5 days post-hospitalisation expenses, transportexpenses and any expenses arising due to complications while in hospital.Under RSBY, package rates for 725 inpatient surgical procedures, includingmaternity and newborn care have been pre‐defined. Provided below is anindicative list of package rates for various surgical procedures.Sl. No.Surgical ProcedurePackage Rate 3(Rs.)1. Adeno Tonsillectomy 6,0002. Antrostomy – Bilateral 6,0003. Appendectomy 6,0004. Cholecysostomy 10,0005. Cryosurgery 7,0006. Duroplasty 9,0007. Endoscopic Septoplasty 65008. Fenestration 7,0009. Fimbriolysis 5,00010. Fissurectomy 7,00011. Fistula Repair 5,00012. Gastric Perforation 10,00013. Hernioplasty 7,00014. Hydrocele - Excision - Bilateral 5,50015. Hydrocele - Excision - Unilateral 3,00016. Lipoma 2,00017. Lords Procedure (haemorrhoids) 5,00018. Mastoidectomy 6,00019. Myringotomy - Bilateral 4,50020. Tumour Excision 5,0003 Source: Alankit TPA – RSBY Information Sheet2010 RSBY Guidebook Page 23

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Annex II: Indicative List of Day Care/Proceduresunder RSBYDay care surgeries are the procedures which require a surgical intervention butpatient need not be admitted to hospital after the surgery. An indicative list ofday care surgeries under RSBY is provided below:Sl. No. Day Care Surgeries/Procedures 41 Bartholin Abscess I & D2 Cataract – Bilateral & Unilateral3 Corn - Large - Excision4 Corneal Grafting5 Cyst -Vaginal Enucleation6 D&C ( Dilatation & curettage)7 Dermoid Cyst - Large - Excision8 Dermoid Cyst - Small - Excision9 Dislocation - Elbow10 Dislocation - Shoulder11 Drainage of Abscess Cold12 Drainage of large Abscess13 Electro Cauterisation Cryo Surgery14 Excision Bronchial Sinus15 Excision of Small Growth from Tongue16 Excision of Small Swelling in Hand17 Ganglion - Small - Excision18 Hip Spica19 Hymenectomy & Repair of Hymen20 Nodular Cyst21Oeshophagoscopy for foreign bodyremoval22 Ovarian Cystectomy23 Polypectomy24 Retro Pharyngeal Abscess - Drainage4 Source: RSBY Agreement between Government of Delhi & Oriental Insurance Co.2010 RSBY Guidebook Page 25

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Annex III: List of Empanelled Hospitals under RSBY in NCTList of Empanelled Hospitals 5 - Central DistrictSl. No. Hospital Name Address Contact Person Contact Number1Dr. Shroff's Charity EyeHospital2 Geetanjali Medical Centre3 Nijhara Hospital Pvt. Ltd.45Sanjeevan Medical &Research CentreSaraswati MemorialHospitalKedarnath Road ,Daryaganj,New Delhi-110 0026425 / 8, Dev Nagar, KarolBagh,New Delhi-110 0052979/3, Ranjit Nagar(Near Shiv Mandir) SouthPatel Nagar,New Delhi-110 00824,Ansari Road, Daryaganj,New Delhi, 110002332/2, Thansingh Nagar,Anand Parbat, New Delhi-110 005Mr. Hari S. Gupta(9868238870)Dr. Suresh Gupta(9811056256)Dr. Govrav Nizhara(9811075034)Dr. Prem Agarwal(9810203358)Dr. Anuj(9350815331)232538802325158023251581(9868238870)2573389530903441(9811056256)25848721258436289811075034.23257143‎9810203358Mr. Dhiraj(9310809394)28763130287625395 List of Empanelled Hospitals under RSBY in National Capital Territory of Delhi (NCT) provided by Alankit Healthcare TPA Ltd.2010 RSBY Guidebook Page 27

