Family Planning Indemnity Scheme Manual

Manual for

Family Planning

Indemnity Scheme

Family Planning Division

Ministry of Health and Family Welfare

Government of India

March 2016

Ministry of Health & Family Welfare

Government of India, Nirman Bhawan, New Delhi-110101

Any part of this document may be reproduced and excerpts from it may be quoted without

permission provided the material is distributed free of cost and the source is acknowledged.

1

st

Edition, October 2013

2

nd

Edition, March 2016

Prologue

Quality of services plays a major role in acceptance of any service.

Poor quality of services leads to unsatised clients resulting in

under-utilization of services. To build the condence of clients it

is necessary to provide them safeguards against adverse events.

Sterilization services are largely provided through public and

accredited Pvt/NGO health facilities. There is a continuing concern

about the number of adverse events following sterilization as well

as litigations faced by the facilities /doctors against such cases.

To mitigate this, the Government of India introduced the National

Family Planning Insurance Scheme which was later modied

as Family Planning Indemnity Scheme “FPIS”, now operational

through State NHM Program Implementation Plan instead of

private sector insurance company.

This updated manual is the second edition of the “Manual for Family

Planning Indemnity Scheme, October 2013” and is in accordance

with the “Standards and Quality Assurance in Sterilization

Services, Nov 2014”. This manual has been revised with a view to

provide guidance to the state, district health authorities and service

providers alike to process the payment of compensation for adverse

events following sterilization and provide indemnity coverage to

the service providers both in public and accredited private/NGO

facilities. In addition to this, it will also be of assistance to program

managers in assessing quality of sterilization services.

Manual for Family Planning Indemnity Scheme

5

CONTENTS

Background 9

Introduction 10

Target Audience 10

Chapter 1: Family Planning Indemnity Scheme-Overview 11

Chapter 2: Scheme Implementation 15

Chapter 3: Operational Procedure for Claim Selement 18

Chapter 4: Monitoring of the Scheme 23

Annexure-1: Claim Form for Family Planning Indemnity Scheme 27

Annexure-2: Application Cum Consent Form for Sterilization Operation 31

Annexure-3: Medical Record & Check List for Female / Male Sterilization 34

Annexure-4: Sterilization Certicate 40

Annexure-5: Post Operative Instruction Card 41

Annexure-6: Proforma for Conducting Audit of Death 43

Annexure-7: Report on Complications/Failures following Sterilization 45

Annexure-8: Checklist of FPIS Claim Documents 49

Annexure-9: Beneciary Wise Claim Status 51

Annexure-10: Quarterly Report Form 52

Annexure-11: Statewise Annual Claims Status 53

Annexure-12: Sterilization Death Audit Report 54

Manual for Family Planning Indemnity Scheme

7

ABBREVIATIONS

CMO Chief Medical Ocer

DBT Direct Benet Transfer

DISC District Indemnity Sub-Commiee

DQAC District Quality Assurance Commiee

EAG Empowered Action Group

FOGSI Federation of Obstetric and Gynaecological Societies of India

FPIS Family Planning Indemnity Scheme

HFS High Focus States

IAP Indian Academy of Pediatrics

IAPSM Indian Association of Preventive and Social Medicine

IMA Indian Medical Association

IUD Intra Uterine Device

MTP Medical Termination Of Pregnancy

NGO Non-Government Organization

NHM National Health Mission

NPCC National Program Coordination Commiee

PIP Program Implementation Plan

RCHO Reproductive & Child Health Ocer

RHFWTC Regional Health & Family Welfare Training Centre

SIHFW State Institute of Health & Family Welfare

SISC State Indemnity Sub-Commiee

SQAC State Quality Assurance Commiee

TFR Total Fertility Rate

USG Ultra Sonography

UT Union Territory

Manual for Family Planning Indemnity Scheme

9

Background

India was the rst country to launch a National Family Planning Programme way back in 1952,

emphasizing fertility regulation for reducing birth rates to the extent necessary to stabilize the

population at a level consistent with the socio-economic development and environment protection.

Since then the demographic and health proles of India have steadily improved.

With a view to encourage people to adopt permanent methods of Family Planning ,the Government has

been implementing a centrally sponsored scheme since 1981 to compensate sterilization beneciaries

for the loss of wages for the period they require for recuperation following sterilization. This

compensation scheme for beneciaries of sterilization services was revised with eect from 31.10.2006

and was further improved upon with eect from 07.09.2007. The scheme has now been enhanced for 11

high focus states namely Uar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Jharkhand, Chhaisgarh,

Uarakhand, Odisha, Assam, Haryana and Gujarat where the TFR continues to be high. The scheme

has been modied in the light of rise in cost of living and transportation costs.

Previously, under the scheme, the Central Government released funds to States/UTs @ Rs.300/- per

Tubectomy, Rs.200/- per Vasectomy and Rs.20/- per IUD Insertion. The States/UTs had the exibility

to decide the amount of apportionment among various components, provided minimum amount of

Rs.150 was paid to the beneciaries of Tubectomy/Vasectomy and Rs.60 per Tubectomy, Rs.25 per

Vasectomy and Rs.20 per IUD insertion was used by the medical facility towards drugs and dressing.

This was intended to ensure quality of service in these procedures. Flexibility rested with the States for

determining sub components of the remaining amount, within the total package. In the case of EAG

States viz. Bihar, Chhaisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uar Pradesh and

Uaranchal, the compensation package for sterilization was further raised from Rs.300/- to Rs.400/-

per Tubectomy, Rs.200/- to Rs.400/-per Vasectomy if conducted in a public health facility or accredited

private health facility and from Rs.20 to Rs.75 per IUD insertion, if conducted in an accredited private

health facility.

Apart from providing cash compensation to the beneciaries of sterilization for loss of wages,

transportation, diet, drugs, dressing etc out of the funds released to States/UTs under this scheme,

States/UTs apportioned some amount for creating a miscellaneous purpose fund. This fund was

utilized for payment of ex-gratia to the beneciary of sterilization or his/her nominee in the unlikely

event of his/her death or incapacitation or for treatment of post-operative complications aributable

to the procedure of sterilization, as under:

i) Rs. 50,000/- per case of death

ii) Rs. 30,000/- per case of incapacitation

iii) Rs. 20,000/- per case of cost of treatment of serious post operation complication

Any liability in excess of the above limit was to be borne by the State/UT/NGO/ Voluntary Organization

concerned from their own resources.

Under the then existing Government Scheme no compensation was payable for failure of sterilization,

and no indemnity cover was provided to Doctors/Health Facilities providing professional services for

conducting sterilization procedures etc. Moreover, no apportioning of the amount disbursed under

the revised compensation scheme (2007) was admissible for creating a miscellaneous purpose fund

for payment of compensation with respect to death/failure/complication aributable to sterilization

operations.

On the other hand, there was a great demand in the states for indemnity insurance cover to doctors/

health facilities, since many empanelled doctors/facilities were facing litigation on account of claims

led by the beneciaries for compensation following death/failure/complication. This led to reluctance

among the doctors/health facilities to conduct sterilization operations and the programme suered.

10

Manual for Family Planning Indemnity Scheme

To address this issue, the Government of India introduced the “National Family Planning Insurance

Scheme” since 25th November, 2005 which has now been modied into “Family Planning Indemnity

Scheme (FPIS)” with eect from 1st April, 2013.

The objective of the FPIS is to indemnify all beneciaries of sterilization, doctors and health facilities

(public and accredited private/NGO) conducting sterilization operation in the unlikely event of death/

failure/complication following sterilization operation.

Introduction

This updated manual on “Family Planning Indemnity Scheme” will serve as a guide for the process

of payment of compensation for death/failure/complication cases aributable to sterilization for

beneciaries and indemnity coverage for service providers both in the public and in the accredited

private/NGO facilities. In addition to this it will also serve as a guide to program managers for assessing

quality of sterilization services.

This updated manual is in accordance with the “Standards and Quality Assurance in Sterilization

Services, Nov 2014” and sets out the guidelines for indemnity coverage to beneciaries as well as

service providers.

Target Audience

This document is meant to be used universally all over the country, by all stakeholders comprising of

policy makers at the national and state levels, programme managers at the national, state, district and

block levels, faculty of medical colleges, trainers at the national and state level, service providers at all

levels as well as by the beneciaries who want to get acquainted with the nuances of the programme

and be aware of their rights and responsibilities.

Manual for Family Planning Indemnity Scheme

11

Chapter 1

Family Planning Indemnity Scheme-Overview

Sterilization is still the most popular family planning method adopted by the clients to limit their family

size. Family planning services are largely being provided through a network of public and private

accredited facilities. However, persistent high unmet need for limiting methods and lack of trained

providers at peripheral level leads to dependence on the camp approach. There has been growing

concern about the quality of sterilization services being oered, particularly at the camp facilities.

The continuing deaths, failures and complications following sterilizations also results in increased

litigation being faced by the providers, which is another barrier in scaling up the sterilization services.

Directives of Hon’ble Supreme Court

The Hon’ble Supreme Court of India in its Order dated 1.3.2005 in Civil Writ Petition No. 209/2003

(Ramakant Rai V/s Union of India) had, inter alia, directed the Union of India and States/UTs for

ensuring enforcement of Union Government’s Guidelines for conducting sterilization procedures and

norms for bringing out uniformity with regard of sterilization procedures by –

1. Introduce a system of having an approved panel of doctors and limiting the persons entitled to

carry on sterilization procedure in the State to those doctors whose names appear on the panel.

The panel may be prepared either State-wise, District-wise or Region-wise.

2. The State Government shall also prepare and circulate a checklist which every doctor will be

required to ll in before carrying out sterilization procedure in respect of each proposed patient.

The checklist must contain items relating to (a) the age of the patient, (b) the health of the patient,

(c) the number of children and (d) any further details that the State Government may require

on the basis of the guidelines circulated by the Union of India. The doctors should be strictly

informed that they should not perform any operation without lling in this check list.

