Business Operational Manual by cjq17795

VIEWS: 70 PAGES: 77

More Info
									                      PSW

Operational manual for SE’s 2008




                      Dr Deepali Kulkarni
                      Swabhimaan
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association

                                 SE’s operational manual (PSW)

Subject                              Manual

Project                              Uplift Health

Topic                                Contents of operational manual for SEs




                                 Health        1




1
    UpLift Health is a project of UpLift India Association, a non-profit association of NGOs, MFI and MIUs in Maharashtra.


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
            Operational manual                                                                                 1-Feb-11 by   Page 2 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Comment           This file contains the contents of operational manual for the service executives.

Keywords            Contents,Operational manual
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                   India Association
Author(s)         Dr Deepali Kulkarni


Created           5/8/2007 11:45 AM                                                 Status:               started


Version           96        Last Edited                                             Editing Time          4950

Table of Contents
1   Introduction ............................................................................................................ 5
 1.1 Introduction of the NGO                     5
 1.2 Concept of health mutual fund                         6
CBHMF as a concept ...................................................................................................... 6
 1.3 Health Insurance and Mutual funds                               6
 1.4 Objective:- 7
 1.5 Goals 7
 1.6 Health mutual fund 8
    1.6.1      How does one become a member? 8
      1.6.1.1         Contribution System 10
 1.7 Product benefits                10
    1.7.1      Hospitalization reimbursement               10
    1.7.2      Maternity support:- 14
    1.7.3      Additional benefit:- 14
 1.8 Product services                15
    1.8.1      Health Care Support               15
    1.8.2 Exclusions                 17
 1.9 Parvati Family Security Fund                          19
2 Operational processes ............................................................................................. 20
 2.1 Promotion              21
    Objective 21
    2.1.1      Preparatory work 21
    2.1.2      Actual promotion : Policy details to be highlighted              22
    2.1.3      Responsibilities after promotion            24
    2.1.4 Monthly target of promotions for CM’s                                 24
    2.1.5 Role of SE in promotion                          24
 2.2 Orientation 26
    Objective 26
    2.2.1 Preparatory Work                       26
    2.2.2      Actual orientation 28
    2.2.3 Advices during orientation                       29
    2.2.4 Recording of Orientations done.                            29
    2.2.5 Follow up post orientation meeting. 29
    2.2.6 Format of Orientation register.                            30
 2.3 Enrolment 31
    Objective 31
    2.3.1      Enrolment procedure:-             31
    2.3.2      Subsidy to SLL3 in contribution             33
    2.3.3      Process of enrolment              33
      2.3.3.1         Receipt preparation                  34
    2.3.4 Policy start date:-                    35
    2.3.5 Receiving nidhicards:- 35
    2.3.6 Visit to member for Nidhi card distribution. 35
    2.3.7      Specimen of enrolment form                  41
 2.4     Referral and guidance services 42
    Objective 42
    2.4.1                       of SE’s in Flat No. 14, referral services effectively? 42
               ResponsiblitiesRegd. Office: providing4th Floor, Land Mark Apartment, B. J. Road,     Printed on
         Operational manual                                                                         1-Feb-11 by     Page 3 of 77
    2.4.2                      Sadhu Vaswani to members
               Follow up of referrals-Visit Circle, Pune-411001      43                                 SSD
    2.4.3         45
    2.4.4      Referral letter specimen.         46
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 4 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association


1 Introduction


       1.1 Introduction of the NGO
                    Parvati Swayamrojgar (PSW) started working in the urban slums of Pune (India)
                    from September 2002 with the mission of alleviating poverty.
                    Its founder members, having more than 15 years experience in the social sector,
                    sought to use their expertise in the process of sustainability of poor through the fi-
                    nance, health and family development through three sets of programmes i.e.




                    PSW has been involved in the Income Generation activities by providing micro–
                    business loans to partners to start or expand business. Additionally, the organisa-
                    tion successfully runs health, family development, training, family security, educa-
                    tion & awareness programs.
                    These programs are run in seven urban slum pockets of Pune city:




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 5 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
        1.2 Concept of health mutual fund


    CBHMF as a concept

                    With “Health in Our Hands” as an underlying principle Community Based Health
                    Mutual Fund (CBHMF) is a health care financing tool that uses the principle of Soli-
                    darity to bring people together to collectively achieve financial access to quality
                    health care using the option of mutual funds- the idea being that such a financing
                    arrangement is created through mutual contribution that people can avoid or re-
                    duce their expenditures on health services at their time of use.

                    The need for health care financing has arisen due to the fact that today as health
                    care costs are increasing and public health services diminishing, it’s the marginalized
                    sections of the society for whom access to health care becomes an economic hazard
                    having a direct bearing on their livelihoods. According to a comprehensive study it is
                    estimated that one-quarter of all Indians fall into poverty as a direct result of medi-
                    cal expenses in the event of hospitalization.2




1.3             Health Insurance and Mutual funds
                                                    For the low-income people, insurance was never considered to
                                                  be an option in the past. They were assumed to be too poor to
                                                  save and pay premium. Hence, the government assumed the
                                                  responsibility of meeting health care needs of the poor.

                                                  However the strategy of free public health provision has not
                                                  worked well in most states. In India. shrinking budgetary sup-
                                                  port to the public health services, inefficiency in provision and


2
    The World Bank (2002)

                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 6 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                                                  unacceptably low quality of these services is reflective of this.

                                                  Also and very importantly, health insurance can be used as a
                                                  platform to promote healthy behaviour-prevention that is miss-
                                                  ing from almost every agenda on health insurance.

                                                  Mutual fund and that too a community-based mutual fund pro-
                                                  vides us with such a health micro insurance option whereby its
                                                  possible for people to come together and become responsible
                                                  for their health and health care.

                                                  Various models have been worked out but the one we write
                                                  about has the community in charge of the funds making it one
                                                  of the most transparent and participative processes.




       1.4 Objective:-




       1.5 Goals
                         To provide a community based sustainable health financing system accessible
                         for the poor, where:

                          Member is requested to become a health activist, and participate in all deci-
                                sion processes

                          Members receive Same Health protection without discrimination



                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 7 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                          Members receive Solidarity Support at any moment of Life

                          Member avails guidance and counseling toward Quality health care with dis-
                                counts

                          Member receives Prevention to enjoy healthier lives

                          Financial aid at affordable price.



       1.6 Health mutual fund
                    The fund is intended to provide health care financing to the poor in order to man-
                    age the unexpected health expenses through pooling of money through a certain
                    contribution from every member and use it on the principles of insurance.

                    Based on the first premise MEMBERS CAN CONTRIBUTE AS PER THEIR MEANS AND
                    RECEIVE AS PER THEIR NEEDS, the fund is created by a nominal contribution (to be
                    given by each member) kept with the affordability factor in mind of the communi-
                    ties we work with.

                    The fund is flexible to incorporate a contribution related benefit meaning that reim-
                    bursement will be based on the contribution made by a member. The scheme may
                    be started by only one contribution but may later have multiple contribution op-
                    tions.


1.6.1 How does one become a member?


                                                                                     •     To enroll as a member of the fund, a
                                                                                           family as a unit joins with a small
                                                                                           monetary contribution paid per
                                                                                           member/year.
                                                                                     •     The enrolment form is to be filled up
                                                                                           with one family photographs.
                                                                                     •     This scheme has no age discrimina-
                                                                                           tion: All family members can join.
                                                                                     •     The policyholder should be above 18
                                                                                           years of age.      Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 8 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association




                    Enrolment of IGP members:-

                    When a person approaches the NGO for loans he/she should be given complete in-
                    formation about the health mutual fund after which the person can decide to enroll
                    or not. If the member wishes to enroll then the CM can fill the enrolment form and
                    also collect the contribution.

                    Enrolment of non IGP members:-

                    People who are not interested in loans can also be the members of the health mu-
                    tual fund. The service executive can provide detail information of the fund to such
                    non IGP members to get them enrolled.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 9 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
       1.6.1.1 Contribution System




       1.7 Product benefits
                    The collective fund that has been created will be used as a micro insurance fund for
                    health care of the members.


 1.7.1 Hospitalization reimbursement
                                           In case the member is hospitalized he can avail
                                                                                       reimbursement of
                                           hospitalisation expenses maximum up to 15000Rs(at the current
                                           contribution of 100 Rs)


                                           If the member is hospitalized in a Network private hospital-
                                           Reimbursement will be 80 % of the total hospital expenses or Rs
                                           15000 whichever is less.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 10 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                                           If the member is hospitalized in a public hospital

                                           Reimbursement will be 100% or maximum 15000Rs whichever is
                                           less from the fund.

                                           If the member is hospitalized in a private hospital out of network

                                           There will be no reimbursement in case of use of health care pro
                                           vider out of network.

                                           However in case of an emergency situation if the member is

                                           admitted in a private out of network hospital the reimburse
                                           ment will be 80% or Rs 15000 whichever is less provided the
                                           emergency is proved by the treating doctor.


                    Since different diseases have different treatment costs the                                     reimbursements
                    (Claims) have been categorised into the following five categories




                    CLW, simple Fracture (needing closed reduction without general Anesthesia). Biopsy
                    done under local anesthesia, Traction therapy on OPD basis.(for 1st time only.),
                    Traction process for the first time( treatment given on – on admission diagnosis for
                    1st time only i.e. on admission diagnosis only.)

                    Maternity: Abortion (medical/ missed/spontaneous/ incomplete abortion / threat-
                    ened / complete / inevitable abortion ) to save life of mother or in case of not livea-
                    ble child (physical & mental abnormality) or for social Indication when done in fist 8
                    weeks.(D&C).




                    Medical Treatment: Pyrexia of unknown origin, , Upper Respiratory Tract Infections,


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 11 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                    Lower Respiratory Tract Infections, Typhoid, Malaria, Sub – acute intestinal obstruc-
                    tion needing conservative treatment.
                    Opht: Pterygium, Stye, Surg: lymphoma(small), Abscess(small/medium) – requiring
                    local anaesthesia ,
                    Accident: simple fractures needing anaesthesia, Head injury under investigation (CT
                    Scan needed) for a day – when the report is normal ,
                    Genito-Urinary Syst: Urinary tract infection, Hydrotherapy for kidney stone, Circum-
                    cision (unless it is congenital)
                    ENT: Tonsillectomy Acute Gastro- enteritis Pleural effusion.

                    Maternity/Gyneac:
                    Abortion to save life of mother or in case of not liveable child (physical & mental
                    abnormality) or for social Indication when done in second trimester (Intrauterine
                    instillation of hypertonic soln).

