AUTH APPROVAL LETTER

(INITIAL / EXTENSION 1 / EXTENSION 2)

To
10/04/2023
Fortis Hospitals Limited, Kolkatta
III A Rashbehari Avenue (730, Anandapur)
KOLKATA
WEST BENGAL
700107

Dear Sir/Madam,

Subject: Cashless Authorization no 2023041000308.A1 under Policy H1181740 of JAYANTA LODH, Member ID H1181740-4-0

This has reference to the request for Authorization received by us on with following details:

1. Date of admission : 11/04/2023

2. Proposed Length of stay : 5
3. Diagnosis : Gall bladder disorders
4. ICD Code : K80
Till date, the authorization amount approved is Rs. 90,155 . All previous authorization(s), if any, stands cancelled.

This is initial authorization only. Covered for Active Medical/Surgical management only. Admission only for investigation and evaluation will not be payable. Full and
final will be made at the time of discharge strictly as per policy terms and conditions and hospital tariff. Kindly collect non payables from the patient or will be deducted
at the time of final settlement. Kindly note: If Patient is released from Hospital without Final Cashless Approval then this authorization will be considered as cancelled
and thereafter insurer is not liable to pay any previous authorized amount to the service provider. AL has a limit period of validity which is 15 days from the issuing of
the authorization letter or last day of the policy period whichever is earlier.
Please Note

1) Claim settlement will be done as per the Agreed upon tariff. If any amount over and above the agreed tariff is collected from insured, it will be deducted from your final
settlement.
2) Please collect expenses for all Non payable items, as per the list provided to you at time of MOU, from insured.
3) Any change in line of treatment / Room category / Length of stay must be informed immediately.
4) We will not be liable for payment if Information provided in “Request for authorization letter” and subsequent information during claims is found to be incorrect, modified
or undisclosed.

Deduction Types Claimed Amount Deducted Amount Reason for Deduction Remarks Approved Amount

MiscellaneousCharges 191203.0 91203.0 initial

Reinstatement Premium 9845.0 90,155

Yours Sincerely,

Authorized Signatory

Claim Documents should be sent at below address -

IFFCO Towers, Surinder Jhakhar Bhawan, Plot No. 3, 4th Floor, Sector 32, Gurugram, Haryana - 122003

Contact Toll Free No: 18001035499, Email ID: cashless@iffcotokio.co.in