3. The State Government shall also circulate uniform copies of the proforma of consent. Until the

Union Government certies such proforma, for the time being, the proforma as utilized in the

State of U.P. shall be followed by all the States ;and

4. Each States shall set up a Quality Assurance Commiee which should, as being followed by the

State of Goa, consist of the Director of Health Services, the Health Secretary and the Chief Medical

Ocer, for the purpose of not only ensuring that the guidelines are followed in respect of pre-

operative measures (for example, by way of pathological tests, etc), operational facilities (for

example, sucient number of necessary equipment and aseptic conditions) and post-operative

follow ups. It shall be the duty of the Quality Assurance Commiee to collect and publish six

monthly reports of the number of persons sterilized as well as the number of deaths or complications

arising out of the sterilization.

5. Each State shall also maintain overall statistics giving a breakup of the number of the sterilizations

carried out, particulars of the procedure followed(since we are given to understand that there are

dierent methods of sterilization), the age of the patients sterilized, the number of children of

the persons sterilized, the number of deaths of the persons sterilized either during the operation

or thereaer which is relatable to the sterilization , and the number of persons incapacitated by

reason of the sterilization programmes.

6. The State Government shall not only hold an enquiry into every case of breach of the Union of

India guidelines by any doctor or organization but also take punitive action against them. As

far as the doctors are concerned, their names shall, pending enquiry, be removed from the list of

empanelled doctors.

7. The state shall also bring into eect an insurance policy according to the format followed by the

state of Tamil Nadu until such time the Union of India prescribes a standard format.

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Manual for Family Planning Indemnity Scheme

8. The Union of India shall lay down within a period of four weeks from date uniform standards

to be followed by the State Governments with regard to the health of the proposed patients, the

age, the norms for compensation, the format of the statistics, check list and consent proforma and

insurance.

9. The Union of India shall also lay down the norms of compensation which should be followed

uniformally by all the states. For the time being until the Union Government formulates the norms

of compensation, the States shall follow the practice of the State of Andhra Pradesh and shall pay

Rs 1 lakh in case of death of the patient sterilized, Rs 30,000/- in case of incapacity and in the case of

post- operative complications, the actual cost of treatment being limited to the sum of Rs 20,000/-

The Union Government complied with the orders of the Supreme Court as enumerated below:

1. Creation of panel of doctors/health facilities for conducting sterilization procedures and laying

down criteria for empanelment of doctors for conducting sterilization procedures.

2. Laying down of medical record and checklist to be followed by every doctor before carrying out

sterilization procedures.

3. Laying down of uniform proforma for obtaining ‘consent’ of persons undergoing sterilization.

4. Seing up of Quality Assurance Commiees at State and District level for ensuring enforcement

of pre and postoperative guidelines regarding sterilization procedures.

5. The Union of India brought into eect an Insurance Policy for all States/UTs with eect from

29

th

Nov, 2005 .

Against the backdrop of the directions of the Hon’ble Supreme Court, the “NFPIS” was introduced

from 29th Nov, 2005 so as to do away with the complicated process of payment of ex-gratia to the

beneciaries of sterilization for treatment of post-operative complications, failure of sterilization or

death aributable to the procedure of sterilization. Since then, the scheme has witnessed changes in

the insurers and modications in limits and payment procedures.

Initially the scheme was operated by The Oriental Insurance Company Limited from 29th Nov, 2005

and renewed w.e.f. 29-11-2006 with modication in the limits and payment procedures.

Later, the scheme was operated by ICICI Lombard General Insurance company w.e.f. 01-01-08 up

to 31-03-2013 with yearly renewals. The scheme thereaer has been modied as “Family Planning

Indemnity Scheme” and is operational from 01.04.2013.

Settlement of cases not covered under Family Planning Insurance Scheme (FPIS):

There might be cases not covered by the Family Planning Insurance Scheme, viz. cases of sterilization

operations conducted before coming into force of Insurance Scheme, i.e. prior to 29

th

November,2005

or the cases already pending in courts etc.

Liability in respect of such cases has to be met aer the due clearance from SISC/DISC by the State

Government/UTs Administration from the Miscellaneous Purpose Fund created in respective State/

UTs by apportioning some amount from the grants released to them by the Union Government under

the Scheme of Compensation.

1.1. Family Planning Indeminty Scheme

(Under NHM State Programme Implementation Plans (PIPs) w.e.f. 1st April ,2013)

Under the Family Planning Indemnity Scheme it has been decided that States/UTs would

process and make payment of claims to beneciaries of sterilization in the event of death/

failure/complication and indemnity cover to doctors/health facilities. It is envisaged that

States/UTs would make suitable budget provisions for implementation of the scheme through

their respective Program Implementation Plans (PIPs) in the relevant head under the National

Health Mission (NHM). The scheme is uniformly applicable for all States/UTs.

Manual for Family Planning Indemnity Scheme

13

It will be the responsibility of the SISC/DISC to ensure timely ling and processing of eligible

claims. With eect from 1st April 2013, liability in respect of such cases would be met by the

State Government/UT Administration from funds released by Government of India, under

the National Health Mission (NHM), as per the approval in NPCC of respective State PIPs.

The maximum fund allocated by Government of India to the States /UTs would be on the

basis of average number of sterilization cases in the last three years multiplied by a premium

amount of Rs. 50/- per sterilization case. However, if the State wishes to provide more or

spends more than the allocation, the state may make payment of claims, from their state

budget. States whose claims are less would also be free to allocate lesser funds than their due,

so that resources within the approved envelope for their PIP could be beer utilized for other

activities. In smaller States and UTs where the average number of beneciaries of sterilization

is very low, a minimum amount to the extent of Rs 5 lakhs may be proposed.

The available benets under the Family Planning Indemnity Scheme are as under

Section Coverage Limits

SECTION I (A-D) : For Beneciaries

I A Death following sterilization (inclusive of death during process

of sterilization operation) in hospital or within 7 days from the

date of discharge from the hospital

Rs. 2 lakh

I B Death following sterilization within 8 - 30 days from the date of

discharge from the hospital

Rs. 50,000/-

I C Failure of sterilization Rs 30,000/-

I D Cost of treatment in hospital and up to 60 days arising out of

complication following sterilization operation (inclusive of

complication during process of sterilization operation) from the

date of discharge

Actual not

exceeding

Rs. 25,000/-

SECTION II: Empanelled Doctors under Public and Accredited Private/NGO Sector and

Health Facilities under Public and Accredited Private/NGO Sector

II* Indemnity coverage up to 4 cases of litigations per doctor and

per health facility in a year

Upto Rs. 2 Lakh

per case of

litigation

*Indemnity coverage for service providers/health facilities has been detailed in Chapter 3.

1.2. Salient Features of the Scheme

1. The Family Planning Indemnity Scheme has all India coverage.

2. All persons undergoing/undergone sterilization operations in public health facility or

private/NGO facilities accredited by SQAC/DQAC for sterilization services are covered

under Section- I–A, I-B, I-C and I-D of the scheme.

3. The Consent Form duly lled in by the beneciary at the time of enrolling himself/herself

for sterilization operation duly countersigned at the medical facility shall be a proof of

coverage under the scheme (Annexure 2).

4. The medical records and checklist for female/male sterilization should also be duly lled

in by the Doctors/Health Facilities (Annexure 3).

5. All the doctors/health facilities in public sector and private/NGO facilities empanelled/

accredited with SQAC/DQACs conducting such operations are covered under Section-II

of the scheme. There is a stipulated criterion for empanelment of doctors/accreditations

of health facilities for sterilization which can be referred from “Standard and Quality

Assurance in sterilization services, Nov 2014”

6. All claims arising under Section I and Section II shall be admissible from 1

st

April 2013,

under the scheme.

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Manual for Family Planning Indemnity Scheme

7. Claims arising out of cases of sterilization operations which were detected and reported

aer 1st April, 2013, will come under the purview of State Programme Implementation Plans

(PIPs). Claims arising out of cases of sterilization operations detected and reported before

1st April, 2013, will not come under the purview of State Programme Implementation

Plans (PIPs). Such claims would be covered and processed as per the respective guidelines

of expired policies from 29th November 2005 to 31st March, 2013 and the convener of DISC

(CMO or Equivalent) designated for this purpose at district level would be responsible for

unpaid/time barred claims above. No provision will be made for unpaid claims in the State

PIPs.

8. The claims will fall within the “Family Planning Indemnity Scheme” only if the beneciary

les the claim with the DISC within 90 days from the occurrence of the event of death/

failure/complication.

9. Every claim, writ and summons related to the event of death/failure/complication should

be forwarded to SISC/DISC by the doctors/health facilities under Section II.

Manual for Family Planning Indemnity Scheme

15

Scheme Implementation

Chapter 2

2.1. Quality Assurance Committee

Quality Assurance Commiees (QACs) have been formed at the State and Districts level

to ensure that the Standards for female and male sterilization as laid down by the GoI are

followed in respect of pre-operative measures, operational facilities etc. The composition of the

Commiee would be as follows:

2.1.1 AT STATE LEVEL: State Quality Assurance Committee (SQAC)

2.1.1.1 Composition:

1. Secretary, Medical and Health (Chairperson)

2. Mission Director –NRHM (Vice Chairperson)

3. Director Family Welfare/Director Health Services/Director Public Health

Equivalent (Convener): to be nominated by the Chairperson.

