26/01/2017(AuthorisationDate)

CashlessClaimNumber:13849627

To,

AnanthapuriHospitalsAndResearchInstitute
T.C.31/1424,Karali,Chacka,NationalHighway,Thiruvananthapuram695024
04712506767/2506868/2506969/2579900
ananthapurihri@gmail.com

DearSir/Madam,

Werefertothepreauthorizationrequestforextendingcashlessfacility.Basedontheinformationfurnished,PleaseextendCashlessFacility
totheinsuredpatientasperthedetailsgivenbelowandraisethebillinthenameofNationalInsuranceCo.Ltd..A/CKrishnaAnjali

PatientDetails
NameOfPatient KrishnaAnjali HID 55418

PolicyHolder/PrimarybenefName VishnuSreekumar IPNo: 0

PatientAge 25 MAID: 5025555855

CorporateName InfosysLimited EMPID: 704320

InsuranceCompany NationalInsuranceCo.Ltd. PolicyNo: 602200/46/16/8500000114_Sez

TreatmentDetails
Maternalcareforknownorsuspectiedabnormalityof
ProvisionalDiagnosis DOA 16Jan2017
pelvicorgans

Procedure/Treatment CervicalCirclage DOD 26Jan2017

SingleWard(Private/
Doctor'sName Dr.SaradaDevi RoomCategoryOccupied
Special/ExecutiveWard)

Summaryofauthorization
TotalBilled: 49528 PreviousApprovedAmt 40000

PayableByInsured(patient
15036 CurrentEnhancement 34492
party)

HospitalDiscount 0 OtherDeductions 0

TDS PANno: UB*******37

PayableByInsurance 34492

PleaseupdateMediAssistifthereisanyvariationintheaccountdetailsupdatedat1/17/20173:27:43PM.

Reasonsforpayablebyinsured(patientparty):
Amount Reasons

0 Copay

15036 ExcessofDefined/AilmentLimit

Total:15036

Note:Abovedeductionsarebasedonthedetailsofthebill/estimatesubmittedbytheHoapital,Actualdeductionmayvaryifthe
bills/estimatesarerevised.
ReasonsforOtherDeductions:
Amount Reasons

0 HospitalDiscount

NotetoHospital:AboveDeductionsarebasedontheclaimadjudicationwiththeavailableinformation,ifyoudontagreewiththedetailsofdeduction
PleaseintimateMediAssistimmediatly.
Notetoinsured(patientParty):Amountdeductedinotherdeductionmaynotbeadmissibleunderthepolicyasperreasonablenecessaryexpenses
inyourpolicy.

Instructions to Hospital:

1. Finalapprovalofcashlessisaspertheagreedtraiff..
2. MediAssist/Insurerwillnotbeliableforpaymentincaseifitisfoundthatthematerialfactsweresuppressed/misrepresented/not

disclosed.
3. Authorizationisvalidfortheproposedlineoftreatment.Anychangeinthelineoftreatmentmustbeinformedimmediately,failing

whichtheAuthorisationstandsCancelled.
4. ExpensesforIrrelevantInvestigations/Diagnostictestwillbededucted.PleasecollectthesamefromthePatient.
5. ExpensesofMedicines/DrugsforchronicAilmentssuchasDiabetics,Hypertension,Hyperthyroidismetcwhichthepatienthasbeen

takingwillbededucted.
6. Authorizationinvalidifadmittedlaterthan31/01/201723:59hrs(ForDialysisandRadiotherapyThePeriodMentionedinthe

PARequest).
7. PleasecollecttheNonmedicalExpenses/Surcharges/Servicecharges/luxurytaxes,etcandCopayasmentionedabove.(Visit

www.mediassistindia.comforNonMedicalList).
8. TheCopyofthereceiptforhavingcollectedtheamountfromthepatientshouldbesentalongwithotherdocumentsfailingwhich

doublethecopayindicatedabovewillbedeductedwhilesettlingtheCashlessClaim.
9. Patient's/Representative'ssignatureonthefinallbillismandatory,pleasegetthesignatureontheFinalBill.
10. Pleasesendustherelevantdocumentswithinamaximumof7daysafterthepatientisdischarged.

