No Duty of Disclosure. Notwithstanding the issue of the Tender Documents and any other information provided by the State Health Agency prior to the date of this Insurance Contract, the Insurer hereby acknowledges that it does not rely on and has not been induced to enter into this Insurance Contract or to provide the Covers or to assess the Premium for providing the Covers on the basis of any statements, warranties, representations, covenants, undertakings, indemnities or other statements whatsoever and acknowledges that none of the State Health Agency or any of its agents, officers, employees or advisors or any of the enrolled Beneficiary Family Units have given or will give any such warranties, representations, covenants, undertakings, indemnities or other statements. Prior to commencement of each Policy Cover Period for any State, the State Health Agency or NHA undertake to prepare or cause a third party to prepare the Beneficiary Database as correctly as possible. The Insurer acknowledges that, notwithstanding such efforts being made by the State Health Agency, the information in the Beneficiary Database may not be accurate or correct and that the Beneficiary Database may contain errors or mistakes. Accordingly, the Insurer acknowledges that the State Health Agency makes no warranties, representations, covenants, undertakings, indemnities or other statements regarding the accuracy or correctness of the Beneficiary Database that will be provided by it to the Insurer. The Insurer represents, warrants and undertakes that it has completed its own due diligence and is relying on its own judgment in assessing the risks and responsibilities that it will be undertaking by entering into this Insurance Contract and in providing the Covers to the enrolled Beneficiary Family Units and in assessing the adequacy of the Premium for providing the Covers for the Beneficiary Family Units. Based on the acknowledgements of the Insurer in this Clause, the Insurer: acknowledges and confirms that the State Health Agency has made no and will make no material disclosures to the Insurer; acknowledges and confirms that the State Health Agency shall not be liable to the Insurer for any misrepresentation or untrue, misleading, incomplete or inaccurate statements made by the State Health Agency or any of its agents, officers, employees or advisors at any time, whether made wilfully, negligently, fraudulently or in good faith; and hereby releases and waives all rights or entitlements that it has or may have to: make any claim for damages and/or declare this Insurance Contract or any Policy issued under this Insurance Contract declared null and void; or as a result of any untrue or incorrect statements, misrepresentation, mis-description or non-disclosure of any material particulars that affect the Insurer’s ability to provide the Covers. Fraud Control and Management The insurer is expected to have the capability of develop a comprehensive fraud control system for the scheme which shall at the minimum include regular monitoring, data analytics, ecards audit, medical audit, field investigation, hospital audit, corrective action etc It shall comply with provisions of PMJAY Anti-Fraud Guidelines and Advisories as issued time to time. For an indicative (not exhaustive) list of fraud triggers that may be automatically and on a real-time basis be tracked as provided in Schedule 13. The Insurer shall have capactities and track the indicative (not exhaustive) triggers and it can add more triggers to the list. For all trigger alerts related to possible fraud at the level of EHCPs, the Insurer shall take the lead in immediate investigation of the case in close coordination and under constant supervision of the SHA. Investigations pursuant to any such alert shall be concluded within 07 (seven) days and all final decision related to outcome of the Investigation and consequent penal action, if the fraud is proven, shall vest solely with the SHA. The SHA shall take all such decision within the provisions of the Insurance Contract, PMJAY Anti Fraud Guidelines, Recovery Guidelines and Advisories etc.and be founded on the Principles of Natural Justice and as per applicable laws. The SHA shall on an ongoing basis measure the effectiveness of anti-fraud measures in the Scheme through a set of indicators. For a list of such indicative (not exhaustive) indicators, refer to Schedule 14. The Insurer shall be responsible for monitoring and controlling the implementation of the AB-PMJAY in the State in accordance with Clause 23. In the event of a fraudulent Claim being made or a false statement or declaration being made or used in support of a fraudulent Claim or any fraudulent means or device being used by any Empanelled Health Care Provider or the TPA or other intermediary hired by the Insurer or any of the Beneficiaries to obtain any benefits under this Insurance Contract or any Policy issued by the Insurer (each a Fraudulent Activity), then the Insurer’s sole remedies as per the approval of SHA shall be to: refuse to honour a fraudulent Claim or Claim arising out of Fraudulent Activity or reclaim all benefits paid in respect of a fraudulent Claim or any Fraudulent Activity relating to a Claim from the Empanelled Health Care Provider and/or any entity that has undertaken or participated in a Fraudulent Activity; and/or take disciplinary action against the Empanelled Healthcare provider that has made a fraudulent Claim or undertaken or participated in any unethical practices, including but not limited to issuing showcause notice, levying penalties as per provisions or refer for suspension or de-empanelment to the State Empanelment Committee, with the procedure specified in Schedule 5; terminate the services agreement with the intermediary appointed by the Insurer; and/or provided that the Insurer keeps the SHA informed of actions taken by it along with details thereof.