4. Additional/Joint Director (FW)/Deputy Director (FW)/Equivalent,

designated by the state government as the nodal ocer for the Quality

Assurance (QA) Cell (Member Secretary)

5. Director, Medical Education

6. Director/Principal of state training institution e.g. SIHFW/CTI/RHFWTC

7. One Empanelled Gynaecologist (from public institutions)

8. One Empanelled Surgeon (from public institutions)

9. One Anaesthetist (from public institutions)

10. One Paediatrician (from public institutions)

11. State Nursing Adviser/ Equivalent

12. One member from an accredited private sector hospital/ NGO (health care

sector)

13. One representative from the legal cell

14. One representative from medical professional bodies e.g. FOGSI/ IMA/

IAP/IAPSM/ Association of Public Health

15. Any other member or representatives of public health organisations of

eminence as nominated by the state government

Note: The Quality Assurance Commiee as laid down in the ‘Standards

& Quality Assurance In Sterilization Services’, Nov 2014 shall stand

subsumed within the QAC mentioned above.

However a 5 member “State Indemnity Sub-Commiee (SISC)” from within

the SQAC would redress, dispose and disburse claims/complaints received

through the DQAC, to the district health society as per procedure and time

frame laid down in this manual.

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Manual for Family Planning Indemnity Scheme

The subcommiee would comprise of the following:

1. Mission Director –NRHM (Chairperson)

2. Director Family Welfare/Director Health Services/Director Public Health Equivalent

(Convener)

3. Additional/Joint Director (FW)/Deputy Director (FW)/Equivalent

(Member Secretary)

4. Empanelled Gynaecologist (from public institutions)

5. Empanelled Surgeon (from public institutions)

2.1.1.2 Terms of Reference of the Committee

y Visit both public and private facilities providing family planning services

in the state to ensure implementation of national standards.

y Review and report deaths/complications following Sterilization in the

state.

y Review and report conception due to failure of sterilization in the state

y Give directions on implementation of measures to improve quality of

sterilization services.

y Review the implementation of the National Family Planning Indemnity

Scheme / payment of compensation in the state.

y Share review report with all district commiees and other stakeholders.

y Send the regular reports on sterilization related indicators (Death,

Failure,Complication) to the Centre aer ratication of the same by the

Chairperson of the SQAC.

y The “State Indemnity Sub-Commiee(SISC)” would meet every six

months or sooner if warranted.

y At least three members would constitute the quorum of this sub-

commiee.

2.1.2 AT DISTRICT LEVEL: District Quality Assurance Committee (DQAC)

2.1.2.1 Composition

1. District Collector, Chairperson

2. Chief Medical Ocer/District Health Ocer (Convener)

3. District Family Welfare Ocer/RCHO/ACMO/equivalent (Member

Secretary)

4. Nodal Ocers of Programme Divisions at districts

5. One empanelled gynaecologist (from public institutions)

6. One empanelled surgeon(from public institutions)

7. One anaesthetist (from public institutions)

8. One paediatrician (from public institutions)

9. One representative from the nursing cadre

10. One representative from the legal cell

11. One member from an accredited private sector hospital/ NGO (health care

sector)

12. One representative from medical professional bodies e.g. FOGSI/IMA/

IAP/IAPSM/ Association of Public Health

Manual for Family Planning Indemnity Scheme

17

However a 5 member “District Indemnity Sub-Commiee (DISC)” from

within the DQAC would review and process claims received from the

clients and complaints/ claims lodged against the surgeons and accredited

facilities, as per procedures and time frame laid down in this manual.

The subcommiee would comprise of the following:

1. District Collector, (Chairperson)

2. Chief Medical Ocer/District Health Ocer (convener)

3. District Family Welfare Ocer/RCHO/ ACMO/ equivalent (member

secretary)

4. Empanelled gynaecologist (from public institutions)

5. Empanelled surgeon (from public institutions)

2.1.2.2 Terms of Reference of the committee

y Conducting medical audit of all deaths related to Sterilization and sending

reports to the State QA commiee oce.

y Collecting information on all hospitalization cases related to complications

following sterilization, as well as sterilization failure.

y Reviewing all static institutions i.e. Government and accredited Private/

NGOs and selected camps providing sterilization services for quality of

care as per the standards and recommend remedial actions for institutions

not adhering with standards.

y Review, report and process compensation claims for onward submission

to the SISC under the National Family Planning Indemnity Scheme for

cases of deaths, failure and complication following male and female

sterilization procedures.

y In case facility reports sterilization related death, the convenor of the DISC

should inform the convenor of the SISC within 24 hours.

y Death audit needs to be undertaken mandatorily for each case of death by

the DISC.

y The “District Indemnity Sub-Commiee (DISC)” would meet every

three months or sooner if warranted.

y At least three members would constitute the quorum of this sub-

commiee.

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Manual for Family Planning Indemnity Scheme

Operational Procedure for Claim Settlement

Chapter 3

3.1. Claims Procedure for Section I (Death/Failure/Complication)

1. In the event of death/failure/complication following sterilization, the beneciary shall

immediately ll up claim form (Annexure 1).

If such covered cause is detected “during examination of the beneciary in health facility”,

the health facility shall ensure to get the claim form lled from the beneciary on the

spot without loss of time. The health facility shall forward the claim papers along with

necessary documents to the DISC.

2. On receiving the claim papers, proper acknowledgement must be made by the DISC, for

further processing and payment of the claims. Based on the submied documents, claims

shall be processed by the DISC under dierent sections of the scheme.

3. The claims processing under Section-I (death, failure and complication) following

sterilization operation will be processed by the DISC and forwarded to SISC. The SISC can

scrutinize the documents and ask for any new and relevant piece of information missing

from the recommendation of the DISC. However, if the district is reporting suspiciously

large number of claims for failure/complication, the SISC has the right to verify the claims

and recommend the release of funds to the district accordingly.

4. The SISC should review and examine every single case of death before endorsing.

5. Verication and medical evaluation of the claim lodged by the beneciary would be done

by the DISC and for all purpose the authority shall be with the convenor of DISC (CMO or

Equivalent) designated for this purpose at district level.

6. The Claims processing together with all the required documents should preferably be

completed within 30 days of ling of claims by the beneciary.

7. Stipulated time limit for selement of claims under Section-I of the scheme would

be 15 working days in case of death and 21 days in case of others, aer completion of

documentation.

3.1.1. Death Following Sterilization (Section I-A & B)

Claims under Section-I-A (death following Sterilization (inclusive of death during

process of sterilization operation) in hospital or within 7 days from the date of discharge

from the hospital) and under Section I-B (death following sterilization within 8-30

days from the date of discharge from the hospital) shall be paid equally in favor of the

spouse and unmarried dependent children whose names are entered in the relevant

rows of Consent Form. In case there is no surviving spouse, the payment shall be made

to the unmarried dependent children only.

If the death occurs within 7 days of discharge or during the process of sterilization

operation the amount of Rs 50,000/- (in cash only if there is no accounts/Jan Dhan

accounts) should be released immediately from the State or District Health Society

funds. The balance amount of Rs 1.5 lakhs will be released through account payee

cheque/DBT(wherever account number /Jan Dhan account is available) later only

when the DISC recommends compensation under “Death aributable to Sterilization”

to the SISC and the SISC endorses (Please refer D.O No. Y.11013/1/2016-FP dated 29

th

January, 2016 for further clarication).

If the death occurs beyond 7 days of discharge to one month, the DISC should examine

the case and establish the cause. If death is aributed to sterilization and subsequently

Manual for Family Planning Indemnity Scheme

19

endorsed by SISC, Rs 50,000/- (through account payee cheque/DBT, wherever account

number /Jan Dhan account is available) should be paid to the kin of the deceased whose

names are entered in the relevant rows of the Consent Form.

If the dependent children are minor, the payment shall be made by the District Health

Society in the name of minor children. The cheques, in this case would be issued by the

District Health Society in the name of minor beneciary with the following endorsement

(overleaf);

“Amount to be deposited as FDR in the name of minor Sh/Ku ................. till the minor

aains the maturity. No premature payment of FDR is allowed. Quarterly interest

may be paid to the guardian”.

In case, there are no surviving spouse/unmarried dependent children, the claim shall

then be payable to the legal heir of the deceased beneciary subject to production of

legal heir certicate.

In case of ling claims for death under Section-I (IA & IB) following sterilization

operation (inclusive of death during process of sterilization operation), following

documents are required to be submied by the kin of the deceased beneciary:

a) Claim Form Cum Medical Certicate in original,

b) Copy of death certicate issued by hospital/ municipality or any other authority

c) Copy of Post-Operative Instruction Card/Discharge Certicate

Documents required for processing of claims for death following sterilization under

(Section I-A & B)

a) Claim Form cum Medical Certicate in original duly signed and stamped by the

convener of DISC (CMO or Equivalent ) designated for this purpose at district level

(Annexure 1).

b) Copy of Consent Form & Medical Record and Checklist duly aested by the

convener of DISC (CMO or Equivalent )designated for this purpose at district level

(Annexure 2 & Annexure 3).

c) Copy of Post-Operative Instruction Card /Discharge Certicate duly aested by the

convener of DISC (CMO or Equivalent) designated for this purpose at district level

(Annexure 5).

d) Copy of Death certicate issued by Hospital/Municipality or authority designated

duly aested by the convener of DISC (CMO or equivalent) designated for this

purpose at district level.

e) Proforma for Conducting Audit of Death by DISC (Annexure 6).

3.1.2. Failure of Sterilization (Section I-C)

In case of ling claims for failure of sterilization under Section I-C, following

documents are required to be submied by claimant.

a) Claim Form cum Medical Certicate in original

b) Copy of Sterilization Certicate

c) Copy of any Diagnostic Report conrming Failure of Sterilization

20

Manual for Family Planning Indemnity Scheme

Documents required for processing of claims for failure of sterilization under

(Section I-C)

a) Claim Form cum Medical Certicate in original duly signed and stamped by the

convener of DISC (CMO or Equivalent) designated for this purpose at district level

(Annexure 1).

b) Copy of Consent Form & Medical Record & Checklist duly aested by the convener

of DISC (CMO or Equivalent) designated for this purpose at district level (Annexure

2 & 3).

c) Copy of Sterilization Certicate duly aested by the convener of DISC (CMO or

Equivalent) designated for this purpose at district level (Annexure 4).

d) Copy of any of the Diagnostic Reports (as given in Section 3.1.2.1, 3.1.2.2) conrming

failure of sterilization duly aested by the convener of DISC (CMO or Equivalent)

designated for this purpose at district level.

e) Report on complication/failure following sterilization by District Quality Assurance

Commiee (Annexure 7).