List of Empanelled Hospitals -East DistrictSl. No. Hospital Name Address Contact Person Contact Number1 Ashok Nursing Home23Dr. Gupta NursingHome & HospitalHoly Child NursingHome4 Kesar Hospital5Khandelwal Hospital &Urology Centre6 Mahesh Hospital7 Narula Medical CentreF3/15-16,East Krishna Nagar,Shahdara , Delhi-110 05125, Raj Block, Navin Shahdara,New Delhi—110 032C-43-44, East Krishna Nagar,(Opp. Swarn Cinema),Shahdara,Delhi-110 051Ah-11, Shalimar Bagh,New Delhi – 110 088B-16, Main Road,East Krishna Nagar, Shahdara,New Delhi-110 051Patparganj Society Complex,Near Engineer Estate, D-437,West Vinod Nagar, I.P.ExtnDelhi-110 092.179,Madhuban,Delhi-110 092Dr. Ashok Singh(9811100764)Mr. U. P SharmaDr. Veena GuptaDr. VikramMr. Paramjeet(9910966899)Dr. Ayush GuptaMr. Shahil(9891551931)Dr. Mahesh(9810869765)Dr. Dhiren Narula(9313267399)997155202099717720209311101776Mr. U. P Sharma(9210041093)22322218223216222200281997172774612747882227478823989932686722094846220948442247114522471525288222702882227199109668999810966899Page 282010 RSBY Guidebook

89Sai Nursing Home &Charitable DispensarySanjivani MedicalCentre10 Shanti Medical Centre11 Shivam Nursing Home12Shri Ram SinghHospital & HeartInstitute13 Singhal Nursing Home14Surgi Centre NursingHome15 Taneja Hospital16 Virmani HospitalA-86,100ft.Road,Natthu Colony Chowk,Jagat Puri, Shahdara,Delhi-110 093Near- V3s Mall, 90/3,East Guru Angad Nagar,Delhi-110 092D-5, Pandav Nagar, MotherDairy,New Delhi-110 092A-93, Gurudwara Road,New Seelampur Market,Delhi-110 053B-25, 26, 26-A, East KrishnaNagar, Shahdara,Delhi-110 051.9/3, Main Road, Kailash Nagar,New Delhi-110 031D-15, Vivek Vihar,New Delhi-110 095F-15, Preet Vihar, Vikas Marg,Delhi -110 092Plot No. 8,Mayur Vihar Phase II,New.Delhi-110 091Dr. Ravinder KumarSharma(9810334568)Dr. D.K. Sharma(9810071445)Dr. Subhash BadhawanDr. S. K. Gupta(9810148550)Dr. Ashok Singh(9811100764)Mr. Dinesh PanditDr. N.K. Gupta(9810048331)9350171455Dr. S. M. Taneja(9810323336)Mr. Devender Singh(9810212407)92502937372258422022013631224167286452008298107141719312275326224885532248855422560530981022364199715520209971772020931110177698112554069811137742987108882022154127221401172252573822526856227747482277923299107790382010 RSBY Guidebook Page 29

Sl.No.List of Empanelled Hospitals -North DistrictHospital Name Address Contact Person Contact Number1 Aastha Hospital2Agarwal NursingHomeD-42, Near Bank Of Baroda, Badli,New Delhi – 110 0422528, Tri Nagar, Tota Ram Bazar,Delhi-110 035Dr. Manish Sharma(9891002289)Dr. Ashok Agarwal(9810048230)926848523998115255202738336627383377273833883 Bhagwati HospitalCs/Ocf-6, Sector-13, Rohini,Delhi-110 085Dr Naresh Pamnani(9811207171)2786893827554182.4 Avantika HospitalA-168, Pocket-Oo, Sector-2, Rohini,Delhi -110 085Dr. R. K. Midha(9810037376)55188147275193245 Mittal Nursing Home4302/5 Jai Mata Market, Tri Nagar ,New Delhi-110 035Dr. Anil Mittal(9899213815)9899213815273925266Navjeewan MedicalCentreT-655, Onkar Nagar, Tri Nagar,New Delhi-110 035Dr. Praveen Bansal(9811403215)Ashok (9350187823)27386838273826507Nazar Kawar SuranaHospital219/220, Gulabi Bagh,New Delhi-110 007Dr. Suresh Gupta(9811211189)23640951236409528 Samyak HospitalBm- 7, East Shalimar Bagh,New Delhi-110 088Dr. Rishi Jain(9810192430)2749862527490025Page 302010 RSBY Guidebook

