AuthorizationLettertotheHospitalfortheTreatmentandGuaranteeofPayment

21MAR16
VasanEyeCareHospitalPreetVihar ALNumber:110200564940
F14,OppMetropillar,No.94,OppMetroGateNo.2,PreetVihar
METROSTNGATENO2
NEWDELHI,Delhi110092
Tel:Mob:
DearSir/Madam,
WeherebyauthorizeandguaranteeforpaymentuptoRs36000(inwords)RupeesTHIRTYSIXTHOUSANDonlyfor
Admission/PreAuthorizationrequestnotesentbyyouwiththefollowinginformation:
Nameofthepatient :GoreLalSinghGautam
UHIDNumber :ILGIC/2IF/00/000000011/F
ClassofAccommodation :DayCare
:CataractAndOtherDisordersOfLensIn
ForProvisionalDiagnosis
DiseasesClassifiedElsewhere
PolicyPeriod :08OCT2015To07OCT2016
DateofAdmission :22MAR2016
Event Date CopaymentAmount FinalSanctionedAmount
InitialApproved 21MAR2016 0 36000
Remarks:
KindlynoteinitialAL(110200562691)standsnullandvoid.Duringfinalsettlementofclaim,anyexcessamountthat
hasbeenapprovedatthetimeofinitialauthorizationorsubsequentlimitenhancement,discountsandexpenses
incurredonnonmedicalexpensesshallbededucted.Finalclaimsettlementwillbedonestrictlyaspertheterms
andconditionsspecifiedinMOU.
ImportantNote:ThisauthorizationisvalidforAdmissionwithin15daysfromtheDateofAdmissionmentionedorexpiry/cancellationofthe
Insurancepolicywhicheverisearlier.ThisAuthorizationbecomesnullandvoidifthepatientisdischargedbeforethedateofthisletter
issuance.CopaymentAmounthastobecollectedfromInsured.ClaimProcessing/SettlementwillbeasperagreedratesinMOU/Tariff.Thisis
anelectronicallygenerateddocumentandthisrequiresnoseal/stamp

ChiefUnderwriting&Claims
ICICILombardGeneralInsuranceCompanyLtd,

ForRealtimeUpdatelogonto:https://www.icicilombard.com/ILHealthCare
Address:ICICILombardGIC,ICICILombardHealthCare,ICICIBankTower,PlotNo12,FinancialDistrict,NanakramGuda,
Gachibowli,Hyderabad,500032,Telangana,TollFreeHelplineNo:18002666,TollFreeFaxNo:18002098880,
FaxNo.Line:04066989160/61,Email:ihealthcare@icicilombard.com
IRDARegistrationNo.115
ImportantInstructionstoHospitals:1)Ifthehospitalbillisestimatedtobehigherthantheguaranteeofpayment,arequestletterforadditionalamountneedstobe
senttoILGIC2)Ifnofurtherguaranteeisavailable,thehospitalmustcollecttheexcessamountdirectlyfromthebeneficiaryatthetimeofadmission/priorto
dischargefromthehospital,asperhospitalrulesandregulations3)Pleasecollectthehospitalbillsummarywithfinalbillwithdetailsofunitsofeachservice
(authenticatedbypatientssignature).4)Pleasecollectthedischargesummaryandreportsofallinvestigations(original).5)Pleasecollectanundertakingfromthe
insured/patientforsubmittinghis/herdocumentstoILGICLtdinoriginal.6)Chargesforthefollowingmiscellaneousservicesandrelatedalliedservicesmustbe
collecteddirectlyfromthepatient.i)Registration/admissionchargesii)Ambulancecharges(unlessauthorized)iii)Attendant/visitorpasscharges.iv)Special
nursingchargesnotauthorizedbytheattendingdoctorv)Servicechargesnotformingapartofthebedchargesingeneralward,maintenancecharges,surcharges
vi)Chargesforextrabedforattendantetcvii)Bedretainingchargesviii)ChargesforTV,Laundryetcix)Telephone/Faxchargesx)FoodandBeveragesforattendants
andvisitors.xi)Toiletriesetcxii)Purchaseofmedicinesnotrelatedtothetreatmentxiii)Stationery,Xeroxorcertifyingcharges.

FollowingDetailsaremandatoryforclaimsettlement
DateofDischarge

FinalBillAmount
AmountPaidbyPatient SignatureofthePatient/Relative HospitalStamp&Signature
AllpaymentstoHospitalsaresubjecttodeductionoftaxatsourceasperprevailingrateunlesslower/nilTDScertificatehadbeenprovidedtothepayer,under
section194JasperCircularNo8/2009.Dated24112009fromIncomeTaxDept.