3.1.2.1 In Case of Failure of Tubectomy following Documents can be Submitted

1. Urine test report supported by Physical Examination report/ANC Card/

USG report

2. Physical examination report

3. USG report

4. Certicate of MTP /MTP report

3.1.2.2 In Case of Failure of Vasectomy

1. Semen Examination Report

NOTE: Any one of the diagnostic reports detecting failure of sterilization would be

sucient for processing the claim under this section.

3.1.3. Complications Arising Following Sterilization (Section I-D)

For claims arising due to complications following sterilization operation (inclusive of

complication during process of sterilization operation) as per Section I-D, following

documents are required to be submied by claimant.

a) Claim Form cum Medical Certicate in original

b) Copy of Post-Operative Instruction Card/Discharge Certicate

c) Original Bills/Receipts/Cash Memos along with Original Prescription and Case

Sheet conrming treatment taken for complication due to sterilization.

Documents required for processing claims of complications arising due to

Sterilization under (Section I-D)

a) Claim Form cum Medical Certicate in original duly signed and stamped by the

convener of DISC ( CMO or Equivalent )designated for this purpose at district level

(Annexure 1).

b) Copy of Consent Form & Medical Record & Checklist duly aested by the convener

of DISC (CMO or equivalent ) designated for this purpose at district level (Annexure

2 & 3).

Manual for Family Planning Indemnity Scheme

21

c) Copy of Post-Operative Instruction Card /Discharge Certicate duly aested by the

convener of DISC (CMO or Equivalent) designated for this purpose at district level

(Annexure 5).

d) Original Bills/Receipts/Cash Memos along with Original Prescription and Case

Sheet conrming treatment taken for complication following sterilization. Convener

of DISC (CMO or Equivalent) designated for this purpose at district level shall

certify the cost of treatment of such complications incurred by the beneciary and

or hospital.

e) Report on complication/failure following sterilization by District Quality Assurance

Commiee (Annexure 7).

NOTE: No additional document should be solicited by the designated district level

ocer

Flowchart Illustrating the Steps of the Claims Process

Beneciary to le the claims document (within 90

days from the occurrence of event of Death/Failure/

Complication).

Stipulated time limit

for selement of

claims would be 15

working days in case

of death and 21 days

in case of others,

aer completion of

processing.

DISC to process (Signing, Stamping and

Authenticating the documents) the claims arising

out of death, complication and failure aributable to

sterilization and put up to SISC.

SISC to scrutinize the documents and if required, call

for any new and relevant material missing from the

recommendation of DISC. SISC to endorse the cases

and release funds to the district, wherever applicable.

Mandatory : SISC TO REVIEW EVERY SINGLE

CASE OF DEATH BEFORE ENDORSING

The Claims processing together with all the required

documents should preferably be completed within 30

days from the date of receipt of claim.

3.2 Claims Procedure for Section II ( Indemnity Coverage to Doctors/Facilities)

1. For claims under Section II of the scheme, it will be the responsibility of the doctor/health

facility on receiving any Legal Notice/ Summons from the Court to immediately inform,

in writing, to SISC/DISC, who would thereaer, take over entire defense process of the

case, including engagement of advocate and payment of legal expenses which would be

paid later by State Health Society/ District Health Society. However, State Health Society/

District Health Society shall not be liable to pay more than the amount mentioned in the

Section - II in any case, under all heads.

22

Manual for Family Planning Indemnity Scheme

2. In emergent situation the defence costs incurred by the doctor/health facility shall be

reimbursable, if incurred in consultation with the SISC/DISC; the defence costs shall be

limited to Rs. 5,000 per incidence for such cases under section II.

3. Liability of the State Health Society under Section -II would be limited to four cases of

litigation in respect to every doctor and health facility in a year. Empanelled Doctors*

under Public and accredited Private/NGO Sector and Health Facilities** under Public and

Private/NGO Sector accredited with SQAC/DQACs for rendering sterilization services shall

stand indemnied against the litigation cases arising out of death, failure or complication

resulting therefrom, up to a maximum amount of Rs. 2 lakh per doctor and per facility upto

4 cases of litigation per year.

*For Empanelled Public/Private Providers: A maximum of 4 cases of litigation

y Irrespective of the number of sterilization cases he/she performs.

y Irrespective of the number of health facilities where he/she conduct surgeries.

**For Public and Accredited Private/NGO Facilities: A maximum of 4 cases of litigation

y Irrespective of the number of sterilization cases performed in that facility

y Irrespective of the number of empanelled providers conducting surgeries at that

facility.

3.2.1 Documents Required Under Indemnity Cover (Section II)

a) Intimation in writing

b) Copy of summons/FIR

c) Copy of Sterilization Certicate (Annexure 4)

d) Copy of Consent Form (Annexure 2)

e) Certicate from the convener of DISC (CMO or Equivalent) designated for this

purpose at district level conrming that the sterilization operation was conducted

by the doctor etc.

f) Copy of the award given by the court along with the original receipts for which

payment is made to the lawyer

In case any claim is found untenable, the reason for rejection of the claim will be

communicated to the beneciary/kin by the convener of DISC (CMO or Equivalent) of

the district with a copy to the State Nodal Ocer.

District Health Society shall not be liable under this scheme for compensation

under more than one Section in respect of the same eventuality except under section

(I-C & D).

Manual for Family Planning Indemnity Scheme

23

Monitoring of the Scheme

Chapter 4

4.1 Mechanism of Monitoring of the Scheme

4.1.1 At State/District Level-

y District Quality Assurance Commiee (DQAC) shall review quarterly the status

of accredited facilities, empaneled providers, claim status, period of pendency of

claims and advice the district ocials to respond/comply with the deciencies, if

any. In case the numbers of pending claims are high, the commiees can meet sooner

if warranted. Moreover, SISC may intervene to fast track the claim disbursement

process.

y In case of death aributable to sterilization DISC should audit every single case as

per procedure laid in Quality Assurance Guidelines issued by Ministry of Health

and Family Welfare, GOI in compliance with the Hon’ble Supreme Court directions

(Annexure 6).

y The claims aer due diligence by the DISC should be put up to the SISC who would

be the nal arbiter for the same.

y SQAC/DQAC shall ensure that each district and health facility is provided with

FPIS Manual and mandatory documents required for claims.

y SISC/DISC shall ensure that District Ocials are ling the FPIS Claims well within

the stipulated period as per the scheme.

y Convener of SISC (Director Family Welfare or Equivalent) designated for this

purpose at state level shall review all pending maers including pending claims on

monthly basis.

y State shall organize review meetings on biannual basis to review all pending maers

including pending claims under the chairmanship of Mission Director (NHM) with

the designated district machinery.

y State shall monitor the low/high reporting trend of FPIS claims from the districts;

review the performance of the empanelled providers and issues necessary guidelines

for corrective measures.

y The MOHFW, GOI shall conduct annual review on all maers relating to FPIS.

4.1.2 Reporting Mechanism

y State will collate the district wise beneciary claim status as per the prescribed

format and will furnish the details to the Government of India on quarterly basis

(Annexure 9).

y District will submit Quarterly Report to the State showing claims pertaining to

death, complication, failure of sterilization, including claims under Section II

(Annexure 10).

y Copy of all death audit reports will be analysed by the state in a periodic manner

and the same will be shared quarterly with FP Division at Central Level (Annexure

6 & Annexure 12).

y States/UTs will share the annual claim status pertaining to death, complication,

failure of sterilization and the amount paid as compensation under each category

(Annexure 11).

24

Manual for Family Planning Indemnity Scheme

ANNEXURES

Manual for Family Planning Indemnity Scheme

27

Claim Form for Family Planning Indemnity

Scheme

Annexure-1

1. This form “Claim Form cum Medical Certicate” is required to be completed for lodging claim

under Section-I of the scheme.

2. This form is issued without admission of liability and must be completed and returned to the

District Health Society/State Health Society for processing of claim.

3. No claim can be admied unless certied by the convener of DISC (CMO or Equivalent )

designated for this purpose at district level by the State Government.

Claim no. : _________________

PART A: Beneciary/Claimant Information (To be Submied by Claimant)

1. Details of the Claimant:

Name in full: ___________________________________________________ Present Age: ______ Years

Relationship with the beneciary of Sterilization: __________________________________________

Residential Address: ___________________________________________________________________

_________________________________________ Telephone no. ________________________________

2. Details of the person undergone sterilization operation:

Name in Full: ______________________________________________ Age: __________________ Years

Son /daughter of: ______________________________________________________________________

Name of the Spouse: _______________________________________ Age of the Spouse: _______Years

Address: ______________________________________________________________________________

3. Occupation/Business: __________________________________________________________________

4. Details of Dependent children:

S. No. Name Age

(Yrs)

Sex

(M/F)

Whether

Unmarried

If unmarried,

Whether

dependent

1

2

3

5. (a) Date of Sterilization Operation:______________________________________________________

(b) Nature of Sterilization operation:

(i) Interval Tubectomy: ____________________________________________________________

(ii) Vasectomy: ____________________________________________________________________

(iii) MTP followed by sterilization: ___________________________________________________

28

Manual for Family Planning Indemnity Scheme

(iv) Post Partum Sterilization (Caesarean/ Normal Delivery): ______________________________

(v) Any other surgery followed by sterilization: _______________________________________

6. (a) Name and address of the doctor who conducted the operation:

__________________________________________________________________________________

(b) Name and address of the hospital where operation was conducted:

__________________________________________________________________________________

(c) Nature of claim:

1) Failure of sterilization :

2) Complication due to Sterilization (state exact nature of complication):

a. Date: _______________

b. Details of Complication:__________________________

c. Doctor /Health facility: ___________________________

3) Death aributable to sterilization:

a. Date of Admission: _______________ Time:___________

b. Date of Discharge :________________ Time:___________

c. Date of Death:____________________ Time:___________

7. Give details of any disease suered by beneciary prior to undergoing sterilization operation:

______________________________________________________________________________________

I HEREBY DECLARE that the particulars are true to the best of my knowledge and warrant the

truth of the foregoing particulars in every respect, and I agree that if I have made, or shall make any

false of untrue statement, suppression or concealment of fact, my right to the compensation shall

be absolutely forfeited.