                    Hyper emesis Gravidum

                    Polyhydramnios, Oligohydramnios, Eclampsia, post partum haemorrhage (Conserva-
                    tive Treatment)

                    Severe Anemia, Jaundice related to pregnancy

                    Premature rupture of membranes, Puerperal Sepsis

                    Children: Tract infection, Bronchitis, Pneumonia, Aspiration Pneumonia, Diarrhea,
                    Dysentery, Vomiting, Cholera, Bronchiolitis, Pneumonia, Empyema, Ingestion of for-
                    eign body. Asthma, Gastro enteritis, epileptic attack.




                    Medical Treatment: Complex medical diseases e.g. Hepatitis, Cardiac problems, Em-
                    physema, COPD, Asthma. Complex diseases not needing ICU Treatment. Cardiac
                    problems not needing ICU Treatment. Emphysema,


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 12 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                    Surgery: Piles/ fistula, Abscess (medium - large), Breast lump(medium), Appendix,
                    Hernia, biopsy done under spinal and general anaesthesia for investigation.
                    Accident: multiple open wounds not in strategic area , Fractures needing invasive
                    procedures,
                    Genito-Urinary System: lithotripsy
                    ENT: DNS, Tymphanoplasty, COPD, invasive

                    Maternity/Gynec: Hydatidiform mole, Polyhydramnios, Oligohydramnios,

                    Children: diseases of the previous section with treatment requiring 1 day ICU usage.




                    Medical Treatment: Multiple diagnosis (diseases) each requiring separate line of
                    treatment.. , Debilitating condition (disease) not needing ICU but many days of
                    stay(detected only after the policy has started),Lung consolidation, Pericarditis, Sep-
                    ticaemia
                    Surgery: Breast Lump/ Abscess (big), nerve decompression, Cholecystectomy, Thy-
                    roidectomy. operatives for – slip disc, disc bulging and other spinal cord related dis-
                    eases. Intestinal obstruction needing invasive therapy.
                    Accident: fracture humerus involving invasive procedure,
                    Genito-Urinary System: stag horn kidney, prostate

                    Maternity: Fibroid with pregnancy, Tumor with pregnanc, operative procedure for
                    ectopic pregnancy,

                    Eclampsia, post partum haemorrhage (invasive Treatment) L.S.C.S., Hysterectomy
                    (Vaginal Laparoscopic




                    Accident: multiple joint fracture, Multiple wound (open wounds) at vital areas com-
                    pound          fracture.          Fracture            joint.               involving      invasive        procedure.


                                                                                                                 Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                   1-Feb-11 by    Page 13 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                    SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                    Surgery: joint replacement, vertebrae replacement, CABG, organ transplant. , kid-
                    ney removal, angioplasty, valve replacement, cancer treatment. Abdominal opera-
                    tives – spleenectomy, jejunectomy, and other intestinal operatives.

                    Medical Treatment: ICU treatment for medical, surgical and accidental reasons,
                    cancer treatment.

                    Maternity/gynaecology: Rupture of uterus , carcinoma of breast




 1.7.2 Maternity support:-




 1.7.3 Additional benefit:-
                                           Dental                           Dental treatments necessary due to accidents
                                           will be reimbursed
                                           Cataract      The cataract surgeries will be covered in the new
                                           product but the maximum reimbursement will be Rs 600




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 14 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association



       1.8 Product services

1.8.1 Health Care Support




          24X7 helpline                                                                   2 Health checkup camps




3 referrals to specialist OPD/IPD                                   4 Network of OPD doctors in the local area




5 Laboratory investigation
at concessional rates                                             6 Medicines at concessional rates


                    The strength of this initiative lies in the fact that while it provides for reimburse-
                    ments to its members, it is has created a network of quality health care providers
                    and has bargained on treatment costs for its members.

                    On needing health care a member can avail guidance and counselling towards the

                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 15 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                    India Association
                    best quality health care provider .The health care providers consist of

                          Public Hospitals

                          Private hospitals

                          Trust Hospitals

                          General practitioners-These are the OPD doctors residing in the community
                                itself.

                          Laboratories and radiological investigation centres- for investigations at con-
                                cessional rates.

                          Medical stores- For medicines at concessional rates.

                          NGO’s like Pathway.



                    This service is provided on a 24 X 7 basis

                    How to avail referrals




                    Going by the holistic overview of health needs, health check-up camps and health
                    awareness workshops are conducted. The idea is to augment the preventive side of
                    health rather than just curative.

                    While this ensures quality treatment to the members it also the way to reduce costs
                    and thus reduce the load on the fund as claim amount will be low.




                                                                                                                 Printed on
                                   Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                   1-Feb-11 by   Page 16 of 77
                                   Sadhu Vaswani Circle, Pune-411001
                                                                                                                    SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
 1.8.2 Exclusions
                    The fund management does not allow claims to be given for the following:

                Pre Existing Diseases as per first time diagnosed prescription / declaration during
                 policy inception.—to avoid moral hazard and adverse selection, product design
                 (with low premium) can not cover all expenses; as claim ratio will increase.

                STD and related ailment (AIDS). – As STD do not require admissions.
                Natural calamities (cyclone, drought, epidemics, floods after declaration from
                 govt.).—as it is responsibility of government. and a risk which is not predictable.

                War and terrorist activities, injury or disease due to nuclear weapons. -- as it is re-
                 sponsibility of government.


                Plastic surgery for cosmetic purpose with out complications.—surgery for cosmetic
                 purpose is not covered.

                Dental treatment not requiring G.A. / S.A. / Cosmetic purpose. – as it can be treated
                 on OPD basis, and most often it is due to self negligence. How ever dental treat-
                 ment arising out of accidents will be covered.


                Expenses for vitamins, tonics (Tx for Malnutrition). – as malnutrition happens due to
                 long standing deficiency, have on going govt. programmes to cover it, and its not a
                 treatment which needs hospitalisation
                MTP.- as it is illegal, but if it fulfills all required criteria and advised by doctor then
                 can be payable.

                Sterilisation and family planning surgery.- as it is a national programme and it is not
                 a disease but a means of contraception.


                Maternity for more than 2 living children.- As our govt. follows 2 child norm all beni-
                 fits can be provided till 2 living children.

                Suicidal or self induced complications. – self induced/ not risk.


                Ailments (pathological i.e. Hepatic cirrhosis, lung cancer /accidental i.e. RTA, fall,
                 trauma etc.) due to bad habits i.e. smoking, alcoholism, tobacco chewing etc.—it is
                 self induced, negligence and due to unnatural habits.


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 17 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                MLC suggesting member as culprit in case of fights, quarrels, assault.—self induced


                Vaccination and inoculation.—as it’s not a treatment for disease but pre-cautionary
                 measure, further govt. have national vaccination programmes.

                Hospitalisation only for investigation, evaluation and oral treatment.—as in this
                 case hospitalisation is not essential.


                External aids (spectacles, hearing aids, contact lenses etc.).—as these is not curative
                 treatment but palliative treatment and doesn’t require hospitalization.

                Naturopathy treatment.—Treatment does not require hospitalisation and can be
                 done in OPD basis.


                Domiciliary treatment(treatment which is taken at home)- as hospitalization need to
                 be done in hospital only.

                Cataract.—as it is a national health programme.


                Normal delivery.—as normal delivery is a normal/natural phenomena




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 18 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
       1.9 Parvati Family Security Fund
                                           The objective of the scheme is to provide life insurance protection to
                                           the rural and urban poor persons below poverty line and marginally
                                           above the poverty line.
                                           Family security fund is a group insurance scheme and is tied up with
                                           LIC .Parvati Swayamrojgar serves as a nodal agency for this scheme.
                                           ELIGIBILITY:
                                           A person who is
                                           *Aged between 18 and 59 years.
                                           *Below or marginally above poverty line
                                           *A member of any of the approved vocation/occupation groups


                                           The premium for Janashree is Rs.200/-per annum per member.
                                           However the Central Govt gives a subsidy of 50% (ie Rs 100 is paid by
                                           the govt for every person insured under this scheme through the so-
                                           cial security fund) to specified groups .Further the state government
                                           of Maharastra gives a subsidy of 50 Rs.


    Contribution                                         100 Rs per year per person
                         Benefits                     1. 75 000 Rs capital indemnity in case of
                                                         Accidental Death or total permanent
                                                         disability


                                                      2. 37,500 Rs in case of partial permanent
                                                         disability


                                                      3. 30,000 Rs capital indemnity in case of
                                                         Natural Death


                                                      4. 1000 Rs in case of spouse or kids
                                                         death/partial disability as emergency
                                                         financial help.This help is not given by
                                                         LIC but by Parvati Swayamrojgar
                                                         through the collected fund.


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 19 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association

                                           The NGO charges the member Rs 100 (in continuance with the old
                                           policy) where the following distribution happens




                                           From each member a contribution of RS 100 is taken per person per
                                           year. Out of this 100 RS contribution 50 Rs is send to LIC.
                                           Remaining 50 RS remains with the NGO. The division of this 50 Rs is
                                           Rs 30 as administration fund and Rs 20 as Emergency help fund that
                                           is used for a financial help of Rs 1000 in case of death of the policy
                                           holder’s spouse or child.




2 Operational processes

                                           The fund operation requires a detailed set of processes and functions
                                           and responsibilities. Given below are the same with a description of
                                           conducting the processes.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 20 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
       2.1 Promotion


         Objective                                 To give basic information regarding HMF and FSF to new
                                                   families living in the communities

          Who                                    CM(Collector motivator)

           Where                                  Door to door in the community area

            When                                  A week prior to each loan release.

           Duration                               5 minutes

            Tools                                 Script

                                                   HMF posters in A4 size for benefits

 2.1.1 Preparatory work
                    Planning


                                                    For each branch loan releases are twice a month and usually
                                                    are in the second and fourth week of the month. So it is easy
                                                    for the CM’s to plan the promotion visits which are to be done
                                                    a week prior the loan release.

                                                     The houses to be promoted can be decided by the CM’s as
                                                     per the area allotted to them.


                    Tools required

                          Script

                          HMF posters in A4 size

                          Registers to note down which families have been promoted and their re-
                                marks




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 21 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
 2.1.2 Actual promotion : Policy details to be highlighted
                    Self introduction: Introduce yourself along with the organization you are working for
                    briefly.

                    Also specify the purpose of your visit to the family.

                    Families in the slums are always interested for loans so start the discussion by giving
                    information of IGP and then link up the family interest with the other benefits(HMF
                    and FSF) available along with microloans in case of unexpected and emergency
                    medical expenses.

                    Also highlight that the health mutual fund will be community based and the family
                    after becoming a member can actively participate in the activities and decisions of
                    the fund.

