Cashless Authorization Letter

(Part-D) Printed on 13/11/2019

Claim Number: DEL-1119-PA-0001116 (please quote this number for all further correspondence) Date : 13/11/2019

Authorization is valid for admission up to 09/11/2019 (date)

DR ANDALS LAKSHMI FERTILITY RESERCH & Name of Insurance Company : ORIENTAL INSURANCE COMPANY LIMITED
LAPAROSCOPIC SURGICAL CENTRE
16-2-94 POGATHOTA NEAR RAGHAVA CINI Name of TPA : Vidal Health Insurance TPA Pvt Ltd

Proposer Name : SHAIK WASEEM AKRAM

COMPLEX

Patient's Member ID / TPA / Insurer Id of the : DEL-OI-H0351-001-0087215-B

NELLORE Patient

Andhrapradesh
Relation with Proposer : Spouse
524001

08612329747

Rohini Id: 8900080176669

Dear Sir /Madam ,

This has reference to the pre-authorization request submitted on 13/11/2019 12:18 PM We here by authorize cashless facility as per details
mentioned below:

Patient Name : HUMA NIGAR MOHAMMED Age : 26 Gender : Female

Policy Number : 124500/48/2020/3211 Expected Date of Admission : 09/11/2019

Policy Period : 01-OCT-19 TO 30-SEP-20 Expected Date of Discharge : 14/11/2019

Room category
Eligible Room : Estimated length of stay : 5 days
Category as per T&C
of Policy Contract:

G3P1L1A1 WITH 38 WEEK OF GE WITH

Provisional Diagnosis : Proposed line of treatment : surgical management
LABOUR PAIN

Authorization Details :

Date and time Reference number Amount Status

13/11/2019 12:28 PM DEL-1119-PA-0001116 47500 Approved

Total Authorized amount:- Rupees Forty Seven Thousand Five Hundred Only (in words)

Authorization Remarks:
ATL APPROVED AS PER CAP.
Hospital Agreed Tariff:

I Package case :

Agreed package rate : ,

II Non -Package case :

i. Room Rent / day :

ii. ICU Rent / day :

iii. Nursing Charges / day :

Iv. Consultant Visit Charges / day :

v. Surgeon's fee / OT / Anaesthetist :

vi. Others (specify) :

Authorization Summary:

Total Bill Amount : 61270.00 (INR)

*Other Deductions : 11270.00 (INR) (At the time of Final Authorization)

Discount : 0.00 (INR) (At the time of Final Authorization)

Co-Pay : 2500.00 (INR)

Deductibles : 0.00 (INR)

Total Authorised Amount: : 47500.00 (INR)

Amount to be paid by lnsured : 13770 (INR) (At the time of Final Authorization)

*Other Deductions Details :

Deducted Amount Admissible

S.no Description Bill Amount Deduction Reason
Amount

1 PACKAGE CHARGES 61270.00 11270.00 50000.00 AS PER AILMENT CAP

 Terms and Conditions of Authorization:

1. Cashless Authorization letter issued on the basis of information provided in Pre- Authorization form. In case misrepresentation /
concealment of the facts, any material difference / deviation / discrepancy in information is observed in discharge summary /
IPD records then cashless authorization shall stand null & void. At any point of claim processing lnsurer or TPA reserves right
to raise queries for any other document to ascertain 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 costs
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 costs 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 a treatment / procedure is 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 policy holder.

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM

1. Detailed Discharge Summary and all Bills from the hospital.

2. Cash Memos from the Hospitals / Chemists supported by proper prescription.

3. Diagnostic Test Reports and Receipts supported by notc from the attending Medical Practitioner / Surgeon recommending such
Diagnostic supported by note from the attending Medical Practitioner / Surgeon recommending such diagnostic tests.
.
4. Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt.