I hereby claim a sum of Rs._________________________/- under the scheme, which I agree in full

selement of my claim and shall have no further right whatsoever to claim under the scheme.

Date: _______________ Name of Client/Claimant: _____________________________________

Place: ______________ Signature (in full) or thumb impression

Manual for Family Planning Indemnity Scheme

29

PART B: MEDICAL CERTIFICATE

(To be issued by CMO or Equivalent designated for this purpose at district level)

It is certied that Smt/Shri. _________________________________________________________________

S/o/W/o: _________________________________________________________________________________

R/o______________________________________________________________________________________

had undergone ________________________________(Specify which procedure was done) sterilization

operation on_____________ at _______________________________________ (hospital) and conducted

by Dr.__________________________________Qualications _______________________empanelled for

____________________procedure posted at ___________________________________________________

____________________________________________________

Nature of Sterilization operation done:

(i) Interval Tubectomy: ___________________________________________________________________

(ii) Vasectomy: __________________________________________________________________________

(iii) MTP followed by Sterilization: __________________________________________________________

(iv) Post Partum Sterilization (Caesarean/ Normal Delivery): ___________________________________

(v) Any other surgery followed by Sterilization: ______________________________________________

I have examined all the medical records and documents and hereby conclude that the sterilization

operation is the antecedent cause of:

(a) Failure of Sterilization (Aach documentary evidence)

(b) Complication: (please give the details as under)

(i) Nature of Complication:______________________________ ____________

(ii) Period: ________________________________________________________

(iii) Expenses incurred for treatment of complication Rs. ___________ (Aach Original Bills/

Receipts/Prescriptions)

(c) Death of Person (cause): ___________________________________________________

a. Date of Admission: ______ Time: _____

b. Date of Discharge:______ Time: ______

c. Date of Death: ______________ Time: __________ (Aach death certicate)

I have further examined all the particulars stated in the claim form and are in conformity with my

ndings and is eligible for a compensation of Rs…………………… due to……………………… (Cause).

30

Manual for Family Planning Indemnity Scheme

Please pay Rs_________________________ to the beneciary.

Documents Enclosed:

(a) Original Claim cum Medical certicate ( )

(b) Aested copy of sterilization certicate ( If applicable) ( )

(c) Aested copy of consent form ( )

(d) _________________________________ ( )

(e) _________________________________ ( )

Date:______________________________ Seal:

Name____________________________ Designation___________________

Tel/Mob. No. _____________________ Signature _____________________

Manual for Family Planning Indemnity Scheme

31

Application Cum Consent Form for

Sterilization Operation

Annexure-2

An informed consent is to be taken from all clients of sterilization before the performance of the surgery

as per the consent form placed below

Name of Health Facility………….……………….............................…………………………………………..

Client Hospital Registration Number: …...........................……………………………………………………

Date: ………/……./20…..…

1. Name of the Client: Shri/Smt. ….………………..………........................…………………………………

2. Name of Husband/Wife: Shri/Smt. ………….………….........................………………………………....

3. Address …………………..………………………………........................…………………………………..

4. Contact No: ……………………....................................................................................................………..…

5. Names of all living, unmarried dependent Children

i) ……..………………………........…………… Age……………………………………..............………….

ii)……………………….........………………… Age………………………………...............……………....

iii)……………………….........………………… Age…………………………..............…………………....

iv)………………………………..........………… Age…………………….............…………………………

6. Father’s Name of beneciary: Shri……………………………........................………………..…………..

7. Address: ………………………………………………........................……………………………………...

8. Religion/Nationality: ………………………………..........................……………………….……………...

9. Caste- SC/ST/General………………........................……………………………………………………….

10. Status- APL/BPL

11. Educational Qualications…….............................…………………………………………………………

12. Business/Occupation: …………………………………............................…………….……………………

13. Operating Centre: …………………………………...........................……………………………………….

32

Manual for Family Planning Indemnity Scheme

I, Smt/Shri …………………………………… (client) hereby give consent for my sterilization operation.

I am ever married. My age is ……years and my husband/wife’s age is …… years. I have …(Nos.) male

and …. (Nos.) female living children. The age of my youngest living child is …… years.

a) I have decided to undergo the sterilization / re-sterilization operation on my own without any

outside pressure, inducement or force. I declare that I / my spouse has not been sterilized previously

(not applicable in case of re-sterilization).

b) I am aware that other methods of contraception are available to me. I know that for all practical

purposes this operation is permanent and I also know that there are still some chances of failure of

the operation for which the operating doctor and health facility will not be held responsible by me

or by my relatives or any other person whomsoever

c) I am aware that I am undergoing an operation, which carries an element of risk.

d) The eligibility criteria for the operation have been explained to me and I arm that I am eligible to

undergo the operation according to the criteria.

e) I agree to undergo the operation under any type of anaesthesia, which the doctor/health facility

thinks suitable for me and to be given other medicines as considered appropriate by the doctor/

health facility concerned. I also give consent for any additional life-saving procedure, if required

f) I agree to come for follow-up visits to the Hospital/Institution/Doctor/health facility as instructed,

failing which I shall be responsible for the consequences, if any.

g) If, aer the sterilization operation, I experience a missed menstrual cycle, then I shall report within

two weeks of the missed menstrual cycle to the doctor/health facility and may avail of the facility

to get an MTP done free of cost. I shall be responsible for the consequences, if any.

h) I understand that Vasectomy does not result in immediate sterilization. *I agree to come for

semen examination 3 months aer the operation to conrm the success of sterilization surgery

(Azoospermia) failing which I shall be responsible for the consequences, if any.

*Applicable for male sterilization cases)

i) In case of complications, failure and the unlikely event of death aributable to sterilization, I/

my spouse and dependent unmarried children will accept the compensation as per the existing

provisions of the Government of India “Family Planning Indemnity Scheme” as full and nal

selement and will not be entitled to claim any other compensation including compensation for

upbringing of the child, if any, born on account of failure of sterilization, over and above the

one oered, from any court of law in this regard.

I have read the above information or the above information has been read out and explained to me in

my own language and that this form has the authority of a legal document.

I am aware that I have the option of deciding against the sterilization procedure at any time without

sacricing my rights to other reproductive health services.

Date: …….....………… Signature or Thumb Impression of the Client

Name of client: ….....................………………………….

Signature of Witness (Clients side):

Full Name: ……………..........……………………….……

Full Address………………………………………........….

Manual for Family Planning Indemnity Scheme

33

I am aware that client is ever married and has 1 living child over one year of age

Signature of ASHA/ Counsellor/ Motivator:……………………………………………...........................……

Full Name: …………………………………….……………………………………............................………….

Full Address…………………………………………………………………...........................………………….

I certify that I have satised myself that -

a. Shri/Smt……………………………………is within the eligible age-group and is medically t for the

sterilization operation.

b. I have explained all clauses to the client and that this form has the authority of a legal document.

c. I have lled the Medical record–cum-checklist and followed the standards for sterilization

procedures laid down by the Government of India.

Signature of Operating Doctor Signature of Medical Ocer in-charge of the Facility

(Name of Operating Doctor) (Name of Medical Ocer in-charge of the Facility)

Date: ………..............……… Date: ………………………

Seal Seal

DENIAL OF STERILIzATION

I certify that Shri/Smt………………………………………………………………..is not a suitable client for

sterilization/re-sterilization for the following reasons:

1. ……………………………………………………………..................................……………………………….

2. ………………………………………..................................…………………………………………………….

He/She has been advised the following alternative methods of contraception.

1. ……………………………….................................……………………………………………………………..

2. ………………………………………...............................………………………………………………………

Signature of the Doctor making the decision

Date: ……........……

Name and full Address: …………………........…............................…………………………………………

34

Manual for Family Planning Indemnity Scheme

Medical Record & Check List for Female /

Male Sterilization

Annexure-3

A checklist is to be lled by the doctor before conducting sterilization procedure for ensuring the

eligibility and tness of the client for sterilization.

Name of Health Facility: ………………………...............................................…………………………………

Beneciary Registration Number: ……….....................................................…………………………………..

Date………………….

A. Eligibility Checklist

Client is within eligible age Yes…………….... No……..………….

Client is ever married Yes…………….... No……..………….

Client has at least one child over one year of age Yes…………….... No……..………….

Lab investigations (Hb, urine) undertaken are within

normal limits (7.0 gms or more)

Yes…………….... No……..………….

Medical status as per clinical observation is within normal

limits

Yes…………….... No……..………….

Mental status as per clinical observation is normal Yes…………….... No……..………….

Local examination done is normal Yes…………….... No……..………….

Informed consent given by the client Yes…………….... No……..………….

Explained to the client that consent form has authority of

a legal document

Yes…………….... No……..………….

Abdominal/Pelvic examination has been done in the

female and is within normal limits

Yes…………….... No……..………….

Infection prevention practices as per laid down standards Yes…………….... No……..………….

B. Menstrual History (for female clients)

Cycle Days

Length

Regularity Regular………........…………………...

Irregular………........………………….

