Cashless Authorization Letter

(Part-D)
Printed on 06/02/2024
Date : 06/02/2024
Claim Number: BLR-0224-PA-0001754 (please quote this number for all further correspondence)

Authorization is valid for admission up to 02/02/2024

RUBY HALL CLINIC Name of Insurance Company : UNITED INDIA INSURANCE COMPANY LTD

59/6, Azad Nagar, Wanowarie, Pune Name of TPA : Vidal Health Insurance TPA Pvt Ltd

Proposer Name : SHIREEN PIRZADE

Patient's MemberID / TPA/Insurer Id of the : BLR-UI-W0215-022-0001501-D

Patient

Relation with Proposer : Child (2)

Maharashtra , 411040

Rohini Id: 8900080124844

Dear Sir /Madam ,

This has reference to the pre-authorization request submitted on 06/02/2024 03:27 PM , We here by authorize cashless facility as per details
mentioned below:

Patient Name : NEW BORN TWIN 1ST Age :0 Gender : Female

Policy Number : 0703002823P110276982/AIROLI Expected Date of Admission : 02/02/2024

Policy Period : 01-11-23 TO 31-10-24 Expected Date of Discharge : 05/02/2024

Room category : General Multi-Bed

: Estimated length of stay : 3 days

Eligible Room General Multi-Bed
Category as per T&C
of Policy Contract

Provisional Diagnosis : LATE PRE TERM Proposed line of treatment : Medical management

Insurer Claim Number :

Authorization Details :

Date and time Reference number Amount Status

06/02/2024 03:47 PM BLR-0224-PA-0001754 16650 Approved

Total Authorized amount:- Rupees Sixteen Thousand Six Hundred and Fifty Only (in words)

Authorization Remarks:

FINAL APPROVAL As Per The Final Bill And D/S.

Previous Atl Stands Null And Void.
Non-Medical Expenses Are Not Payable.
Subject To Verification During Claims.
co pay deducted
 BLR-0224-PA-0001754

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 : 32184.00 (INR)

*Discount : 2388.00 (INR) (At the time of Final Authorization)

Excess of package amount:

(Not to be collected from the insured) : 0.00 (INR) (At the time of Final Authorization)

*Other Deductions : 11296.00 (INR) (At the time of Final Authorization)

Co-Pay : 1850.00 (INR)

Co-Pay Buffer : 0.00 (INR)

Deductibles : 0.00 (INR)

Exceeds Policy Limit : 0.00 (INR)

Policy Deductable Amount : 0.00 (INR)

Total Authorised Amount: : 16650.00 (INR)

Amount to be paid by lnsured : 13146 (INR) (At the time of Final Authorization)

* Discount & Other Deduction Details

Deducted Amount Admissible

S.no Description Bill Amount Deduction Reason
Amount

1 LABORATORY INVESTIGATIONS 1650.00 132.00 1518.00 , Rs.132 deducted for discount.

under pad,baby wipes..............are non
2 PHARMACY 2334.00 896.00 1438.00 payable UCR deduction amount is.
Rs.896
3 PROFESSIONAL 8200.00 656.00 7544.00 , Rs.656 deducted for discount.
4000 per day limit, Rs.1600 deducted for
4 ROOM/BOARDING EXPENSES 20000.00 12000.00 8000.00
discount.
 BLR-0224-PA-0001754

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.

7. The above payment is subject to applicable TDS.

Kindly submit complete claim documents within 2 days from the date of discharge, falling which claim will be processed
subject to delay condonation approval by the Insurer.

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.

6. Original cashless claim form, bills and discharge summary in IRDAI format

7. Copy of all the authorization letters

8. Original letter/s of clarification provided during the authorization , all investigation reports

9. Original sticker and invoice for all the implants & high value consumables

10. Self-attested copy of photo id card of the patient is mandatory; any one of these documents will be accepted-
(a) Aadhar Card (b) Driving License (c) PAN Card (d) VoterID Card (e) School/College Id card for students (f) Passport

11. If the bill amount exceeds INR 1lakh, it is mandatory to collect the address proof of the Primary Beneficiary; any of these documents
will be accepted (a) Aadhar Card (b) Driving License (c) Passport (d) Voter ID Card

Name of the Product : GROUP HEALTH POLICY UIN No. UIIHLGP21226V022021

Disclaimer: This is an electronic generated communication and does not require a signature

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: R U B Y H A L L C L I N I C

SECTION A
a) Hospital ID: H O S M U M 0 1 0 1 4 6 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: N E W B O R N T W I N 1 S T

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

SECTION B
f) Date of Admission: 0 2 0 2 2 4 g) Time: 1 2 0 3 h) Date of Discharge: 0 5 0 2 2 4 i) Time : 1 2 0 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 1 6 6 5 0

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

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

LATE PRE TERM

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 5 9 / 6 , A Z A D N A G A R , W A N O W A R I E , P U N E , ,

City: P U N E State: M A H A R A S H T R A
SECTION E

Pin Code: 4 1 1 0 4 0 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: