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of___________between Park Mediclaim TPA Pvt. Ltd., a company duly registered under the Companies Act. 1956, having its Head Office at 702, Rajendra Place, New Delhi 110008. (hereinafter referred to as company, which expression shall unless it be repugnant to the context or meaning thereof shall mean and include its successors and assignees).






at_____________________________ (hereinafter referred to as Participating Provider Hospital, which expression shall unless it be repugnant to the context or meaning thereof shall mean and include its successors and assignees).

Where the company has been entrusted to provide TPA services to the Policyholders of Insurance Companies of India under different Health Insurance Policies / Schemes (hereinafter referred to as scheme) under which the individuals who enrolled under the scheme either individuals or in groups are provided with hospitalization benefits AND WHEREAS in pursuance of the providers of an agreement with the company has agreed to extend insurance cover to the members on the terms and conditions, hereinafter appearing. It is agreed and between the parties as follows:1. That the Company shall provide to each member, of the scheme, with an identification card with recent photograph of the member, his / her name, date of birth and blood group. The details of the benefits to which the member is eligible and conditions thereof and the monetary limit of the insurance cover duly signed by the member and attested by an authorised person of Company which shall be presented for purpose of assisting hospital in verifying member eligibility. For any verification or clarification with regard to the status / eligibility of any member of the scheme during the validity period of the scheme the hospital should correspond with the company. 2. The company shall provide thirty days (30 days) advance notice to the Participating Provider Hospital of any changes in cover services or conditions of coverage applicable thereto. 3. That the Participating Provider Hospital shall admit the member of the Scheme into the Hospital after due verification of the members eligibility by verifying all the details given on the identity card and give the member appropriate treatment within the monetary limit specified therein, for covered service only. 4. In case the Participating Provider Hospital finds any tempering, false or incorrect information or any thing to the effect in the identification card of any member of the scheme. The Participating Provider Hospital shall immediately inform the company on which the company shall take necessary steps and instruct the Participating Provider Hospital with regards to the eligibility of the member. 5. The Participating Provider Hospital shall not admit or treat any member if he / she falls under the general exclusion specified in the Annexure hereto. 6. Except in an Emergency, Participating Provider Hospital shall provide Hospital inpatient Services to a member only after the Participating Provider Hospital has received certification from the company in advance of admission of each member. Services that

have not been so approved or authorized shall be the sole financial responsibility of the Participating Provider Hospital. 7. In case of any Emergency, the Participating Provider hospital shall inform the company within 24 hours of admission of a valid member by Fax, Telex, and Telegram. In case the admission of member is conveyed by Telephone call within 24 hours the same should be confirmed by a Letter / Fax with in next 24 hours. 8. The Participating Provider Hospital shall submit / send to the company the original of the discharge summary along with all original bills, copies of prescriptions, diagnostic / investigations reports, pathological reports accompanied by the claim within 15days from the date of discharge of the member from the Participating Provider Hospital. No claim shall be entertained after 30 days from the date of discharge of the member of the scheme. 9. The Participating Provider Hospital shall make available to the company such information / additional information and assistance as may be required by the company and regard to settlement of the claim of the Participating Provider Hospital. 10. The Participating Provider Hospital shall be paid the bills amount within a period of 30 days of receipt of bills at the company office. 11. The participating Provider Hospital shall give (mutually agreed upon percentage) discount on total bills to the clients of the company. 12. While making a claim the Participating Provider Hospital shall draw the claim as permissible under the rate card (hospital Tariff) and permitted by the company at the time of agreement. 13. This agreement shall be in force from the date herein above mentioned and either party can terminate the agreement with a one month prior written notice to the other party. 14. For brevity sake it is agreed between the company Participating Provider Hospital that various terms as referred to in different clauses of this agreement shall have the same meaning as defined herein after in Annexure II. 15. The Participating Provider Hospital shall ensure that all members of the Scheme are admitted / treated as the case may be urgent basis. The Park Mediclaim Consultant Pvt. Ltd. will be given due preference or priority and shall not be held up for want of funds. In case there is no accommodation available for the members in the Participating Provider Hospital the Provider shall make all attempts through his good office to accommodation available for the members in the Participating Provider Hospital the Provider shall make all attempts through his good offices to accommodate and admit the member to other Hospital/ Nursing Home, subject to confirmation from the concerned