                    Link up family interest for micro-loan with other benefits available in case of unex-
                    pected and emergency medical expenses.

                    The benefits features are directly decided by the community people

                    Policy details about HMF:

                    Coverage up to 5000rs in case of hospitalization,

                    Free health care facilities like :-

                         1. Health check up camps,

                         2. Health talks,

                         3. 24x7 helpline

                         4. OPD at concessional rates,

                         5. Medicines at concessional rates,




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 22 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                    India Association


                    Policy details about FSF:

                    Financial help in case in natural or accidental death, coverage up to 75000Rs

                    Emergency help of RS 1000 to the family members in case of death of spouse or kid
                    of the policy holder.

                    Informing about orientation meeting: time, date, venue




                            Do’s                                                                          Don’ts 
      Understand about the family atmos-                                        Don’t use words like : Insurance (Vi-
       phere                                                                      ma), premium
      Ask about any recent health incidents                                     Don’t emphasize on a systematic 5000
                                                                                  Rs coverage.
      Visit each door step.
                                                                                 Do not make promotion in the nearest
      Be well aware of the geographical area
                                                                                  area as per the convenience.
       and legal status of the slums.
                                                                                 Don't go without keeping identity
      Plan the promotion timing taking into
                                                                                  proof.
       consideration convenience of the
       community people.                                                         Don't miss any house in the row while
                                                                                  promotion.
      Always carry your identity card while
       going for promotional visits.                                             Don't give wrong or miss information.
      Always be respectful towards people
       while promotion.
      Seek permission before entering hous-
       es for promotion.
      Keep follow up of missed houses




                                                                                                                   Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                     1-Feb-11 by   Page 23 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                      SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association



 2.1.3 Responsibilities after promotion




 2.1.4 Monthly target of promotions for CM’s
                                Per month each CM should do a minimum of 20 promotions .


 2.1.5 Role of SE in promotion
                                           The loans are not sanctioned until the member attends one orienta-
                                           tion and one business training. So the service executive has to keep a
                                           record whether the members attends both the meetings and record
                                           the attendance


                Standard format of promotion register.



                  NO              DATE                           NAME                                RESPONSE                 SIGN




                                                                                                                 Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                   1-Feb-11 by   Page 24 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                    SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association




                                                      DOOR TO DOOR PROMOTION




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 25 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                      India Association
       2.2 Orientation


                                     Objective                          To give detailed information of the health
                                                                        mutual fund thus introducing the policy to
                                                                        the new families.

                                      Who                             Service Executives(SE)

                                       Where                           Branch office

                                        When                           One fixed day in a week

                                       Duration                        30 minutes to one hour.

                                        Tools                          Flip chart, Promotional posters, Orienta-
                                                                        tion register, promotional tool kit.



 2.2.1 Preparatory Work


                      Monthly planning of the orientation meetings-Orientation meeting in each branch
                    is on fixed days as per week.

                                No                     Branch                    Day of orientation meeting

                         1                  Janata Vasahat                      Thursday

                         2                  Dandekar bridge                     Wednesday

                         3                  Indira nagar                        Tuesday

                         4                  Kashewadi                           Monday

                         5                  Lohianagar                          Tuesday

                         6                  Ramtekdi                            Friday

                         7                  Upperindiranagar                    Friday




                                                                                                                   Printed on
                                     Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                     1-Feb-11 by   Page 26 of 77
                                     Sadhu Vaswani Circle, Pune-411001
                                                                                                                      SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                    Essentials in the branch office:

                          HMF posters

                          Enrolment forms –At least 50.

                          Impact forms.

                               Receipts books.

                          Maps and charts of network health care provider of the community.

                          Essential phone numbers

                          Promotion pamphlets

                          List of health awareness programs in the community

                          Chart displaying the list of claim beneficiaries of the fund.

                          Virtual account chart.

                          Promotional Kit.

                          Flip chart.

                          Partner visit record forms and partner benefit forms.

                         The above things should be kept ready at the branch office.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 27 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
     Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
      2.2.2 Actual orientation

No   Points                                                                                                                   Time required
1    Self introduction                                                                                                        2 min
     Name and information of the project you are working for
2    Introduction of the NGO-                                                                                                 5 min
           information regarding year of establishment
           objectives behind starting the NGO
           Area of work.
           Different projects
           Success stories.
3    Present health care status, the availability and affordability of public and private 5 min
     health care providers,
     How the families manage in case of an health event,
4     Concept of health mutual fund- health expenditure, unexpected health cost 5 min
     ,financial burden on the families.
     Case or experience sharing by the audience.
     Concept of risk pooling.
     How coming together can benefit rather than being alone,
     One for all and all for one.
     Active participation and democratic decision making by the members in the fund
5     Actual product –                                                                                                        15 min
     Reimbursement in case of hospitalization-category wise
     Product benefit- claim process ,Maternity benefits, wage loss
     Product services-24X7 helpline, health camp, health talk, network of health care
     providers,
     Contribution
      Exclusions
     Case sharing of the benefitted member.
6    FSF details                                                                                                              5 min
7    Answers to queries if any                                                                                                5 min



                                                                                                                     Printed on
                                       Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
                Operational manual                                                                                  1-Feb-11 by   Page 28 of 77
                                       Sadhu Vaswani Circle, Pune-411001
                                                                                                                        SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association


 2.2.3 Advices during orientation

         Make proper sitting arrangement for men and women.
         Follow the schedule time of meeting.
         Use orientations tools.
         Maintain sizeable group according to available place.
         Use simple and clear language.
         Give local examples


                   Do’s                                                                      Dont’s

      Start on the time.                                             Don’t tolerate latecomers.
      Prepare before meeting.                                        Don’t give wrong information to
                                                                       participant in orientation.
      Finish on the time.
                                                                      Don’t miss any activity during
      Try to make comfortable sitting
                                                                       orientation.
       arrangement.
                                                                      Don’t make personal comments
      Make meeting participatory.
                                                                       in the meeting
      Use orientation tool.
      Give time for question-answer in
       the end of meeting.




 2.2.4 Recording of Orientations done.
                    Register all the names of the people who attend the orientation meeting with their
                    signatures.

                    Also record if the members are already insured by some other policies like ESIS.




 2.2.5 Follow up post orientation meeting.
                    As HMF policy is not compulsory with loans some people may not take the policy.
                    Note the reasons if any.


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 29 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                    Take follow up of members who are negative and try to convince them either by
                    doing home visits or during loan release meeting.




 2.2.6 Format of Orientation register.


Sr No        Name                     Address                 IGP              HMF/FSF               Sign




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 30 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
       2.3 Enrolment

                                                        To enrol families as members when the full
                       Objective                        contribution is paid (Rs/person/year)


                        Who                           SE’s

                         Where                         Door to door

                          When                         The day after the orientation meeting

                         Duration                      15 mins.

                          Tools                        Enrolment forms, Receipts, CBU with-
                                                        drawal slips.



 2.3.1      Enrolment procedure:-




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 31 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association

No      Process                 Actor           Activity                                                   Documents     Send       to        HO
                                                                                                                         when
1       Enrolment               CM              According to the orientation regis- Enrolment                            Within 24 hours
        form filling                            ter a record is taken of all the form                                    Filled forms are
                                                members who are willing to get                                           checked by the
                                                enrolled in the health mutual fund.                                      SEs and then
                                                The CM then visits such members                                          send it to HO by
                                                for the filling of enrolment forms                                       courier      who
                                                the very next day of the orientation                                     everyday goes
                                                meeting.                                                                 to the branches
                                                                                                                         for IGP collec-
                                                The enrolment form and the im-
                                                                                                                         tion.      Forms
                                                pact form filling is completed prior
                                                                                                                         should      reach
                                                to the loan release.
                                                                                                                         the HO within
                                                The member is also asked for a                                           24 hours
                                                family photograph to be pasted on
                                                the nidhicard. The photo should
                                                include all the members whose
                                                contribution is taken.


2       Contribution            CM              If the member pays in cash he is Cash                             re- HMF summary
        collection                              given receipt. CM prepares the ceipts                                 sheet (Xerox)is
                                                triplicate copy of the receipt.                                       kept at the
                                                                                                                      branch     level
                                                1st copy for the member
                                                                                                                      which contains
                                                2nd copy sends to the HO.                                             CM wise data of
                                                3rd copy remains with the branch                                      collected con-
                                                in the receipt book itself.                                           tribution.

                                                In case of CBU transfer after the                                        The SE checks
                                                form filling CM fills up the CBU                                         the    summary
                                                withdrawal slip with the prior con-                                      sheet as per the
                                                sent of partner and attaches it to                                       enrolled forms
                                                the enrollment form and the re- CBU with-                                and    is    for-
                                                ceipt is given to the member.       drawal slip                          warded to the
                                                                                                                         HO by courier
                                                                                                                         every day.




                                                                                                                 Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                   1-Feb-11 by   Page 32 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                    SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
 2.3.2 Subsidy to SLL3 in contribution
                                                    With the increase in the health care cost(20 % as compared to
                    the last year) there is an urgent need to revise the contribution of the health mutual
                    fund from 60 Rs to 100 Rs. This revision was done only after discussing the facts
                    with the community.

                    This increase in contribution also increases the sum assured from Rs 5000 to Rs
                    15,000. The increase in Rs 40 per head is not affordable for some families in the
                    slum (families below level three).But with the view that health is the basic need of
                    all the health facilities provided should also be same for all.

                    Thus the families with SLL3 will be pay the HMf contribution as Rs 60 as before and
                    the remaining Rs 40 will be subsidized by Interaid.


 2.3.3 Process of enrolment
                    As per the planning of 2008 the Parvati Swayamrojgar plans to disburse 40 % of its
                    total loans to the families of SLL3.

                    Before the loans are disbursed the impact forms and loan forms are filled. Through
                    the impact form it is possible to identify the level of the family. The CM’s will ma-
                    nually calculate the SLL levels on the impact form .They will prepare a list of families
                    falling into SLL3 level along with address and hand over the list the SE’s .

                    The SE will visit those families again with the already filled impact forms to confirm
                    the levels. They will once again ask all the questions to assess the family level and
                    confirm the family as SLL3.They will tick mark the family to confirm its level 3 on the
                    list provided by the CM.

                     Every month the SE will prepare the list of newly enrolled families of level three.
                    This list and the entire information of the families will be validated by the communi-
                    ty director of that respective branch. In case of negative feed back from the CR’s the
                    families will be rechecked by the SE’s .



                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 33 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                    According to the final validated list the CM’s will take the contribution from the
                    families as 60 Rs per head per year.



     Format of remarks of community directors on approval of SLL3 families enrolled in the
     month.

