r-'l

lJ +91 - 812812 3067 X [email protected]

TGH'Q9'L,FE +91 - 812812 4067

9 TGH Onco-Life Cancer Centre,
Talegaon General HosPital,
Concer Centre Talegaon-Chakan Road, Talegaon-
Managed BY: Dabhade, Pune. Maharashtra 410506.
0nco -Life Cancer Centre Pvt. Ltd.
Ilospital Ejnerl Btl

PATIENT NAME M RS. ZAMBRI] CIJAAYA SHRI I(RUSI{NA Bill No. TI,.I 3BT]
DOCTOR DT. IAYAN]' I,LI N D I,I K GAWAN DF]
DAIGNOSIS CA RICIIT BRh.AS.f PRN NO. T-2259
DOA 12-09-20231356 13-09-2023 1)" _\t)
ADDRESS Pr.rne, Maharashtra TRF:ATMIiNT CII IJMOTtItiRAI)\

.SR, NO PARTICULARS RATE Days TOTAI, AMOIINT'

1 BED CHARGT]S 5000 1 5000

2 CONSUI,TANT VISIT CIIARGHS [DR. JAYANT 1 000 1 1 000
C I I I] M OTII I.] RA PY P I,A N N I N G A N I'] I N F' I] S I O N
3 8000 1 tt00{)
CIIAIlGF]S
4 PATTIOI,OGY INVF;STIGNTION
CI]C (COM PI,I]TI.] BI,OOD COTJNT( CBC/I IAIiMOGRAM J 350 I 3 lr0
Serum Creatinine Zlt0 I ;0
Illcctrolytcs (r00 1 60(
SGOT 250 1 2!;0
SGPT 250 1 2 !;0

SLIItUM I]II,I,IRU I]IN 250 1 2 lt0

RBS 100 I

,, PTIARMACY
-[t,
1047i
TOTAI. AMOI]NT ?6.?7
Discount
Gross'lotal A,nount. 26527

I]NTY SIX TIIOUSAND T'IVF] IIUNDRI]D AND TWI]NTY SHVEN RUPEF]S ONI,Y,

IIOSPITAI. RI|G.

For ONCO.I,IFIi CANCI|R CI.:NT,RI.: PV,I'. I,,I'I)

q lo
,i

G;9
 ONCO LIFE CANCER CENTRE PVT.LTD.
Nr' Railwav Station , Talegaon Dabhade
Xl C O - Ll F E
U=\-----l-
Tal. Maval, Dist- pune 410507.
('< r.rrrr' ('.r:t:
': ph. No.: gL2g122.406r

R ECEI PT

Receipt No. II.AR-23-24-2207

MRS. ZAMBRE CHAAYA SHRIKRUSHNA MRN T.2259

Pune, Maharashtra Gender/Age Female / 66 Years

Mode Cheoue/ECS/CC No. Credit Card Bank Name Amount

zas) 7 oo

Total Amount 2657 / OO

NTY SIX THOUSAND FIVE HUNDRED AND TWENTY SEVEN RUPEES ONLY.

Amount Utiliezed Against Bill No -TL.l- 388

Q''
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-

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 ONCO.I!FE CANCER CENTRE PVT. tTD TALEGAON

NR. RAII.WAY STATION, TATEGAON OABHADE, TAT. MAVAI., DIST. PIJN€ - 41,0507

Medicine Bill
Patient Name : MRS, ZAMBRE CHAAYA SHRIKRUSHNA Registration No. : TL.IPD-23-?4-386
Department Name : MEDICAL ONCOLOGY Admission Date : 12-09-2023
Category : INSURANCE

Bill Amount : to477.37 Company Credit : 0.00 Medicine Purchased : L0477.37

Discount : 0.00 Patient Amount : LO477.O0 Medicine Returned : 0.00
Net Amount : LO477.37 Patient Paid : LO477 Net Purchased: 1.0477.37
Bill Round Off : -0.37 Credit Settlement 0
Total Amount : to477.OO Pending Amount : 0

Sales [TL.SB-2340 I [ 12-09-2023 03:25 PM ]

Items Category Covered Expiry Dt Batch Quantity Selling Amt Disc.
PREPTT 12sl80 MG CAP M N 07 12024 APREKT2lO 1 KII 1693.50 1693.5 0.00
Optinuron Fort lnjection M N 06/2024 tD223008 1 tNl 74.1 t4.t 0.00