9 Sant HospitalMain Burari Road, Sant Nagar,Delhi – 110 084Dr.V.K.Sehdev(9873096775)27614879931226993310 Santom HospitalD-5, Prashant Vihar,Main Outer Ring Road, Rohini,Delhi-110 085Dr. Sushma(9873205961)20254284275622552756102411Satyam HospitalPvt. Ltd.64, 65/A-4, Sector-16, Rohini,Delhi110 085.Dr. Vijay Kumar Kohli(9810125758)2785098027850990.12Sehgal NursingHomeA-6 , Panchvati ,Opp. Azadpur Sabzi Mandi ,Metro Pillar No 84 ,Delhi-110 033Dr. N. Sehgal(9810038999)99113613312767536313Shyam Lal EyeHospitalMalkaganj,Delhi-110 007Dr. S. N. Gupta2385648323857066Sl.No.12List of Empanelled Hospitals - North-East DistrictHospital Name Address Contact Person Contact NumberDr.MukeshOrthopaedic &Trauma CentreKamal NursingHome & Hospital2374-T(21a) Mandi Extn.,Near Corporation Bank,Bawana Road, Narela,Delhi-110 040790, Indra Chowk, Jaffrabad,Delhi-110 053Dr. Mukesh Aggarwal(9811097515)Dr. Alam(9910575050)27285280931388447222564197221983082010 RSBY Guidebook Page 31

Sl.No.1 A- One Hospital2 Daya Hospital3 Indian Hospital45List of Empanelled Hospitals - North-West DistrictHospital Name Address Contact Person Contact NumberJeewan CharitableHospitalK.R. Gangwal MemorialHospital6 Kamlesh Medical Centre7 Shri Jiyalal Hospital8Sunderlal Jain CharitableHospitalA-1/7, Paschim Vihar,Main Rohtak Road,New .Delhi-110 063A-4/16, Paschim Vihar,New Delhi-110 063Ag-35, Shalimar Bagh,New Delhi-110 088R-225,26,27,28,29.Mangolpuri,Delhi-110 08385, 86, 87, 20th Point , PlotSindhu Border Road, Narela,Delhi-110 040423, Bhera Enclave, PashchimVihar,New Delhi110 0876, Inder Enclave, RohtakRoad,(Near Peera Garhi Chowk),New Delhi-110 087.Ashok Vihar, Phase-III,Delhi-110 052Dr. Harmesh Kapoor(9810301850)25271177423111779910779038Dr. Pradeep Mittal 25252057Dr. Rajesh Kumar Singh(9871111128 / 7)Dr. Ravi DubeDr. Gangwal(9811072362)Dr. Atul Thapar(9811086235)Dr. Sushil Garg(9312256610)Dr.Tripta(47030907)Mr.Tapash(9810921578)47001616470366662791668927915743277827152525241925252421981013469347030900(100lines)Prerna(9818877921)Page 322010 RSBY Guidebook

List of Empanelled Hospitals - South DistrictSl.No.Hospital Name Address Contact Person Contact Number1 Aakash Hospital90/43, Malviya Nagar,New Delhi-110 017Mr. Kamal Kataria(9810580749)266871485183082298181669962 Agarwal Medical CentreE-234, Greater Kailash,Part-I,New Delhi-110 048Dr. Neeraj(9818495417)4173091998184954173Dr. Sunder Lal MemorialHospitalC-201, Jawahar Park,Devli Road, Khanpur,New Delhi -110 062Dr. Anil Vij (9999847796)Dr. Gaurav Gupta(9810372598)29915642245277534Sawan Neelu AngelsNursing HomeJ-293, SaketNew Delhi-110 017Dr. Ashok Kumar(9811140145)29555284295517945Sitaram Bhartia InstituteOf Science & ResearchB-16, Qutub InstitutionalArea,New Delhi-110 016Shomya Ray Choudhary(9717490222)4211111197178947236Vashishta Clinic &HospitalB-35, Shivalik, MalviyaNagar,New Delhi-110 017Dr. R. S. Vashishta(9810060931)26691177266923617 Visitech Eye CentreR-13, Greater Kailash-I,New Delhi-110 048Mr. Abhijit(9871465770)41731777417318802010 RSBY Guidebook Page 33

