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What happens in case of any dispute?
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:
Dispute between Beneficiary and Health Care Provider
The parties shall refer such dispute to the redressal committee constituted at the District level under the chairmanship of concerned District magistrate and authorized representative of the insurance company as members. This committee will settle the dispute.
If either of the parties is not satisfied with the decision, they can go to the State level committee which will be Chaired by the Principal Secretary………. with representative of the Insurance Company as a member.
Dispute between Health Care Provider and the Insurance   Company
The parties shall refer such dispute to the redressal committee constituted at the District level under the chairmanship of concerned District magistrate, authorized representative of the insurance company and a representative of the health care providers as members. This committee will settle the dispute.
If either of the parties is not satisfied with the decision, they can go to the State level committee which will be chaired by the Principal Secretary …………. with representative of the Insurance Company as a member.
Note: If State redressal committee is unable to resolve the dispute, mentioned in section a and section b above, within 60 days of it being referred to them, then it will be settled as per procedure given in section c below.
Dispute between Insurance Company and the State   Government
A dispute between the State Government/Nodal Agency and Insurance Company shall be referred to the respective Chairmen/CEO’s/CMD’s of the Insurer 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.
How will the publicity for RSBY will be done and who will do it?
Insurance Company in consultation with State Nodal Agency will prepare and implement a communication strategy for launching/ implementing the RSBY. The objective of these interventions will be to inform the beneficiaries regarding enrolment and benefits of the scheme.
In addition to this State Government will also undertake communication activities, especially to improve the utilization of the scheme.
What is District Kiosk and what are its functions?
District Kiosk shall be set-up by the insurer in all the project districts. The main points regarding district kiosk are as follows:
Location: District Kiosk shall be located at the district headquarter. The State Government may provide a place at the district headquarter to the insurer to set up district kiosk. It can be at a prominent place which can be accessed easily by beneficiaries. Alternatively the insurer can set up district kiosk in their district office.
Specifications: District Kiosk shall have at least following hardware, according the specifications of Government of India, so that it can carry out its tasks in an efficient way:
A Computer
A Smart Card Printer
Two Smart Card readers
One Fingerprint Scanner
Web Camera
A telephone line
In addition to these a District Kiosk Card shall be available at the district kiosk which will be issued by Ministry of Labour and Employment, Government of India.
Role: District Kiosk will be the focal point of activity at the district level, especially post issuance of the smart card. The role of district kiosk will be including but limiting to as follows:
• To modify the existing smart cards with respect to changing the details of the dependents in the card. However, all the changes in the smart card shall be from within the BPL list only and the total number of members on the smart card cannot be more than the members in the BPL list. In case of death of a member of the household a new name can be added from the existing BPL list. Presence of FKO is not necessary to perform this role.
• To split the existing smart cards as per the need of the beneficiary household. However, the total amount of both the cards combined shall be 30,000 in case the card has not been used till now or it will be the balance amount in the smart card at the time of splitting. The splitting amounts will be decided by the beneficiary. Presence of FKO is not necessary to perform this role.
• To issue new smart cards in place of missing/ damaged smart cards. The new smart card will have the exact details as were there on the original smart card. The original smart card which is lost/ damaged will be hotlisted by the person issuing the new card at the district kiosk to prevent misuse of the lost/ damaged card. Presence of FKO is not necessary to perform this role.
• To issue new smart cards for beneficiaries who were left during the round of enrollment at the village. The beneficiary will need to come with all the family members whom he/ she want to be enrolled. Presence of FKO is necessary for this function.
The Insurer needs to make an arrangement with the District authorities so that they have access to FKO on a periodic basis to carry out this function.
Note: A small charge needs to be paid by the beneficiary for this. The amount for providing this service will be decided by the respective State Governments.
What are the intermediaries and what is their role in RSBY?
The Insurer may enter into service agreement(s) with one or more intermediary institutions for the purposes of ensuring effective outreach to Beneficiaries and to facilitate usage by Beneficiaries of Benefits covered under this tender. The role of intermediaries will not only be to help in mobilizing people for enrolment but they will also provide IEC and BCC for service delivery. The Insurer will also compensate such intermediaries for their services at an appropriate rate.