Date of LMP (DD/MM/YYYY) …………/……../………………

C. Obstetric History (for female clients)

Number of Spontaneous Abortions

Number of Induced Abortions

Currently Lactating Yes………….......…. No…....…………

Amenorrheic Yes………….......…. No…....…………

Whether Pregnant Yes………….......…. No…....…………

If Yes (No. of weeks pregnancy)

……………………….....................

No. of Children Total No…........................................…..

Date of Birth of Last Child (dd/mm/yyyy) ……../………../………..

Manual for Family Planning Indemnity Scheme

35

D. Contraceptive History

Have you or your spouse ever used contraception? Yes..........…………. No….......……….

Are you or your spouse currently using any contraception

or have you or your spouse used contraception during the

last six months?

() Tick the option

None……..........…………..………….

IUCD………..........…………………..

Condoms…........…………………….

Oral Pills……........…………….…….

Any Other (specify)………......…….

E. Medical History

Recent medical Illness Yes…………….... No……..………….

Previous Surgery Yes…………….... No……..………….

Allergies to medication Yes…………….... No……..………….

Bleeding Disorder Yes…………….... No……..………….

Anemia Yes…………….... No……..………….

Diabetes Yes…………….... No……..………….

Jaundice or liver disorder Yes…………….... No……..………….

RTI/STI/PID Yes…………….... No……..………….

Convulsive disorder Yes…………….... No……..………….

Tuberculosis Yes…………….... No……..………….

Malaria Yes…………….... No……..………….

Asthma Yes…………….... No……..………….

Heart Disease Yes…………….... No……..………….

Hypertension Yes…………….... No……..………….

Mental Illness Yes…………….... No……..………….

Sexual Problems Yes…………….... No……..………….

Prostatitis (Male sterilization) Yes…………….... No……..………….

Epididymitis (Male Sterilization) Yes…………….... No……..………….

H/O Blood Transfusion Yes…………….... No……..………….

Gynecological problems (Female Sterilization) Yes…………….... No……..………….

Currently on medication (if yes specify) Yes…………….... No……..………….

Comments ........................................................................................................................................................

............................................................................................................................................................................

F. Physical Examination

BP…………....................……………….Pulse…………….................………..Temperature……..………..

Lungs Normal……….. Abnormal……...……

Heart Normal……….. Abnormal……...……

Abdomen Normal……….. Abnormal……...……

36

Manual for Family Planning Indemnity Scheme

G. Local Examination (Strikeout whichever is not applicable)

1. Male Sterilization

Skin of Scrotum Normal……....................….. Abnormal…..........…...……

Testis Normal……....................….. Abnormal…..........…...……

Epididymis Normal……....................….. Abnormal…..........…...……

Hydrocele Yes…..........…....…….…..…. No………....................…….

Varicocele Yes…..........…....…….…..…. No………....................…….

Hernia Yes…..........…....…….…..…. No………....................…….

Vas Deferens Normal……....................….. Abnormal…..........…...……

Both Vas Palpable Yes…..........…....…….…..…. No………....................…….

2. Female Sterilization

External Genitalia Normal……....................….. Abnormal…..........…...……

PS Examination Normal……....................….. Abnormal…..........…...……

PV Examination Normal……....................….. Abnormal…..........…...……

Uterus Position A/V……….................………R/V……...............………….

Mid position…….................Not determined…...............

Uterus size Normal……….. Abnormal……...……Size…………

Uterus Mobility Yes…..................…..No………………. Restricted / Fixed

Cervical Erosion Yes…..........…....…….…..…. No………....................…….

Adnexa Normal……....................….. Abnormal…..........…...……

Comments ........................................................................................................................................................

............................................................................................................................................................................

H. Laboratory Investigations

Hemoglobin level ………...……..............................………………….Gms%

Urine: Albumin Yes…..........…....…….…..…. No………....................…….

Urine- Sugar Present…….......................... Absent…..............................

Urine test for Pregnancy Positive: ……........................ Negative: …….....................

Any Other (specify) ...............................................................................................

Name: Signature of the Examining Doctor

Date: HOSPITAL SEAL

Manual for Family Planning Indemnity Scheme

37

I. Preoperative Preparation

Fasting Yes ..................duration…….... hrs. No…................……

Passed urine Yes…..........…....…….…..…. No………....................…….

Any other (specify)

J. Anaesthesia/Analgesia

Type of anesthesia given

() Tick the option

y Local only

y Local and analgesia

y General, no intubation

y General, intubation

y Any other (specify)

Time

Drug name

Dosage

Route

..............................................................................................

*Signature of anaesthetist in case of regional or general anaesthesia

K. Surgical Approach

Male sterilization

Local anaesthesia Lignocaine 2% ............................cc/Other...............................

Technique Conventional.............................. NSV................................

Type of incision Conventional NSV Single vertical....................... Double vertical........................

Single puncture .......................................................................

Material for occlusion of vas 2-0 Silk ................................... 2-0 Catgut...............................

Fascial interposition Yes …….........................…… No……….............…………

If no, give reasons...............................................................

……………………………..................……………………..

Length of vas resected .......................................................................................... Cm

Suture of skin for conventional

vasectomy

Silk ................................... Other ...................................

Surgical notes

Any other surgery done at time of

sterilization?

Yes …….........................…… No……….............…………

If yes give details...................................................................

Specify details of complications and

management

Name…………………………………….. Signature of the Operating Surgeon

Date……………………………………

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Manual for Family Planning Indemnity Scheme

Female sterilization

Local anaesthesia Lignocaine %

Other

Timing of procedure

() Tick the option used

y Within 7 days post-partum...............................................

y Interval (42 days or more aer delivery or abortion) ..

y With abortion, induced or spontaneous.........................

y Less than 12 weeks .......................................................

y More than 12 weeks

y Any other (specify)

Technique

() Tick the option used

y Minilap Tubectomy

y With C section

y With other surgery .........................................................

y Laparoscopy Tubal Occlusion

y SPL/DPL ..........................................................................

Method of occlusion of fallopian

tubes

() Tick the option used

y Modied Pomeroy Laparoscopy:

y Ring

y Clip

Details of gas insuation

pneumoperitoneum created (CO2/

Air)

Yes ………...................................….. No………....…………..

Insuator used Yes ......................................... No............................................

Specify details of complications and

management

Name ………………………………………… Signature Of The Operating Surgeon

Date…………………………………………..

L. Vital Signs: Monitoring Chart (For Female Sterilization)

*Sedation: 0—Alert 1—Drowsy 2—Sleeping/arousable 3—Not arousable

Event Time Sedation* Pulse Blood

Pressure

Respiratory

Rate

Bleeding Comments

(Treatment)

Preoperative (every 15

in aer premedication)

Intra-operative

(continuous)

Post-operative

1. Every 15 min for

rst hour and longer

if the patient is not

stable/awake

2. Every 1 hour until 4

hours aer surgery

15 min

30min

45 min

1 hr

2 hrs

3 hrs

4 hrs

Name: .................................................................... Signature of the Aending Sta Nurse

Date: .......................................

Manual for Family Planning Indemnity Scheme

39

M. Post-Operative Information

Passed urine Yes .............................. No........................................

Abdominal distension Yes .............................. No........................................

Patient feeling well Yes .............................. No........................................

If no, please specify

N. Instructions For Discharge

Male sterilization client observed for half an

hour aer surgery

Yes .............................. No........................................

Female sterilization client observed for four

hours aer surgery

Yes .............................. No........................................

Post-operative instructions given verbally Yes .............................. No........................................

Post-operative instructions given in writing Yes .............................. No........................................

Patient counselled for postoperative

instructions

Yes .............................. No........................................

Comments

Name…………………………………… Signature of the Discharging Doctor

Date: .......................................

40

Manual for Family Planning Indemnity Scheme

Sterilization Certiﬁcate

Annexure–4

Hospital Registration No. (IPD/OPD) _______________

1. This is to certify that Smt/ Shri………................................................................................ S/O; W/O Shri

............................................................................. working as .......................................residing at ..............

....................... ........................................................ has undergone Minilap Tubectomy – (Interval/Post-

Partum/Post Abortion/Concurrent with other procedures)/Laparoscopic Tubal Occulsion (Interval/

Post Abortion/Concurrent with other surgeries)/Vasectomy Conventional/NSV) in this facility/

hospital ....................................................................(Name of facility/Hospital) on .................................

by Dr..............................................................................

For Female Sterilization:

2. She has resumed her menstrual Cycle (LMP_____) or she has not resumed her menses within the

month of sterilization but pregnancy test is negative.

For Male Sterilization:

3. His semen examination undertaken on (Date)_________________ revealed no sperm (azoospermia)

*Strike out whichever is not applicable

She/ He is therefore certied to be sterile

Signature of Medical Ocer I/c

Name…………….....…………….

Date ............................ Seal .............................................

Note :

• Client should acknowledge ‘received’ on the duplicate copy before receiving the original copy. The

duplicate to be maintained as a record in the facility as per state norms.

Manual for Family Planning Indemnity Scheme

41

Post Operative Instruction Card

Annexure–5

Name and type of hospital/facility

Client's name

Father's name

Husband's name/Wife’s Name

Address

Contact number (if available)

Date of operation (dd/mm/yyyy) ....................../ ....................../ ......................

Type of operation Minilap/Post-partum/Laparoscopic (SP/DP)/

Conventional Vasectomy/NSV................................

1. Follow-up:

a) Aer 48 hours, rst contact is established

b) On the 7th day for stitch removal

c) For Female Sterilization: Aer one month or aer rst menstrual period, whichever is earlier

For Male Sterilization: Aer 3 months, for semen examination for sperm count

d) In an emergency, as and when required to the nearest health facility

2. Medication as prescribed

3. Return home and rest for the remainder of the day

4. For Female Sterilization: - Resume only light work aer 48 hours and gradually return to full

activity in two weeks following surgery.