List of Empanelled Hospitals - South-West DistrictSl.No.Hospital Name Address Contact Person Contact Number1 Central Hospital2 Deepan HospitalA-142/1, Ganesh Nagar,Near Ganesh Nagar, TilakNagar ,New.Delhi-110 018Kh-139-140, NajafgarhRoad,Kapashera,New DelhiMr. Rambyas Singh(9899525169)Dr. Deepan (9212616001)259946609811085264656598382506461192126160013 Dr. Nanda Eye Care Centre A-200,Sector-8,Dwarka,New Delhi-110 075Dr. Rohit Nanda (9811079895)2536090998713100004 Sai HospitalPlot No.254, Amberhai,Sector-19, Dwarka,New Delhi-110 075Dr. Nand Kisor Rana(9810385036)5 Sidhant Hospital6 Singhal HospitalD-7, Main Palam- DabriRoad,Mahavir Enclave,DwarikaNew Delhi-110 045.C-4, Gali No. 9,Near- DESUOffice, Mangla Puri, SadhNagar, Palam Colony. NewDelhi-110 045Dr. Ranvir Solanki(9312666655)Mr. Rohtas Singh(9810988545)25032226981159630625055191250570149312041613Page 342010 RSBY Guidebook

List of Empanelled Hospitals - West DistrictSl.No.Hospital Name Address Contact Person Contact Number1 Ansari HospitalRz-20 F/B, Street No-6, MainSagarpur, New Delhi-110 046Dr. Ansari(9899045780)25395194253925482 Ashray Medical CentreWhs-2/24, Timber Market, Kirti Nagar,New Delhi-110 015Dr. Ashok Gupta(9891201977)25411359329947303 Behl HospitalB-128, Naraina ViharNew.Delhi.110 028Mr. Deepak KumarSudan(9213333850)9213333850(Mr. Sudan)257776404 Bimal Hospital Pvt. Ltd17/1, Main Rohtak Road, Nagloi,New Delhi-110 041Dr. J. B. Dangi(9818480633)25943314259436385 Bhagat Chandra HospitalRz F- 1/1, F-Block,Mahavir Enclave, Dwarka,.New Delhi- 110 045Dr. PankajShrivastava(20406563)25058542329126356 Family HospitalWz-26a, New Sahib Pura,(Opp. C.R.P.F Main Gate), Tilak Nagar,New Delhi-110 018.Dr. Manjit Singh(9971171864)921002535028331857 Gandhi Nursing HomeC-50, Om Vihar, Uttam Nagar,New Delhi -110 059Dr. Pawan Gandhi(9312222922)2533513525335099253331792010 RSBY Guidebook Page 35

8 Handa Nursing Home57, Raja Garden,New Delhi-110 015Mr. Jagdeesh(9811487670)25433342254157269 Jyoti Nursing HomeC/234, Vikas Puri.,New Delhi-110 018Dr. R. C. Madan9810761200)255564642552039981076120010Kalawati KaustubhHospital Pvt. Ltd.2, Inder Enclave,Main Rohtak Road, Peeragarhi,New Delhi-110 087Mr. Nitin Mittal(9212378829)2522575409811183413989101107511 Kapoor Medical CentreE-18, Naraina ViharNew.Delhi-110 028Dr. Kapoor(9810077777)257913872579312412 Kesar Nursing HomeWz61a/3b,Vashisht Park,Pankha Road, Janakpuri,New Delhi -110 046Dr. A. K. Kesar(9810850566)253826833090523113Lamba Hospital & NursingHome14 Navjeevan HospitalB-1/453, Janakpuri,(Near DESU Office B-1block),New Delhi-110 058.A-12, Pushpanjali Enclave,Pitampura,New Delhi- 110 088Dr. Lamba(9811043350)Dr. Naveen Bansal(9311030777)554580202552484998110433509216828440270160815515872915 New Medical CentreB-39,Moti Nagar.New DelhiDr. Monika Thapar(9810128398)98101283989810491610(Deepak)Page 362010 RSBY Guidebook

