Grievance Redressal

There shall be the following Grievance Committees, at different levels, to attend to the grievances of various stakeholders:

District Grievance Redressal Committee (DGRC)

This will be constituted by the State Nodal Agency in each district within 15 days of signing of MoU with the Insurance Company. The District Grievance Redressal Committee will comprise of at least the following members:

a.       District Magistrate or an officer of the rank of Addl. District Magistrate or Chief Medical Officer: Chairman

b.      District Key Manager/ District Grievance Nodal Officer: Convenor

c.       Representative of the Insurance Company: Member

District administration may include additional members for this purpose.

State Grievance Redressal Committee (SGRC)

This will be constituted by the State Nodal Agency within 15 days of signing of MoU with the Insurance Company. The State Grievance Redressal Committee will comprise of at least the following members:

                  a. State Principal Secretary/Secretary of Department handling Swasthya Sathi Scheme: Chairman

                  b. State Nodal Officer for Swasthya Sathi / State Grievance Nodal Officer for Swasthya Sathi: Convenor

                  c. State Representative of the Insurance Company: Member ( if more than one Insurance Companies are   active in the State, then one insurance company may be selected for a fixed period on rotation basis)

State Govt. /Nodal Agency may include additional members for this purpose.

If any stakeholder has a grievance against another stakeholder during the subsistence of the policy period or thereafter, in connection with the validity, interpretation, implementation or alleged breach of any provision of the scheme, it will be settled in the following way:

Grievance of Beneficiary

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Content Review Policy (CRP)

If a beneficiary has a grievance on issues relating to enrolment or hospitalization, against the FKO, Insurance Company, hospital or their representatives, beneficiary will approach DGRC. The DGRC should take a decision within stipulated period of receiving the complaint.

If either of the parties is not satisfied with the decision, they can appeal to the SGRC within stipulated days of the decision of DGRC. The SGRC shall decide the appeal within stipulated period of receiving the Appeal. The decision of the SGRC on such issues will be final.

Grievance against DKM or other District Authorities - If the beneficiary has a grievance against the District Key Manager (DKM) or an agency of the State Government, it can approach the SGRC for resolution. The SGRC shall decide the matter within stipulated period of the receipt of the grievance.

Grievance of Healthcare Provider

If a healthcare provider has any grievance with respect to Beneficiary, Insurance Company or their representatives, it can approach the DGRC. The DGRC should be able to reach a decision within stipulated days of receiving the complaint.

If either of the parties is not satisfied with the decision, they can go to the SGRC which shall take a decision within stipulated days of receipt of Appeal. The decision of the Committee shall be final.

Grievance against DKM or other District Authorities - If the healthcare provider has a grievance against the District Key Manager (DKM) or an agency of the State Government, it can approach the SGRC for resolution. The SGRC shall decide the matter within stipulated period of the receipt of the grievance. The decision of the SGRC shall be final.

Grievance of Insurance Company

Grievance against FKO – If insurance company has any grievance against a Beneficiary, or Field Key Officer (FKO), it will approach the DGRC. The DGRC should take a decision within stipulated days of receiving the complaint.

If either of the parties is not satisfied with the decision, they can appeal to the SGRC within stipulated days of the decision of the DGRC. The SGRC shall decide the appeal within stipulated days of receiving the appeal. The decision of the SGRC on such issues will be final.

Grievance against DKM or other District Authorities – If Insurance Company has a grievance against District Key Manager or an agency of the State Government; it can approach the SGRC for resolution. The SGRC shall decide the matter within stipulated period of the receipt of the grievance.

Note

There would be a fixed date, for addressing these grievances in the respective Committees (DGRC/SGRC). This would enable all grievances to be heard within the set time frame of within stipulated period.