Cashless Authorization Letter (40626947)
(Please quote this reference number in all future correspondence)
E-card Claims Plan hospitalzation Hospitals
Medi Assist Insurance TPA Pvt. Ltd
Member communication
(Private and confidential - not to be shared with hospitals/ other collaborators)
Date: 16 Nov 2024
Dear Mohd Imran Qureshi,
With reference to your request (40626947) for final cashless pre-authorization, we hereby authorize INR 110000 against your final bill amount INR 147826. The
details of the pre-authorization are as follows:
Patient Details
Patient Name Mohd Imran Qureshi
Relation to Primary Beneficiary Self
Age 42
Gender M
Insurance Company The Oriental Insurance Co. Ltd.
Medi Assist ID 5097223106
Policy Holder Axis Bank Limited
IP No. 0
Policy No. 590000/48/2024/997_Ex
Policy/Plan Period 01 Oct 2024 to 30 Sep 2025
Primary Beneficiary Mohd Imran Qureshi
Insurer Claim No
Insurer Member ID
Treatment Details
Provisional Diagnosis Calculus of gallbladder with acute cholecystitis without obstruction
Expected/Actual Date Of Admission 12 Nov 2024
Treating Doctor D R Dhawan
Procedure / Treatment Planned Cholecystectomy
Estimated/Actual Date of Discharge 16 Nov 2024
Room Category Occupied Single private room
Length Of Stay 4
Eligible Room Category Single Ward ( Private / Special / Executive Ward)
Hospital Name Soni Manipal Hospital ( A Unit Of Manipal Hospitals (Jaipur) Pvt. Ltd.)
Approval Information
Excess billing Out of pocket expenses
Claimed amount Discount applied Approved amount (by Insurer)
(Not to be paid by you) (To be paid by you)
147826 6390 110000 0 31436
Note:
1. KYC (know your customer) details of proposer/employee/beneficiary are mandatory for claim payout above Rs.1 lakh.
2. Network provider shall not collect any additional amount from the individual in excess of Agreed Package Rates except cost 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)
3. Expenses on investigations / diagnostic tests, etc. which are not related to the condition for which admission is sought are not admissible
4. Expenses are excluded which are not covered / not payable as per health insurance policy terms and conditions are not admissible
5. Expenses related to medicines/drugs incurred post discharge and Differential cost borne by the policyholder may be reimbursed by Insurer subject to terms
and conditions of the policy
Detailed breakup as follows:
Claimed amount : 147826
Deduction
Deduction reason Deduction remarks Derivation
amount
(i) Excess of agreed tariff / package
0 147826
billed by the hospital
(ii) Discount from Hospital as per
6390 Hospital Discount 141436
Contract
clinical management fee sac 999311 cipd007 dietary wards
(iii) Non-admissable as per policy
1020 consultation:-420.00; admission charges sac 999311 ipbedc1 140416
terms
admission charges:-600.00
(iv) Higher room rent occupancy and
0 140416
related medical services
(v) Co-sharing as per policy contract
0 140416
(co-pay)
(vi) Defined ailment / procedure limit
30416 Cholecystectomy- 50000, Kidney stone removal- 60000/- 110000
(Sub-limit) in policy
(vii) Eligible sum-insured under the
0 110000
policy
(viii) Reasonable cost 0 110000
(ix) Other deductions applicable 0 110000
(x) Due Premium collected 0 110000
Final Authorized amount : 110000
Authorization Details
# Status Received Date Cumulative Amount Cumulative Authorized
1 Pre-Auth Processed 11 Nov 2024 14:11 120000 60000
2 Pre-Auth Processed 16 Nov 2024 13:11 147826 110000
Authorization Remarks :
Final AL Paid as per policy terms and condition, Cholecystectomy- 50000/-, renal stone removal- 60000/-
Note: If Top Up is available and applicable, as per policy conditions, Top Up claims will be processed and additional amounts will be approved along with base
amount as per your benefit.
In case of package claim :
Claimed package / bill amount 83929
Excess of tariff/ package 0.0
Discount on package billing 0
Non medical items 0.0
Reasonable cost 0
Applied package amount as per policy guidelines : 83929
Total Authorized amount is Rs 110000 (One Lakh Ten Thousand Only).
Definitions :
Definitions :
i. Excess of agreed tariff / Package billed by the hospital - Package Rate means the fixed maximum charges for a Medical Treatment or Surgical Procedure
or for any Follow-up Care that will be paid by the Insurer under Cover, which shall be determined in accordance with the rates provided in this Contract.
ii. Discount from Hospital as per Contract - A hospital discount is a reduction in a hospital's Final bill or specific bill component amount for medical treatment,
surgery, diagnostic, or any other healthcare service provided. Typically, insurers/TPA offer these discounts to reduce claimants out-of-pocket expenses.
iii. NME - Non-admissible expenses are usually those expenses that may be a part of the hospitalization or treatment procedure but are not necessarily included
in health insurance coverage due to various reasons.
iv. Proportionate deduction - Proportionate Deduction is a deduction applicable on 'Associate Medical Expenses', if the Insured Person opts for a higher Room
than his/her eligible category.
v. Copay - Is a cost-sharing requirement under a health insurance policy that provides that the Insured Person will bear a specified percentage of the admissible
amount. A co-payment does not reduce the Sum Insured.
vi. Capping or sub-limit - Means a cost sharing requirement under a health insurance policy in which the insurer would not be liable to pay any amount in
excess of the pre-defined limit. The limit will be on the ailment or the procedure or a sub-limit on the sum insured.
vii. Sum insured - Sum Insured is the maximum amount of coverage opted for each Insured Person under the Policy with specific Period.
viii. Usual, Customary, and Reasonable (UCR) - Reasonable and customary clause means the charges for services or supplies, which are the standard
charges for the specific provider and consistent with the prevailing charges in the geographical area for identical or similar services, taking into account the
nature of the Illness / Injury involved.
ix. Deductible - A deductible is a cost-sharing requirement under a health insurance policy that provides that the Insurer will not be liable for a specified rupee
amount of the covered expenses, which will apply before any benefits are payable by the insurer. A deductible does not reduce the sum insured.
x. Due Premium - The Health Insurance Premium is the amount of money need to pay periodically to an insurer in order to avail the medical coverage as well as
to ensure that the policy remains in force.
Beneficiary Information :The guideline provided above is for your information only. The benefit terms, conditions, exclusions, limitations and claim procedure etc.
are as per your Mediclaim policy conditions. In case of any dispute, the interpretation and decision by the Insurer/ Payer is final.
Note: In no event shall Medi Assist Insurance TPA Pvt. Ltd be liable for any direct, indirect, punitive, special, incidental, exemplary or consequential damages or
any damages whatsoever (including without limitation, damages for loss of use, data, information, profits or business interruption) arising out of or in any way
related to the use or performance of this information/ website or any linked website or to any material, information, data, products or services obtained through this
website, or otherwise arising out of your use of this website, your inability to use this website or any decision made or action taken by you in reliance of any
information, advice or materials provided on this website, whether such damages are based in tort, contract, negligence, strict liability or otherwise.
Download the MAvencare app
visit -Medi Assist Blog & News
Registered & Corporate Office | Bangalore
Tower D, 4th Floor, IBC Knowledge Park, 4/1 Bannerghatta Road, Bangalore - 560029
Warm Regards,
Medi Assist Insurance TPA Pvt. Ltd
Helpline: 0120-6937324
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.
App Connect
THIS IS A SYSTEM GENERATED CORRESPONDENCE. PLEASE DO NOT REPLY TO THIS EMAIL
© 2018 Medi Assist
