PARAMOUNT HEALTH SERVICE & INSURANCE TPA PRIVATE LIMITED

(IRDA License No.006) Validity: From 21-03-2020 to 20-03-2023

Plot No.A-442,Road No-28.M.I.D.C Industrial Area,Wagale Estate,Ram Nagar, Vitthal Rukhumani Mandir, Thane-400604 Tel-(022)-66620808, Fax No-68342754, E-mail
contact.phs@paramounttpa.com.
Branch Code : 011

Cashless Authorization Letter

(Part-D)

Claim Number: 5605787 (Please quote this number for all further correspondence) Date: 08/08/2022 1:55:15 PM

Authorization is valid for admission up to 21/08/2022.

FERNANDEZ HOSPITAL(HYDERABAD) Name of Insurance Company :IFFCO Tokio General Insurance Company Ltd.
Door No. 4-1-1230 Opp. Ywca Bogulkunta,Hyderabad,Telangana- Name of TPA : Paramount Health Services & Insurance TPA Pvt. Ltd.
500001
Rohini Id : 8900080157309 Proposer Name : PABBA SANTHOSH KUMAR
Patient's Member : POLOJU KAVITHA
ID/TPA/Insurer ID of the Patient : 26496166
Relation With Proposer : Wife
Corporate Name: FIITJEE LIMITED

Dear Sir /Madam,

This has reference to the pre-authorization request submitted on 08/08/2022 12:26:48 PM. We hereby authorize cashless facility as per details mentioned below:

Patient Name : POLOJU KAVITHA Age : 30 Gender : FEMALE

Policy Number : H1026182 Expected Date of Admission : 06/08/2022
Policy Period : 22/06/2022-21/06/2023 Expected Date of Discharge :09/08/2022
Room category : Single room
Estimated Length Of Stay:3
Category as per T&C of Policy Contract
Provisional Diagnosis : Elective Lscs Proposed line of treatment : Elective Lscs

Claim Remarks:

Authorization Details :-

Date & Time Reference number Amount Status

08/08/2022 01:55 3947958 60000 Authorized

Total Authorized amount:- Rs 60000 (SIXTY THOUSAND )

Authorization Remarks: REVERT WITH FINAL BILL & DISCHARGE CARD

Hospital Agreed Tariff:

I Package Case:
Agreed Package Rate : NA
II Non-package Case:
i. Room Rent/day : NA
ii. ICU Rent/day : NA
iii. Nursing Charges/day : NA
iv. Consultant Visit Charges/day : NA
v. Surgeon's fee/OT/Anesthetist : NA
vi. Others (specify) : NA

Authorization Summary:

Total Bill Amount : 77000

*Other Deductions : 17000
Discount :0
Co-Pay :0
Deductibles :0
Total Authorised Amount : 60000
Amount to be paid by insured : 17000
*Other Deduction Details :

Sr.no Description Bill Amount Deducted Amount Admissible Amount Deduction Reason
1 Miscellaneous charges 77000 17000 60000 INITIAL AL

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 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 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 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 empanelled 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.
6. Please submit member paid receipt copy of the difference in AL amount and Hospital bill (excluding TPA discount) at the time of claim submission.
7. Invoice of implants.

Name of the Product INSURANCE GENERAL MEDISHIELD FLOATER and UIN No- Important Policy terms & conditions (sub-limits/co-pay/deductible etc)

Please note that the amount authorized is provisional and is subject to change based on the final bill and discharge summary and deduction of TDS as applicable.

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 NOAS, issued by national Health systems Resources Centre (NHSRC) on or
before July26, 2019.

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.

This is a system generated letter hence signature is not required.