Cashless Authorization Letter (122295438)

(Please quote this reference number in all future correspondence)

E-card Claims Plan hospitalzation Hospitals

Medi Assist Insurance TPA Pvt. Ltd

Date :15 Jun 2024

To,

The Administrator / Medical Superintendent,

Yashoda Hospital,
Sp Road, Beside Hari Hara Kalabhavan, Secunderabad - 500003
Hospital ID: (57340)
Rohini Id: 8900080157941

Dear Partner,

With reference to your request (122295438) for final cashless pre-authorization, we here by authorize INR 172874 against your final bill amount INR 307765.
The details of the pre-authorization are as follows:

Patient Details

Patient Name Bapurao Guggilla

Relation to Primary Beneficiary Father

Age 63

Gender M

Insurance Company The New India Assurance Co. Ltd

Medi Assist ID 4045333601

Policy Holder Tavant Technologies India Pvt Ltd

IP No.

Policy No. 90000034230400000139_Parents

Policy/Plan Period 07 Oct 2023 to 06 Oct 2024

Primary Beneficiary Guggilla Sateesh Kumar

Insurer Claim No TP00390000024900001397

Insurer Member ID MEMBER632

Treatment Details

Atherosclerotic heart disease of native coronary artery without angina

Provisional Diagnosis
pectoris

Expected/Actual Date Of Admission 12 Jun 2024

Treating Doctor DR RAMESH G

Procedure / Treatment Planned PTCA with stenting-Transluminal coronary angioplasty with stenting

Estimated/Actual Date of Discharge 15 Jun 2024

Room Category Occupied Semi private room

Length Of Stay 3

Eligible Room Category Sharing Ward (Semiprivate / Multibed Ward)

Total Authorized amount Rs 172874 (One Lakh Seventy Two Thousand Eight Hundred and Seventy Four).

Authorization Remarks :

Final processed, IVUS charges max payable 80k as per reasonable & customary charges & kindly provide the catheter & stent invoice at the time of cashless
mandatorily

Note: If Top Up is available and applicable, as per policy conditions, Top Up claims will be processed and additional amounts will be approved along with base
amount as per your benefit.

Authorization Summary

Total bill amount (INR) 307765

Other Deductions(INR)* 12909

Policy Excess / Deductible (INR) 119982

Excess of Defined / Ailment Limit (INR) 2000

Hospital Discount (INR) 0

 Deductibles (INR) 0

Total Authorized Amount(INR) 172874

Amount to be paid by Insured (INR) 134891

Detailed list of deductions have been shared with the claimant

Terms and conditions for authorization:

1. Cashless authorization letter issued on the basis of information provided in pre authorization form. In case of misrepresentation/concealment of facts,
any material difference/deviation/ discrepancy in information is observed in discharge summary / IPD records then cashless authorization stands null &
void. At any point of claim processing Insurer or TPA reserves the right to raise queries for any other document to ascertain the 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 cost 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 the cost 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 treatment / procedure 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 the policyholder.
7. Expenses on investigations / diagnostic tests, etc. which are not related to the condition for which admission is sought are not admissible
8. Expenses are excluded which are not covered / not payable as per health insurance policy terms and conditions are not admissible
9. Expenses related to medicines/drugs incurred post discharge and Differential cost borne by the policyholder may be reimbursed by Insurer subject to
terms and conditions of the policy

The following documents must be submitted in full within 7 days from date of discharge to enable settlement of claim:

1. Original cashless claim form in IRDAI format

2. Government ID proof and Medi Assist ID card of the patient along with KYC form
3. Detailed discharge summary with Main hospital bill along with Break-up of the bill amount being claimed
4. Cash memos from the Hospitals / Chemists supported by proper prescriptions
5. Diagnostic Test Reports, X-ray films, and Receipts supported by note from the attending Medical Practitioner / Surgeon recommending such diagnostic
tests
6. Original sticker for all the implants & high value consumables
7. Surgeon's Certificate stating the nature of operation performed and Surgeon's Bill and Receipt
8. Certificates from attending Medical Practitioner / Surgeon giving patient's condition and advice on discharge
9. Copy of the receipt for the amount settled by the patient / representative
10. Final hospital bills should be issued in the name of The New India Assurance Co. Ltd as a payer for payment of cashless claims. This is a mandatory
requirement for claim settlement.
11. Please send cashless documents to the address mentioned in the last page of the letter. (Beneath signature)

Note: As per Modified Guidelines on Standards and Benchmarks for Hospitals in the Provider Network issued by IRDAI vide Circular Ref:
IRDA/HLT/REG/GDL/114/07/2018 dated 27th July 2018, your Hospital is mandatorily required to Register with ROHINI and obtain either Pre-entry level
Certificate (or higher level of certificate) issued by NABH or State Level Certificate (or higher level of certificate) under NQAS, issued by National Health
Systems Resources Centre (NHSRC) on or before July 26, 2019.

QUICK LINKS:

For partner hospital

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Warm Regards,

Medi Assist Insurance TPA Pvt. Ltd

CIN: U85199KA1999PTC025676.
Cashless Processing Centre
#58/1A, Singhasandra.
Hosur Main Road,
Begur Post.
Bangalore. PIN - 560068.
Helpline: 0120-6937324

Disclaimer: The TPA extends the cashless facility subject to the standard terms & conditions of the policy and the information provided in the cashless request form. We suggest that the
patient continues with the treatment as advised by the treating doctor, irrespective of the pre-authorization/cashless facility.

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