5. For Male Sterilization: - Scrotal support or snug undergarment for 48 hours.

- Resume normal work aer 48 hours and return to full activity,

including cycling, within one week following surgery.

6. Resume normal diet as soon as possible.

7. Keep the incision area clean and dry. Do not disturb or open the dressing.

8. Bathe aer 24 hours following the surgery. If the dressing becomes wet, it should be changed so

that the incision area is kept dry until the stitches are removed.

9. Sexual intercourse:

Vasectomy/ Tubectomy does not interfere with sexual pleasure, ability, or performance

Female Sterilization: In the case of interval sterilization (Minilap and Laparoscopic), the

client may have intercourse one week aer surgery or whenever she

feels comfortable thereaer.

In case of post partum sterilization (aer caesarian or normal delivery)

client may have intercourse 2 weeks aer sterilization or whenever she

feels comfortable.

Male Sterilization: The client may have intercourse whenever he is comfortable aer the

surgery but must ensure use of condom if his wife/partner is not using

any method of contraception.

42

Manual for Family Planning Indemnity Scheme

10. Report to the doctor or clinic if there is excessive pain, fainting, fever, bleeding or pus discharge

from the incision, or if the client has not passed urine, not passed atus and experiences bloating

of the abdomen.

11. Contact health personnel or a doctor in case of any doubt.

12. Female Sterilization: Return to the facility if there is any missed period/suspected pregnancy,

within two weeks to rule out pregnancy.

13 Male Sterilization: Return to the facility aer three months for semen examination to see

if azoospermia has been achieved. If semen still shows sperm return to

facility every month till 6 months.

Follow-up report

Follow up Time aer surgery Date of follow-up Complications,

if any

Action

Taken

1

st

48 hours

2

nd

7

th

day

3

rd

1 month aer surgery or aer the

rst menstrual period, whichever is

earlier (Female Sterilization)

Aer 3 months for semen examination

(Male Sterilization)

Emergency

Comment ................................................................................................................................................................

...................................................................................................................................................................................

Result of Semen Examination:

Name……………………….. Designation…………………

Date .......................... Signature of the Person Filling Out the Report

Manual for Family Planning Indemnity Scheme

43

Proforma for Conducting Audit of Death

Annexure-6

To be submied within one month of sterilization by DISC and forwarded to SISC

Copy of this report has to be sent to the MOHFW Mandatorily

Name of the State/District/Union Territory: ......................................................................................................

Details of the Deceased

1 Full name

2 Age

3 Sex Female……...............…….Male………................

4 Name of spouse ( his/her age) ......................................................................................

5 Address of the deceased ......................................................................................

......................................................................................

6 Number of living children (with details

concerning age and sex)

......................................................................................

7 Whether the operation was performed aer

delivery or otherwise

......................................................................................

8 If aer delivery:

Date of delivery

Place of delivery

Type of delivery

Person who conducted the delivery

......................................................................................

9 Whether tubectomy operation was done

along with MTP

......................................................................................

10 Whether wrien consent was obtained

before the operation

......................................................................................

11 Whether the operation was done at a camp

or as a xed day static procedure at the

institution.

......................................................................................

Details of Operations

12 Place of operation ......................................................................................

13 Date and time of operation (D/M/Y)

14 Date and time of death (D/M/Y)

15 Name of surgeon ......................................................................................

16 Whether surgeon was empanelled or not Yes ................................... No ....................................

......................................................................................

17 If the operation was performed at a camp,

who primarily screened the client clinically?

......................................................................................

18 Was the centre fully equipped to handle

any emergency complications during the

procedure?

Yes ................................... No ....................................

......................................................................................

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Manual for Family Planning Indemnity Scheme

19 Number of clients admied and number of

clients operated upon on the day of surgery

......................................................................................

20 Did any other clients develop complications?

If so, give details of complications.

......................................................................................

Anaesthesia/Analgesia/Sedation

21 Name of anaesthetist, if present

22 Details of anaesthesia drugs used

23 Type of anaesthesia/analgesia /sedation ......................................................................................

24 Post-operative complications(according to

sequence of events)

A. Details of symptoms and signs ......................................................................................

B. Details of laboratory and other

investigations done

......................................................................................

C. Details of treatment given, with

timings, dates, etc. from time of

admission until the death of the patient

......................................................................................

Details of Death Audit

25 Cause of death (Primary cause) ......................................................................................

26 Has post-mortem been done? If yes, aach

the post-mortem report

......................................................................................

27 Whether rst notication of death was sent

within 24 hours.

Yes .................................... No ...................................

If not, give reasons

28 Details of the ocers from the District

Quality Assurance Commiee (QAC) who

conducted the enquiry

......................................................................................

29 In the opinion of the chairman of the DQAC,

was death aributable to the sterilization

procedure?

Yes .................................... No ...................................

......................................................................................

30 What factors could have helped to prevent

the death?

......................................................................................

31 Were the sterilization standards established

by GOI followed?

Yes .................................... No ...................................

32 Did the facility meet and follow up the

sterilization standards established by GOI?

If no, list the deviation[s].

Yes .................................... No ...................................

......................................................................................

33 Additional information ......................................................................................

......................................................................................

34 Recommendations made ......................................................................................

......................................................................................

35 Action proposed to be taken ......................................................................................

......................................................................................

Date: Signature

Name Designation

Note: If any member of the SQAC/DQAC has performed the operation, he/she should recuse himself/

herself from the proceedings of this audit.

Manual for Family Planning Indemnity Scheme

45

Report on Complications/Failures following

Sterilization

Annexure-7

(To be lled in by the DISC)

Name of the State/ District/Union Territory……...........................................…………………………………

Date of this report (D/M/Y)………...................…………/………….............…………/………….............……

1 Name and address of client

2 Name of spouse

3 Date of sterilization (D/M/Y) ......................../.............................../............................

4 Place where surgery was performed Camp……………………...............…………………

PP Centre………………….............………………...

PHC/CHC…………………………..............………

District Hospital…………………............…………

Medical College Hospital………...........…………..

Accredited private/NGO facility……............…….

(Also specify the name of the facility)….........…....

…………………………………………..............……

5 Type of surgical approach Minilap……………............…………………………

Laparoscopy………………….........……………….

Post-Partum Tubectomy…….........………………..

Conventional Vasectomy……….........…………….

NSV……………………………….............………….

Any other specify……………..........……………….

6 Level of experience of the person who

performed the sterilization procedure

Trainee……………………………....................…….

Empanelled surgeon……………................………..

7 Type of anaesthesia Local without sedation……...................……………

Local with sedation……………...................……….

Spinal/Epidural/General……..................………….

Part A: Complications aributable to sterilization requiring hospitalization

8 Date when complication was rst

reported(D/M/Y)

Types of complication(s)

......................../.............................../............................

A. If complications were related to

anaesthesia, list all anaesthetic agents,

analgesics, sedatives and muscle

relaxants

46

Manual for Family Planning Indemnity Scheme

B Injury/Trauma

y Injury to bladder

y Injury to fallopian tube

y Mesosalpinx

y Injury to bowel

y Uterine perforation

y Testicular artery

y Spermatic cord

y Any other (specify)

Yes ............................. No ...........................................

i. What factors contributed to injury/

trauma?

C Haemaorrhage

y Epigatric vessel

y Fallopian Tube

y Haematoma requiring intervention/

hospitalization

y Any other(specify)

Yes ............................. No ...........................................

i. What factors contributed to the

haemorrhage?

ii. Did the client have a blood transfusion? Yes ............................. No ...........................................

D Infection

y Wound Infection

y Pelvic Infection

y Epididymoorchitis

y Generalized peritonitis

y Any other (specify)

Yes ............................. No ...........................................

E. Complications not mentioned in 8A-D

(specify)** including need to abandon

the procedure or adopt a change in

approach

F. Was sterilization done postpartum or

with MTP?

If Yes, was hospitalization a result of

complications arising from those

procedures and not from sterilization?

Yes ............................. No ...........................................

G. Describe the procedure leading to the

complication

9 Describe the type of treatment administered

aributable to complication Medical/

surgical

Yes ............................. No ...........................................

10 Date of recovery(D/M/Y) ............................./............................../........................

11 Number of days of hospitalization

Part B: Pregnancy or Failure aributable to male sterilization ( Pregnancy aer certication of

vasectomy)

12 If Pregnant

A. Estimate date of conception (D/M/Y) ............................./............................../........................

B. Was semen examination done Yes/No…………..............………………………….

C. If yes, give date

Result of analysis

............................./............................../........................

Manual for Family Planning Indemnity Scheme

47

D. In the opinion of Medical Ocer

y Pregnancy was due to unprotected

intercourse before azoospermia was

achieved

y Pregnancy existed before vasectomy

y Cause of pregnancy could not be

determined

y Any Other (Specify)

Yes/No…………..............………………………….

Part C: Pregnancy or failure aributable to female sterilization

13 A. Date pregnancy was detected

(D/M/Y)

…………./……………/………

B. Estimated date of conception …………./……………/………

C. Conrmation of pregnancy test done

USG

Yes/No…………..............………………………….

D. Location of pregnancy

() Tick the option

y Intrauterine

y Ectopic

y Undetermined

E. Was the women already pregnant at

time of sterilization

Yes/No…………..............………………………….

F. In opinion of the Commiee Members,

the pregnancy was due to:

Names, designations and signatures of the Commiee Members

…………………………………………… ……………………………………………

Comments by QAC

In the opinion of the QAC:

(a) Were the sterilization standards established by GOI followed? Yes/No

(b) Was the complication/failure aributable to the sterilization procedure? Yes/No

(c) What factors contributed to the complication/failure………………............................…………………

…………………………………………………………………………………………………………………

…………………………………………………...........................................………

(e) Was the woman already pregnant at the time of sterilization? Yes/No

(f) Does the facility meet all the physical and other requirements as laid down in the GOI Standards

for Sterilization? Yes/No

48

Manual for Family Planning Indemnity Scheme

If no, list the deviation[s]:………………………………………………………………......................…….

