ApprovalLetterClaim Letter

Cashless Authorization Letter
(Part-D)
Claim Number AL: 80421142(Please quote this number for all further correspondence) Date:31/Aug/2020
Authorization is valid for admission up to 05/Sep/2020(date).
LOKMANYA HOSPITALS PVT LTD (51080918) Name of Insurance Company :Religare Health Insurance Company Ltd
484/6,MITRAMANDAL CO-OP SOCIETY,ARYA Name of TPA : NA
Pune Proposer Name : Dhanashree Sohani
Pune City Patient’s Member: 59323883
411009 ID/TPA/Insurer Id of the Patient
Rohini ID : 8900080121164 Relation with Proposer : MMBR
Dear Sir / Madam,

This has reference to the pre-authorization request submitted on 31/Aug/2020.We hereby authorize cashless facility as per details
mentioned below:
Patient Name : Dhanashree Age : 31 Gender : Male

Sohani
Policy No : 12195570 Expected Date of Admission: 31-Aug-2020
Policy period : 06-03-2020 to Expected Date of Discharge : 03-Sep-2020
21-08-2021
Room category Eligible Room Estimated length of stay : 3
Category as per T&C of Policy
Contract: Single AC
Provisional diagnosis :Fracture of Proposed line of treatment : Surgical Treatment
forearm
Class of Accommodation Opted Claim Amount : 146350.00
: Private
Additional Sanction :0 Total Sanctioned Amount : 90000.00
Authorization Details:
Date & Time Reference Number Approved Amount Status

31/Aug/2020 06:51:06 80421142-00 90000.00 Cashless
Approved,Cashless
Approved -
Communication Pending
90000.00
Total Approved amount Rs.90000.00(Ninety Thousand Only)

Authorization remarks : APPROVED AS PER AGREED TARIFF FOR SURGICAL MANAGEMENT .KINDLY PROVIDE MLC /FIR
REPORT FOR FURTHER APPROVAL .ROOM RENT ELIGIBILITY LOWEST SINGLE AC PROPORTIONATE APPLICABLE IF
EXCEEDS.KINDLY PROVIDE ADDRESS PROOF AND PASSPORT SIZE PHOTO OF PROPOSER- DHANASHREE SOHANI
Hospital Agreed Tariff:-
I. Package Case:- Agreed package rate :
II. Non Package Case (Please refer Below Grid)
Authorization Summary:
Total Bill Amount 146350.00

Other Deductions 56350.00
Discount 0
Co-pay 0
Deductibles 0.00
Total Authorized Amount 90000.00
Amount to be paid by 0.00
Insured
Other Deduction details:
S.no Description No.of Day/Visits/ Rate per Bill Amount Admissible Deducted Deduction Reason Remarks
Quantity day/Quantity Amount Amount
Total 0 0 0
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 and 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 payout above Rs I 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 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.
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 note 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 Name of the
Product : Care and UIN No - IRDAI/HLT/RHI/P-H/V.II/253/16-17 important Policy terms and conditions
(sub-limits/co-Day/deductible etc.)
Notes to the hospital
1) KYC documents i.e. Identity Proof/Address Proof and Latest photo of the proposer to be sent if bill estimate is more than Rs.
1.0 Lakh.
2) If the hospital bill is estimated to be higher than the guarantee of payment, the additional amount would need to be sanctioned
by RHICL
3) In absence of such additional guarantee, the hospital must collect the excess amount directly from the insured at the time of
admission or prior to discharge.
4) The hospital bill summary and the detailed final bill will have to be authenticated with the insured's signature.This along with the
original discharge summary and investigation reports will have to be submitted to the company.
5) Please collect an undertaking from the insured/patient for submitting his/her documents to RHICL in original.
6) Charges for the following miscellaneous services must be collected directly from the patient :
a) Registration charges g) Charges for Tv, Laundry, Telephone, Fax

etc
b) Attendant / Visitor charges h) Food and Beverage for attendance/visitors
c) Ambulance charges unless authorized i) Toiletries
d) Nursing charges not authorized j) Medicines not related to treatment
e) Service charges k) Stationary and other charges
f) Charges for extra bed
Notes:
• This authorization is valid for admission within 15 days Date need to mention from the date of issue or expiry / cancellation of the policy whichever
is earlier.
• The authorization will not be valid if the patient is discharged before the date of issue of this letter.
• Co payment amount will be collected from insured.
• Claim Settlement will be as per agreed tariff structure between RHICL & the hospital.
• This is an initial approval and stands cancel where Misinterpretation of Facts is noticed.
All payment to hospital will be subject to deduction of tax at source as per prevailing government rates except where Nil/Low TDS certificates have
been provided.
Please note that hospitalization for Treatment of following conditions is not payable:
i) Investigation and Evaluation, Infertility, STD, Self-inflicted Injury, conditions caused by use of alcohol/tobacco/intoxicating drugs
and others conditions as per policy terms.
ii) Religare Health Insurance Company will not be liable in the event of any discrepancy between the facts presented at the time
of admission & at time of final discharge documentation.
Religare Health Insurance Company Ltd
Authorized Signatory

ApprovalLetterClaim Letter

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Cashless Authorization Letter

Dear Sir / Madam,

Patient Name : Dhanashree Age : 31 Gender : Male

Date & Time Reference Number Approved Amount Status

Total Approved amount Rs.90000.00(Ninety Thousand Only)

Hospital Agreed Tariff:-

I. Package Case:- Agreed package rate :

II. Non Package Case (Please refer Below Grid)

Total Bill Amount 146350.00

Other Deduction details:

Terms and Conditions of Authorization

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM

1) Detailed Discharge Summary and all Bills from the hospital.

Notes to the hospital

a) Registration charges g) Charges for Tv, Laundry, Telephone, Fax

Religare Health Insurance Company Ltd

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