HOSPITAL ALLIANCE SERVICES - Pre-Authorization Letter [ Admission Letter ]

Print Date : 08/05/2023

KPJ Johor Specialist Hospital RESTRICTED 11901004

Dear Sir/Madam,

Claim Number : 23161081

Policy Number : 34897176
Life Assured : ABDUL LATIFF BIN HAMZAH
Life Assured's I/C Number : A3255256/750319017449
Provisional Diagnosis : ac bronchitis bronchospsm

Plan Benefit : FXM0 : 21/10/2014

Coinsurance : No
Deductible Amount : 0.00

With reference to the terms in our Hospital Alliance Services Agreement with the hospital, we hereby issue this Pre-Authorization Letter
to cover the above named Life Assured's admission in your hospital above under the Plan Benefit above, up to maximum amount of
MYR 2,500.00 inclusive of Hospital Room Charges at MYR 200.00 per day (inclusive of service tax).

Our pre-authorization herein shall only be for the medical expenses related to the Provisional Diagnosis above, and is further subject to
the terms and conditions of the Insurance Policy for the Life Assured above. For the avoidance of doubt, this Pre-Authorization Letter is
limited to one (1) in-patient admission/day surgery, the details for which are as follows:

Admission Date : 07/05/2023

Doctor Name : DR MUHAMMAD REDZWAN BIN S RASHID ALI
Treatment/Surgery Plan : iv med neb cxr

Maximum Length of Stay : 2.0

Current Available Limit * : Above estimated total costs stated in Pre-Authorization Form
(as at the date of this letter)
* Please note that the limit assessment is done as at the date of this letter, and does not take into account any claim or adjustment in
progress. PAMB reserves the right to amend and/or revise this limit assessment to reflect the actual available limit, before the issuance
of the Final Worksheet

IMPORTANT NOTE:
PRUflexi med medical Plans with Deductible Option is subject to a deductible amount of MYR 300.00 or zero.

POLICY EXCLUSIONS (if any) : N/A

Common items that are excluded under our Pre-Authorization Letter (including but not limited to this list):
• Filmarray Gastrointestinal Panel, Respiratory Pathogens
• The POLICY EXCLUSION(S) above (if any).
33/Filmarray and similar nature of diagnostic tests.
• Any non-medical related expenses, drugs/ medicine, treatment ,
or investigations that are not related to the Provisional Diagnosis • Any robotic-assisted treatment / surgery / investigation.
above.

• Any take home drugs/medicine beyond one (1) month from the
• Treatment of plastic/ cosmetic nature.
discharge date.

• Any advance payment/ deposit for tests and/or treatments not • Aids for correction of eyesight (e.g. multifocal / enhanced
performed during admission. monofocal/ toric lens) and hearing (e.g. cochlear implant).

• Any charges exceeding the fees schedule stipulated in the 13th

schedule of the Private Healthcare Facilities and Services (Private • Any treatment or surgical operation for congenital abnormalities
Hospitals and Other Private Healthcare Facilities) Regulations or deformities including hereditary condition.
2006.

• Any "Non-Payable Charges" as described in our Hospital Alliance • Dental treatment or oral surgery except as necessitated by
Service Agreement with the hospital. accidental injuries to sound natural teeth.

Kindly be informed that you are required to notify us in advance if any additional amount is required for the Life Assured's admission,
which may be due to insufficiency in the maximum amount and/or the Maximum Length of Stay stated above. Our agreement to pay this
additional amount (if any) shall be subject always to our further review and approval in writing, as per our Top Up Process.

Issued by : Healthcare - Claims

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*Disclaimer:
Prudential Assurance Malaysia Berhad reserves the right to exclude payment for Charges that are deemed unnecessary/unrelated, as
stipulated in our Hospital Alliance Services Agreement.

No signature is required on this computer generated document.

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