…………………………………………………………………………………………………………………

……………………………………………………………….......................................................…………….

Additional information discussed, not presented in the report:…................…………………………

…………………………………………………………………………………………………………………

………………………………………………………………………….......................................................….

Based on the investigation report, the following recommendations are made:……................…....….

…………………………………………………………………………………………………………………

…………………………………………………………........................................................……………….

Reviewed by Signatures Designation

…………………………....... …………………………....... ………………………….......

Note: If any member of the QAC has performed the operation, he/she should not act as a chairman/

member for this report.

Manual for Family Planning Indemnity Scheme

49

Checklist of FPIS Claim Documents

Annexure–8

Section IA-IB Section IC Section ID Section II

Death Failure Complication Indemnity cover for

Doctor/Facility

Original & duly

Completed” Claim

Form Cum Medical

certicate”

Original & duly

Completed” Claim

Form Cum Medical

certicate”

Original & duly

Completed” Claim

Form Cum Medical

certicate”

Intimation in writing

Copy of Consent Form

& Medical record and

Checklist

Copy of Consent Form

& Medical record and

Checklist

Copy of Consent Form

& Medical record and

Checklist Copy

Copy of Consent Form

Copy of Post-

Operative Card/

Discharge certicate

Copy of Sterilization

Certicate

Copy of Post-

Operative Card/

Discharge Certicate

Copy of Sterilization

Certicate

Copy of Death

certicate issued by

hospital/municipality

or any other

designated authority.

Copy of any of the

diagnostic Report

conrming failure of

Sterilization

Original Bills/

Receipts/Cash Memos

along with Original

Prescription and Case

Sheet

Certicate from the

convener of DISC

(CMO or equivalent)

designated for this

purpose at district

level conrming

that the Sterilization

Operation was

conducted by the

doctor etc.

Copy of Summon/FIR

Proforma for

Conducting Audit of

Death by DISC

Report on Failure

following sterilization

by DQAC

Report on

Complication

following sterilization

by DQAC

Copy of the Award

given by the court

along with the

original receipts for

which payment is

made to the lawyer

Note: All the documents should be duly aested by the Convener of DISC (CMO or equivalent) designated for

this purpose at district level

Before forwarding the Claim Form and other Required Document, it has to be checked that:

A. Consent Form

1. Registration number of the beneciary, date, and signature or thumb impression of the

beneciary are properly placed in respective columns.

2. Examination of patient record is lled in properly and doctor has put his signature and date.

3. Details of dependents of a beneciary are lled in.

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Manual for Family Planning Indemnity Scheme

4. All columns of Consent form and Medical Record & Check List for female / male sterilization

are lled properly

B. Claim Form

1. Claim is submied in a prescribed Claim Form in original.

2. Claim forwarded through Medical Ocer/Health Facility conducting sterilization procedures.

3. Name and address of the beneciary are same mentioned on Consent form.

4. Signature or thumb impression of beneciary is same as mentioned on Consent form.

5. Date of sterilization is same as mentioned in the Sterilization Certicate and Consent form.

6. Other details lled in are tallied with other relevant documents which are becoming part of

claim form.

7. All columns of Medical Certicate which is a part of Claim Form are lled in and date, signature

and seal of CMO or Equivalent designated for this purpose at district level has been placed.

C. Sterilization Certicate

1. Name of beneciary is same as lled in on Consent form.

2. Date of sterilization is mentioned under specic column.

3. Certicate issued have signature and date of issuing authority.

4. Sterilization Certicate is in proper format as prescribed and having Registration Number and

date.

D. Diagnostic Report Issued for Failure of Sterilization

1. Report issued should be in a proper document i.e. hospital case sheet/ proper diagnostic report.

2. It should have registration number and date.

3. Cause detected for failure has been properly recorded by the issuing authority on the document.

4. First diagnostic report by which a failure is detected is aached.

E For Claims under Complication

1. The case sheet / prescription have the name of beneciary.

2. Case sheet/ prescription have proper hospital registration number and date.

3. Case sheet/ prescription have a date of sterilization.

4. Nature of post-operative complication has been recorded.

5. Medicines prescribed should tally with cash memo.

6. Case sheet/prescription and bills/cash memo are in original.

F. Death Certicate

1. Death certicate has been issued by the proper authority.

2. Name of deceased, date of death etc. are rightly lled in on the certicate.

3. Certicate should have registration number and date of issue and signature of issuing authority.

G. Post-Operative Discharge Card

1. Name of beneciary is same as lled in the Consent form.

2. Date and type of of sterilization is mentioned under specic column.

3. All columns of the post –operative discharge card should be properly lled.

4. Card should bear the name, designation, signature of the person lling the card.

Manual for Family Planning Indemnity Scheme

51

Beneﬁciary Wise Claim Status

Annexure–9

A B C D E F G H I J K L M N O P Q R S T U V

S. No

Name of the District

S. No

Name of Beneciary /Claimant

Sex& Age

Address

Date of operation

Type of procedure

(Minilap/Post-Partum/Laparoscopic/ Conventional

Vasectomy/ NVSV)

Facility Name where operation conducted

Facility Type (PHC/CHC/DH/Medical college/

Accredited PVT/NGO Facility)

Operation done in Camp/ Fixed Day Static

Name of Surgeon/doctor who operated

Type of claim (Death/Complication/Failure)

Date Of Claim Submission

Diagnostic Report conrming Failure of

sterilization(Urine Test Report/ Usg/ Per Abdominal

Examination/ Mtp/ Semen Test Report)

Amount Claimed(in Rs)

Claim Approved / Rejected/Pending

Amount Paid

Mode of payment (Cheque/DBT)

Date of Payment

Outstanding Amount if any

If Rejected Reasons for Rejection

State needs to submit this list on quarterly basis to GoI

52

Manual for Family Planning Indemnity Scheme

Quarterly Report Form

Annexure–10

Quarterly report on maintenance of quality, failure of sterilizations, complications or deaths aributable

to sterilizations is to be sent by the Convener of DISC (CMO or equivalent) designated for this purpose

at district level to the SISC in the format given below.

Name of the District / Name of the State: ………….....................................................................…………..

To be submied by DISC to SISC.

REPORTING QUARTER: ………………………

1 Number of sterilization conducted in the districts/States in the reporting

quarter

(i) In Government Hospitals.

(ii) In Accredited Private/NGO Facility

2 Death reported in hospital or within 7 days from discharge.

3 No of cases where Rs. 50,000 paid from State/ District Health Society

4 Death reported between 8 – 30 days from discharge.

5 Number of claims accepted by District Health Society

Failure.......................................................................................................................

Complications .........................................................................................................

Death .........................................................................................................................

6 Number of cases where payment released by District Health Society

7 Number of claims pending for selement by District Health Society

Period of pendency: Number of Claims

30 days: ......................................................................................................................

31-90 days: .................................................................................................................

More than 90 days: ....................................................................................................

8 No. of Court cases against doctor/ health facility, if any.

(i) Action taken on court cases against doctor/ health facility:

(ii) Court cases for non-selement of claims in consumer courts etc.

9 Number of private doctors / health facilities empanelled/ accredited:

10 Whether prescribed consent forms are available in local languages with all

Doctors/ Health facilities in sucient number (as per manual).

11 Problem, if any, with general public reporting failures/ Complications / deaths etc. following

sterilization:

12 Details of enquiries held into each case of breach of guidelines by doctor or

health facility, punitive action taken against them including names of doctors

and health facilities removed from the panel.

(To be given

on separated

Sheet)

13 Any other information (To be given

on separated

Sheet)

Manual for Family Planning Indemnity Scheme

53

Statewise Annual Claims Status

Annexure–11

State

Claim

Intimation

Paid Rejected Out

Standing

Complication

Death

Failure

Grand Total

Complication

Death

Failure

Total

Amount

Complication

Death

Failure

Total

Amount

Complication

Death

Failure

Total

Amount

Bihar

Chaisgarh

Himachal Pradesh

Jammu & Kashmir

Jharkhand

Madhya Pradesh

Orissa

Rajasthan

Uar Pradesh

Uarakhand

Arunachal Pradesh

Assam

Manipur

Meghalaya

Mizoram

Nagaland

Sikkim

Tripura

Andhra Pradesh

Goa

Gujarat

Haryana

Karnataka

Kerala

Maharashtra

Punjab

Tamil Nadu

West Bengal

A & N Islands

Chandigarh

D & N Haveli

Daman & Diu

Delhi

Lakshadweep

Puducherry

State needs to submit this on annual basis to GoI

54

Manual for Family Planning Indemnity Scheme

Sterilization Death Audit Report

Annexure–12

Name of the state/union territory……...........................………………………………………………………

Report for the quarter ending …………………………..........................…………………………………….

S.No

District

S.No

Name of the Deceased Beneciary

Age

Sex

Date of operation

Type of Facility where operation was conducted

((PHC/CHC/DH/Medical college/Accredited PVT/

NGO Facility)

Camp of Fixed Static

Type of Procedure

(Interval Minilap/Post-Partum Minilap/

Laparoscopic/Conventional Vasectomy/ NSV)

If Post Partum

(With Cesarean/Normal delivery/MTP)

Atropine used in

preanaesthetic medication (Y/N)

Surgery under Anesthesia(LA/GA)

Empanelled Provider (Y/N)

Date of death

Time of death

Place of Death

Under-lying cause of death

Death audited By DISC (Y/N)

Action Taken

Medical death audit report must be annexed for each case.

Name of State FP Nodal Ocer ……………… Signature

State needs to submit this report on quarterly basis to GoI

Manual for Family Planning Indemnity Scheme

55

56

Manual for Family Planning Indemnity Scheme