Cashless Authorization Letter Date :- 18-JUN-2024

*6653214*
AL No : HAT /25/6653214 (Please Use this no for any communication regarding this AL)
Claim Number
Authorization is valid for admission up to
CLOUDNINE (KIDS CLINIC INDIA PVT. LTD.) - NOIDA
C-9, SECTOR-51,NEAR KENDRIYA VIHAR APPARTMENT,NOIDA - 201301

NOIDA
Pin Code:- 201301
Phone No:- (120)9620343444 Fax No:- (120)0

Rohini ld :-

Proposer Name:-

Relation with Proposer:-

Patient ID card Number:- GMC-24990630178-670A

Dear Sir/Madam,

This has reference to the pre authorization request submitted on . We here by authorize cashless facility as per details mentioned be-
low:

Patient Name : PAYEL MUKHERJEE Age :

[GMC-24990630178-670A]
Policy Number : Gender:
Expected Date Of Admission : 18-JUN-24 Expected Date Of Discharge :
Policy Period : to Estimated length of stay :
Availed Room Category : TWIN SHARING - AC Eligible Room category :
Provisional Diagnosis : endocervical polyp with AUB Proposed line of treatment :

Authorization Details:-

Date and Time Reference Number Amount Status

28874
1

Total Authorized amount: TWENTY-EIGHT THOUSAND EIGHT HUNDRED SEVENTY-FIVE Rs/-

Hospital Agreed Tariff:-

I. Package Case
Agreed Package Case /-
II. Non Package Case
i. Room rent /day - /-
ii. ICU rent /day - /-
iii. Nursing Charges /day- /-
iv. Consultant Charges /day- /-
v. Surgeon`s fee - /-
vi. OT charge - /-
vii. Anaesthetist - /-
viii. Others - /-
Authorization Summary:-
Note: **** Field are to be considered as a deduction and should not be added in the Bill Amount.

Particular Bill Amount Disallowed Tariff Excess De- Approved Amount Disallowance
Amount duction Reason
Miscellaneous 5950 1950 0 4000 Linen Charges Semi
Special-
750,Documentation
Processing Fee-
1200
Pharmacy Charges 14179 7139 0 7040 Plain Sheet
120X210Cm
(Nobel-440,Normal
Saline Eurolife 0.9
%W/V Infusion
(3000 Ml-
1084,Patient Gown
(Medisafe)-299,Enc
ore Latex Micro-
456,Surgeon Gown
(Medisafe)-475,Cut
aprep-Pv P 10
%W/V Solution
(100
Ml)-214,Venflon
Pro Safety Iv Can-
nula 22G
(Bd-485,Ot Apron
(Medisafe)-357,Lyo
n Eco Underpad
10S
(Bapuji)-500,Gauze
Swab
10X10X12Ply 4S
(Medicare Hy-
giene)-528,Friends
Under Pad
Single(Noble Hy-
geine)-220,Examina
tion Gloves M
(Kaltex)-359,Tegad
erm 1633
(3M)-214,Universal
Clipper Blade
Sc002
(Medovation)-750,F
lexi Mask Adult
Oxygen Mask-
Sh-2020
(Romsons)-302,Enc
ore Latex Micro
Powder Free Gloves
6.5 (Ansell)-456
Pathology Charges 2780 0 0 2780
Non-Medical 0 0 0 0
Charges
Package Charges 33000 0 0 33000
Discount*** 4125 4125 0 --- 12.5% discount on
final bill except
pharmacy
Other Deduction*** 13820 13820 0 --- over an above pack-
age do not collect
form patient
Equipment Charges 1200 1200 0 0 Cardiac Monitor-
1200

Payment Details
Claimed Amount 57109
Total Approved Amount 28875
Disallowed Amount 28234
Amount to be collected from Insured 0
Beneficiary Name KIDS CLINIC INDIA PVT. LTD.

Authorization Remarks :
*
*
*
*
*Please send Medicine and Investigation bill break up with original claim documents for settlement mandatorily.
* IPD Discount of 12.5% on final bill except pharmacy

Terms and conditions of Authorizations:

1. Above mentioned IPD discounts will be auto adjusted in the Balanced Sum insured of the policy holder, during the time of final
claim settlement with the hospital.
2. Cashless Authorization letter issued on the basis of information provided in Pre- Authorization form. In case Misrepresentation/conceal-
ment 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.
3. KYC (Know your customer) details of proposer/employee/Beneficiary are mandatory for claim payout above Rs 1 lakh.
4. Network provider shall not collect any additional amount from the individual in excess of Agreed Package Rates except costs to-
wards 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. 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)
6. 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 Pro-
vider and/or take necessary action, as provided under the MoU.
7. Where a treatment/procedure is to be carried out by a doctor/surgeon of insured's choice (not empaneled with the hospital), Net-
work Provider may give treatment after obtaining specific consent of policyholder.
8. Differential Costs borne by policyholder may be reimbursed by insurers subject to the terms and conditions of the policy.
9. Cashless payments shall be made by electronic mode only. Cheques / DDs will not be issued. For detailed information on Electron-
ic Payment process, please contact us at [email protected]

10. If documents are not received within 60 days from the date of discharged and claim will be closed without payment.
11. Post claim closure for delayed submission of claim documents , any further payment is subject to Balance Sum Insured for the
Customer's policy. If Sum Insured of patient is exhausted in due course time of claim closure and receipt of claim documents from the
hospital . BAGIC will not be liable to make any payment.
12. In case of short payment or short approval kindly contact us immediately within 7 days from the date of settlement. Later on any
short payment query shall not be entertain.
13. The Provider shall submit the final invoice and all supporting documentation required within 2 days of the discharge date.
14. Hospital discharge summary should be signed by treating doctor and it will also signed by patient or attendant, in discharge sum-
mary hospital should mention ICD code and date and time of discharge.
15. In Hospital final bill should mention complete address of the insured, name of insurance company, policy number and it will also
signed by patient or attendant.

* Please send cashless claim documents to Health Administration Team, Bajaj Allianz Insurance Company, 2nd Floor, Bajaj
Finserv Building, Survey No. 208 / B - 1, Behind Weikfield IT Park, Off Nagar Road, Viman Nagar, Pune-411 014 within 2
days of patient's discharge.

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.
If you are still not satisfied with the claim decision of the Insurance Company, you may approach the Insurance Ombudsman, estab-
lished by the Central Government for redressal of grievance. The Insurance Ombudsman is empowered to adjudicate on personal line
insurance claims up to Rs.20 lacs. Detailed process along with list of Ombudsman offices are available at ht-
tp://www.policyholder.gov.in/Ombudsman.aspx

Name of the Product is And UIN No

Authorised Signatory

Health Administration Team - Bajaj Allianz General Insurance Company Limited.

2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune.Maharashtra-411014
Toll Free: 1800-103-2529 Phone: (020) 30305858 Fax: (020) 30512224/6/7
Email: [email protected] Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-209-5858 Email: [email protected]
CIN No.: U66010PN2000PLC015329 UIN No.:
With warm regards,

Authorised Signatory
For Bajaj Allianz General Insurance Company Limited
Health Administration Team