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    22 views2 pages

    Screenshot 2023-12-07 at 4.44.56 PM

    Uploaded by

    sachin Gour

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    To: tpa@kokilabenhospitals.com From: cashlessrequest@cicilombard.com Subject: Enhacement Request 1102016338 11-2 is Queried at 07:57:56 PM. Please contact hospital TPA desk for required information. Sent Wed, 06 Dec 2028 15:28:12 +0530 ‘AUTION EXTERNAL MAIL: This email originated from outside of the organization. Do not click links or open ttachments unless you recognize the sender and know the content is safe. == ADDITIONAL INFORMATION REQUEST FORM, Date: 06-DEC-23, To, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute Four Bunglows, Andheri (W) MUMBAI, Maharashtra-400053 Tel: Mob: Dear Sir/Madam, Claim of PREMRAJ KANOJIA UHID 121665958504 Policy Number .4016/X/273358664/00/000 Policy Name SHAKTI PUMPS INDIA LTD Policy Period 10-DEC-2022 to 09-DEC-2023, Date of Admission 21-NOV-2023 AL Number 110201633811-2 We refer to the Admission request note dated 05-DEC-23 in respect of above claim. After perusal of the same we request you to provide the following information to enable us to process the cashless request. ‘SENO Reason Description ] i (Documents not received 1. Inadequate query reply. Kindly furnish the detailed past Medical treatment papers of the: ailments Chronic pancreatitis and Liver cirrhosis and furnish the details of treatment taken tll date. Provided documents are not properly scanned. Kindly send us properly scanned IPD Papers to proceed further. ‘Any Other document: We request you to submit the above information at the earliest to avail the cashless benefit, NOTE: Query reply not received in 2 days will result in Rejection of the case. “For any cashless queries, write on cashl lombard.com” Associate Vice President - Health Claims ICICI Lombard General Insurance Company Ltd, “Disclaimer: IL can pre-authorize cashless treatment subject to the terms and conditions of the policy based on the adequate, relevant medical information. However the patient is advised to continue/follow his/her treatment as advised by the treating doctor and not to discontinue the same pending the processing of preauthorization request Address: ICICI Lombard GIC, ICICI Lombard Health Care, 01st, 04th, 05th & 06th Floor, Varun Towers II, Opp Hyderabad Public School, Begumpet, Hyderabad - 500016, Telangana. Email: ihealthcare@icicilombard.com IRDA Registration No. 115 Important Instructions to Hospitals 1) the hospital ils estimated to be higher than the guarantee of payment, request et for adtiona ammount needs tobe ‘Sent 10 ILGIC 2 no furer guarantee is avalatle the hospital must caflec the excess amount cvecty fom the beneficiary a the tre of admission ror ©

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