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
contact.phs@paramounttpa.com.
Branch Code : 011
Cashless Authorization Letter
(Part-D)
Claim Number: 7150795 (Please quote this number for all further correspondence) Date: 11/12/2024 04:55:02 PM
Authorization is valid for admission up to 30/12/2024.
R G STONE UROLOGY & LAPROSCOPY HOSPITAL Name of Insurance Company :HDFC Ergo General Insurance Company Limited
B-1, Vishal Enclave, Vishal Enclave, Rajori Garden,,New
Name of TPA : Paramount Health Services & Insurance TPA Pvt. Ltd.
Delhi,Delhi-110027
Rohini Id : 8900080003132 Proposer Name : RAJIT VASUDEV
Patient's Member : SNEHA VASUDEV
ID/TPA/Insurer ID of the Patient : 41070781
Relation With Proposer : Wife
Corporate Name: DLF LIMITED
Dear Sir /Madam,
This has reference to the last documents received for pre-authorization request on 11/12/2024 04:23:27 PM. We hereby authorize cashless facility as per details mentioned
below:
Patient Name : SNEHA VASUDEV Age : 34 Gender : FEMALE
Policy Number : 2999204786418202000 Expected Date of Admission : 15/12/2024
Policy Period : 01/07/2024-30/06/2025 Expected Date of Discharge :16/12/2024
Room category : semi private
Estimated Length Of Stay:2
Category as per T&C of Policy Contract
Provisional Diagnosis : Cholelithiasis Proposed line of treatment : Cholelithiasis
Claim Remarks:
Authorization Details :-
Claim No Policy No Date & Time Reference number Amount Status
7150795 2999204786418202000 11/12/2024 04:55 5658882 45000 Authorized
Total Authorized amount:- Rs 45000 (FORTY FIVE THOUSAND )
Authorization Remarks: REVERT WITH FINAL BILL DISCHARGE CARD FOR VALIDATION AL
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 : 102480
*Other Deductions : 57480
Discount :0
Co-Pay :0
Deductibles :0
Total Authorised Amount : 45000
Amount to be paid by insured : 57480
*Other Deduction Details :
Bill Deducted Admissible
Sr.no Description Deduction Reason
Amount Amount Amount
Miscellaneous This is initial authorization confirming the claim admissibility. Final Authorization Amount will be confirmed
1 102480 57480 45000
charges 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 - GROUP MEDICLAIM-FLOATER and UIN No - Important Policy terms & conditions (sub-limits/co-pay/deductible etc)
IN CASE OF DEATH: We request you to release the deceased body and hand over the mortal remain to the relatives immediately post final approval from
TPA.
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.