Appears in 1 contract
Samples: Insurance Contract
No Duty of Disclosure. a. Notwithstanding the issue of the Tender Documents and any other information provided by the State National Health Agency Authority prior to the date of this Insurance Implementation Support Contract, the Insurer ISA hereby acknowledges that it does not rely on and has not been induced to enter into this Insurance Implementation Support Contract or to provide the Covers or to assess the Premium Fee for providing the Covers on the basis of any statements, warranties, representations, covenants, undertakings, indemnities or other statements whatsoever and acknowledges that none of the State National Health Agency Authority or any of its agents, officers, employees or advisors or any of the enrolled Beneficiary Family Units beneficiaries have given or will give any such warranties, representations, covenants, undertakings, indemnities or other statements. .
b. Prior to commencement of each Policy Cover Period for any StatePeriod, the State National Health Agency Authority or NHA undertake to prepare or cause a third party to prepare the Beneficiary Database as correctly as possible. The Insurer ISA acknowledges that, notwithstanding such efforts being made by the State National Health AgencyAuthority, the information in the Beneficiary Database may not be accurate or correct and that the Beneficiary Database may contain errors or mistakes. Accordingly, the Insurer ISA acknowledges that the State National Health Agency Authority makes no warranties, representations, covenants, undertakings, indemnities or other statements regarding the accuracy or correctness of the Beneficiary Database that will be provided by it to the Insurer. ISA.
c. The Insurer ISA represents, warrants and undertakes that it has completed its own due diligence and is relying on its own judgment in assessing the risks and responsibilities that it will be undertaking by entering into this Insurance Implementation Support Contract and in providing the Covers to the enrolled Beneficiary Family Units eligible Beneficiaries and in assessing the adequacy of the Premium Fee for providing the Covers for the Beneficiary Family Units. beneficiaries.
d. Based on the acknowledgements of the Insurer ISA in this Clause, the Insurer: ISA:
(i) acknowledges and confirms that the State National Health Agency Authority has made no and will make no material disclosures to the Insurer; ISA;
(ii) acknowledges and confirms that the State National Health Agency Authority shall not be liable to the Insurer ISA for any misrepresentation or untrue, misleading, incomplete or inaccurate statements made by the State National Health Agency Authority or any of its agents, officers, employees or advisors at any time, whether made wilfully, negligently, fraudulently or in good faith; and and
(iii) hereby releases and waives all rights or entitlements that it has or may have to: – make any claim for damages and/or declare this Insurance Contract or any Policy issued under this Insurance Implementation Support Contract declared null and void; or – as a result of any untrue or incorrect statements, misrepresentation, mis-mis- description or non-disclosure of any material particulars that affect the InsurerISA’s ability to provide the Covers. Fraud Control and Management The insurer is expected to have the capability of develop a comprehensive fraud control system for the scheme which shall at the minimum include regular monitoring, data analytics, ecards audit, medical audit, field investigation, hospital audit, corrective action etc It shall comply with provisions of PMJAY Anti-Fraud Guidelines and Advisories as issued time to time. For an indicative (not exhaustive) list of fraud triggers that may be automatically and on a real-time basis be tracked as provided in Schedule 13. The Insurer shall have capactities and track the indicative (not exhaustive) triggers and it can add more triggers to the list. For all trigger alerts related to possible fraud at the level of EHCPs, the Insurer shall take the lead in immediate investigation of the case in close coordination and under constant supervision of the SHA. Investigations pursuant to any such alert shall be concluded within 07 (seven) days and all final decision related to outcome of the Investigation and consequent penal action, if the fraud is proven, shall vest solely with the SHA. The SHA shall take all such decision within the provisions of the Insurance Contract, PMJAY Anti Fraud Guidelines, Recovery Guidelines and Advisories etc.and be founded on the Principles of Natural Justice and as per applicable laws. The SHA shall