PARAMOUNT HEALTH SERVICE & INSURANCE TPA PRIVATE LIMITED

(IRDA License No.006) Validity: From 21-03-2023 to 20-03-2026

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
[email protected].
Branch Code : 080

Cashless Authorization Letter

(Part-D)

Claim Number: 6957711 (Please quote this number for all further correspondence) Date: 06/09/2024 02:22:42 PM

Authorization is valid for admission up to 20/09/2024.

APOLLO CRADLE (APOLLO HEALTH AND LIFESTYLE Name of Insurance Company :Future Generali India Insurance Company Ltd.
LIMITED)
Name of TPA : Paramount Health Services & Insurance TPA Pvt. Ltd.
101/209, Itpl Main Road Kundalahalli, Brooke Fieled, Marathhalli
Brooke Fieled,Bangalore,Karnataka-560037 Proposer Name : KARTHIKEYAN CHOKKALINGAM
Rohini Id : 8900080326767 Patient's Member : KHASHWIKA KARTHIKEYAN
ID/TPA/Insurer ID of the Patient : 39433295
Relation With Proposer : Daughter
Corporate Name: HARMAN CONNECTED SERVICES CORP. INDIA PVT. LTD.

Dear Sir /Madam,

This has reference to the last documents received for pre-authorization request on 06/09/2024 01:40:28 PM. We hereby authorize cashless facility as per details mentioned
below:

Patient Name : KHASHWIKA KARTHIKEYAN Age : 4 Gender : FEMALE

Policy Number : FGH-12-24-7003925-00-000 Expected Date of Admission : 05/09/2024
Policy Period : 31/03/2024-30/03/2025 Expected Date of Discharge :07/09/2024
Room category : single
Estimated Length Of Stay:2
Category as per T&C of Policy Contract
Provisional Diagnosis : Fever Proposed line of treatment : Fever

Claim Remarks:

Authorization Details :-

Claim No Policy No Date & Time Reference number Amount Status

6957711 FGH-12-24-7003925-00-000 06/09/2024 02:22 5441789 15000 Authorized

Total Authorized amount:- Rs 15000 (FIFTEEN THOUSAND )

Authorization Remarks: All charges will be payable as per agreed tariff between phs & hospital. Standard non medical exp not payable. 10% co-pay applicable.
Revert with discharge summary, FB, all ICP,

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 : 30000

*Other Deductions : 15000
Discount :0
Co-Pay :0
Deductibles :0
Total Authorised Amount : 15000
Amount to be paid by insured : 15000
*Other Deduction Details :

Bill Deducted Admissible

Sr.no Description Deduction Reason
Amount Amount Amount
Miscellaneous Initial AL. Further authorization/ Final admissible amount will be decided only after receipt of enhancement
1 30000 15000 15000
charges request and Validation of this amount will be done upon receipt of Final bill and discharge summary.

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.
8. Radiology Films.

Name of the Product - FUTURE GENERALI INDIA - 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.

IMPORTANT POINT FOR CASHLESS PAYMENT:

1. Final Bill & Discharge summary is mandatory for validation of authorized amount. In the absence of discharge intimation or final authorization all previous AL amount
will stand null & void.
2. Insurer reserve the right to demand invoice and /or sticker of high value implant & consumables or medicine at the time of settlement. Non submission may lead to
denial of entire claim or deduction of such amount during final settlement or possible recovery of such amount due to non-submission of invoice.
3. Radiology films and all original investigation report to be submitted in the claim file to avoid payment delay or recovery of such amount paid erroneously on account
of non-submission.
4. Hospital is requested to submit the claim file within 2 days from patient discharge date for hassle free payment.

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