Authorization Letter

Authorization Letter to the Hospital for the Treatment and Guarantee of Payment. Valid for Admission
before 18/02/2011 Or before the Expiry Date mentioned on FHPL ID.Whichever is earlier.

To, Date : 07/02/2011

Bollineni Hospitals PA.No : 50404/1
# 77-7-77/1, Seelam Nookaraju Complex, ,Katari Gardens,
Rajahmundry

Organisation Name : Capital IQ Information Systems (I) Pvt Ltd

We are in receipt of the Admission / Pre Authorization request note with the following information :

Name of the patient U D Chandra Kantam UHID No UIIC.511155

Age 60 Years Gender Female
Room Board Category under Semi Private For(Ailment) Acute Anterior MI
We hereby authorize and guarantee for Payment up to (in figures) Rs. 98000.00/- Plus service tax as applicable
(In Words) Ninety Eight Thousand Only
The Probable Date of Admission is 04/02/2011

Hospital Alert

1) If the hospital bill is estimated to be higher that the guarantee of payment, a request letter for additional amount needs to be sent to us. If no further
guarantee is available, the hospital must collect the excess amount directly from the beneficiary at the time of admission / prior to discharge from the
Hospital, as per Hospital Rules and Regulations.
2) FHPL will not be liable for payment to the Hospital in the event of the facts presented by the Hospital / Insued during the preauthorization are
found to be incorrect/revised.
3) The Claim settlement would be as per the Tariff Discounts contracted in the Network agreement.
4)Service Tax will be paid on the bill amount payable by the Insurance Co. to the hospital.

5)Service Tax charged will be paid as per the Service Tax Act subject to
i) Invoice should be in the name of Insurance Co. ii) Service Tax registration number should be mentioned in the Invoice
iii) Service Tax Calculation should be shown seperately.

Please ensure to collect % from the member

The Charges Pertaining to nonpayable items as per the Annexure 6 of the Network Manual

Doctors Note :
Covered for PTCA+Stenting. Total sum insured approved collect balance from the patient. 10% Co-payment already deducted.
.

For Billing : Please send the following Documents Within 7 days from the discharge of patient.
1) Enclose Photo ID card copy of the patient. 2) ARN(Admission Request Note). 3) Approval copy.
4) Hosp.bill summary with final bill showing details of units of each service(Authenticated by the patients signature.)
5) Discharge summary and reports of all Investigations(Original),prescription of Medicines.
6) The Above payment is subject to applicable TDS. 7) Enclose a copy of receipt given to patient for the amount paid by him.

8) Claim form of United India Insurance Co. Ltd

Dr.John Suraj Ch
Authorized By Date : 2/5/2011 1:31:00 PM

Disclaimer:The cashless access in FHPL network of Hospitals merely a facility extended by your health coverage payer. FHPL/Payer does not
guarantee the availability, quality & outcome of the treatment. Choosing of a network or a non-network hospital is prerogative of the patient/Insured.

Please Note: Hospitalization for Treatment of the follwing conditions is not payable:

convalescence, General Debility, 'Run Down' condition, Congenital External Disease, Sterility ,Infertility , STD, Intentional self Injury & Use of
Alcohol/Intoxicated Drugs, Maternity expenses covered for first two children wherever maternity is payable. Admission only for investigation &
Evaluation.

Undertaking by the patient

I authorize the hospital/provider to submit the attested Indoor Case Papers(Case Sheet) & any other documents/information related to my treatement
to FHPL If ask for.

Signature of the Patient/Insured

Family Health Plan (TPA) Ltd,Srinilaya - Cyber Spazio,Suite # 101,102,109 & 110,Ground Floor,Road No.2,Banjara Hills,Hyderabad-500 034.