The role of intermediaries would include among others the following:
Undertaking on a rolling basis campaigns in villages to increase awareness of the RSBY scheme and its key features.
Mobilizing BPL households in participating districts for enrolment in the scheme and facilitating their enrolment and subsequent re-enrolment as the case may be.
In collaboration with government officials, ensuring that lists of participating households are publicly available and displayed.
Providing advice to beneficiary households wishing to avail of Benefits covered under the scheme and facilitating their access to such services as needed.
Providing publicity in their catchment areas on basic performance indicators of the scheme.
Providing assistance for the grievance redressal mechanism developed by the insurance company.
Providing any other service as may be mutually agreed between the insurer and the intermediary agency.
What is meant by Project office and District office of RSBY and what are their functions?
Insurer shall establish a separate Project Office at convenient place for coordination with the Government/Nodal agency at the State Capital. The project office shall coordinate with State Government/ State Nodal Agency on a daily basis. Insurer will have appropriate people in their own/TPA, State and District offices to perform following functions:
To operate a 24 hour call center with toll free help line in local language and English for purposes of handling queries related to benefits and operations of the scheme, including information on Providers and on individual account balances.
Managing District Kiosk for post issuance modifications to smart card.
Management Information System functions, which includes collecting, collating and reporting data, on a real-time basis.
Generating reports, in predefined format, at periodic intervals, as decided between Insurer and State Government / Nodal Agency.
Information Technology related functions which will include, among other things, running the website and updating data on a regular interval on the website. Website shall have information on the scheme in local language and English with functionality for claims settlement and account information access for Beneficiaries and Providers.
Pre-Authorisation function for the interventions which are not included in the package rates.
Claims settlement for the hospitals with electronic clearing facility.
Health Camps oganisation and coordination with health care providers and State Nodal Agency.
Publicity for the scheme so that all the relevant information related to RSBY reaches beneficiaries, hospitals etc.
Grievance Redressal and Dispute resolution  There are various Grievance Committees, at district, state & central levels, to attend to the grievances of various stakeholders .
Feedback functions which include designing feedback formats, collecting data based on those formats, analyzing feedback data and suggest appropriate actions.
Coordinate with district level Offices in each selected district.
Coordinate with State Nodal Agency and State Government.
The Insurer shall set-up a district office in each of the project districts of the State. The district office will coordinate activities at the district level. The district offices in the selected districts will perform the above functions at the district level.
What is Call Center Service and what it does?
The Insurer shall provide telephone services for the guidance and benefit of the beneficiaries whereby the Insured Persons shall receive guidance about various issues by dialing a State Toll free number. This service provided by the Insurer is collectively referred to as the “Call Centre Service”.
Call Centre Information: The Insurer shall operate a call centre for the benefit of all Insured Persons. The Call Centre shall function for 24 hours a day, 7 days a week and round the year. As a part of the Call Centre Service the Insurer shall provide the following :
Answers to queries related to Coverage and Benefits under the Policy.
Information on Insurer’s office, procedures and products related to health.
General guidance on the Services.
For cash-less treatment subject to the availability of medical details required by the medical team of the Insurer.
Information on Network Providers and contact numbers.
Benefit details under the policy and the balance available with the Beneficiaries.
Claim status information.
Advising the hospital regarding the deficiencies in the documents for a full claim.
Any other relevant information/related service to the Beneficiaries.
Any of the required information available at the call centre to the Government/Nodal Agency.
Maintaining the data of receiving the calls and response on the system.
Any related service to the Government/Nodal Agency.
Language: The Insurer undertakes to provide services to the Insured Persons in English and local languages.
Toll Free Number: The Insurer will operate a state toll free number with a facility of a minimum of 5 lines. The cost of operating of the number shall be borne solely by the Insurer. The toll free numbers will be restricted only to the incoming calls of the clients only. Outward facilities from those numbers will be barred to prevent misuse.
Insurer to inform Beneficiaries: The Insurer will intimate the state toll free number to all beneficiaries along with addresses and other telephone numbers of the Insurer’s Project Office. Insurer may provide the details of the call center service with the technical proposal.





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