Authorization Letter to the Hospital for the Treatment and Guarantee of Payment

(Part-D)

Date : 15-JAN-25

AL Approved Date :15-JAN-25

AL Requested Date : 15-JAN-25

Life Line Hospital
Rohini ID :8900080106666
Vishal Complex, A-Wing, S V Road, Malad (W)
MUMBAI,Maharashtra-400064
Tel: Mob:
AL Number:110202004476-1

Dear Sir/Madam,
We hereby authorize and guarantee for payment of Rs 38479 (in words) Rupees THIRTY-EIGHT THOUSAND FOUR
HUNDRED SEVENTY-NINE only. Authorization is valid for 15 days from the date of approval or proposed date of
admission, whichever earlier (Provided date of admission remains same).
Admission/ Pre-authorization request note sent by you with the following information:
Policy related Deductions :
Name of the Patient :THOMAS DINESH RAGADE
Co-Pay :0
UHID Number :IL22699372400
Deductible :0
Requested Room Type :General Ward or Economy
BSI Exhaustion :0
Class of Accommodation :Twin Sharing Room
Sub Limit :0
Provisional Diagnosis :Q Fever
Proportionate as per Eligible Room :0
Policy Period :01-JAN-2025 To 31-DEC-2025
Non-Medical Expenses* (Please refer Annexure
Date of Admission :12-JAN-2025 :2983
for details)
Policy Name :ICICI BANK LTD
Others: :0
Patient IP No :I250112030
Remarks (deductions will be calculated at the
Age :23 time of final settlement)
Gender :MALE
Policy No :4016/111550300/09/000 Network related Deductions (Not to be
Proposer Name : collected from Insured)
Relation with Proposer :SELF Hospital Tariff Deductions :0
Date of Discharge :15-JAN-25 Discounts
Estimated length of stay :4 (Shall be applied at the time of Final :9620
Authorization)
Proposed line of treatment :MEDICAL
Total Bill Amount :51082
:
UIN : Amount to be paid by Insured
2983
BSI :361521
at discharge

Final
Event Date & Time Status Final Requested Amount Sanctioned
Amount
Initial Approved 13-JAN-2025 03:48:55 PM APPROVED 51082 38479
Enhancement 15-JAN-2025 03:11:09 PM APPROVED
Final Approved Amount APPROVED
 Hospital Agreed Tariff :
1. Package case
Agreed Package Rate :NA

2. Non-package Case

Hospital Agreed Tariff Non Package Case-Rent/day

Surgeon
Nursing Consultant super specialist Others
Room Rent ICU Rent fee/OT/
Charges Visit Charges charges (Specify)
Anaestheist
0 0 Included in 0 0 0
Room Rent

Remarks:
Rs..2983/-..Deducted as Non admissible items (to be borne by patient)

“For any cashless queries, write on cashlessrequest@icicilombard.com”

Note: "Please submit PAN of your hospital and Aadhaar Number of the Authorized Signatory (with copy) for settlement
of the Claim."

Important Note: This authorization is valid for Admission within 15 days from the Date of Admission mentioned or expiry
/cancellation of the Insurance policy whichever is earlier. This Authorization becomes null and void if the patient is discharged
before the date of this letter issuance. Copayment Amount has to be collected from Insured. Claim Processing / Settlement will
be as per agreed rates in MOU/Tariff. This is an electronically generated document and this requires no seal / stamp

“If you have an alternative health insurance policy / policies from other insurance companies, kindly file a claim for the
balance amount with this claim settlement letter of ICICI Lombard GIC. Also, do reach us out for any further requirement or
assistance.”

Address: ICICI Lombard GIC, ICICI Lombard Health Care, 01st, 04th, 05th & 06th Floor, Varun Towers II, Opp Hyderabad
Public School, Begumpet, Hyderabad - 500016, Telangana.
Email: ihealthcare@icicilombard.com
IRDA Registration No. 115.

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 pay out above
Rs I 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 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

MANDATORY 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 supposed 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. Implant Invoice

Important Instructions to Hospitals :1)If the hospital bill is estimated to be higher than the guarantee of payment, a request
letter for additional amount needs to be sent to ILGIC 2) If no further guarantee is available, the hospital must collect the
excess amount directly from the beneficiary at the time of admission/ prior to discharge from the hospital, as per hospital rules
and regulations 3) Please collect the hospital bill summary with final bill with details of units of each service (authenticated by
patients signature). 4) Please collect the discharge summary and reports of all investigations (original). 5) Please collect an
undertaking from the insured / patient for submitting his/her documents to ILGIC Ltd in original. 6) Charges for the following
miscellaneous services and related allied services must be collected directly from the patient.i) Registration / admission
charges ii) Ambulance charges (unless authorized) iii) Attendant / visitor pass charges. iv) Special nursing charges not
authorized by the attending doctor v) Service charges not forming a part of the bed charges in general ward, maintenance
charges, surcharges vi)Charges for extra bed for attendant etc vii)Bed retaining charges viii)Charges for TV, Laundry etc ix)
Telephone/Fax charges x) Food and Beverages for attendants and visitors. xi) Toiletries etc xii) Purchase of medicines not
related to the treatment xiii) Stationery, Xerox or certifying charges.

Following Details are mandatory for claim settlement

Date of Discharge
Final Bill Amount
Amount Paid by Patient Signature of the Hospital Stamp &
Patient/Relative Signature
All payments to Hospitals are subject to deduction of tax at source as per prevailing rate unless lower/nil TDS certificate had been provided to the payer, under
section 194J as per Circular No 8/2009. Dated 24-11-2009 from Income Tax Dept

Annexure- Details of Non-Medical expenses

Bill No Bill Date Particulars Amount (In Rs)

1250112030434 15-JAN-25 Registration Charges 1000
1250112030434 15-JAN-25 Bio Medical Waste 350
1250112030434 15-JAN-25 Mrd Charges 350
1250112030434 15-JAN-25 Dietcian Charges 600
No Bills 15-JAN-25 Disp Skin Blade 108
No Bills 15-JAN-25 Nebulizer Mask Adult 575
TOTAL 2983

Annexure for MOU deductions

MOU
Requested Amount (In
Bill Type MOU Amount (In Rs) Deducation
Rs)
(In Rs)
Consumable Charges 350 350 0
Consultation Visit Charges 3600 3600 0
Room Charges 6800 6800 0
 Procedure Charges 2900 2900 0
Investigation Charges 11440 11440 0
Others 1350 1350 0
Medicines Pharmacy Charges 24642 24642 0
TOTAL 51082 51082 0