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Cashless - Approval - 1099197 - Ajinath Rama Mahajan - 46077

The cashless request ID 1099197 for Mr. Ajinath Rama Mahajan has been approved for treatment of malignant neoplasm of the kidney, with an expected admission date of 19/03/2025 and a length of stay of 1 day. The approved amount is Rs. 114,999. KYC details are mandatory for claims above Rs. 1 lakh, and any changes in diagnosis or treatment will require revised approval.

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8 views3 pages

Cashless - Approval - 1099197 - Ajinath Rama Mahajan - 46077

The cashless request ID 1099197 for Mr. Ajinath Rama Mahajan has been approved for treatment of malignant neoplasm of the kidney, with an expected admission date of 19/03/2025 and a length of stay of 1 day. The approved amount is Rs. 114,999. KYC details are mandatory for claims above Rs. 1 lakh, and any changes in diagnosis or treatment will require revised approval.

Uploaded by

demogithub2002
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Date: 17/03/2025

To,
MPCT Hospital - Thane
Plot No. 7, Sector No. 4, Sanpada, Navi Mumbai
Contact Number/Fax Number: 2536322

Dear Service Partner,

We are glad to inform that initial cashless request id 1099197 is approved at 17/03/2025 15:44:24. Please refer to the
following details.

IMPORTANT:
1. Revised approval required if there is any change in the following
a. Diagnosis
b. Length of stay
c. Cost of treatment
d. Line of treatment
2. KYC (Know your customer) details of proposer/employee/Beneficiary mandatory for claim payout above Rs. 1 lakh.
(Refer page 2 of letter for details).

Patient Name: Mr. Ajinath Rama Mahajan

Age/ Gender: 55 / Male

Member id: 19175155

Approved Room Category: DAY CARE

Provisional Diagnosis: Malignant neoplasm of kidney, except renal pelvis

Proposed line of treatment: MEDICAL

Expected Date of Admission: 19/03/2025

Approved length of stay: 1

Expected Date of Discharge: 20/03/2025

Co-payment: 0.00

Requested amount: 115,000.00

Approval Amount (Rs). 114,999.00


Remarks

Case has been approved as per package agreed. This is full and final approval. Further approval/ Discharge
authorization is required only if there is change in History, diagnosis and treatment

Warm Regards,
Claims Team- Niva Bupa

This is a system generated letter and does not require signature

TERMS AND CONDITIONS OF AUTHORIZATION:

1. Cashless Authorization letter issued on the basis of information provided in Pre - Authorization form. In case of
misrepresentation/ concealment of the facts or any material difference / deviation/ discrepancy in information is observed in
discharge summary/ IPD records, the cashless authorization shall stand null & void. At any point of claim processing,
Insurer or TPA reserves right to raise queries for any other document to ascertain admissibility of claim .
2. KYC (Know your customer) details of proposer/employee/Beneficiary are mandatory for claim pay out above Rs. 1 lakh.
KYC Documents means proof of address, proof of identity and latest passport size photograph.

· Proof of identity- PAN Card, Job card issued by NREGA duly signed by an officer of the State Government
· Proof of Address- Telephone bill pertaining to any kind of telephone connection like , mobile, landline, wireless, etc.
provided it is not older than six months from the date of insurance contract/ Current Passbook with details of
permanent/present residence address (updated up to the previous month)/ Current statement of bank account with
details of permanent/present residence address (as downloaded)/ Electricity bill/Ration card/ Valid lease agreement
along with rent receipt, which is not more than three months old as a residence proof.

3. Network provider shall not collect any additional amount from the individual in excess of Agreed Package Rates except
costs 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).
4. Network Provider shall not make any recovery from the deposit amount collected from the Insured except for costs
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).
5. In the event of unauthorized recovery of any additional amount from the Insured in excess of Agreed Package Rates , the
authorized TPA / Insurance Company reserves the right to recover the same or get the same refunded to the policyholder
from the Network Provider and/or take necessary action, as provided under the MoU.
6. Where a treatment/procedure is to be carried out by a doctor/ surgeon of insured’s choice (not empaneled with the
hospital), Network Provider may give treatment after obtaining specific consent of policyholder.
7. Differential Costs borne by policyholder may be reimbursed by insurers subject to the terms and conditions of the policy .
8. All settlements will be done as per agreed terms and conditions and tariff with provider .
Disclaimer: Insurance is the subject matter of solicitation. Niva Bupa Health Insurance Company Limited (formerly known as
Max Bupa Health Insurance Company Limited) (IRDAI Registration Number 145). ‘Bupa’ and ‘HEARTBEAT’ logo are
registered trademarks of their respective owners and are being used by Niva Bupa Health Insurance Company Limited
(formerly known as Max Bupa Health Insurance Company Limited) under license. Registered office:- C-98, First Floor, Lajpat
Nagar 1, New Delhi-110024, Customer Helpline: 1860-500-8888. Fax: +91 11 41743397. Website: www.nivabupa.com. CIN:
U66000DL2008PLC182918.

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