     Month
     Branch name
     Name of community Director
     We the community director of …….. branch confirm that on the basis of impact form informa-
     tion given by the families ,the following families fall in the category of SLL3 and should be al-
     lowed the subsidy for the HMF premium.


     Sr          Name of policy holder                                                          Area
     no
     1
     2


       2.3.3.1 Receipt preparation
                    The receipts will be prepared by the CM’s at the time of enrolment. The amount will
                    be 60 Rs per head. On the receipts SLL3 will be written in bold letters by the CM’s.

                    On the BCS also number of level 3 policies and their contribution will be written
                    separately. The SE’s will check the BCS’s before sending it to HO.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 34 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
 2.3.4 Policy start date:-




     1. If the member pays contribution in the first 15 days of the month his policy starts on first of
        the next month.
     For e.g.:- If the member pays the contribution on 6th June his policy will start on 1st July.
     2. If the member pays the contribution within 16-31st of the month then the policy starts one
        and a half months after.
     For e.g.:- If the member pays the contribution on 20th June his policy will start on 1st Aug

 2.3.5 Receiving nidhicards:-
     •    The nidhicards of the newly enrolled and renewed policies are received within a weeks pe-
          riod from the day of sending forms and contribution.
     •    After the SE receives the nidhicards the photos of the families should be pasted on each
          nidhicard before distributing it to the members.



 2.3.6 Visit to member for Nidhi card distribution.
                     This refers to the visit done by the service executive to distribute Nidhi cards to
                    newly enrolled HMF member at the time of first loan instalment. Basically, SE
                    should read out information written in the card and highlight major points.

                    Objective- Welcoming the members into the fund , providing complete information
                    on the policy , how to use referrals and claims and clearing doubts of the member if
                    any.

               It is necessary to take the signature of the member in the nidhi card register
               after delivering him/her the nidhicard.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 35 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                    Soft Skills Required

                    The SE introduces himself/herself.

                    The member is first welcomed on joining the health mutual fund.

                    The member is then informed about three important dates

                          Policy start date.

                          Policy end date.

                          Renewal date

                    The script for the SE while providing information to members how to avail the re-
                    ferrals and claim benefits.

                    For availing OPD

                    In case of a health event the member should contact the concerned SE or the area
                    OPD doctor.

                    For availing helpline services.

                    The member can also contact the ‘Arogyanidhi phone seva’ incase of emergency
                    and in need of guidance to appropriate health care provider.

                    Arogyanidhi phone seva-020-26051524

                    Day-Monday to Saturday

                    Time- Morning 9.30-Evening 5.30

                    After 5.30 members can call the network doctor-Dr Amit Wadkar on 9225516860
                    for any help.

                    For the use of Nidhi Card

                    Explain the member the importance of Nidhicard and referral letter in the following
                    words:.” You get a Nidhi Card that works like an identity proof and that should be
                    used to get relevant concessions on OPD basis in the network health care provider


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 36 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                    and when you are hospitalized.”

                    Advantage of referral letter

                    Get quality treatment at concessional rates when you go to a OPD Doctor.

                    When you are hospitalized you will get reimbursed for the costs incurred by you as
                    per the guidelines laid down in the fund.

                    The SE then explains the reimbursement features of the policy

                    How to avail reimbursement for the hospitalization incurred?

                    If the member has been hospitalized following a referral then he should submit all
                    hospitalization papers maximum within 15 days after he has been discharged from
                    the hospital.

                    If it was an emergency and he could not use referral he should call the branch office
                    or the Network Doctor (Tel: 9225516860 ) the very next day and inform the same.

                    In any case, after discharge submit all hospitalization papers maximum within 15
                    days.

                    The SE then explains the documents that the member needs to sub-
                    mit to avail post hospitalization benefits?




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 37 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                      How will your reimbursement request be processed?

                    Once all the above listed documents within the time period are submitted the next
                    step is to fill the claim form with the members signature.

                    The claim form is then sent to the Fund office for checking of the papers on line of
                    treatment and cost of treatment.

                    Afterwards the claim is categorized according to the fund guidelines as shown in the
                    following section.

                      Claim Category Guidelines

                    The health event that has occurred to you have been standardized in categories as
                    all health events are not same.

                    For example the cost of a complex surgery like hernia is not the same that as the
                    treatment of malaria.

                    The SE explains clearly the member the categories of benefit.

                    There are five categories

     1.   2500 Rs max for On Day Discharge
     2.   Up to 5000 Rs max
     3.   Up to 7500 Rs max
     4.   Up to 10,000 Rs
     5.   Up to 15,000 Rs
                 Claim Percentage Guidelines

                    The community has laid down certain percentage norms on the way the claim will
                    be disbursed depending on how the referral services have been utilized.

                         1. 100% - Use of Public hospital

                         2. 80% - Use of Network hospitals –general ward

                         3. 0%- Use of Non network hospitals




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 38 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                    India Association
                     Claim/Reimbursement Decision

                    The final decision on the claim amount given would be taken by the claim commit-
                    tee in a claim meeting where your case will be heard and decision will be taken on
                    the following points




                     When can claims be rejected by the Fund:-

                    The SE also explains the member the specific conditions in which the claim can be
                    rejected

                          Policy not valid (Ended policy)

                          During waiting period(before policy starts)

                          Claimant not covered

                          Pre-existing disease

                          Chronic Long term diseases (Cancer, AIDS) except 1st hospitalization

                          Cosmetic surgeries & complex dental surgeries other than accidental

                          Substance Abuse or self inflicted illnesses

                          Injuries or Illnesses arising out of intentional involvement in riot or political
                                or illegal act


                                                                                                                 Printed on
                                   Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                   1-Feb-11 by   Page 39 of 77
                                   Sadhu Vaswani Circle, Pune-411001
                                                                                                                    SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                          Willing fully not following the guidance/referral

                          (Less reimbursement as per group decisions)

                          Misrepresentation of Facts.

                          Fraud, providing false bills, documents.

                     The SE after every information can ask the member if he/she has any question.

                     The SE then calls upon the member to spread the information among relatives,
                    friends and neighbours.

                    He/she makes them understand that more members mean more money in the fund
                    and better services can be availed.

                    After explaining the benefits the SE also talks about the responsibilities of the
                    member towards the health mutual fund in the following manner.


  Product Benefits                 Responsibilities            Benefits to members
1 24x7 emergency helpline  Use the helpline in case of Easy access to health care pro-
                           emergency                        vider.
2 Network OPD doctor       Visit in case of illness         Concession in OPD charges.
                                                            Help to prevent the disease
                                                            getting worse.
3 Network health care pro- Use network hospitals only Reduces hospitalization cost.
vider.                     while getting admitted in any Assured quality health care.
                           health crisis.                   Maximum claim reimburse-
                                                            ment.
4 Health talk/Health camps Attend the health talks and Prevention of health crisis .
                           health camps and use of the Detection of disease in an early
                           health information in day to day stage to prevent further health
                           life for their own health im- loss.
                           provement.

5 Nidhi cards                              Carry Nidhi card during visit to Helps in identification and
                                           any health care provider.        thereby getting concession.

6 Claim decision                           Attend the claim meeting and Get information about the fund
                                           provide active support to the status.
                                           fund operations.

                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 40 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                             India Association


 2.3.7 Specimen of enrolment form

                                                                                                                                                              Enrollment Form
                                                                                                                                                                     No.
                                                                           HMF & FSF ENROLLMENT FORM
 Policy Holder's Name :                                                                                                           HMF Policy No.

 Address :                                                                                                                        FSF Policy No.

 Community                                                                                                                        Religion

 Branch Name                                            Receipt Date                         S.E. NOTE :                          Ration Card

 Occupation                                             HMF Receipt No.                                                           Ph./M. No.

 Income                                                 HMF Amount (Rs.)                                                          CBU Receipt No.

 Age (of Policy Holder)/D.O.Birth.                      FSF Receipt No.                                                           Alcoholic
 Sex   (of Policy Holder)                               FSF Amount (Rs.)                                                          Civil Status
                                                                                                                                  Pre - Existing Diseases:
 No. of Dependents                                      Alcoholic Charges:                                                        (policy holder)


 Collector's Name                                       Total Amount (Rs.)                          NGO                PSW        CBU Amount (Rs.)
                                                                                             Pre - Existing     Civil Status/
        Dependent's Name                Age/D.O.Birth   Relation               Sex           Diseases           Occupation        Income
 1
 2

 3

 4

 5
                                                   FSF MEMBERS OTHER THAN POLICY HOLDER (for extra members)                                                  FSF policy No.

 1
 2

 3

 I here by read all the terms and conditions mentioned here after and agree to te same


     Signature of the Policy                             Signature of SE &                   Signature of CM                          Signature of
         holder & Date                                         Date                              & Date                              Encoder & Date




                                                   Format of Nidhicard register


Sr no                Date            Partners name                 Policy no          Policy period                 Sign        Remark




                                                                                                                                 Printed on
                                           Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
                  Operational manual                                                                                            1-Feb-11 by         Page 41 of 77
                                           Sadhu Vaswani Circle, Pune-411001
                                                                                                                                    SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
       2.4      Referral and guidance services



                       Objective                        To refer the members to appropriate
                                                        health care provider and to provide them
                                                        necessary guidance in case of an health
                                                        event.

                        Who                           Service Executives(SE)

                         Where                         Branch office or in the community

                          When                         In any case of a health problem which the
                                                        member suffers

                          Tools                        Referral letter


 2.4.1 Responsiblities of SE’s in providing referral services effectively?


          Referrals from branch:-                   If the member visits the branch office in case of sickness he
                                                    should be referred to the appropriate health care provider
                                                    along with the referral letter. Proper address and timing of
                                                    the HCP should also be provided.
                                                    The member should be informed that using the network HCP
                                                    will not only save money but also be useful in getting quality
                                                    health service.
                                                    The service executive should also motivate people to make
                                                    more use of public hospitals rather than private hospitals as
                                                    this can reduce the out of pocket expenditure thus reducing
                                                    the financial burden on the family facing the health incidence.
          Referrals from the field:-                The Service executive should always carry the referral
                                                    letter pad during field visits so that any needful member
                                                    can be provided with the referral letter.




       The service executive should maintain a chart which displays complete information about
the health care provider of their area.The chart should include following details



                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 42 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
Sr no                   Health care Address                     Resource              Phone No             Faculty        OPD       tim-
                        provider                                person                                                    ings
Hospitals
OPD
Investigatory
labs
Medical
shops

 2.4.2 Follow up of referrals-Visit to members


                    Objective:

                           To check whether the members are using the referral letter for getting the
                                referral services.

                           To check whether the members are getting the concessions and quality as
                                per the MOU with the HCP.

