Please Quote This Reference Number in All Future Correspondence
Please Quote This Reference Number in All Future Correspondence
Please Quote This Reference Number in All Future Correspondence
To,
Dear Partner,
With reference to your request (37860161) for enhancement of cashless pre-authorized amount, we here by enhance the authorization to INR 388800 against
your request for INR 450000. The details of the pre-authorization are as follows:
Patient Details
Age 59
Gender F
IP No. NULL
Insurer Claim No
Insurer Member ID
Treatment Details
Length Of Stay 5
Authorization Details
Total Authorized amount Rs 388800 (Three Lakh Eighty Eight Thousand Eight Hundred).
Authorization Remarks :
Enhance given, Final bill settlement will be as per agreed package and policy terms and conditions only.
Note: If Top Up is available and applicable, as per policy conditions, Top Up claims will be processed and additional amounts will be approved along with base
amount as per your benefit.
Hospital Agreed Tariff :
I. Package Case
Consultation Visit Charges/ Surgeon's fee/ OT/ Anaesthetist : As per customary and reasonable charges
Authorization Summary
Other Deductions(INR)* 0
Deductibles (INR) 0
Amount to be paid by Insured (INR) 43200 (Will be determined upon receipt of final bill and discharge summary)
*Deduction Details
Deducted Admissible
Bill Amount
S.no Description Amount Amount Deduction Reason
(INR)
(INR) (INR)
No Non-Medical Expences
1. Cashless authorization letter issued on the basis of information provided in pre authorization form. In case of misrepresentation/concealment of facts,
any material difference/deviation/ discrepancy in information is observed in discharge summary / IPD records then cashless authorization stand null &
void. At any point of claim processing Insurer or TPA reserves right to raise queries for any other document to ascertain the admissibility of claim.
2. KYC (know your customer) details of proposer/employee/beneficiary are mandatory for claim payout above Rs.1 lakh.
3. Network provider shall not collect any additional amount from the individual in excess of Agreed Package Rates except cost towards non admissible
amounts (including additional charges due to opting higher room rent than eligibility/choosing separate line of treatment which is not
envisaged/considered in Package)
4. Network provider shall not make any recovery from the deposit amount collected from the insured except for the cost towards non admissible amounts
(including additional charges due to opting higher room rent than eligibility/choosing separate line of treatment which is not envisaged/considered in
Package)
5. In the event of unauthorized recovery of any additional amount from the insured in excess of Agreed Package Rates, the authorized TPA/Insurance
company reserves the right to recover the same or get the same refunded to the policy holder from the network provider and/or take necessary action as
provided under the MOU.
6. Where treatment / procedure to be carried out by a Doctor/Surgeon of insured's choice (not empaneled with the Hospital) network provider may give
treatment after obtaining specific consent of the policyholder.
7. Differential cost borne by the policyholder may be reimbursed by Insurer subject to terms and conditions of the policy.
Please note that the amount authorised is provisional and is subject to change based on the final bill and discharge summary, and deduction of TDS, as
applicable.
Note: As per Modified Guidelines on Standards and Benchmarks for Hospitals in the Provider Network issued by IRDAI vide Circular Ref:
IRDA/HLT/REG/GDL/114/07/2018 dated 27th July 2018, your Hospital is mandatorily required to Register with ROHINI and obtain either Pre-entry level
Certificate (or higher level of certificate) issued by NABH or State Level Certificate (or higher level of certificate) under NQAS, issued by National Health
Systems Resources Centre (NHSRC) on or before July 26, 2019.
QUICK LINKS:
Warm Regards,
Disclaimer: The TPA extends the cashless facility subject to the standard terms & conditions of the policy and the information provided in the cashless request form. We suggest that the
patient continues with the treatment as advised by the treating doctor, irrespective of the pre-authorization/cashless facility.
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