Cashless Claim Reference Number: (Claim No.

19591786)
(Please quote this reference number in all future correspondence)

Dear Insurer,

Hospitalization Claim Details For Insurer Approval / Denial

Claim No Policy No. & Policyperiod Insured Patient

19591786 93000034180400000087_NonSez / Shrivignesh Sivalingam Shrivignesh Sivalingam

27 Jan 2019 To 26 Jan 2020

Policy Type GMCand Conditions Claim Type Preauth Type

Floater Jones Lang Lasalle Property Pre Authorisation Enhancement

Consultans India Pvt Ltd

Date of Inception Sum Insured / Balance Sum Relationwith Insured Gender & Age
Insured

27 Jan 2019 300000 / 250424 Self M / 35

Hospital Name City / State PPN & Category Room rent for Single Room

Ktvr Group Hospital Coimbatore / Tamil Nadu NO

Disease / Diagnosis Line of treatment ICDCode(s) Applicable PPN/Package rate

Hemorrhoids Stapled haemorrhoidectomy I84 NO

Date of Admission Date of Discharge & LOS No. of days Room No. of Days ICU

13 May 2019 16 May 2019 / 3 3

ID proof obtained Room Type Room Rent Perday CO-Paymnet

YES Single Ward ( Private / Special / N/A

Executive Ward)

Roomrent Eligibility Disease / Procedure

Note: Post discharge medications not payable.

Hospitalization bill break up

Payable Amount Non Pay Amount Reason for

Charge Type Bill Amount (INR)
(INR) (INR) Non-Payment

Pharmacy & Medicine Charges 2826 2584 242 mask =24/-caps=24/-betadine solution=194/-

Consultant Charges 31500 31500 0 ,,

Surgery Charges 12000 12000 0

Investigation & Lab Charges 3000 3000 0

Hospital Charges 7350 6000 1350 ,Excess of RoomRent Rs.1350

Total 56676 55084 1592

(LESS)Hospital Discount 0

(LESS)Copay 5508

Present PA Approved Amount Total Autorized Amt Date and Time of sending format

36076 49576 16 May 2019 16:53

Confirmation by TPA: We have processed the file as per Policy terms & condition ,applicable capping and we confirm:

1. Disease & treatment is covered under Policy.

2. Charges allowed are as per PPN package / policycapping and proportionate deduction has been made for stayin higher room (wherever applicable).
3. The expenses allowed are as per reasonable & customaryclause.
4. Anyamount allowed in excess byTPAwill be liable for recovery.
5. For GMCs pls specifyconditions of revised GMC deleted & additional conditions imposed if any.
6. If amount of diagnostic exceeds Rs.5000/- separate sheet giving breakup of diagnostic along with TPAs observation on relevance of test shouls be
submitted.

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If there were to be no revert to the referred mail, then the claim will be considered as an insurer approval for further process.

Warm Regards,
Medi Assist Insurance TPA Pvt. Ltd
(Formerly known as Medi Assist India TPA Private Limited) CIN: U85199KA1999PTC025676. Regd Off: Tower "D", 4th floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore - 560
029.
Helpline: 1800 208 1028 | Email: hospital.medibuddy@mediassistindia.com
Disclaimer: The TPA extends the cashless facility subject to the standard terms & conditions of the policy and the information provided in the cashless request form. We suggest that the
patient continues with the treatment as advised by the treating doctor, irrespective of the pre-authorization/cashless facility.

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