                           To assess the amount saved thanks to referral and guidance.

                           To check for any difficulty in getting the referral services or documents.

                    Soft skills required:

                    After the member has taken the referral letter the SE visits the member to check
                    whether the referral letter was used .Consequently there can be three situations


                    .

                    In this case the SE has to sensitively ask the reason and determine that there was no
                    gap from the provider’s side.

                    If the member could not go due to personal reasons or has lost the referral chit the
                    SE should then motivate the member to use it saying that a preventive and timely
                    measure can avoid any health complication in future.

                                                                                                                  Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                    1-Feb-11 by   Page 43 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                     SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association




                     The SE asks about the present health status of the member and if there was any
                    problem accessing the OPD service, whether the cost was concessional and if the
                    patient is satisfied about the treatment .

                     If the patient has any complains the SE should note it down and give a date to fol-
                    low-up with the patient on the same.

                     The SE also notes the amount paid by the member for Calculating amount saved
                    thanks to guidance.

                    This visit should happen within 7 days of issue of referral letter to the patient.

                    In case the member has any complains a second visit is required.




                    The SE should visit the member while in the hospital if there is a serious situation ei-
                    ther financial or medical.

                    Otherwise the SE should visit the patient post discharge and ask about the present
                    health status of the member and if there was any problem accessing the medical
                    service in the hospital, whether the cost was concessional and if the patient is satis-
                    fied about the treatment.

                    If the patient has any complains the SE should note it down and give a date to fol-
                    low-up with the patient on the same.

                    The SE also notes the amount paid by the member for Calculating amount saved
                    thanks to guidance.

                    This visit should happen within 7 days of issue of referral letter to the patient.

                    In case the member has any complains a second visit is required.


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 44 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association


 2.4.3
                    The service executive should check the receipts of HCP from the HMF members and
                    compare them with the Normal Rate List (Standard Rate List) i.e. either with the
                    normal rates of the HCP, or with the Standard Rates given to them:

                    Public Hospital: Amount saved in minimum 4 times the billed amount.

                    Trust Hospital: Amount saved is minimum 2-3 times the billed amount.

                    Private (Network Hospital) – Uplift Scheduled Rate List : Amount saved is 30-40% of
                    the total bill expensed.

                    Private (Network Hospital) – Specific % concession on the Hospital Bill. The conces-
                    sion is written on the Hospital Bill.

                    OPD – General Practitioners: Normal Rates - Scheduled rates.

                    Investigations – 50% concession of the normal rates

                                           Normal rates – Scheduled rates

                    Medicines – 8-10% concession on the normal price.

                    Format of referral register

 Sr no         Date             Name                                   Sex            Age          Disease    Referred         Follow
                                                                                                              where            up




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 45 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                    India Association
 2.4.4 Referral letter specimen.
From
       Name:
     Position:
Branch &NGO:

To
 Dr. / Service
Hospital/Clinic
       Adress

Date                  Dr Deepali Kulkarni

                      This file contains the contents of operational manual for the service execu-
Object
                      tives.


Dear Sir, Dear Madam,

We are referring you a patient named:

Mr / Mrs

Age:                                    Sex:

This Patient complains about:



We would demand you to kindly examine this patient and do the needful.
We would request you to consider this patient for an extra concession. Yes                                   
(Signature of HealthLift coordinator and Doctor requested).

Thanking you in advance,

                                                                                                                  Signature
This part should be returned to the branch:
--------------------------------------------------------------------------------------------------------------------------------
Hospital acknowledgement
          Patients Name                               ___________________________________________

          Patient has taken treatment                                                   
          Patient will take treatment                                                   
          Patient disagrees to take treatment                                           




                                                                                                                  Printed on
                                   Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                    1-Feb-11 by    Page 46 of 77
                                   Sadhu Vaswani Circle, Pune-411001
                                                                                                                     SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association



       2.5 Health preventive measures.

 The mutual fund though is pooling of risks its all a medium to work out the preventive and pro-
 motive aspects of health as the goal is that the members and their families remain healthy. Sub-
 sequently the fund undertakes some programmes with this perspective:


        Health talks-How to conduct health talks :-
     1. Health talks are to be conducted once a month.
     2. It will be effective if the SE first studies the health needs in the community and tries to
        detect the current health problems according to the season and then arrange for the
        health talk.
          For eg :- Diseases prevalent in rainy season like typhoid, Malaria, Jaundice                                       should     be
          taken in rainy season.
     3. Use of effective tools during health talks-Use of visual communication tools during health
        talks is more effective than using only verbal communication. So use of charts, posters,
        photos carrying health in    formation should be included in health talks.
     4. It is more important that the SE gives such health tips to the members which can be used
        immediately by them in their day to day life rather than difficult medical information.
     5. The health tips should be easy to understand and useful to create health awareness.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by    Page 47 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association




Health camps

             Preparatory work
             .HMF coordinators propose a tentative planning of health check-up camps of the next 3
             months. They should mention:
               .    The camp’s topic
               .    The communities where they should take place
               .    Tentative dates and timings required
             The coordinators with the assistance of the service executives should contact the nearby
             health care providers (resource persons) as per the tentatively decided health topics.
             Camp dates, timings and venue should be decided by both the sides mutually well in ad-
             vance – at least one month before the camp.


            On the Service Executive side


                 Nevertheless, since hospitals and doctors have fluctuating timings, Service ex
          ecutive will be confirming the camp within 10 days


           On HealthLift doctor side

               In case of any problem regarding non-availability of the health care provider or
other problems related to the camp the service executives/ coordinators should           contact the
HealthLift doctor.
       HealthLift doctor on his part will contact the health care providers and confirm the
       stipulated date of camp if available/ solve problem regarding the camp if any.
.


          On Hospital side

          When the date is finalized with Hospital, HMF Coordinator will send a confirmation                                         let-
ter       including the details of the camp [cf template]




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 48 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
          Planning

       Camps should be included in the monthly planning of HMF terms with fluctuations of 1 or
2 days due to hospital doctors’ availability].


          Publicity

          HMF and IGP staff should advertise about camp in the communities one week in ad
          vanced through different channels.

         Community boards like Mitra Mandal, near temples
         Committee leaders: with the help of a leaflet, they are expected to spread the message
         Branch office
         Meeting held in the community [cluster meeting, health talk ]
         One day in advanced, put a banner regarding the camp and its venue


          Camp arrangement


      Material required for the specific camp will be ready should be prepared according                                             the
concerned pamphlet.

          Service executive makes the set ready for the camp [except for BP apparatus,
          stethoscope, Gymea speculum and torch]

          Service executive will make sure that material is ready and stock is ready.


          On the day of the camp

Reminder:-Service executive will ring up the hospital doctor to confirm the details of the camp.


         Arrangements of the camp


      HMF and IGP staff of the respective branch is responsible for the camp room arrangement.

      Initial registration and fees collection: 1 staff member



                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 49 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association


      Detailed registration with name and health complains: Health Lift doctor or any trained
       staff member

                                                                             If further treatment is suggested by the
                                                                              consultant , the patient must be given a re-
                                                                              ferral letter. Those information should be
                                                                              recorded.

                                                                             During the camp, staffs promote the fund
                                                                              to non members

                                                                             Hospitalities are arranged by staff.

                                                                             When camp is over, staff should tide up the
          camp room.


Follow up
Patients:- Patients marked up with a star should be followed up within a week by service execu-
tive.

Doctors

Doctors who have participated in the camp should receive a “thank you letter” according to the
template in a week time.

Coordinators

HMF coordinators will keep records of the camp regarding the camp taken, the network health
care provider involved ,total attendance of the camp (HMF,non HMF),prevailing health incidence
and follow upof referred patients. That information will be conveyed during cluster meetings,
claim meetings, orientation meeting by the Service Executives




OPD services.

                                           The members may need OPD services in case of minor health prob-
                                           lems .Taking this into consideration each slum has a general practi-

                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 50 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                                           tioner who is tied up with the network services.
                                           It is the responsibility of the SE to maintain good relation with this
                                           general practitioner in order to get better services for the members
                                           The SE is supposed to visit the OPD doctor twice a month and collect
                                           the information from him as to how many members have availed the
                                           OPD services in the previous month.
                                           This data can be easily obtained by collecting the OPD coupons from
                                           the doctor and keeping the record of it.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 51 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
       2.6 Claim servicing
                                           Whenever a member is hospitalized during a health incident he
                                           can avail reimbursement from the fund by submitting essential re-
                                           quired documents to the service executive.


          SE should know the required documents in order to reduce the queries level.
                  Claim papers

                         Nidhi Card (photo copy).

                         discharge summary,

                         consolidated main bill with break up,

                         investigation reports,

                         Pharmacy bills with breakups.

                         Investigation reports supporting diagnosis.
                               X-ray reports in case of fracture.
                               Pathological reports in case of illness.
                                              o Blood reports with positive findings.
                               USG reports in case of abdominal surgery, stone disease, tumors, with
                                  positive findings etc.
                               Obs. history (G, P, L, A,) in case of pregnancy or related complications.

                         MLC Copy in case of accidents (fall, trauma, RTA, injury, burn, suicidal attempt,
                          drug toxicity , etc)

                         History of alcohol / drugs in case of accidents (fall, trauma, RTA, injury etc).

                         1st time diagnosed prescription from treating doctor in case of ailments which
                          can be pre-existing. (If required).

                         Policy no. to be written in the claim form.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 52 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
          1. Attaching claim papers :
          SE should know the sequence of documents to be collected.
              To be attached as per serial no.:-




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 53 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
 2.6.1 Claim processing-
                                           This refers to the process which starts from collection of claim
                                           documents from the members till the arrangement of claim meet-
                                           ing to take the claim decision.


       2.6.1.1 Visit to member before claim meeting.
                    The SE should visit the claimant before the decision of claim disbursement is taken
                    in the claim meeting.

                    Objective: - To make the members understand the guidelines of claim benefits as
                    decided mutually in the fund.

                    Soft skill required:-

                          The SE asks the claimant about the health status and then the event and
                                how did he/she manage.

                          The SE then asks whether the claimant has used the referral services and
                                used the network health care provider.

                          If not, the SE should explain how the claimant would have benefited from
                                the services and then now it will also affect the claim amount unless it was
                                an emergency.

                          The SE has to explain the claim categorization to the member and make her
                                understand the category in which the health crisis faced by her falls.

                          The SE explains to the member that the claim decision will be taken by the
                                group according to 4 criteria:

                         1. The submission of documents,

                         2. Network services utilisation,

                         3. The category

                         4. The fund status.

                    This visit should be done at-least a day prior to claim meeting.