on an ongoing basis measure the effectiveness of anti-fraud measures in the Scheme through a set of indicators. For a list of such indicative (not exhaustive) indicators, refer to Schedule 14. The Insurer shall be responsible for monitoring and controlling the implementation of the AB-PMJAY in the State in accordance with Clause 23. In the event of a fraudulent Claim being made or a false statement or declaration being made or used in support of a fraudulent Claim or any fraudulent means or device being used by any Empanelled Health Care Provider or the TPA or other intermediary hired by the Insurer or any of the Beneficiaries to obtain any benefits under this Insurance Contract or any Policy issued by the Insurer (each a Fraudulent Activity), then the Insurer’s sole remedies as per the approval of SHA shall be to: refuse to honour a fraudulent Claim or Claim arising out of Fraudulent Activity or reclaim all benefits paid in respect of a fraudulent Claim or any Fraudulent Activity relating to a Claim from the Empanelled Health Care Provider and/or any entity that has undertaken or participated in a Fraudulent Activity; and/or take disciplinary action against the Empanelled Healthcare provider that has made a fraudulent Claim or undertaken or participated in any unethical practices, including but not limited to issuing showcause notice, levying penalties as per provisions or refer for suspension or de-empanelment to the State Empanelment Committee, with the procedure specified in Schedule 5; terminate the services agreement with the intermediary appointed by the Insurer; and/or provided that the Insurer keeps the SHA informed of actions taken by it along with details thereof.
Appears in 1 contract
No Duty of Disclosure. Notwithstanding the issue of the Tender Documents and any other information provided by the State Health Agency prior to the date of this Insurance Implementation Support Contract, the Insurer ISA hereby acknowledges that it does not rely on and has not been induced to enter into this Insurance Implementation Support Contract or to provide the Covers or to assess the Premium Fee for providing the Covers on the basis of any statements, warranties, representations, covenants, undertakings, indemnities or other statements whatsoever and acknowledges that none of the State Health Agency or any of its agents, officers, employees or advisors or any of the enrolled Beneficiary Family Units have given or will give any such warranties, representations, covenants, undertakings, indemnities or other statements. Prior to commencement of each Policy Cover Period for any State, the State Health Agency or NHA undertake to prepare or cause a third party to prepare the Beneficiary Database as correctly as possible. The Insurer ISA acknowledges that, notwithstanding such efforts being made by the State Health Agency, the information in the Beneficiary Database may not be accurate or correct and that the Beneficiary Database may contain errors or mistakes. Accordingly, the Insurer ISA acknowledges that the State Health Agency makes no warranties, representations, covenants, undertakings, indemnities or other statements regarding the accuracy or correctness of the Beneficiary Database that will be provided by it to the InsurerISA. The Insurer ISA represents, warrants and undertakes that it has completed its own due diligence and is relying on its own judgment in assessing the risks and responsibilities that it will be undertaking by entering into this Insurance Implementation Support Contract and in providing the Covers to the enrolled Beneficiary Family Units and in assessing the adequacy of the Premium Fee for providing the Covers for the Beneficiary Family Units. Based on the acknowledgements of the Insurer ISA in this Clause, the InsurerISA: acknowledges and confirms that the State Health Agency has made no and will make no material disclosures to the InsurerISA; acknowledges and confirms that the State Health Agency shall not be liable to the Insurer ISA for any misrepresentation or untrue, misleading, incomplete or inaccurate statements made by the State Health Agency or any of its agents, officers, employees or advisors at any time, whether made wilfully, negligently, fraudulently or in good faith; and hereby releases and waives all rights or entitlements that it has or may have to: make any claim for damages and/or declare this Insurance Contract or any Policy issued under this Insurance Implementation Support Contract declared null and void; or as a result of any untrue or incorrect statements, misrepresentation, mis-description or non-disclosure of any material particulars