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Authorization Letter to the Hospital for the Treatment and Guarantee of Payment
Date : 14-MAR-11 To, Kidney Hospital & Lifeline Medical Institutions AL NO 110200179064 63-64, Waryam Nagar, Cool Road, Jalandhar Date Of Admission 12-MAR-11 JALANDHAR,PUNJAB-144001 We hereby authorize and guarantee for payment up to Rs 24000 (in words) Rupees TWENTY-FOUR THOUSAND only for Admission/ Pre-Authorization request note sent by you with the following information: Name of the Patient SUSHANT ANAND UHID NO ILGIC/BPE/00/000000240/S Class of Accommodation As per eligibility Typhoid and paratyphoid fevers;Other noninfective gastroenteritis and For Provisional Diagnosis colitis Previous Authorized Limit Rs Additional Sum Sanctioned Rs Co-payment Amount Rs 0 Total Sanctioned Amount Rs 24000
Important Instructions to Hospitals 1)If the hospital bill is estimated to be higher than the guarantee of payment, a request letter for additional amount needs to be sent to ILGIC 2) If no further guarantee is available, the hospital must collect the excess amount directly from the beneficiary at the time of admission/ prior to discharge from the hospital, as per hospital rules and regulations 3) Please collect the hospital bill summary with final bill with details of units of each service (authenticated by patients signature). 4) Please collect the discharge summary and reports of all investigations (original). 5) Please collect an undertaking from the insured / patient for submitting his/her documents to ILGIC Ltd in original. 6) Charges for the following miscellaneous services and related allied services must be collected directly from the patient. i) Registration / admission charges ii) Ambulance charges (unless authorized) iii) Attendant / visitor pass charges. iv) Special nursing charges not authorized by the attending doctor v) Service charges not forming a part of the bed charges in general ward, maintenance charges, surcharges vi)Charges for extra bed for attendant etc vii)Bed retaining charges viii)Charges for TV, Laundry etc ix) Telephone/Fax charges x) Food and Beverages for attendants and visitors. xi) Toiletries etc xii) Purchase of medicines not related to the treatment xiii) Stationery, Xerox or certifying charges.

Remarks : Room rent Limit (including Nursing ch) Rs 1000/- Per day. Difference in treatment cost due to higher room category is to be borne by the insured in same proportion.Kindly furnish detailed course of hospitalization with Discharge summary and Final bill break up. Final claim settlement as per MOU, Policy T & C.

For ICICI Lombard General Insurance Company Ltd ICICI LOMBARD HEALTH CARE
Important Note: This authorization is valid for Admission within 15 days from the Date of Admission mentioned or expiry /cancellation of the Insurance policy whichever is earlier. This Authorization becomes null and void if the patient is discharged before the date of this letter issuance. Copayment Amount has to be collected from Insured. Claim Processing / Settlement will be as per agreed rates in MOU/Tariff. This is an electronically generated document and this requires no seal / stamp
All payments to Hospitals are subject to deduction of tax at source as per prevailing rate unless lower/nil TDS certificate had been provided to the payer, under section 194J as per Circular No 8/2009. Dated 24-11-2009 from Income Tax Dept. Service Tax is Payable on the Amount finally payable by ICICI Lombard at the rate of 10.30%. Service tax amount is over and above the authorized amount and it should not be collected from the patient. Please do not collect any Service Tax amount from the Patient. Service tax is payable provided: 1) Service tax registration number is clearly mentioned on the invoice, 2) The invoice is in the name of ICICI Lombard General Insurance Company limited, 3) Category of services under which the registration is obtained should be mentioned on the invoice, 4)The amount of Service Tax should be separately mentioned on the invoice.

Address : ICICI Lombard GIC, ICICI Lombard Health Care, TGV Mansion, 6th Floor, Plot No. 6-2- 1012 Khairatabad, Hyderabad 500004, Andhra Pradesh

Email: Toll Free Helpline Number Toll Free Fax Number Fax Number

ihealthcare@icicilombard.com 1800 209 8888 1800 209 8880 040-66989160 / 61

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