Cashless Authorization Letter
(Part-D)
Claim Number: GUR-0625-PA-0083534 (please quote this number for all further correspondence)
Printed on 14/06/2025
Date : 14/06/2025
Authorization is valid for admission up to 09/06/2025
MANVI HOSPITAL Name of Insurance Company : NATIONAL INSURANCE COMPANY LTD
LAXMI VIHAR NARNAUL ROAD KUTUBPUR WARD NO.- Name of TPA : Vidal Health Insurance TPA Pvt Ltd
31 DISTT. TEH. - REWARI HARYANA 123401 ,
Proposer Name : VIKAS YADAV
Patient's MemberID / TPA/Insurer Id of the : GUR-NC-I0728-001-0001132-D
Patient
Relation with Proposer : Spouse
Haryana , 123401
Rohini Id: 8900080635166
Dear Sir /Madam ,
This has reference to the pre-authorization request submitted on 10/06/2025 04:47 PM , We here by authorize cashless facility as per details
mentioned below:
Patient Name : POONAM YADAV Age : 39 Gender : Female
Policy Number : 361400502410003439 Expected Date of Admission : 09/06/2025
Policy Period : 21-JUN-24 TO 20-JUN-25 Expected Date of Discharge : 14/06/2025
Room category : Single Room
: Estimated length of stay : 5 days
Eligible Room Single Room
Category as per T&C
of Policy Contract
Provisional Diagnosis : UTI Proposed line of treatment : Medical management
Insurer Claim Number :
Authorization Details :
Date and time Reference number Amount Status
14/06/2025 10:04 AM GUR-0625-PA-0083534 70835 Approved
Total Authorized amount:- Rupees Seventy Thousand Eight Hundred and Thirty Five Only (in words)
Authorization Remarks:
FINAL APPROVAL DONE
GUR-0625-PA-0083534
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 : 88781.00 (INR)
*Discount : 17756.00 (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 : 190.00 (INR) (At the time of Final Authorization)
Co-Pay : 0.00 (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: : 70835.00 (INR)
Amount to be paid by lnsured : 190 (INR) (At the time of Final Authorization)
* Discount & Other Deduction Details
Discount Deducted Admissible
S.no Description Bill Amount Deduction Reason
Amount Amount Amount
1 CONSULTATION 5400.00 0.00 4320.00 , Rs.1080 deducted for discount.
2 LABORATORY INVESTIGATIONS 19370.00 0.00 15496.00 , Rs.3874 deducted for discount.
CANFIX NP, Rs.10802 deducted for
3 MEDICINE CHARGES 54011.00 190.00 43019.00
discount.
4 ROOM/BOARDING EXPENSES 10000.00 0.00 8000.00 , Rs.2000 deducted for discount.
Total 88781.00 190.00 70835.00
GUR-0625-PA-0083534
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 and 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 and 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 : National Group Mediclaim Policy UIN No. NICHLGP21171V042021
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 and 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,