that affect the InsurerISA’s ability to provide the Covers. Fraud Control and Management The insurer ISA is expected to have the capability of develop a comprehensive fraud control system for the scheme which shall at the minimum include regular monitoring, data analytics, ecards audit, medical audit, field investigation, hospital audit, corrective action etc It shall comply with provisions of PMJAY Anti-Fraud Guidelines and Advisories as issued time to time. For an indicative (not exhaustive) list of fraud triggers that may be automatically and on a real-time basis be tracked as provided in Schedule 13. The Insurer ISA shall have capactities and track the indicative (not exhaustive) triggers and it can add more triggers to the list. For all trigger alerts related to possible fraud at the level of EHCPs, the Insurer ISA shall take the lead in immediate investigation of the case in close coordination and under constant supervision of the SHA. Investigations pursuant to any such alert shall be concluded within 07 (seven) days and all final decision related to outcome of the Investigation and consequent penal action, if the fraud is proven, shall vest solely with the SHA. The SHA shall take all such decision within the provisions of the Insurance Implementation Support Contract, PMJAY Anti Fraud Guidelines, Recovery Guidelines and Advisories etc.and be founded on the Principles of Natural Justice and as per applicable laws. The SHA shall on an ongoing basis measure the effectiveness of anti-fraud measures in the Scheme through a set of indicators. For a list of such indicative (not exhaustive) indicators, refer to Schedule 14. The Insurer ISA shall be responsible for monitoring and controlling the implementation of the AB-PMJAY in the State in accordance with Clause 2324. In the event of a fraudulent Claim being made or a false statement or declaration being made or used in support of a fraudulent Claim or any fraudulent means or device being used by any Empanelled Health Care Provider or the TPA or other intermediary hired by the Insurer ISA or any of the Beneficiaries to obtain any benefits under this Insurance Implementation Support Contract or any Policy issued by the Insurer ISA (each a Fraudulent Activity), then the InsurerISA’s sole remedies as per the approval of SHA shall be to: refuse to honour a fraudulent Claim or Claim arising out of Fraudulent Activity or reclaim all benefits paid in respect of a fraudulent Claim or any Fraudulent Activity relating to a Claim from the Empanelled Health Care Provider and/or any entity that has undertaken or participated in a Fraudulent Activity; and/or take disciplinary action against the Empanelled Healthcare provider that has made a fraudulent Claim or undertaken or participated in any unethical practices, including but not limited to issuing showcause notice, levying penalties as per provisions or refer for suspension or de-empanelment to the State Empanelment Committee, with the procedure specified in Schedule 5; terminate the services agreement with the intermediary appointed by the InsurerISA; and/or provided that the Insurer ISA keeps the SHA informed of actions taken by it along with details thereof.
Appears in 1 contract
Samples: Implementation Support Contract
No Duty of Disclosure. a. Notwithstanding the issue of the Tender RFE Documents and any other information provided by the State National Health Agency Authority prior to the date of this Insurance ContractEmpanelment Agreement, the Insurer ISA hereby acknowledges that it does not rely on and has not been induced to enter into this Insurance Contract Empanelment Agreement or to provide the Covers or to assess the Premium Fee for providing the Covers on the basis of any statements, warranties, representations, covenants, undertakings, indemnities or other statements whatsoever and acknowledges that none of the State National Health Agency Authority or any of its agents, officers, employees or advisors or any of the enrolled Beneficiary Family Units beneficiaries have given or will give any such warranties, representations, covenants, undertakings, indemnities or other statements. .
b. Prior to commencement of each Policy Cover Period for any StatePeriod, the State National Health Agency or NHA undertake Authority undertakes to prepare or cause a third party to prepare the Beneficiary Database as correctly as possible. The Insurer ISA acknowledges that, notwithstanding such efforts being made by the State National Health AgencyAuthority, the information in the Beneficiary Database may not be accurate or correct and that the Beneficiary Database may contain errors or mistakes. .