5. Certificates from attending Medical Practitioner / Surgeon giving patient's condition and advice on discharge.

Authorized signatory :

(Insurer / TPA)

Address : Vidal Health Insurance TPA Pvt.Ltd, SJR iPark, 1st Floor,Tower 2,EPIP Zone, Whitefield Road, Opp.Sathya Sai Hospital,
BANGALORE - 560066,
 CLAIM FORM - PART B
CLAIM FORM - PART B is mandatory.
Please indicate the Date, affix the Stamp and sign in the DECLARATION BY THE HOSPITAL column at the bottom.
The issue of this Form is not to be taken as an admission of liability. (To be Filled in block letters)
Kindly include the original pre-authorization request form in lieu of Claim Form PART A.
DETAILS OF HOSPITAL

a) Name of the hospital: D R A N D A L S L A K S H M I F E R T I L I T Y R E S E R C H &

L A P A R O S C O P I C S U R G I C A L C E N T R E

SECTION A
a) Hospital ID: H O S H Y D 6 4 4 5 c) Type of Hospital: Network Non Network : (if non network fill section E)

c) Name of the treating doctor:

e) Qualification: f) Registration No. with State Code: g) Phone No.

DETAILS OF THE PATIENT ADMITTED

a) Name of the Patient: H U M A N I G A R M O H A M M E D

b) IP Registration Number: c) Gender: Male Female d) Age: Years Months e) Date of birth:

SECTION B
f) Date of Admission: 0 9 1 1 1 9 g) Time: 0 1 4 3 h) Date of Discharge: 1 4 1 1 1 9 i) Time : 0 1 4 3

j) Type of Admission: Emergency Planned Day Care Maternity k) If Maternity i) Date of Delivery: ii) Gravida Status:

I) Status at time of discharge: Discharge to home Discharge to another hospital Deceased m) Total claimed amount 4 7 5 0 0

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

a) ICD 10 Codes Description b) ICD 10 PCS Description

G3P1L1A1 WITH 38 WEEK OF GE WITH LABOUR PAIN

I. Primary Diagnosis: i. Procedure 1:

ii. Additional Diagnosis: ii. Procedure 2:

iii. Co-morbidities: iii. Procedure 3:

SECTION C
iv. Co-morbidities: iv. Details of Procedure:

c) Pre-authorization obtained: Yes No d) Pre-authorization Number:

e) If authorization by network hospital not obtained, give reason:

f) Hospitalization due to injury: Yes No I. If Yes, give cause Self-inflicted Road Traffic Accident Substance abuse / alcohol consumption

ii) If injury due to substance abuse / alcohol consumption, Test conducted to establish Yes No (If Yes, attach reports) iii. If Medico legal: Yes No iv. Reported to Police Yes No

v. FIR No. vi. If not reported to police give reason:

CLAIM DOCUMENTS SUBMITTED - CHECK LIST

Claim Form duly signed Investigation reports

Original Pre-authorization request CT/MR/USG/HPE investigation reports

Copy of the Pre-authorization approval letter Doctor’s reference slip for investigation

Copy of Photo ID Card of patient Verified by hospital ECG

SECTION D
Hospital Discharge summary Pharmacy bills

Operation Theatre Notes MLC reports & Police FIR

Hospital main bill Original death summary from hospital where applicable

Hospital break-up bill Any other, please specify

DETAILS IN CASE OF NON NETWORK HOSPITAL (ONLY FILL IN CASE OF NON-NETWORK HOSPITAL)

a) Address of the Hospital 1 6 - 2 - 9 4 P O G A T H O T A N E A R R A G H A V A C I N I , C O

M P L E X , N E L L O R E

City: N E L L O R E State: A N D H R A P R A D E S H
SECTION E

Pin Code: 5 2 4 0 0 1 b) Phone No. c) Registration No. with State Code:

d) Hospital PAN: e) Number of inpatient beds f) Facilities available in the hospital i. OT Yes No ii. ICU Yes No

iii. Others:

DECLARATION BY THE HOSPITAL (PLEASE READ VERY CAREFULLY)

We hereby declare that the information furnished in this Claim Form is true & correct to the best of our knowledge and belief. If we have made any false or untrue statement, suppression or concealment of any material fact, our
right to claim under this claim shall be forfeited.
SECTION F

Date:

Place: Signature and Seal of the Hospital Authority: