ERICSON INSURANCE TPA PVT. LIMITED.

11-C, Corporate Park, S.T.Road, Chembur, Mumbai-400071

Website: www.ericsontpa.com, E mail: - care@ericsontpa.com
Call Centre: 022-25280234 Fax No.: 022-25270200

Cashless Authorization Letter Dated : 1-Nov-2022

(Part-D)
Claim number: 268612 (Please quote this number for all further correspondence)

Authorization is valid for admission up to (date) 16-November-2022

VADAMALAYAN HOSPITALS PVT LTD Name of Insurance Company : National Insurance Co. Ltd.

15, JAWAHAR ROAD, CHOKKIKULAM, Name of TPA : Ericson TPA Pvt.Ltd.

NEAR INCOME TAX OFFICE Proposer Name : IOB

Patient's Member : B NAGASASTIKHA

Rohini ld: 8900080331662
ID/TPA/insurer Id of the Patient : 3091871

Relation with Proposer : Daughter

Dear Sir /Madam,

This has reference to the pre - authorization request submitted on: 11/01/2022 we hereby authorize cashless facility as per details mentioned
below:

Patient Name : B NAGASASTIKHA Age: 0 Gender: F

Policy Number : IOB BASE NA Expected Date of Admission : 30/10/2022

Policy Period : 01/10/2022 To: 30/09/2023 Expected Date of Discharge :

Room category : ICU Estimated length of stay : 0

Eligible Room
Category as per T&C :
of Policy Contract

Provisional Diagnosis : breathing Proposed line of treatment : Medical

Authorization Details :

Date & Time Reference number Amount Status

11/1/2022 7:21:31PM 268612 18,000.00 Intial Approval

Total Authorized amount:- Rs ( In words ) Rupees EIGHTEEN THOUSAND Only

Authorization Remarks:
conditional approval
Need to submit investigation report
Hospital AgreedTariff

I. Package case
Agreed Package Rate : 0

II. Non-package case

i. Room Rent/day : 0
ii. ICU Rent/day :
iii. Nursing Charges/day :
iv. Consultant Visit Charges/day :
v. Surgeon's fee/OT/Anaestheti st : 0
 ERICSON INSURANCE TPA PVT. LIMITED.
11-C, Corporate Park, S.T.Road, Chembur, Mumbai-400071
Website: www.ericsontpa.com, E mail: - care@ericsontpa.com
Call Centre: 022-25280234 Fax No.: 022-25270200
vi. Others (specify) :

Authorization Summary:
Total Bill Amount : 60,000.00
*Other Deductions : conditional approval
Need to submit investigation report
Discount :
Co-Pay :
Deductibles :
Total Authorised Amount : 18,000.00
Amount to be paid by lnsured : 0.00

*Other Deduction Details:

SNO Description Bill Amount Deducted Amount Admissible Amount Deduction Reason
1 conditional approval 18000 conditional approval
Need to submit investigation Need to submit investigation
report report

Terms and Conditions of Authorization:

1. Cashless Authorization letter issued on the basis of information provided in Pre- Authorization form. In casemisrepresentation/concealment
ofthe facts, any material difference/ deviation/ discrepancy in information is observed indischarge summary/ IPD records then cashless
authorization shall stand null & void. At any point of claim processinglnsurer 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 I lakh.
3. Network provider shall not collect any additional amount from the individual in excess of Agreed Package Rates exceptcosts towards
non-admissible amounts (including additional charges due to opting higher room rent than eligibility/choosing separate line oftreatment which
is not envisaged/considered in package).
4. Network provider shall not make any recovery from the deposit amount collected ftom the Insured except for coststowardsnon-admissible
amounts (includingadditional charges due to opting higher room rcnt than eligibility/ choosing separateline oftreatment which is not
envisaged/considered in package).
5. In the event ofunauthorized recovery ofany additional amount from the Insured in excess ofAgreed Package Rates, theauthorized TPA /
tnsurance Company reserves the right to recover the same or get the same refunded to the policyholderfiom the Network Provider a.nd/or take
necessary action, as provided under the MoU.
6. where a treatment/procedure is to be carried out by a doctor/surgeon ofinsured's choice (not empaneled with the hospital),Network
Provider may give treatment after obtaining specific consent ofpolicyholder.
7. Differential Costs bome by policyholder may be reimbursed by insurers subject to the terms and conditions ofthe 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 notc from the attending Medical Practitioner / Surgeonrecommending such Diagnostic
supponed by note from the attending Medical Practitioner/ Surgeon recommending suchdiagnostic tests.
4. Surgeon's Certificate stating nature ofoperation performed and Surgeon's Bill and Receipt.
5. Certificates from attending Medical Practitioner / Surgeon giving patient's condition and advice on discharge.

Name of the Product: TAILORMADE GMC POLICY and UIN No: 268612 lmportant Policy terms & conditions
(sub-limits/co-Pay/deductible etc)

Authorized signatory:
(Insurer/TPA)

Address:
 ERICSON INSURANCE TPA PVT. LIMITED.
11-C, Corporate Park, S.T.Road, Chembur, Mumbai-400071
Website: www.ericsontpa.com, E mail: - care@ericsontpa.com
Call Centre: 022-25280234 Fax No.: 022-25270200

Ericson Insurance TPA Pvt. Ltd.

11-C, Corporate Park, S. T. Road, Chembur,
Mumbai - 400071. Maharashtra.
Tel : 022-25280280

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