AUTH APPROVAL LETTER

(FINAL)
24/03/2021
To

Sarvodaya Hospital And Research Center

KJ-7, KAVI NAGAR
GHAZIABAD
UTTAR PRADESH
201002

Dear Sir/Madam,

Subject: Cashless Authorization no 2021031803954.A2 under Policy H0484212 of ANAND BOSE, Member ID H0484212-1-0

This has reference to the request for Authorization received by us on with following details:

1. Date of admission : 22/03/2021

2. Date of Discharge : 24/03/2021
3. Proposed Length of stay :2
4. Diagnosis : Fractures
5. ICD Code : S52

Till date, the authorization amount approved is Rs. 34,327. All previous authorization(s), if any, stands cancelled.

This is full and final authorization, previous authorization stands cancelled. Non medical will be deducted at the time of final settlement. The final settlement will be
done strictly as per policy term and condition and agreed hospital tariff. PLEASE NOTE- 1) FINAL AUTHORIZATION MUST BE SIGNED BY INSURED. 2) IF
PATIENT / INSURED PAYS ANY AMOUNT OVER AND ABOVE HOSPITAL TARIFF AGREED WITH US, IT WILL BE TREATED AS VOLUNTARILY
PAID, HE WILL NOT CLAIM IN REIMBURSEMENT.CHARGES OVER AND ABOVE SOC / AGREED TARIFF SHOULD NOT BE COLLECTED FROM
PATIENT. IF COLLECTED, THE SAME AMOUNT WILL BE DEDUCTED FROM YOUR CASHLESS CLAIM SETTLEMENT.

NOTE :'' Final Settlement will be done as per agreed tariff, Any difference in charges of account of tariff will be deducted at the time of final payment to the hospital''.
Please Note

1) Claim settlement will be done as per the Agreed upon tariff. If any amount over and above the agreed tariff is collected from insured, it will be deducted from your final
settlement.
2) Please collect expenses for all Non payable items, as per the list provided to you at time of MOU, from insured.
3) Any change in line of treatment / Room category / Length of stay must be informed immediately.
4) We will not be liable for payment if Information provided in “Request for authorization letter” and subsequent information during claims is found to be incorrect, modified
or undisclosed.

DEDUCTIONS REASONS:
Deduction Types Claimed Amount Deducted Amount Reason for Deduction Remarks Approved Amount

disposable, velfix, gown charges

37832.0 1850.0
deducted.
Hospital Discount 1655.0

Reinstatement Premium 0.0 34,327

Yours Sincerely,

Authorized Signatory

Claim Documents should be sent at below address -

IFFCO Towers, Surinder Jhakhar Bhawan, Plot No. 3, 4th Floor, Sector 32, Gurugram, Haryana - 122003

Contact Toll Free No: 18001035499, Email ID: cashless@iffcotokio.co.in