member. However, the company shall not be responsible for the settlement of such bills, if the Hospital / Nursing Home is not a provider, recognized by the company. (the member will have to settle the bills of such non-recognized or non accredited hospital / Nursing Home and forward the bills along with the cash memos, pathological reports, prescriptions, discharge summary showing the details of the treatment etc. along with duly completed claim form for settlement of claim of the member). 16. The company shall prescribe quality standards to the Participating Provider Hospital. It is mandatory for the Participating Provider Hospital to adhere to these standards and they are subject to periodic inspection and review. 17. The Provider will ensure the highest level of service to its members. The Doctors/ Authorized representatives of the company shall be free to visit Participating Provider Hospital to check quality standards, review and discuss treatment. During such visit and enquires, the representatives of the company shall have full access to the member patients medical records. 18. The company as well as the Participating Provider Hospital shall have a right to terminate this agreement at any time without assigning any reason by giving a 30 days prior notice. 19. The Participating Provider Hospital shall not take any deposit of any kind or any amount of money in lieu of depositing at the time of admission from the members of the company. 20. The Participating Provider Hospital shall treat the members in the hospital only for the required number of days for treatment and carry out only the required investigations/procedures for the particular ailment or disease as the case may be for which the members has been admitted / checked as per guidelines to be followed. 21. The Participating Provider Hospital shall have no objection to the Company using its name, as a preferred provider, in their advertising and promotional literature. 22. The company shall not be responsible for any dispute between the member and the Participating Provider Hospital with regard to any allegation of medical negligence on the part of the Participating Provider Hospital on the Doctor / Doctors concerned. 23. The Provider Hospital shall directly charge the individuals for a) Telephone Charges, b) Ambulance Charges, c) Registration / Admission or File Charges, d) Extra diet charges, so incurred by the member or any of his family members during their stay in the Provider Hospital.

N.B: In case patient declines to pay the difference between the authorized amount & Hospital Amount estimate the hospital has got the right to refuse admission. Signed, Witnessed and delivered by the with named For Park Mediclaim TPA Pvt. Director By the hand of Its authorized official Signed, Witnessed and Delivered by the within named Participating Provider Hospital By the hands of Its authorized official Witnessed by




a) Injury /disease directly or indirectly caused by or arising from or attributable from or attributable to war invasion. Act of foreign enemy, war like operations (whether war be declared or not). b) Circumcision unless necessary for treatment of a disease, not excluded here under or as may be necessitated due to an accident, vaccination or inoculation due to an accident or as part of any illness. c) The cost of spectacles, contact lenses and hearing aids. Dental treatment or surgery of any kind unless requiring hospitalization. d) Convalescence, general debility, Run-Down condition or rest cure, congenital external defects, disease or anomalies, sterility, venereal disease, intentional self injury and use of intoxication drugs/alcohol. e) All expenses arising out of any condition directly or indirectly caused by associated within human T-Cell lymph tropic virus type III or Deficiency syndrome or condition of similar kind commonly referred as AIDS. f) Charges incurred at hospital or nursing home primarily for diagnosis, X-ray or Laboratory examination or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at hospital/nursing home under the agreement as defined. g) Expenses on vitamins and tonics unless forming part of treatment for injury or disease as certified by the attending physician. h) Injury or disease directly or indirectly cased by or contributed to by nuclear weapons materials. i) Treatment arising from or traceable to pregnancy, childbirth including caesarian section & voluntary medical termination of pregnancy during the first 12 weeks from date of conception. j) Naturopathy treatment. needs hospitalization for the period not less than 24 hours except in case such as k) The member shall be entitled to the benefit under the scheme, provided the ailment

dialysis, chemotherapy, laser beam treatment, removal of kidney stone by lithotripsy method. l) The participating provider hospital shall follow the entry specifically made in the authorization letter regarding the converge of an existing illness. The provider may also arrange to obtain medicines, injections, disposables, as prescribed by the provider from the authorized chemist, druggist and include those bills in the final bills, which should accompany the prescription.

ANNEXURE II DEFINITIONS: COVERED SERVICES : Means benefits to which the member are entitled to under the term and conditions of the agreement and do EXCLUSIONS : not fail in the exclusion list of Annexure I Means benefits/treatments that are not covered under the scheme for which the company shall not be HOSPITALZATION OUT PATIENT CARE : : responsible Means any treatment, which needs admission of the patient as an in-patient in the hospital Means investigations and consultation regarding any medical complaint not requiring members admission to a hospital with monertary limit for which the member is PARTICIPATING PROVIDERT : entitled to. Means a hospital or any other licensed institution under contract with the company to HOSPITAL provide Health Care facilities to members.


Person enrolled with the company individually or by the company during the validity period of the coverage of the scheme. Means those medically necessary treatment provided in connection with an Emergency defined as a sudden or unexpected onset of a condition requiring medical or surgical care with the Member receives after the onset of such conditions (or as soon thereafter). Means medical facilities offered by the company to the best of their ability to any valid member within the monetary limit for which the member is entitled to during the validity period of membership.



The Courts of DELHI alone shall have the juridication to try any suit, matter touching or concerning this agreement.