Cashless Authorization Letter

(Part-D)

Claim Number: HI-IFT-001461188(0) (Please quote this number for all correspondence) Date: 08/12/2021
Authorization is valid for admission up to 09/12/2021

Name of Insurance Co.: IFFCO Tokio General Insurance Co. Ltd.

Anand Mangal Hospital
C-2/51 Shree Ram Mandir Cinema Road,Kamla
Nagar,,Agra,Uttar Pradesh,282004
Rohini Id: 8900080417236
Corporate Name: THE SUPREME INDUSTRIES LIMITED
Name of TPA: HealthIndia Insurance TPA Services Pvt. Ltd.
Proposer Name: MOHAMMAD IMRAN
Patients Member ID/TPA/Insurer Ids of the Patient: 2786904E
Employee Code: 1900122
Relation with Proposer: Employee

Dear Sir / Madam,

This has reference to the pre-authorization request submitted on 08/12/2021. We hereby authorize cashless facility as per details mentioned below:

Patient Name: MOHAMMAD IMRAN Age: 25 Gender: MALE

Policy Number: H0608561 Expected Date of Admission: 07/12/2021
Policy Period: 01/01/2021-31/12/2021 Expected Date of Discharge: 09/12/2021
Room Category: Private Estimated Length of Stay: 1 days

Eligible Room
Category as per T&C
of Policy Contract: 3000
Provisional Diagnosis: appendicitis Proposed line of treatment: Surgical
,
Authorization Details:-
Date & Time Reference Number Amount Status
07/12/2021 17:22:04 HI-IFT-001461188-1 30000 AL Issued
08/12/2021 23:09:22 HI-IFT-001461188-2 12387 AL Issued

Total Authorized Amount:- Rs. 42387.00

Authorization Remarks:- Deduction: Rs 250/- reg, Rs 500/- capping on room rent. Rs 5432/- 14 % proportionate charges applied

,
Hospital Agreed Tariff:-

I. Non-Package case:-

i. Room Rent/day : 3500

ii. ICU Rent/day :0
iii. Nursing Charges/day :0
iv. Consultant Visit Charges/day :0
v. Surgeons fee/OT/Anaesthetist :0
vi. Others (specify) :0
,
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 Insurer 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 policyholder 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 insureds choice (not empaneled with the hospital), Network Provider may give treatment after obtaining specific consent of
policyholder.
7. Differential Costs borne by policyholder may be reimbursed by insurers subject to the terms and conditions of the policy.

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

1. Detailed Discharge Summary and all Bills from the hospital

2. Diagnostic Test Reports and Receipts supported by notc from the attending Medical Practitioner / Surgeon recommending such Diagnostic supponed by note from the attending Medical Practitioner/
Surgeon recommending such diagnostic tests.
 3. Certificates from attending Medical Practitioner / Surgeon giving patients condition and advice on discharge.
4. Network provider shall not make any recovery from the deposit amount collected ftom the Insured except for coststowards non-admissible amounts (includingadditional charges due to opting higher
room rcnt than eligibility/ choosing separate line oftreatment which is not envisaged/considered in package)

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 NOAS, issued by national Health systems Resources
Centre (NHSRC) on or before July26, 2019.

Name of the Product : - and UIN No : -: - Important Policy terms & conditions (sub-limits/co-Day/deductible etc)

Authorized signatory :
(Insurer/TPA)

Address:HealthIndia Insurance TPA Services Pvt. Ltd.

This is a Computer Generated Statement hence no signature is required. For any queries call your nearest Health India Branch.