                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 54 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association


   Processes                        Actors                  Location          Action, Documents                                Timeline
   Submission of hospi- Claimant     Branch                                                    Hospital Bill                  Within 15
   talization    docu- /Policyholder Office                                                                                    days     of
                                                                                               Medicine bills
   ments                                                                                                                       hospital
                                                                                               Investigations bills           discharge
                                                                                               Hospital    discharge Permissible
                                                                                                card                  limit if ex-
                                                                                                                      ception-
                                                                                               Prescriptions     for
                                                                                                                      One
                                                                                                medicine
                                                                                                                      month
                                                                                               Investigation reports
                                                                                               Nidhi card


   Collection of docu- SE, Claimant                         Branch            SE provides Claim Form to the Same Day
   ments, filling of                                        Office            claimant if she/he can write or of submis-
   claim     form   by                                                        else fill up the declaration part sion
   Claimant                                                                   of the form on behalf of the
                                                                              claimant
   Papers are checked SE                                    Branch            Check if all the above men- Same Day
   for completion and                                       Office            tioned documents are there ,if of submis-
   correctness                                                                not, SE asks the claimant to sion
                                                                              bring all the concerned papers
                                                                              and help in procuring if needed
   Claim form and re- SE, Courier                           Branch            SE signs on the form with date 1-2 day
   lated claim papers                                       Office            and sends it to the HO
   are sent to HO
   Claim form and pa- Encoder                               HO                The encoder encodes the form 48 hrs
   pers are received                                                          in open status and all the rele-
   and is encoded                                                             vant bills and reports and read-
                                                                              ies the same to be checked by
                                                                              the Doctor




                                                                                                                  Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                    1-Feb-11 by    Page 55 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                     SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
   Hospitalization(claim Network                            HO                The Network doctor goes 3 days
   papers) papers are Doctor                                                  through every bill and report
   checked on medical                                                         and checks whether it matches
   relevancy, line of                                                         with the period of hospitaliza-
   treatment, cost of                                                         tion, the line of treatment, the
   treatment and is                                                           cost of treatment and the cate-
   categorized                                                                gorization of the incident ac-
                                                                              cording to claim guidelines.
   The medically cor- Network                               HO                The network doctor writes his
   rect amount is calcu- Doctor                                               remark and the medically rele-
   lated                                                                      vant amount to be considered
                                                                              to be disbursed on the form.
   The Claim file is en- Encoder                            HO                The encoder encodes the bills 1 day
   coded                                                                      checked by the Network Doctor
                                                                              and prepares the file in a ready
                                                                              to settle mode and the same is
                                                                              communicated to the Coordina-
                                                                              tor.
   The Claim meeting CO,SE                                  HO,               After the file is ready to be 2 days
   date is decided                                          Branch            processed the CO along with
                                                                              the SE fixes a date for the meet-
                                                                              ing to be held in the commu-
                                                                              nity. The SE then informs the
                                                                              members of a proposed
                                                                              date(within 5 days of communi-
                                                                              cation from CO)
   Claim       meeting CO,SE                                HO,               The CO checks the fund bal- 1 day
   preparation                                              Branch            ance, claim ratio of the branch
                                                                              and the HO, takes CASH or
                                                                              Blank Cheque. The SE arranges
                                                                              for the venue time and atten-
                                                                              dance (many times it is used as
                                                                              a promotion strategy also)




 2.6.2 Claim meeting-
                                               •    In Parvati all the claims are decided in a single meeting
                                                     which takes place once a month in each branch.
                                               •    The SE should ensure that all the claimants whose claims

                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 56 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                                                     are to be decided are present during the meeting.
                                               •    If the claimant is absent the claim will be discussed but the
                                                     amount will not be disbursed.
                                               •    Also it is important that the HMF members of that particular
                                                    area other than the claimants are present for the meeting.
                                               •    The attendance of the PCM members and the PCM signatory
                                                    of that area is compulsory as the signatory has to sign on
                                                    the cheque.


   Processes                Actors                         Location           Action, Documents                              Timeline
   Time      Venue SE                                      Branch             Check with BM                                  One day
   and        space                                        Office             Check with Members
   availability
                                                                              Check with PCM’s
   Inform Mem- SE                                          Branch             Inform members, Community Within
   bers, Directors                                         Office             Directors/PCM members on same day
   about       the                                         Area               date time venue through home
   claim meeting                                                              visits infor through CMs
   Before claim SE                                         Branch             Make sure the claim file and 10 min
   meeting    on                                           Office             related papers are there, that at
   the   decided                                                              least .05 % members of the total
   date                                                                       members of the branch or not
                                                                              less than 10 members are pre-
                                                                              sent along with the CD/PCM
                                                                              member
                                                                              The SE ensures there is a good
                                                                              seating arrangement in a way
                                                                              that he/she can maintain a good
                                                                              eye contact and the setting is
                                                                              democratic.
   Welcome, In- SE                                         Branch             The SE introduces the purpose 10 min
   troduction and                                          Office             of the meeting by self introduc-
   Purpose of the                                                             tion intro of the organisation the
   meeting                                                                    claimant and the case




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by    Page 57 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
   Claim     Case SE , fund mem- Branch                                       The SE facilitates the Discussion 30 min
   Presentation   bers           Office                                       by presenting the details that
                                                                              involve the claimant health inci-
                                                                              dent, usage of hospital , cost of
                                                                              treatment, follow of referral and
                                                                              guidance as also the earned
                                                                              premium of the branch for the
                                                                              month, reserves, claim ratio.


   Members Dis- Members,SE                                 Branch             The members discuss the details
   cuss                                                    Office             presented, SE facilitates to see
                                                                              that every body participates in
                                                                              the discussion, the discussion is
                                                                              not captured by a dominating
                                                                              member(especially if he is a
                                                                              male) and help members to
                                                                              come to a decision.
   Claim indem- Members                                    BO                 The members along with the 10 min
   nity finaliza-                                                             CD/PCM member decide the
   tion                                                                       amount to be paid based on
                                                                              doctors remark and fund bal-
                                                                              ance of the branch
   Claim Amount Members, SE                                BO                 The cheque is prepared accord- 5 min
   is disbursed                                                               ing to the amount decided by
                                                                              the members.The concerned
                                                                              PCM of the branch signs on the
                                                                              cheque.
   Claim is closed          SE,CO,Accountant HO,                              The claim papers are sent back   With 48
                                             Branch                           after writing the claim amount   hours of
                                                                              and signature of the community   papers
                                                                              members.                         coming
                                                                              All the claim documents with all back   to
                                                                              the necessary information filled office
                                                                              by the coordinator,the cheque
                                                                              signed by the PCM signatory is
                                                                              send to the head office to the
                                                                              accountant.
                                                                              After completion of the ac-
                                                                              counts job it is send to the MD


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 58 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                                                                              for his signatures.
                                                                              Then all the claim documents
                                                                              and the cheque is sent back to
                                                                              CO who sends it back to the
                                                                              branch office .Then the cheque
                                                                              is disbursed to the Claimant in
                                                                              the branch office.


                                                                              The file is encoded in back of-
                                                                              fice as settled and closed




 2.6.3 Visit to member after claim meeting.


                    Objective: - To understand the satisfaction level of the member and make her un-
                    derstand the situation in case her claim was rejected or amount was lessened.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 59 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                    Soft skill required:-



                          SE visits the claimant’s house post claim disbursement and talks to the clai-
                                mant or the policy holder of her opinion about the claim decision .

                          If not the SE should ask if the claimant has some time to talk so that the de-
                                cision can be better explained.

                          If the claimant is OK with it the SE sits down to read out the policy guidelines
                                once again and make the member understand that if the policy continues
                                she can still get many benefits.

                          If the claimant is not ok the SE asks for a later appointment with the mem-
                                ber.

                                When any claim is rejected it is the SE ‘s responsibility to fill the claim rejec-
                                tion letter for each rejected claim and get it signed from the claimant after
                                explaining him well why his or her claim was rejected.




         2.6.3.1 Specimen of claim rejection letter.


Dear Member,


We regret to inform you that your claim dated___________________ for the amount of
Rs________ has been rejected by the monthly claim committee as per the meeting/decision
held by them on the following grounds.


     o    Submission of documents post hospitalization after stipulated time of three months
     o    Incomplete documents (documents not received even after three months)
     o    Pre-existing /Excluded list of diseases.
     o    Lapse of policy period
     o    Fraud/Malpractice on the part of the claimant
     o    Inadequacy of fund

                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 60 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association

We regret the rejection as they are based on guidelines accepted by the fund members and
hope that the fund in future will be useful in your need.
Policyholder’s Name: ________________________________________
Claimant’s Name: ___________________________________________
Policy Period: _______________________________________________
Village/City: ________________________________________________
Amount Claimed: _____________________________________________


Issued today __________________
On behalf of Parvati Svayamrojgar


Signed by
Partner community members
Name and signature(sign of PCM’s)


Programme Coordinator : Name and signature




 2.6.4 Plan of action in case of increased claim ratio:



Reasons of exceeding claim ratio

      Exclusions not managed well

      PED not ruled out.

Responsibilities of SE

     1. Collect all the necessary documents. In case of Accidental cases, injuries , burns and
          wounds MLC copy is a must.

     2. People should be well oriented about exclusions during the orientation meeting.

     3. Each claim should be first scrutinized by the SE before filling the claim paper. In case of any
          query she should contact the network Doctor immediately.


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 61 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                     India Association
     4. In case of maternity cases the SE should first check the inception date with the policy start
          date.

     5. The SE should make the people aware that it is necessary to bring more and more people in
          the fund to increase the reserves and to manage all the claims. Pre existing diseases should
          be monitored during enrolment to prevent adverse selection.

     6. In every claim meeting people should be made aware of the branch earned premium and
          reserves . Also how the reserves will be finished if claims are not given according to some
          standard rules. Before the claim meeting a chart should be prepared of all the claims as fol-
          lows


                                            Month- Nov
                                S
                                            Earned premium of the month:- 4000 Rs
                                u
                                            Total amount that can be used from the reserves:-6000 Rs
                                c
                                            Total reserves:- 20,000 Rs
                                h
           Name of claimant                               Claimable amount                                   Total claimable amount

                                            1 xyz                                            5000 Rs                                       8000 Rs
                                c
                                h           2 abc                                            2500 Rs

                                a           3 jkl                                            3500 Rs

                                r
                                ts should be displayed before the members during the claim meeting.

     7. The members should be made responsible for managing their own fund.

     8. The SE should discuss the claimants who have followed all the guidelines and used the
          network services thereby helping themselves to reduce the health care expense. This will
          be useful to promote members to use the network services.




