To,

RAJARAJESWARI HOSPITALS PRIVATE LIMITED

43, THIRUVALLUR SALAISPENCER

COMPOUND--

Contact Number/Fax Number: 000000 Date: 04/10/2023

Dear Service Partner,

We are glad to inform that cashless request id 2000021329 is approved at 04/10/2023 03:01PM.
Please refer to the following details.
IMPORTANT:

1. Revised approval required if there is any change in the following

a. Diagnosis
b. Length of stay
c. Cost of treatment
d. Line of treatment
2. KYC (Know your customer) details of proposer/employee/Beneficiary mandatory for claim payout above
Rs. 1 lakh.(Refer page 2 of letter for details).

Patient Name: KATHIRESAN K

Age/ Gender: 42 / Male

Policy No.: 50321700202200

Member id: 1008989875

Room Category: PRIVATE/ SINGLE ROOM

Provisional Diagnosis: Calculus of kidney and ureter

Proposed line of treatment: MEDICAL

Expected Date of Addmission: 01/10/2023

Approved length of stay: 4

Expected Date of Discharge: 10/05/2023

Approval Amount: 36907.00

 AUTHORIZATION DETAILS

DATE & TIME REFERENCE NUMBER AMOUNT STATUS

04/10/2023 02:50 PM 2000021329-1000038978 1,757.00 Extension Approved

27/09/2023 02:12 PM 2000021329-1000038343 35,150.00 Cashless Approved

Total Authorized Amount: Rupees THIRTY-SIX THOUSAND NINE HUNDRED SEVEN ONLY
Warm Regards,

Claims Team- Niva Bupa

This is a system generated letter and does not require signature.

TERMS AND CONDITIONS OF AUTHORIZATION:

1. Cashless Authorization letter issued on the basis of information provided in Pre - Authorization form. In case of
misrepresentation/ concealment of the facts or any material difference/ deviation/ discrepancy in information is observed in
discharge summary/ IPD records, the 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. 1 lakh. KYC
Documents means proof of address, proof of identity and latest passport size photograph.

· Proof of identity- PAN Card, Job card issued by NREGA duly signed by an officer of the State Government
· Proof of Address- Telephone bill pertaining to any kind of telephone connection like, mobile, landline, wireless, etc.
provided it is not older than six months from the date of insurance contract/ Current Passbook with details of
permanent/present residence address (updated up to the previous month)/ Current statement of bank account with
details of permanent/present residence address (as downloaded)/ Electricity bill/Ration card/Valid lease agreement
along with rent receipt, which is not more than three months old as a residence proof.
· Proof of both identity and residence- Passport/Voter id card/Driving license.

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.
8. All settlements will be done as per agreed terms and conditions and tariff with provider.

Disclaimer: Insurance is the subject matter of solicitation . Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health
Insurance Company Limited) (IRDAI Registration Number 145). ‘Bupa’ and ‘HEARTBEAT’ logo are registered trademarks of their respective
owners and are being used by Niva Bupa Health Insurance Company Limited (formerly known as Max Bupa Health Insurance Company
Limited) under license. Registered office:- C-98, First Floor, Lajpat Nagar 1, New Delhi-110024, Customer Helpline: 1860-500-8888. Fax: +91 11
41743397. Website: www.nivabupa.com CIN: U66000DL2008PLC182918.