PleaseQuoteHospitalID:55418andCashlessClaimNo:13849627foryourfuturereference.

ThisApprovalLettershallbesubjecttodeductionofTDSasapplicable.

Pleaseensurethatyourlatestemailaddressisupdatedwithusinordertoreceiverealtimecommunicationregardingpreauthorization
andclaimsprocessing.

AuthorisedSignatory
THISISASYSTEMGENERATEDCORRESPONDENCE.PLEASEDONOTREPLYTOTHISEMAIL.
 Pleasesubmityourdocumentstothefollowingaddress:
MediAssistInsuranceTPAPvt.Ltd.,ChicagoPlaza,4thFloor,,RajajiRoad,OFFM.G.Road,Ernakulam682035

DocumentsRequired:

1.OriginalcashlessclaimforminIRDAformat.
2.OriginalRAL(requestforauthorisationletter).
3.Copyofalltheauthorisationletter.
4.OriginalbillinIRDAformat,dulysignedbyPatient's/Representative's.
5.OriginaldischargesummeryinIRDAformatdulysignedbyPatient's/Representative's.
6.Breakupdetailsforthebillclaimed,includingpharmacyandlabbreakup.
7.Alloriginalinvestigationreport.
8.Alltheoriginalclarificationsprovidedduringtheauthorisation.
9.Originalstickerforalltheimplant&highvalueconsumables.
10.CopyoftheinvoiceforhighvalueconsumablesandImplants.
11.Copyofreceiptfortheamountsettledbyinsured(Patient's/Representative's).
12.Copyoftheinitialassessmentsheet.
13.CopyoftheOTnotesforsurgicalcases.
14.ProvideselfattestedcopyofphotoidcardofMr/Ms..(thepatient)(MANDATORY)anyoneofthese(a)DrivingLicence(b)
PANCard(c)VoterIDCard(d)School/CollegeIdcard(e)Passport(f)IDcardissuedbyEmployer(g)Anyothersuitablephoto
identification.
15.Ifphotoidisnotavailableselfattestedphototobesubmitted.
16.IfthebillamountexceedINR1lakh,PleasecollectcopyofaddressproofoftheMr/Ms(PrimaryBeneficiary)
(ApplicabletoIndividualMediclaimPolicies)suchas(a)DrivingLicence(b)Passport(c)VoterIDCard(d)AadharCardetc.

ForProviders:Hospitalscannowmovetheirentireclaimmanagementprocessonline.MediBuddy+,auniqueportalforhospitalsfrom
MediAssist,allowsyoutosubmitpreauthorizationrequests,downloadapprovals,andtrackclaimsuntilsettlementsinrealtime.Writeto
hospital.medibuddy@mediassistindia.comtogetonboardtoday.

ForIndividuals:Doyouknowthatyoucaninstantlycheckyourclaimstatus,locatenearbynetworkhospitals,andevenplanyour
hospitalizationwithyoursmartphone?DownloadtheMediBuddyapp(availableforiPhoneandAndroid)fromMediAsisttodayorvisit
www.MediBuddy.intogetsmarterabouthealthcare.

Undertheregulation,cashlessfacilitywillbeavailableonlytothehospitalsthathaveavalidROHINIregistration.Pleaseregisterand
shareyourROHINIIDwithMediAssist,ifyouhavenotalreadydoneso.Fordetailsontheregistrationprocess,pleasevisit
https://rohini.iib.gov.in/.

MediAssistInsuranceTPAPvt.Ltd.
Phone:04842357682/2357692,FaxTollFree:04842625226,HospitalTollNo:18604250025
Email:cashless@mediassistindia.com|Website:www.mediassistindia.com|CIN:U85199KA1999PTC025676