Health Card-draft Notification MARCH-2012

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AROGYA SRI HEALTH CARE TRUST EMPLOYEE HEALTH CARE FUND DRAFT SCHEME NOVEMBER 2011 A.P.UNITED TEACHERS FEDERATION, ANANTAPUR DISTRICT. Office : Door No.15/472, Surya Nagar, ANANTAPUR – 515 001. Visit us at : Email : CONTENTS Term No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2 3 4 5 6 Subject TERMS OF THE SCHEME General Definitions Fund Details Salient features Benefit coverage Policy and Contribution Period Empanelment Disciplinary actions Medica
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  AROGYA SRI HEALTH CARE TRUST EMPLOYEE HEALTH CARE FUNDDRAFT SCHEME NOVEMBER 2011 A.P.UNITED TEACHERS FEDERATION,ANANTAPUR DISTRICT. Office : Door No.15/472,Surya Nagar, ANANTAPUR – 515 001.Visit us at : www.utfatp.tkEmail :  CONTENTS Term No.SubjectPage No.TERMS OF THE SCHEMEGeneral1 Definitions Fund Details2 Salient features 3 Benefit coverage 4 Policy and Contribution 5 Period 6 Empanelment 7 Disciplinary actions 8 Medical Audit 9  NWH Requirements 10 Obligations of NWH Pre-authorisation and Claims11 Pre-authroisation 12 Claims Implementation Process13 Patient process flow 14 Trust office functions 15 Field operations 16 Web portal and online workflow 17 Project Monitoring – ImplementationCommittees – State and District 18 Packages 19 Follow-up packages THE SCHEME DATA (TSD)2 Salient features 3 Coverage 4 Policy and Contribution 5 Period 6 Empanelment STAFFING Staff requirementEligibility criteria Annexure-1Annexure-2 A.TERMS OF THE SCHEME General  Term No.1Term HeadingDefinitionsSub Term No. .1In this document, the following terms shall be interpreted as indicated below. (a) General Definitions (i) “Applicable Law” means the laws and other instrumentshaving the force of law in India.(ii) “Benefit” shall mean the extent or degree of service the beneficiaries are entitled to receive based on tailor made policy.(iii) “Beneficiary” shall mean all the eligible employees and pensioners along with their family members.(iv) “Employees” shall mean all the employees working under State Government and identified by the Finance Dept.(v) “Claim Float” shall mean the money made available to thescheme by the Trust to meet the claims.(vi) “Claim Float Account” shall mean the bank account wherethe claim float is parked and replenished on agreed terms bythe Trust.(vii) “Co-morbid conditions” shall mean all the associateddiseases being suffered by the patient in addition to thedisease among listed therapy.(viii) “Coverage” shall mean the entitlement by the beneficiary toHealth Services provided under the Policy, subject to theterms, conditions, of the policy.(ix) “Family” shall mean all the dependent members of the  employees and pensioners as provided by the Finance Dept.(x) “Government” means the Government of Andhra Pradesh or the Government of India.(xi) “Government Authority” shall mean either GoAP or GoI or Aarogyasri Health Care Trust (AHCT) or any entityexercising executive, legislative, judicial, regulatory or administrative functions of or pertaining to Governmentand having jurisdiction over the Company, the parties, anyshareholder or the assets or operations of any of theforegoing including but not limited to the InsuranceRegulatory and Development Authority.(xii) “Law” includes all statutes, enactments, acts of legislature,laws, ordinances, rules, bye-laws, regulations, notifications,guidelines, policies, directions, directives, and orders of anyGovernment, Government Authority, Court, Tribunal, Boardor recognized stock exchange of India, as may be applicableto the Scope and Terms of this Agreement.(xiii) “Pensioners” shall mean all the retired employees of stateGovernment receiving pension. The detailed list as provided by the Finance Dept.(xiv) “The Scheme” means the description of services includingthe disease and financial coverage, the terms and conditionsof services as given in volume-1.(xv) “TOS” means Terms of the Scheme.(xvi) “TSD” means The Scheme Data.(xvii) “Eligibility Card” shall mean Health Card issued by theTrust based on the information provided by the FinanceDepartment and data of the civil supplies department.
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