Cashless Authorization Letter

(Part-D)
Printed on 02/02/2023
Date : 02/02/2023
Claim Number: GUR-0123-PA-0003814 (please quote this number for all further correspondence)

Authorization is valid for admission up to 01/02/2023

AMRI HOSPITALS - MUKUNDAPUR Name of Insurance Company : NATIONAL INSURANCE COMPANY LTD

230 BARKHOLA LANE Name of TPA : Vidal Health Insurance TPA Pvt Ltd

Proposer Name : DEVARUP DUTTA

JADAVPUR PURBA

Patient's MemberID / TPA/Insurer Id of the : GUR-NC-E0538-001-0008778-A

Patient

Relation with Proposer : Self

West Bengal , 700099

Rohini Id: 8900080236370

Dear Sir /Madam ,

This has reference to the pre-authorization request submitted on 02/02/2023 12:24 PM , We here by authorize cashless facility as per details
mentioned below:

Patient Name : DEVARUP DUTTA Age : 41 Gender : Male

Policy Number : 354500502210000693 Expected Date of Admission : 01/02/2023

Policy Period : 09-11-22 TO 08-11-23 Expected Date of Discharge : 02/02/2023

Room category
Eligible Room : Estimated length of stay : 1 days
Category as per T&C
of Policy Contract:

Provisional Diagnosis : GSD+UMBILICAL HERNIA Proposed line of treatment : surgical management

Authorization Details :

Date and time Reference number Amount Status

02/02/2023 12:48 PM GUR-0123-PA-0003814 110700 Approved

Total Authorized amount:- Rupees One Lakh Ten Thousand Seven Hundred Only (in words)

Authorization Remarks:
ATL ENHANCED 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. A VALID PHOTO ID OF THE PATIENT IS
MANDATORY DURING CLAIMS.COPAY APPLICABLE,DISCOUNT AMOUNT SHOULD NOT BE COLLECTED FROM THE PATIENT OTHER THAN NMES AND
COPAY
 GUR-0123-PA-0003814

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 : 162860.00 (INR)

*Discount : 38000.00 (INR) (At the time of Final Authorization)

*Other Deductions : 1860.00 (INR) (At the time of Final Authorization)

Co-Pay : 12300.00 (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: : 110700.00 (INR)

Amount to be paid by lnsured : 14160 (INR) (At the time of Final Authorization)

* Discount & Other Deduction Details

Deducted Amount Admissible

S.no Description Bill Amount Deduction Reason
Amount
DIET CHARGE MRD GST NOT
1 PACKAGE CHARGES 162860.00 39860.00 123000.00 PAYABLE, Rs.38000 deducted for
discount.
 GUR-0123-PA-0003814

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 : UIN No.

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: A M R I H O S P I T A L S - M U K U N D A P U R

SECTION A
a) Hospital ID: H O S K O L 6 2 5 4 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: D E V A R U P D U T T A

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

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

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 1 0 7 0 0

DETAILS OF AILMENT DIAGNOSED (PRIMARY)

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

GSD+UMBILICAL HERNIA
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 2 3 0 B A R K H O L A L A N E , J A D A V P U R P U R B A ,

City: K O L K A T A State: W E S T B E N G A L
SECTION E

Pin Code: 7 0 0 0 9 9 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: