Cashless Authorization Letter
Part-D
Claim Number: 1212585054332 (Please quote this number for all further correspondence) Date:08/02/2025
Authorization is valid for admission up to 2025-02-21 00:00:00.0
ABC Hospital : Kokila Ben Hospital Name of Insurance Company : Aditya Birla Health Insurance
Address : Rao Saheb Achutrao, Patwardhan Marg, Four Name of TPA : NA
Bunglows, Andheri West,Rao Saheb Achutrao, Proposer Name : SOHAIL ASHFAK SHAIKH
Patwardhan Marg, Four Bunglows, Andheri Patient's Member : SOHAIL ASHFAK SHAIKH
West,Rao Saheb Achutrao, Patwardhan Marg, Four
ID/TPA/Insurer Id of the Patient : PT97172959
Bunglows, Andheri West,Mumbai,400053
Relation with Proposer : NA
Rohini ld : 8900080104419
Dear Sir /Madam,
This has reference to the pre-authorization request submitted on 31-01-2025 03:35:19 We here by authorize cashless facility as per details
mentioned below:
Patient Name: SOHAIL ASHFAK SHAIKH Age: 36.0 Gender: M
Policy Number: GHI-71-23-5043027-001 Expected Date of Admission: 06/02/2025 03:35 PM
Policy Period: 1Y Expected Date of Discharge: 10/02/2025 03:35 PM
Room category: Shared Room
Eligible Room Category as Estimated length of stay: 4.0
As per Policy schedule
per T&C of Policy Contract:
Provisional Diagnosis: RIGHT KNEE ACL AND MENISCUS TEAR Proposed line of treatment: Surgical Management
Authorization Details:-
Date & Time Reference number Amount Status
08-02-2025 1212585054332 478169.76 Approved
Total Authorized amount:- Rs. 478169.76
Authorization Remarks :Charges will be settled as per agreed tariff.- Charges of MoU discount and Tariff deduction not be collected from
patient ? Kindly submit original bills along with documents at the time of claim submission. Final bill and Discharge summary received.
Hospital Agreed Tariff:
Package case
Agreed Package Rate NA
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/Anaesthetist : NA
vi. Others (specify) : NA
Authorization Summary:
Total Bill Amount: 516166.63
*Other Deductions: 37996.87
Discount: 0.00
Co-Pay: 0.0
Deductibles: 0.00
Total Bill Amount: 516166.63
*Other Deductions: 37996.87
Discount: 0.00
Co-Pay: 0.0
Deductibles: 0.00
Total Authorised Amount: 478169.76
Amount to be paid by lnsured: 37996.87
*Other Deduction Details:
S.no Description Bill Amount Deducted Amount Admissible Amount Deduction Reason
1 ICU Charges 425.00 0.00 425.00 NA
2 Investigation Charges 34407.65 0.00 34407.65 NA
Rs. 830.0 for Cliper Blade 9680
3MRs. 90.0 for Os Trolley Cover
JainamRs. 360.0 for Plain Sheet
Cm Primewear PrimewearRs.
930.0 for Cliper Blade 9680 3MRs.
272.0 for Tegaderm 10Cmx 12Cm
8526In 3MRs. 42.5 for Surgical
Blade 10 Swan Marton 95Wan
MortonRs. 42.5 for Surgical Blade
11 Swan Marton 9SwanRs. 42.5 for
Surgical Blade 15 Swan MartonRs.
1088.0 for Tegaderm 10Cmx 12Cm
8526In 3M Rs. 1380.0 for
Tegaderm Scm X 20Cm 3590 8590
In 3MRs. 124.0 for Tegaderm 6Cm
X 7 Cm 1623 3MRs. 428.0 for
Tegaderm Iv 85 Cm X 105Cm 1635
3MRs. 732.0 for 3M Skin Prep Chg
100Ml Hzd2W38Rs. 1658.0 for
Coban 6 X 5 Yd 1586 3Meter 3MRs.
350.0 for Crepe Bandage
ComfortRs. 1700.0 for Gamjee
Roll 15Cm X 2 Mtr Pk OfRs.
2700.0 for Knee Arthroscopy
Drape W Pouch Careon 27MeRs.
