Cashless Authorization Letter

(Part-D)

Claim Number: BLR-0525-PA-0054347 (please quote this number for all further correspondence)
Printed on 26/05/2025
Date : 26/05/2025
Authorization is valid for admission up to 26/05/2025

KELVIN HOSPITAL-KARIMNAGAR Name of Insurance Company : UNITED INDIA INSURANCE COMPANY LTD

H.No. 3-1-398, Dr. Ambedkar Road, Old Sairam Hospital Name of TPA : Vidal Health Insurance TPA Pvt Ltd
Building Beside Hdfc Bank, Karimnagar,
Proposer Name : PARSHA SHRUTHI
0

Patient's MemberID / TPA/Insurer Id of the : BLR-UI-W0215-001-0148314-A

Patient

Relation with Proposer : Self

Telangana , 505001

Rohini Id: 8900080390119

Dear Sir /Madam ,

This has reference to the pre-authorization request submitted on 26/05/2025 02:25 PM , We here by authorize cashless facility as per details
mentioned below:

Patient Name : PARSHA SHRUTHI Age : 26 Gender : Female

: 0703002824P113678855/GOPANAPALL
Policy Number Expected Date of Admission : 26/05/2025
Y

Policy Period : 01-NOV-24 TO 31-OCT-25 Expected Date of Discharge : 30/05/2025

Room category : Single Room

: Estimated length of stay : 4 days

Eligible Room Single Room
Category as per T&C
of Policy Contract
DIAGNOSTICLAP +D&C SOS
Provisional Diagnosis : Proposed line of treatment : surgical management
HYSTERECTOMY

Insurer Claim Number :

Authorization Details :

Date and time Reference number Amount Status

26/05/2025 03:59 PM BLR-0525-PA-0054347 22500 Approved

Total Authorized amount:- Rupees Twenty Two Thousand Five Hundred Only (in words)

Authorization Remarks:
INITIAL APPROVED
KINDLY PROVIDE TARIFFF WITH HIGHLIGHTED PROCEDURE
 BLR-0525-PA-0054347

Hospital Agreed Tariff:

I Package case :

Agreed package rate :

II Non -Package case :

i. Room Rent / day :

ii. ICU Rent / day :

iii. Nursing Charges / day :

Iv. Consultant Visit Charges / day :

v. Surgeon's fee / OT / Anaesthetist :

vi. Others (specify) :

Authorization Summary:

Total Bill Amount : 50000.00 (INR)

*Discount : 0.00 (INR) (At the time of Final Authorization)

Excess of package amount:

(Not to be collected from the insured) : 0.00 (INR) (At the time of Final Authorization)

*Other Deductions : 25000.00 (INR) (At the time of Final Authorization)

Co-Pay : 2500.00 (INR)

Co-Pay Buffer : 0.00 (INR)

Deductibles : 0.00 (INR)

Exceeds Policy Limit : 0.00 (INR)

Policy Deductable Amount : 0.00 (INR)

Total Authorised Amount: : 22500.00 (INR)

Amount to be paid by lnsured : 27500 (INR) (At the time of Final Authorization)

* Discount & Other Deduction Details

Deducted Amount Admissible

S.no Description Bill Amount Deduction Reason
Amount

1 PACKAGE CHARGES 50000.00 25000.00 25000.00 INITIAL

 BLR-0525-PA-0054347

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 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 policy holder 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 policy holder.

7. The above payment is subject to applicable TDS.

Kindly submit complete claim documents within 2 days from the date of discharge, falling which claim will be processed
subject to delay condonation approval by the Insurer.

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 notc 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. Original cashless claim form, bills and discharge summary in IRDAI format

7. Copy of all the authorization letters

8. Original letter/s of clarification provided during the authorization , all investigation reports

9. Original sticker and invoice for all the implants & high value consumables

10. Self-attested copy of photo id card of the patient is mandatory; any one of these documents will be accepted-
(a) Aadhar Card (b) Driving License (c) PAN Card (d) VoterID Card (e) School/College Id card for students (f) Passport

11. If the bill amount exceeds INR 1lakh, it is mandatory to collect the address proof of the Primary Beneficiary; any of these documents
will be accepted (a) Aadhar Card (b) Driving License (c) Passport (d) Voter ID Card

Name of the Product : GROUP HEALTH POLICY UIN No. UIIHLGP25040V032425

Disclaimer: This is an electronic generated communication and does not require a signature

Insurance is the subject matter of solicitation.

For a complete list of details on exclusions, risk factors, terms & conditions, please read the policy documents carefully before
concluding a sale.

Address : Vidal Health Insurance TPA Pvt.Ltd, SJR iPark, 1st Floor,Tower 2,EPIP Zone, Whitefield Road, Opp.Sathya Sai Hospital,
BANGALORE - 560066.