                                                                                                                       Printed on
                                    Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                         1-Feb-11 by     Page 62 of 77
                                    Sadhu Vaswani Circle, Pune-411001
                                                                                                                          SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
 2.6.5 Utilization of reserves
                                           The earned premium of the branch is utilized for the claim dis-
                                           bursement within that branch. But sometimes the earned premium
                                           is not sufficient to manage all the claims .In such cases some spe-
                                           cific amount from the reserves can be used to disburse the claims.
                                           This amount is to be calculated following certain rules.
                    In order to utilize the reserves effectively for claim disbursement there are some
                    rules to be followed

1- IF NGO Reserve > 3 months of current month earned contribution

                     If branch reserve > 12 months of current month earned Contribution : can utilise 4
                    times the earned contribution

                    For eg:-

                    If branch reserve is 4000 and reserves 48000

                    Then months for which earned premium is available is 48000/4000 i.e 12 months



                    So you can use four times the earned premium i.e 16,000Rs for claim disbursement.



                    If branch reserve > 9 months of current month earned Contribution : can utilise
                    2.5 times the earned contribution

                    For eg:-

                    If branch reserve is 4000 and reserves 36,000

                    Then months for which earned premium is available is 48000/4000 i.e 9 months

                    So you can use three times the earned premium i.e 10,000Rs for claim disburse-
                    ment.

                     If branch reserve > 6 months of current month Contribution : can utilise 2 times
                    the earned contribution

                    If branch reserve is 4000 and reserves 24000

                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 63 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                    Then months for which earned premium is available is 24000/4000 i.e 6 months

                    So you can use two times the earned premium i.e 8,000Rs for claim disbursement.



                    If branch reserve > 3 months of current month Contribution : can utilise 1.5 times
                    the earned contribution

                    If branch reserve is 4000 and reserves 12000

                    Then months for which earned premium is available is 12000/4000 i.e 3 months

                    So you can use 1.5 times the earned premium i.e 6000 Rs for claim disbursement.



                    Otherwise Can utilise the earned contribution only.



                    2- IF NGO Reserve < 3 months of current month earned contribution

                    Can utilise the earned contribution only.

                    If NGO reserves is 10000 and the earned premium(of NGO) is 4000 so it can be used
                    only for two months which is less then the above prescribed rule .

                    In this condition only the earned contribution can be utilised.


       2.6.5.1 SE’s role in Inter Branch Solidarity.
                                           Whenever the earned premium of another branch has to be used
                                           the community representatives of both the branches involved
                                           should be informed.
                                           A letter seeking their permission to used the fund should be
                                           signed by them. They should also be present for that specific claim
                                           meeting .
                                           The issue should be discussed in front of all the members in which
                                           the community representatives of both the branches are present.




                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 64 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
       2.6.5.2 Inter Branch Solidarity form




Date-

Branch-

We the community representatives of ………………………branch give permission to…………….. …..
branch to use our balanced earned premium for the settlement of the following claims-


   Name of the claimant-                              Policy number-                             Claimable        Inter branch
                                                                                                  amount          amount used




                                                                                                                Total        amount
                                                                                                                used -



Name of the community rep-                                          Branch                                    Signature
resentatives of both   the
branches




Signature of the SE-

Signature of the HMF coordinator-


Importance of Inter branch Solidarity.
                                           1 Helps to maintain the transparency in claim procedures.
                                           2 Keeps a systematic record of how the earned premium is used.


 2.6.6 Format of claim register
                                           The following details are to be filled in the claim register .
                                                   Name of the claimant.
                                                   Name of the policy holder.
                                                   Claim incident information.
                                                   Medical condition


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 65 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                                                   Referral and guidance
                                                   Earned premium
                                                   Fund reserve
                                                   Decision of the members
                                                   Signature of the PCM signatory
                                                   Signature of the policy holder
                                                   Signature of other members -




       2.7      Renewals




                       Objective                        To renew the policies ending in the specific
                                                        month.

                        Who                           Service executive

                         Where                         Door to door

                          When                         One month prior to the policy end date

                         Duration                      15 to 20 minutes

                          Tools                        PDR forms, partner benefit forms and
                                                        partner visit forms.

 2.7.1 Pre-                                                                                                                        para-
       tory Work:


               1. The SE receives the PDR of the policies three months in advance of the policy end
                  date. That is if the policy of a member is ending in September the SE will receive it’s
                  PDR in the month of June so that adequate follow-up can be taken.
               2. The PDR are arranged CM wise and the PDR register is updated.

                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 66 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                    India Association
               3. The SE should also carry the information regarding outstanding Balance report and
                  savings report from the branch manager on each PDR form of the concerned policy.
               4. The SE should also carry the partner benefit forms and partner visit record forms
                  along with the PDR forms.
               5. If the member is an IGP defaulter or is a write off case then the remark should be
                  written on the PDR form and should be signed by the CM,BM,IGP CO and SE.
               6. The follow up for renewals should be taken thrice and the dates should be record-
                  ed.If the SE fails to meet the member even after visiting the member three times
                  then that remark should be written on the PDR along with the dates and time be-
                  fore sending it to HO.

 2.7.2 Visit to member before and after renewals.
                    Objective:-

                          To inform the member about the approaching renewal date.

                          To motivate the members to renew the policy.

                          To understand the satisfaction level of members.

                          Addition of new member in the family in case of new birth.

                          Deletion of a member from the policy in case of death.

                          Seek information regarding health incidences of the year.



                    Soft skill required

                          The SE should conduct a visit one month minimum prior to the termination
                                of the member’s policy (that is informed through the PDR)

                          The SE should visit the member according to the member’s convenience and
                                availability.

                          The SE should carry the information if the member has received any claims
                                or has been rejected or has not utilised any of the services.

                          In case the members claim was rejected or the member did not utilize any of
                                the services, the SE has to sensitively handle the questions of the member


                                                                                                                 Printed on
                                   Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                   1-Feb-11 by   Page 67 of 77
                                   Sadhu Vaswani Circle, Pune-411001
                                                                                                                    SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                                and convince her, the reason for rejection or non-utilisation and how the
                                person can continue to have the benefits in the coming year.

                          The SE should congratulate the member for not falling ill and that she is
                                healthy and because of her others are benefiting who were in need.

                          The SE should do a small mathematical calculation showing how the pre-
                                mium paid will always be recovered if the member continues contribution.

                          Also that the money paid by her will be utilised for paying claims for co-
                                members. Similarly when she will get a claim it will be other people who will
                                be pay for her.

                                If the member wishes to renew and pays in cash then he should be given the
                                receipt. If he wishes to pay from the saving account then he should be in-
                                formed about the amount in his account.




       2.8 Role of SE in governance.
                                                To update the virtual account chart monthly which gives detail
                                                 information of the current status of the fund to the members.
                                                It is the responsibility of the SE to give information regarding
                                                  the fund balance, earned premium to the members whenever
                                                  asked for.
                                                To organize and facilitate PCM (partner committee) meetings
                                                 monthly and update the members about the benefits and
                                                 services of the fund also for changes in the policy if any.
                                                To facilitate and organize the claim meetings and to see
                                                 whether the claim decision is taken democratically by the
                                                 community.


             VAC preparation procedures.

                  The virtual account chart is to be updated every month after getting the technical re-

                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 68 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                  ports.It should be displayed in the branch office as it gives a brief idea about the HMF
                  project branch wise.
                                                       Ja       Fe M          Ap       M        Jun        Jul   Au      Se         Oc   No          De
                                                       n        b ar          r        ay                        g       p          t                c
No of members enrolled this
month
Ongoing members
Earned premium
Fund balance since beginning
No of claims open
Amount disbursed for the claims
12 months claim ratio
Renewal ratio
No of referrals given
Amount saved thanks to referrals
No of members using OPD




                                                                                                                       Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                         1-Feb-11 by    Page 69 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                          SSD
       Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                    India Association
        2.9            Reporting tools

                                                      WEEKLY REPORTING FOR SE-PSW

       NAME OF THE SE :-

       BRANCH:-

       DATE:-

       PDR

Week       Total PDR Completed                    this Positive                  Negative                   If –ve What     Sent to
           this      week                                                                                   why?   was your HO    on
           month                                                                                                   action   which
                                                                                                                            date




       EPR

Week          Worked this week                        Positive                               Negative                   Remark of BM




       REFERRALS

Week     Total refer- Health care This weeks Last weeks +’ve                                                      -ve   ?             Amount
         rals    sent provider    follow up  follow up                                                                                saved
         this week




                                                                                                                         Printed on
                                         Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
                  Operational manual                                                                                    1-Feb-11 by    Page 70 of 77
                                         Sadhu Vaswani Circle, Pune-411001
                                                                                                                            SSD
       Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association

       CLAIM

Week          Claim type-HMF/FSF                          Papers sent to HO date                          Status of claim




       ENROLMENT

Week        CM’s name                      New enrolment                Renew enrolment                       Total   Nidhi       Total
                                                                                                              cards distrib-
                                                                                                              uted




       Extra work done by the SE this week




              2.10 Technical Glossary



                                   1. New Members


                                                                                                                         Printed on
                                         Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
                  Operational manual                                                                                    1-Feb-11 by   Page 71 of 77
                                         Sadhu Vaswani Circle, Pune-411001
                                                                                                                            SSD
Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                         Total Number of new members of the mutual fund or the insurance portfolio
                         which first mutual fund/insurance contract date starts within the considered pe-
                         riod.

                            2. On going members

                         Total number of members which contract is on going at the end of the consi-
                         dered period.

                            3. Earned contribution net

                         Earned contribution is the monthly distribution of the 60% claim fund of all the
                         ongoing members of the particular month.

                         For example if the premium is 60 Rs

                         36 Rs becomes the claim fund.

                         This 36 Rs is for the entire contract of 12 months.

                         That means 36 Rs will be distributed equally between 12 months i.e. 3 Rs per
                         month.

                         Therefore the earned premium is the 3 Rs part of all ongoing members in a par-
                         ticular month.

                            4. Claim amount disbursed

                         Total amount of the claims paid during the period

                            5. 12 Months claim ratio

                         Past 12 months paid indemnities / Past 12 Months earned contributions

                            6. 12 Months Claim Frequency

                         Nbr of claims opened 12 Months / Past 12 Months on going members

                            7. Claim Declaration Date –

                                 Also, called as Opened date for claim. It is the date when the Claim Docu-


                                                                                                                Printed on
                                  Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
           Operational manual                                                                                  1-Feb-11 by   Page 72 of 77
                                  Sadhu Vaswani Circle, Pune-411001
                                                                                                                   SSD
  Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
                                  ments are submitted by the partner to the Ngo Staff.

                              8. Admission Date –

                                    The date on which patient gets admitted in the hospital.

