Authorization Letter Date :- 03-MAY-2020

*4110614*
AL No : HAT /21/4110614 (Please Use this no for any communication regarding this AL)
Claim No :- OC-21-1002-8429-00000585
SAI SHREE ORTHOPEDIC SUPER-SPECILITY & JOINT REPLACEMENT CENTER - Pune
251 / 252 , Opp. Telephone Exchange , Near Parihar Chowk,
Aundh , Baner
PUNE
Pin Code:- 411007
Phone No:- (020)41088600 Fax No:- (020)41088609
Dear Sir/Madam
We hereby authorize you to admit below mentioned Bajaj Allianz customer :
Patient : MRS SHOBHA B SAYKAR
[20-88226794-1]
Expected DOA : 04-MAY-20
First Authorized Limit : 50000
Total : 50000
In Words : : FIFTY THOUSAND Only
Room Category : PRIVATE A/C
Provisional Diagnosis : RIGHT SUPRASPINATUS TEAR
Authorization Remarks :
*· Room rent restricted to INR 2000for normal room & INR 0for ICU . In case a higher room is availed then the eligibility, pro-
portionate deductions shall be applicable at the time of final settlement · Zone co-pay and or policy deductible shall be applied as
per applicable policy terms & conditions
*All expenses incurred on non medical items must be collected from the patient at the time of discharge, kindly refer the cir-
culated list of Bajaj Allianz website www.bajajallianz.com for more information on the non payable item.
*Please send Medicine and Investigation bill break up with original claim documents for settlement mandatorily.

Discount Details:

IPD Discount of 15% Discount On Total Hospital Bill Excluding Implants

Disclaimer:
Above mentioned IPD discounts will be auto adjusted in the Balanced Sum insured of the policy holder , during the time of final claim settlement with
the hospital.

Important :
* Expenses incurred during hospitalization shall be settled as per the agreed negotiated tariff/packages with Bajaj Allianz
General Insurance Co. Ltd.
* This authorization is valid for a period of 15 days from the date of issue / date of admission which ever is earlier and one
event of hospitalization only.
* Any expenses not related to the diagnosis specified in the authorization letter must be collected from the patient at the time of dis-
charge.
* If the hospital bill is estimated to be higher than the authorized amount, a request letter for additional amount need to be sent at Ba-
jaj Alianz.
* If no further authorization is available, the hospital must collect the excess amount directly from the beneficiary at the time of dis-
charge from the hospital.
* Please send cashless claim documents to Health Administration Team, Bajaj Allianz Insurance Company, 2nd Floor, Bajaj
Finserv Building, Survey No. 208 / B - 1, Behind Weikfield IT Park, Off Nagar Road, Viman Nagar, Pune-411 014 within 15
days of patient's discharge.
Please note:- If documents are not received in stipulated timeline, additional discounts would be applicable as per below Grid.
Band (No of days) Within 30 30-45 45-60 60-90 Above 90
Additional Discounts applicable Nil 15% 30% 50% 100% (Claim
won't be paid)

Important Note:- Post claim closure (for delayed submission of claim documents), any further payment is subject to Balance Sum in-
sured of the customer's Policy. If Sum insured of patient is exhausted in due course time of Claim closure and receipt of claim docu-

Authorised Signatory

Health Administration Team - Bajaj Allianz General Insurance Company Limited.

2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune.Maharashtra-411014
Toll Free: 1800-103-2529 Phone: (020) 30305858 Fax: (020) 30512224/6/7
Email: [email protected] Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-233-7272 Email: [email protected]
CIN No.: U66010PN2000PLC015329
ments from the hospital, Bajaj Allianz will not be liable to make any payment.

Disclaimer :
The following authorization is being issued as per the medical and billing information provided to Bajaj Allianz General In-
surance Company Limited In case of any discrepancy in the medical information provided to us at the time of cashless request
the authorization shall stand null and void. Expenses not related to diagnosis or line of treatment shall be deducted at the time
of settlement.
Bajaj Allianz General Insurance Company Limited shall not be obliged if the original claim file along with the necessary and
relevant documents are submitted within a period of 7days from the date of discharge of the insured.
Cashless payments shall be made by electronic mode only. Cheques / DDs will not be issued. For detailed information on Elec-
tronic Payment process, please contact us at [email protected]
In case the information provided in the request for authorization letter and subsequent documents during the course of
authorization, is found incorrect or not disclosed or if our internal investigation reveals discrepancies, then we shall not be li-
able [as per this letter] for payments to the Hospital/claimant even if authorisation is given by us.

Authorised Signatory

Health Administration Team - Bajaj Allianz General Insurance Company Limited.

2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune.Maharashtra-411014
Toll Free: 1800-103-2529 Phone: (020) 30305858 Fax: (020) 30512224/6/7
Email: [email protected] Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-233-7272 Email: [email protected]
CIN No.: U66010PN2000PLC015329