16Rao Raghubir Hospital &Maternity CentreNajafgarh Road ,Kamruddin Nagar Morh, Nagloi,Delhi-110 041Dr.( Mrs.) Yadav(98112707744)30974565259444859811270774417Sakuntala Nursing Home& HospitalRz-I-81a, Sagar Pur West(Opp- Delhi Vidhyut Board Colony),New Delhi-110 046Dr. B. P. Dhami(9211783762)253831712539097618 Sardana Eye InstituteA2/19, Rajouri Garden,New Delhi-110 027Dr. JagmohanSardana (25436870)410063662543636619Satya Bhama HospitalsPvt. Ltd126/105, Najafgarh Road, Nangloi,Delhi-110 041Dr. Manisha(9312252349)259431072594634220 Sonia Hospital Pvt. Ltd21 Swasthik Hospital1-Gulshan Park,Main Rohtak Road, Nangloi,New Delhi-110 04114, Gopal Nagar,Opp. Ashok Nagar,New Delhi-110 018Dr. Sachin Bajaj(9911449599)Dr. Vivek Gupta991144959925963004-06(Alam-9210200713)25497222254973332010 RSBY Guidebook Page 37

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Annex IV: Important Contact Information1. Oriental Insurance Co. LtdDivisional Office No. 161 st Floor, 88, JanpathNew Delhi - 110001Phone: 011-23322930, 23351478/79Fax: 011-23357325E-mail: kantiballabh@orientalinsurance.co.in2. Alankit Healthcare TPA Ltd.2E/21, Jhandewalan Extn.,New Delhi –110055Phone: 011- 42541100, 23541234Fax: 011- 42541266-67E-mail: rsby@alankit.com3. Alankit Call CentreToll Free No: 1800 11 3300 (24 hours operational)4. Genins India TPA Ltd. Call Centre(For RSBY Smart Card Holders of South District)Toll Free No: 1800 345 3323 (24 hours operational)2010 RSBY Guidebook Page 39

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Annex V: List & Contact information about TPA’sDistrict KiosksSl.No.DistrictAddressContactno.ContactPersonEmail Id1 NorthShop No. 9,10 &11,Ground Floor, DeepCinema Complex,Ashok Vihar, Phase I,Delhi-110 05240754701-06RakeshRawatalankitavhr@alankit.com2 East104, Pankaj Chambers,Preet Vihar CommunityCentre, Vikas Marg,Delhi-110 092 ,42421135RajeshKumaralankitpv@alankit.com3 CentralShop no. 205-208,Anarkali Complex,Jhandewalan Extn.,New Delhi-110 0554254121442541215SatyamGuptalcanarkali@alankit.com4NewDelhiShop no. 205-208,Anarkali Complex,Jhandewalan Extn., NewDelhi-1100564254121442541215SatyamGuptalcanarkali@alankit.com5 South119/1,Kotla Mubarakpur,New Delhi1800 34533232010 RSBY Guidebook Page 41

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Annex VI: References1. Fundamentals of Insurance – Tena B. Crews2. RSBY Website – http://rsby.in3. Draft agreement document between Oriental Insurance Co. Ltd.and Department of Labour, Government of Delhi2010 RSBY Guidebook Page 43

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Annex VII: Photo Credits1. Page 1 – USAID2. Page 3 – Mission Convergence, Government of Delhi3. Page 5 - Mission Convergence, Government of Delhi4. Page 6 - Alankit Healthcare TPA Ltd5. Page 7 - Mission Convergence, Government of Delhi6. Page 9 - Mission Convergence, Government of Delhi7. Page 11 - Mission Convergence, Government of Delhi8. Page 12 - Mission Convergence, Government of Delhi2010 RSBY Guidebook Page 45