                              9. Discharge date –

                                   The date on which the patient gets discharged from the hospital.

                              10. Treatment period –

                                    The time span in which the patient gets treated for the medical problem.

                              11. Enrollement Date –

                                    The date on which the partner fills up the Enrollement form with organi-
                                   zation.

                              12. Detected date –

                                   the date on which the partner organization comes to know about the
                                   partner’s disease. So in our case it is the date of enrollement.




         2.11 FAQ’s

We are already receiving treatment at cheap rate then what additional benefits we will get??




                                                                                                                  Printed on
                                    Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
             Operational manual                                                                                  1-Feb-11 by   Page 73 of 77
                                    Sadhu Vaswani Circle, Pune-411001
                                                                                                                     SSD
  Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
Low rate is only one benefit. Still a major health problem could occur and even if you get cheap
treatment you could have to pay more than Rs.10000/-. In this case the fund would help you and
provide up to Rs. 5000/- indemnity along with guidance toward the best doctor available for your
need
 This service is completed with more than 12 Free Health check-up organized in the city every
year, along with Administrative support for major treatments such as heart surgery.
This explanation answer your question?

Is the contribution amount received for the HMF scheme, recoverable in future?
Why is the premium paid by us not refunded ?
No Sir/Madam. The principles of insurance are applicable to our Health Mutual Fund. Some of
the fund partners may require incurring Hospitalization expenses while the others will not re-
quire it we don’t know today. . Each of us, by paying a small amount of Rs 50/-, the member will
get assurance to get reimbursed up to Rs.5000/- as the balance fund is used for the benefit of
members only. If your contribution was refunded it would not be possible for you to be reim-
bursed in case of a claim
Still, if no claim has been made for any of the family member then that family may receive a no-
claim-bonus by way of additional benefits extending their claim limits of. 500/-rs additional
Does this explanation answer your question?
Why is the UpLift Health Doctor not providing Medicines to us?
The UpLift Health Doctor is appointed for providing the best and quickest guidance required in
case of an emergency, as well as organizing preventive health care measures such as health
check up camps and so on.
In case of a small health problem, your family doctor would be the best person to handle your
problem. We will guide you to someone reliable, located near your residence if you don’t have
one
Does this explanation answer your question?
If we do not avail the next loan, can we get UpLift Health benefits?

All Services are independent of each other. So Yes, you can avail UpLift Health benefits provided
you have paid your full contribution.
Does this explanation answer your question?
If I am the only UpLift Health member what benefits do my other family members get?

If you join alone as a UpLift Health member, you are the only one entitled to receive benefits.
The only way for the other family members to get the similar benefits as yours is to join the
scheme! And this will be cheaper for you since alone you pay twice the contribution, and to-
gether you pay only Rs 50/- as a yearly contribution per person.
Does this explanation answer your question?
If we receive the claim do we have to pay back the claim amount?




                                                                                                                  Printed on
                                    Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
             Operational manual                                                                                  1-Feb-11 by   Page 74 of 77
                                    Sadhu Vaswani Circle, Pune-411001
                                                                                                                     SSD
  Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
No Sir/Madam. The principles of insurance are applicable to our Health Mutual Fund. If you are
reimbursed a claim, the contributions gathered will be used for your needs. Each of us, by paying
a small amount of Rs 50/- a member will get assurance to get reimbursed up to Rs 5000/- as the
balance fund is used for the benefit of members only. This is possible only because only some of
us (very few: 1 out of 50) will require this need.
Does this explanation answer your question?
Is your scheme more expensive than other insurance services?
No Sir/Madam. UpLift Health scheme is the most economical scheme today. The limits are com-
parable to other schemes but UpLift Health is the only scheme providing additional benefits such
as Guidance Hospital treatment at reduced rates, Health check-up camps Health awareness pro-
grammes and so on. Based on a No profit No loss concept, Claim settlement by partners is not
available in case of other insurance services. Does this explanation answer your question?
How long will HMF operate?
HMF scheme is based on mutual trust and co-operation of members & hence so long as mem-
bers express their trust by paying Renewal premium HMF scheme can continue. To ensure its
viability you are to vote for the accounts every year and every month you are to check the loan
amount. Is the explanation satisfactory? Please feel free to ask us whatever is in your mind.
If the HMF scheme is discontinued by the NGO what will happen to our fund
The NGO will not discontinue the scheme so long as members are supporting the scheme. In case
the scheme is discontinued by decision of member, distributive balance fund will be distributed
amongst members.
Every year you are to vote for the accounts’ validation and every month you are invited to con-
trol the fund’s financial health.
You can be assured that your fund is in safe hands.
Does this answer your query?
Does the HMF take responsibility for proper medical treatment in hospitals?
HealthlLift Federation has linked up with the best hospitals of the city in order to provide its
member with the best treatments available at reasonable rates. The responsibility for proper
medical treatment shall lie on those best hospitals.
However, HMF will monitor and ensure access to proper medical treatment.
HMF was conceived with the idea that partners are provided access to quality health care sys-
tems. Does this answer your question?
Is the scheme subject to change every year?

On the basis of an annual review of fund’s financial position UpLift Health benefits can be en-
hanced or reduced subject to your approval. These changes depend on our responsibility toward
our own health. If we take care of our health through good diet and lifestyle habits, proper hy-
giene preventive measures, sports and exercise then, definitely our health will be good as well as
our fund’s. We intend to uphold participative decision-making and complete involvement of the
partners.
Does this answer your question?


                                                                                                                  Printed on
                                    Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
             Operational manual                                                                                  1-Feb-11 by   Page 75 of 77
                                    Sadhu Vaswani Circle, Pune-411001
                                                                                                                     SSD
  Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
If we haven’t paid the full contribution, will you refund us partly paid?
If you fail to pay full contribution within two months period we will refund you partly paid pre-
mium after deducting Rs10 for administrative expenses per person’s contribution.
Not being a full partner, you will not be entitled to receive any financial benefits until you make
full payment of contribution due. Does this answer your question?
We could not avail any benefits of HMF in first year then what is use of the scheme?
Should we pay Renewal premium even though we have not made any claim for major illness?
Only because of a very good health you are unable to avail any benefits of HMF, you are lucky. It
is not the case of some other members who had to undergo severe operations this year, unluck-
ily. Thanks to your contribution, they could afford to be properly cured.
No one knows whether he/she will face any Health problem in future & only because of this,
every clever person must make provision to face Health problem. The best solution to make pro-
vision for future Health problem is to continue membership of HMF. If you contribute to the fund
before the end of your expiry date, you will be entitled to receive additional benefits as 500Rs
additional as a No Claim Bonus for not making claim in the first year.
Does this answer your question?
When intimation should be given regarding illness /diseases or likely /Hospitalization?
Immediate or at the earliest time intimation should be given regarding illness/diseases or likely
Hospitalization to HMF coordinator/Doctor/Field worker.
Indeed, this immediate intimation will help you to receive the best Guidance/Reference to the
best Hospital related to the problem you would have.
Does this answer your question??
Shall we receive claim reimbursement if we take treatment in any Hospital or Hospital not in-
cluded under HMF tie –up?
Yes you will receive claim benefits for Hospitalization treatment taken in any Hospital, but these
reimbursements will be limited to ceiling amounts.
Even if it is not necessary that you must take treatment in hospital having tie-up with UpLift
Health, it is in your interest to do so since you may save considerable amount when the bill
crosses the 5000 Rs limit. Does this answer your question?
Are the Health check-up camps free of cost? Are the specs provided free of cost?
Health Checkup camps facility is made free for UpLift Health partners. Other people have to pay
to receive this service.
Still specs or any other curing service that can be issued from this camp are not provided free of
cost, but with concessional rates.
Will UpLift Health Doctor do medical examination free of cost?
In case of emergency, UpLift Health Doctor will give his medical examination free of cost. In other
cases, you are proposed to be referred to your local medical practitioner.
UpLift Health Doctor will also provide guidance to ensure you the best quality service regarding
the medical treatments you may receive. Does this answer your question?
Will UpLift Health help to provide medicines required by some of family members very often?



                                                                                                                  Printed on
                                    Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
             Operational manual                                                                                  1-Feb-11 by   Page 76 of 77
                                    Sadhu Vaswani Circle, Pune-411001
                                                                                                                     SSD
  Dc9c65ac-7b80-48ab-b2b6-982a913b2bb4.doc                                                                   India Association
Selling medicine is a very specialized job. UpLift Health will provide guidance toward cheaper
medicine. Does this answer your question?
Are the family members to be made UpLift Health partners compulsorily?
No, of course! You can join alone as a UpLift Health member, then you are the only one entitled
to receive benefits. Still, the only way for the other family members to get the similar benefits as
yours is to join the scheme!
This will be economically beneficial for you since alone you pay twice the contribution, and to-
gether you pay only Rs 60/- as a yearly contribution per person.
Does this explanation answer your question?
We do receive free medicines free medical treatment from corporation dispensary then why
should we join UpLift Health?
Free medicines and free treatment are more and more rare, and there when it is still there, there
is no quality assurance.
UpLift Health not only provide financial support in case of hospitalization expenses but also pro-
vides benefits such as Guidance, Health check-up camp, Health awareness, Health talk, Preven-
tive health measures and Administrative support for higher costs expenses.
So, since you may not receive free medicines free medical treatment for all types of illness or
diseases in corporation dispensary & hence it is better to join HMF to avail all benefits as above.
Does this explanation answer your question?
Other than eleven listed illness there are other major illness or diseases. What benefits are avail-
able for other major illness or diseases?
Proposal is under consideration to cover any illness or diseases not listed in list but not specifi-
cally excluded for benefit not exceeding Rs. 2500/. HMF not only provide limited financial assis-
tance for hospitalization expenses but also provides benefits such as Guidance, Health check-up
camp, Health awareness, Health talk, Preventive health measures, Administrative support. Does
this answer your question?
I am already covered under the ESI scheme. Why should I join?
If you are already covered, you have no reason to join indeed. ESI is already providing a similar
support to UpLift Health.
Still are the members of your family covered under that same ESI scheme? If not, make sure that
they have some potential coverage in case of a health problem.




                                                                                                                  Printed on
                                    Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
             Operational manual                                                                                  1-Feb-11 by   Page 77 of 77
                                    Sadhu Vaswani Circle, Pune-411001
                                                                                                                     SSD
                                          Printed on
                                    Regd. Office: Flat No. 14, 4th Floor, Land Mark Apartment, B. J. Road,
             Operational manual                                                                                   5-Dec-10     Page 77 of 77
                                    Sadhu Vaswani Circle, Pune-411001
                                                                                                                   by SSD

								
To top