480.0 for Ro Gauze 10 Cm X 10
Cm X 12 Ply Pk OfRs. 325.0 for
3 Medicine And Consumable Charges 65401.98 30646.87 34755.11 Aseptoscrub 100Ml Hzd2WB
26SchumacheRs. 985.0 for Chg
Handrub 500Ml 3MHzd2W3Rs.
396.0 for Examination Gloves
Medium Rakshax Pk
27RakshakRs. 330.0 for Sofroll
15Cm GauzetouchRs. 4580.0 for
Sponges 12Inch X 12 Inch X 8 Ply
Pk OfRs. 1980.0 for Steri Drape U
Pack Udkdh1 Careon CareonRs.
320.0 for Theatre Gauze 10Cm
X10 Cm X 8Ply Pk OfRs. 396.0 for
Examination Gloves Medilim
Rakshak Pk 27RakshaxRs. -396.0
for Examination Gloves Medium
Rakshak Pk 27RakshakRs. 15.0
for Chg Swabs W Isopropyl Alcohol
6X10Cm Akt Shwethas HygieneRs.
250.0 for Oxygen Face Mask Adult
Hudson 0428HudsonRs. 6.5 for
Needle 18G 112 BdRs. 3.6 for
Needle 23 1 And 12 RomsonRs.
47.0 for Syringe 10Ml Ll 21Gx1
With Needle Bd 9BdRs. 124.0 for
Syringe 20 Ml Ll Wo Needle Bd
BBdRs. -332.0 for Polyflush 10Ml
PolymedNacl 09 Prefill
27PolymedRs. -188.0 for Syringe
S.no Description Bill Amount Deducted Amount Admissible Amount Deduction Reason
10Ml Ll 21Gx1 With Needle BdRs.
282.0 for Syringe 10Ml Ll 21Gx1
With Needle Bd SBdRs. 20.0 for
Needle 16G 112 RomsonRs. 32.5
for Needle 18G 112 BdRs. 3.6 for
Needle 23 1 And 12 RomsonRs.
141.0 for Syringe 10Ml Ll 21Gx1
With Needle BdRs. 12.0 for
Syringe 2 Ml Plain BdRs. 132.0 for
Syringe 20 Ml Plain WO Needle
BdRs. 33.0 for Syringe 5 Ml Plain
BdRs. 170.0 for Syringe 50 Ml Ll
Wo Needle Bd 9BcRs. 1295.0 for
Knee Brace Long Type X Large D11
Tynor 2BTynorRs. 825.0 for
Microcool Surg Gown L ChemoRs.
553.0 for Easy Bath Wet Wipes 1
X 10 32Cm X 32 CmRs. 553.0 for
Easy Bath Wet Wipes 1 X 10 32Cm
X 32 CmRs. -553.0 for Easy Bath
Wet Wipes 1 X 10 32Cm X 32
CmRs. 448.0 for Steristrip 12 X 4
In 3M
Rs. 3000.0 for Visitor PassRs.
4 Miscellaneous Charges 7282.00 3050.00 4232.00
50.0 for Tea
Rs. 580.0 for Disinfection Charges
5 OT Charges 172705.00 1160.00 171545.00 WardRs. 580.0 for Disinfection
Charges Ward
6 Package Charges 3000.00 0.00 3000.00 NA
7 Professional Fee Charges 219905.00 0.00 219905.00 NA
Rs. 1570.0 for JmsRmo ChargeRs.
8 Room and Nursing Charges 13040.00 3140.00 9900.00
1570.0 for JmsRmo Charge
NA Please Note Since the claims is payable hence the Outstanding Premium/s of INR NA/- is due and deducted from your claims payable amount.
Hence Final payable amount will be of INR NA/-.
Terms and Conditions of authorisation:
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 lnsurer 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 empaneled with the hospital), Network
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 null lmportant Policy terms & conditions (sub-limits/co-Day/deductible etc)
Authorized signatory :
(Insurer/TPA)
Address: 9th Floor, Tower 1, One Indiabulls Centre, Jupiter Mills Compound, 841, Senapati Bapat Marg, Elphinstone Road, Mumbai 400013. Email:
[email protected], Website: adityabirlahealthinsurance.com, Telephone: 1800 270 7000, Fax: +91 22 6225 7700.
