20241016002147cashless Approved

Cashless Authorization Letter Date :- 17 Oct 2024
*7002471*
AL No : HAT /25/7002471 (Please Use this no for any communication regarding this AL)
Claim Number OC-25-1002-8402-00010653
Authorization is valid for admission up to 22-Oct-2024
OM GAGANGIRI HOSPITAL - NAVI MUMBAI
102,SHUBHAM CHS, PLOT NO.77, SECTOR-18,,,,NEAR GULABSONS DAIRY, KOPERKHAIRANE, NAVI MUMBAI -
400709
NEAR GULABSONS DAIRY,,
NAVI MUMBAI
Pin Code:- 400709
Phone No:- (022)2227546808 Fax No:- (022)0
Rohini ld :- 8900080115613
Proposer Name:- Snehal Shivaji Patil
Relation with Proposer:- Self
Patient ID card Number:- GMC-24190120077-47
Dear Sir/Madam,
This has reference to the pre authorization request submitted on 16-OCT-24 . We here by authorize cashless facility as per details
mentioned below:
Patient Name : SNEHAL SHIVAJI PATIL Age : 29

Policy Number : OG-24-1901-8402-00000077 Gender: No Gender
Expected Date Of Admission : 16-OCT-24 Expected Date Of Discharge :20-OCT-24
Policy Period : 23-OCT-23 to 22-OCT-24 Estimated length of stay : 4
Availed Room Category : DELUXE ROOM Eligible Room category :
Provisional Diagnosis : DENGUE FEVER WITH TCP Proposed line of treatment : MEDICAL
Authorization Details:-
Date and Time Reference Number Amount Status

17-OCT-2024 7002471 25000 CASHLESS APPROVED
Total Authorized amount: TWENTY-FIVE THOUSAND Rs/-
Hospital Agreed Tariff:-

I. Package Case
Agreed Package Case /-
II. Non Package Case
i. Room rent /day - 0/-
ii. ICU rent /day - 0 /-
iii. Nursing Charges /day- 0/-
iv. Consultant Charges /day- 0/-
v. Surgeon`s fee - 0/-
vi. OT charge - 0/-
vii. Anaesthetist - 0/-
viii. Others - /-
Authorization Remarks :
*
* This authorization letter is issued for 03 days stay. If the hospital bill exceeds the authorized limit, a request letter for additional
amount needs to be sent to Bajaj Allianz.
* Please note this is initial approval to start the treatment. Final amount is subject to the receipt of discharge summary and detailed fi-
nal hospital bill.
* Expenses incurred during hospitalization shall be settled as per the agreed negotiated tariff with Bajaj Allianz General Insurance Co.
Ltd.
*As per New AML Guidelines Insured/Nominee CKYC Number or CKYC Document is Mandatory each and every claim. Kindly
provide dully filled and signed CKYC form, Pan Card (If PAN card is not available then provide duly filled form-60), Aadhar No &
Government issued address proof (Passport Copy, Voter ID Card, Driving License and NREGA Card) of the proposer/employ-
ee/Beneficiary. If same not received then Hospital payment will be on hold.
*All expenses incurred on non medical items must be collected from the patient at the time of discharge, kindly refer the circulated list
of Bajaj Allianz website www.bajajallianz.com for more information on the non payable item.
*Please send Medicine and Investigation bill break up with original claim documents for settlement mandatorily.
* IPD Discount of 15% on total bill excluding Implants& packages & 5 % on medicines
OPD Discount of 25% on Consultation
OPD Discount of 25% on Investigation
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 Group Mediclaim (Standard) And UIN No BAJHLIP21536V022021
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.: BAJHLIP21536V022021
With warm regards,
Authorised Signatory
For Bajaj Allianz General Insurance Company Limited
Health Administration Team

20241016002147cashless Approved

Uploaded by

Copyright:

Available Formats

20241016002147cashless Approved

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

20241016002147cashless Approved

Uploaded by

Copyright:

Available Formats

Cashless Authorization Letter Date :- 17 Oct 2024

Proposer Name:- Snehal Shivaji Patil

Relation with Proposer:- Self

Patient ID card Number:- GMC-24190120077-47

Patient Name : SNEHAL SHIVAJI PATIL Age : 29

Date and Time Reference Number Amount Status

Total Authorized amount: TWENTY-FIVE THOUSAND Rs/-

Hospital Agreed Tariff:-

Terms and conditions of Authorizations:

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM

1. Detailed Discharge Summary and all Bills from the hospital

Name of the Product is Group Mediclaim (Standard) And UIN No BAJHLIP21536V022021

Health Administration Team - Bajaj Allianz General Insurance Company Limited.

You might also like