90222324201241

Cashless Authorization Letter

(Part-D)

Claim Number: 90222324201241(Please quote this number for all futher correspondence)
Date:12/06/2023
Authorization is valid for admission up to 11/06/2023 01:00:00 AM(date)

Suguna Hospital Name of Insurance

Address: Suguna Hospital Company: The New India Assurance Co. Ltd.
1a/87,Dr. Rajkumar Road,4th N Name of TPA: Raksha Health Insurance TPA
Block,Rajajinagar,Bangalore Pvt.Ltd.
Bengaluru,Karnataka,560010 Proposer Name: Bhola Shanker Pandey
Hospital Id: 892560010023 Patient's Member
Rohini Id: 8900080183308 ID/TPA/Insured Id of the Patient: N90886VILPL
Relation with Proposer: Self

Dear Sir/Madam,
This has reference to the pre-authorization request submitted on 10/06/2023 as per details mentioned below:

Age: 44 Gender: M
Patient Name: Bhola Shanker Pandey
Policy Number: 22070034220400000001 Expected Date of Admission: 11/06/2023 01:00:00
AM
Policy Period: 11/07/2022-10/07/2023 Expected Date of Discharge: 12/06/2023 01:00:00
AM
Room Category:Icu Estimated Length of Stay:1
Eligible Room Category
as per T&C of Policy
Contract:ICU:8000,Room Rent:4000,
Provisional Diagnosis: Anal fissure, unspecified Proposed line of treatement: Surgical Management

Authorization Details:-
Date & Time Reference number Amount Status
2023-06-12 17:42:25.0 90222324201241 -2300 Extension
2023-06-12 10:57:36.0 90222324201241 91400 Initial Approval

Total Authorized amount :- Rs. Eighty Nine Thousand one Hundred.(in words)

Authorization Remarks :
HAEMORRHOIDS AND FISSURE FOR LASER HAEMORRHOIDECTOMY LIS FISSURECTOMY .
LASE NOT PAYABLE .PAYABLE AS PER GIPSA

Hospital Agreed Tariff:

I. Package case
Agreed package Rate :0.0

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. Other(specify)
Authorization Summary:-
 Total Bill Amount :103230(INR)
*Other Deductions :14130(INR)
Discount :0(INR)(Not To Be Paid By Patient.)
Co-Pay :0(INR)
Deductibles :0(INR)
Total Authorised Amount :89100(INR)
Amount to be paid by insured :0(INR)
*Other Deduction Details:
S.no Description Bill Deduction Admissibl Deduction Reason
Amount Amount e Amount
1 Raksha/PPN Package 103230 14130 89100 AS PER GIPSA,REST COLLECT
FROM PT.
Total Other Deduction : 14130

Terms and Conditions of Authorization:

1. Cashless Authorization letter issued on the basis of information provided in Pre- Authorization form.
In case mis- representation/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 oftreatment 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 insured's 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. Cash Memos from the Hospitals / Chemists supported by proper prescription.
3. Diagnostic Test Reports and Receipts supported by note 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.
6. Original Claim Form B duly Signed.
7. PPN Declaration letter form duly signed.
8. Pre-Auth Form Part –C & D in Original.
Hospital is solely responsible to intimate any change in Date of Admission or TPA related any other
service rendered. The hospital is requested to submit the claim within 7 days from Date of Discharge
or else it will be deemed as this Authorization Letter has not been utilized. In all such cases Raksha
TPA holds no responsibility for payment from Insurance company.

Name of the Product.........and UIN No.............

In case of any grievance related to this claim, you may contact Regional / Head Office of the insurance
company.
You may also contact insurance ombudsman for unresolved grievance.The updated list of Office of Insurance
Ombudsman is available on IRDA website www.irda.gov.in and on the website of General Insurance Council
www.gicouncil.in.

Authorized signatory :
For Raksha Health Insurance TPA Pvt. Ltd. :