Authorization Letter to the Hospital for the Treatment and Guarantee of Payment

(Part-D)

Date : 13-MAR-24

AL Approved Date :13-MAR-24

AL Requested Date : 13-MAR-24

IIMT Life Line Hospital
Rohini ID :8900080345263
O Pocket, Ganga Nagar
MEERUT,Uttar Pradesh-250001
Tel: Mob:
AL Number:110201714513-1

Dear Sir/Madam,
We hereby authorize and guarantee for payment of Rs 40744 (in words) Rupees FORTY THOUSAND SEVEN HUNDRED
FORTY-FOUR only. Authorization is valid for 15 days from the date of approval or proposed date of admission, whichever
earlier (Provided date of admission remains same).
Admission/ Pre-authorization request note sent by you with the following information:
Name of the Patient :SHIVAM GUPTA Policy related Deductions :
UHID Number :IL22563784900 Co-Pay :0
Requested Room Type :Private Single Room Deductible :0
Class of Accommodation :Private Single Room BSI Exhaustion :0
Provisional Diagnosis :Other intervertebral disc disorders Sub Limit :0
Policy Period :09-JUN-2023 To 08-JUN-2024 Proportionate as per Eligible Room :0
Date of Admission :08-MAR-2024 Non-Medical Expenses* (Please refer
:3622
:KALYAN JEWELLERS INDIA Annexure for details)
Policy Name
LIMITED Others: :0
Patient IP No : Remarks (deductions will be calculated at the
Age :26 time of final settlement)
Gender :MALE
Policy No :4016/X/222169747/02/000 Network related Deductions (Not to be
collected from Insured)
Proposer Name :
Hospital Tariff Deductions :0
Relation with Proposer :SELF
Discounts
Date of Discharge :13-MAR-24
(Shall be applied at the time of Final :4351
Estimated length of stay :6 Authorization)
Proposed line of treatment :MEDICAL
Total Bill Amount :48717 :
Amount to be paid by Insured
UIN : 3622
at discharge

Final
Event Date & Time Status Final Requested Amount Sanctioned
Amount
Initial Approved 08-MAR-2024 [Link] APPROVED 48717 40744
PM
Enhancement 13-MAR-2024 [Link] APPROVED
PM
Final Approved Amount APPROVED

Hospital Agreed Tariff :

1. Package case
Agreed Package Rate :NA

2. Non-package Case

Hospital Agreed Tariff Non Package Case-Rent/day

Surgeon
Nursing Consultant super specialist Others
Room Rent ICU Rent fee/OT/
Charges Visit Charges charges (Specify)
Anaestheist
0 0 Included in 0 0 0
Room Rent

Remarks:
Rs.80/-Deducted As Non Admissible Items (to be borne by patient),Rs.3542/- Deducted as Reasonable & Customary
charges (To be borne by patient)

“For any cashless queries, write on cashlessrequest@[Link]”

Note: "Please submit PAN of your hospital and Aadhaar Number of the Authorized Signatory (with copy) for settlement
of the Claim."

Important Note: This authorization is valid for Admission within 15 days from the Date of Admission mentioned or expiry
/cancellation of the Insurance policy whichever is earlier. This Authorization becomes null and void if the patient is discharged
before the date of this letter issuance. Copayment Amount has to be collected from Insured. Claim Processing / Settlement will
be as per agreed rates in MOU/Tariff. This is an electronically generated document and this requires no seal / stamp

Address: ICICI Lombard GIC, ICICI Lombard Health Care, 01st, 04th, 05th & 06th Floor, Varun Towers II, Opp Hyderabad
Public School, Begumpet, Hyderabad - 500016, Telangana.
Email: ihealthcare@[Link]
IRDA Registration No. 115.

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 pay out 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

MANDATORY 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 supposed 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. Implant Invoice

Important Instructions to Hospitals :1)If the hospital bill is estimated to be higher than the guarantee of payment, a request
letter for additional amount needs to be sent to ILGIC 2) If no further guarantee is available, the hospital must collect the
excess amount directly from the beneficiary at the time of admission/ prior to discharge from the hospital, as per hospital rules
and regulations 3) Please collect the hospital bill summary with final bill with details of units of each service (authenticated by
patients signature). 4) Please collect the discharge summary and reports of all investigations (original). 5) Please collect an
undertaking from the insured / patient for submitting his/her documents to ILGIC Ltd in original. 6) Charges for the following
miscellaneous services and related allied services must be collected directly from the patient.i) Registration / admission
charges ii) Ambulance charges (unless authorized) iii) Attendant / visitor pass charges. iv) Special nursing charges not
authorized by the attending doctor v) Service charges not forming a part of the bed charges in general ward, maintenance
charges, surcharges vi)Charges for extra bed for attendant etc vii)Bed retaining charges viii)Charges for TV, Laundry etc ix)
Telephone/Fax charges x) Food and Beverages for attendants and visitors. xi) Toiletries etc xii) Purchase of medicines not
related to the treatment xiii) Stationery, Xerox or certifying charges.

Following Details are mandatory for claim settlement

Date of Discharge
Final Bill Amount
Amount Paid by Patient Signature of the Hospital Stamp &
Patient/Relative Signature
All payments to Hospitals are subject to deduction of tax at source as per prevailing rate unless lower/nil TDS certificate had been provided to the payer, under
section 194J as per Circular No 8/2009. Dated 24-11-2009 from Income Tax Dept

Annexure- Details of Non-Medical expenses

Bill No Bill Date Particulars Amount (In Rs)

No Bills 09-MAR-24 Gloves Examination 32
No Bills 09-MAR-24 Gloves Examination 1-100 48
TOTAL 80

Annexure for MOU deductions

MOU
Requested Amount (In
Bill Type MOU Amount (In Rs) Deducation
Rs)
(In Rs)
Consultation Visit Charges 11700 11700 0
Room Charges 12500 12500 0
Medicines Pharmacy Charges 5207 5207 0
Specialized Investigation 9000 9000 0
Investigation Charges 10310 10310 0
TOTAL 48717 48717 0

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