Pre Auth Approval

Date: 18/11/2023
To,
Trustwell Hospitals Pvt. Ltd.
No. 5, Chandrika Towers, J.C. Road
Contact Number/Fax Number: 08041305885
Dear Service Partner,
We are glad to inform that initial cashless request id 769587 is approved at 18/11/2023 14:29:19. Please refer to the following
details.
IMPORTANT:
1. Revised approval required if there is any change in the following
a. Diagnosis
b. Length of stay
c. Cost of treatment
d. Line of treatment
2. KYC (Know your customer) details of proposer/employee/Beneficiary mandatory for claim payout above Rs. 1 lakh.
(Refer page 2 of letter for details).
Patient Name: Mrs. Sincy Srinivasamurthy
Age/ Gender: 44 / Female
Member id: 6077339
Approved Room Category: PRIVATE/ SINGLE ROOM
Provisional Diagnosis: Abnormal uterine and vaginal bleeding, unspecified
Proposed line of treatment: SURGICAL
Expected Date of Admission: 17/11/2023
Approved length of stay: 1
Expected Date of Discharge: 18/11/2023
Co-payment: 0.00
Requested amount: 121,600.00
Approval Amount (Rs). 97,600.00

Remarks
Warm Regards,
Claims Team- Niva Bupa
This is a system generated letter and does not require signature
TERMS AND CONDITIONS OF AUTHORIZATION:
1. Cashless Authorization letter issued on the basis of information provided in Pre - Authorization form. In case of
misrepresentation/ concealment of the facts or any material difference / deviation/ discrepancy in information is observed in
discharge summary/ IPD records, the 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 pay out above Rs. 1 lakh.
KYC Documents means proof of address, proof of identity and latest passport size photograph.
· Proof of identity- PAN Card, Job card issued by NREGA duly signed by an officer of the State Government
· Proof of Address- Telephone bill pertaining to any kind of telephone connection like , mobile, landline, wireless, etc.
provided it is not older than six months from the date of insurance contract/ Current Passbook with details of
permanent/present residence address (updated up to the previous month)/ Current statement of bank account with
details of permanent/present residence address (as downloaded)/ Electricity bill/Ration card/ Valid lease agreement
along with rent receipt, which is not more than three months old as a residence proof.
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 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 .
8. All settlements will be done as per agreed terms and conditions and tariff with provider .
Disclaimer: Insurance is the subject matter of solicitation. Niva Bupa Health Insurance Company Limited (formerly known as
Max Bupa Health Insurance Company Limited) (IRDAI Registration Number 145). ‘Bupa’ and ‘HEARTBEAT’ logo are
registered trademarks of their respective owners and are being used by Niva Bupa Health Insurance Company Limited
(formerly known as Max Bupa Health Insurance Company Limited) under license. Registered office:- C-98, First Floor, Lajpat
Nagar 1, New Delhi-110024, Customer Helpline: 1860-500-8888. Fax: +91 11 41743397. Website: www.nivabupa.com. CIN:
U66000DL2008PLC182918.

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Date: 18/11/2023

Dear Service Partner,

Patient Name: Mrs. Sincy Srinivasamurthy

Age/ Gender: 44 / Female

Member id: 6077339

Approved Room Category: PRIVATE/ SINGLE ROOM

Provisional Diagnosis: Abnormal uterine and vaginal bleeding, unspecified

Proposed line of treatment: SURGICAL

Expected Date of Admission: 17/11/2023

Approved length of stay: 1

Expected Date of Discharge: 18/11/2023

Requested amount: 121,600.00

Approval Amount (Rs). 97,600.00

This is a system generated letter and does not require signature

TERMS AND CONDITIONS OF AUTHORIZATION:

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