c. Accordingly, the Insurer ISA acknowledges that the State National Health Agency Authority makes no warranties, representations, covenants, undertakings, indemnities or other statements regarding the accuracy or correctness of the Beneficiary Database that will be provided by it to the Insurer. ISA.
d. The Insurer ISA represents, warrants and undertakes that it has completed its own due diligence and is relying on its own judgment in assessing the risks and responsibilities that it will be undertaking by entering into this Insurance Contract Empanelment Agreement and in providing the Covers to the enrolled Beneficiary Family Units eligible Beneficiaries and in assessing the adequacy of the Premium Fee for providing the Covers for the Beneficiary Family Units. beneficiaries.
e. Based on the acknowledgements of the Insurer ISA in this Clause, the Insurer: ISA:
(i) acknowledges and confirms that the State National Health Agency Authority has made no and will make no material disclosures to the Insurer; ISA;
(ii) acknowledges and confirms that the State National Health Agency Authority shall not be liable to the Insurer ISA for any misrepresentation or untrue, misleading, incomplete or inaccurate statements made by the State National Health Agency Authority or any of its agents, officers, employees or advisors at any time, whether made wilfully, negligently, fraudulently or in good faith; and and
(iii) hereby releases and waives all rights or entitlements that it has or may have tohave: – to make any claim for damages and/or declare this Insurance Contract or any Policy issued under this Insurance Contract Empanelment Agreement declared null and void; or – as a result of any untrue or incorrect statements, misrepresentation, mis-mis- description or non-disclosure of any material particulars that affect the InsurerISA’s ability to provide the Covers. Fraud Control and Management The insurer is expected to have the capability of develop a comprehensive fraud control system for the scheme which shall at the minimum include regular monitoring, data analytics, ecards audit, medical audit, field investigation, hospital audit, corrective action etc It shall comply with provisions of PMJAY Anti-Fraud Guidelines and Advisories as issued time to time. For an indicative (not exhaustive) list of fraud triggers that may be automatically and on a real-time basis be tracked as provided in Schedule 13. The Insurer shall have capactities and track the indicative (not exhaustive) triggers and it can add more triggers to the list. For all trigger alerts related to possible fraud at the level of EHCPs, the Insurer shall take the lead in immediate investigation of the case in close coordination and under constant supervision of the SHA. Investigations pursuant to any such alert shall be concluded within 07 (seven) days and all final decision related to outcome of the Investigation and consequent penal action, if the fraud is proven, shall vest solely with the SHA. The SHA shall take all such decision within the provisions of the Insurance Contract, PMJAY Anti Fraud Guidelines, Recovery Guidelines and Advisories etc.and be founded on the Principles of Natural Justice and as per applicable laws. The SHA shall on an ongoing basis measure the effectiveness of anti-fraud measures in the Scheme through a set of indicators. For a list of such indicative (not exhaustive) indicators, refer to Schedule 14. The Insurer shall be responsible for monitoring and controlling the implementation of the AB-PMJAY in the State in accordance with Clause 23. In the event of a fraudulent Claim being made or a false statement or declaration being made or used in support of a fraudulent Claim or any fraudulent means or device being used by any Empanelled Health Care Provider or the TPA or other intermediary hired by the Insurer or any of the Beneficiaries to obtain any benefits under this Insurance Contract or any Policy issued by the Insurer (each a Fraudulent Activity), then the Insurer’s sole remedies as per the approval of SHA shall be to: refuse to honour a fraudulent Claim or Claim arising out of Fraudulent Activity or reclaim all benefits paid in respect of a fraudulent Claim or any Fraudulent Activity relating to a Claim from the Empanelled Health Care Provider and/or any entity that has undertaken or participated in a Fraudulent Activity; and/or take disciplinary action against the Empanelled Healthcare provider that has made a fraudulent Claim or undertaken or participated in any unethical practices, including but not limited to issuing showcause notice, levying penalties as per provisions or refer for suspension or de-empanelment to the State Empanelment Committee, with the procedure specified in Schedule 5; terminate the services agreement with the intermediary appointed by the Insurer; and/or provided that the Insurer keeps the SHA informed of actions taken by it along with details thereof.
Appears in 1 contract
Samples: Contract Agreement for Selection of Implementation Support Agency (Isa)