Flamigrip Cannula Fixator M N 0t/2026 AWP3O4I, 1 NOS 71.5C 11.5 0.00

DEXASAYOKA 2ML INJ M N 02/2O2s 10232304c 2 AMP L2.99 25.98 0.00
PANTOAIDE 4OMG INJ M N 0s/202s PGY23085 1 VIAL 56.50 56.5 0.00
Ns 500 Ml lv (Otsuka) M N 02/2026 t23r767 3 NOS 34.82 104.46 0.00
v Set Reg M N or/2028 40293238 1 NOS 168.00 168 o.00
GRANISAYOKA 3MG INJ M N 041202s v2305-064 L VtAt 298.0C 298 0.00
Doxilyd 50 Mg lnjection M N L212023 A 1 NOS 1070.0c 1070 0.00
INTRACATH PLUSKI SAFE
NO 22 M N LO/2027 r2743 1 NOS 17 5.00 L75 0,00
SYR 1OCC B.BRAUN M N 0rl2028 23b178202 3 NOS 26.00 78 0.00
SYR 1OCC B.BRAUN M N 04/2028 2 1 NOS 26.04 26 0.00
lhree Way M N 0r/2028 L0207238 1 NOS 156.00 156 0.00
Face Mask Elastic Apex tN001tNNo
Hygeine M N 041202s VA 5 NOS 4.00 2A 0.00
NUPHOS 5OO MG INJ M N 0412024 322-444 1 VIAL 84.0C 84 0.00
Ns 100 Ml lv M N 06/2025 2 NOS 19.6s 39.3 0.00
NITRILE GLOVES PARAKIN M N L2l2O2s M-0r23 20 NOS 14.4C 288 0.00
Needle 15 Number M N 0L/2028 0931.4P 4 NOS 4.4C 17.6 0.00
Oleanz 2 5 Mg 20 Tablet M N 0812024 stD24714 5 TAB 4.35 2t.75 0.00
Oleanz 2 5 Mg 20 Tablet M N L2/2024 srE0L91A 1. TAB 4.35 4.35 0.00
Pegstim 6 Mg lnjection M N 0s/2025 8300304 l INJ 5240.00 5244 0.00
100Mt M N 04l2O2s 001 1" BTL 95.00 95 0.00
Stemetil MD 15 Tablet M N 03/2024 sEA22035 21 TAB 10,46 219.66 0.00
Lquin 500 Mg 10 Tablet M N 10/2024 sTc21528 7 NOS 9.04 63.28 0.00
Candid Mouth Paint M N 08/202s t122t769 I NOS 158.00 158 0.00
GRANICIP 1MG DT 4 TAB M N 08/2O2s c 12 1536 7 TAB 27.83 194.81 0.00
PANON D 10 TAB M N 07 12024 GPTH-268 7 TAB 13.50 94.5 0.00
Total Medicine 10477.37 0.00
Total Consumable 0.00 0.00
otal Amount t0477.37 0.00

ISigning Authority ] Rupees (lNR) only

Powered by MEDNET for ONCO-LIFE CANCER CENTRE PV'I". LTD TALEGAON

*/NL 'LIFE AN(;C).LIFE SANCER CENTRE FVT. LTD TALEGA()N
C crrrcc r Centr*, 9 Nr. Roilwoy Stotion Tolegoon Dobhode, Tol. Movol, Dist. Pune- 41050/
DISCHARGE SUMMARY
MRS. ZAMBRE CHAAYA SHRIKRUSHNA MRN.T-z2 59
Dob / Age 28-01.-1957 / 66Yr / Female
Address Pune, Maharashtra, lndia, 4L0507 Illllilltilt llilfliillilr
Mobile No 8329412291 Reg. No : 'IL.lPD-23-24-386
Patient Category lnsurance
Ward lnfo Bed 9/Gw Ward/General Ward
Next Of Kin Ph:9767097592
Discharge Type Regular Discharge
Discharge Condition Stable
Department Medical 0ncology
ConsultanLs Dr. fayant Pundlik Gawande [Mbbs Md Dnb Dm]
Admission Date 1.2-09-2023 01:56 PM Discharge Date : 13-09-2023 72:57 PM

FINAL DIAGNOSIS
DIAGNOSIS ICD CODI

MALIGNANT NI]OPI.ASM OF CENTRAI. PORTION OF RIGTIT FEMAI,E BR}:AST c50.11 1

$
CoMORBIDITIES / MEDICAI.I'IISTORY
Type2 diabetes mellitus with hyperglycemia [E11.65) ] Essential (primary) hypertension (110)

PROCEDURE AND THEMPIES

Chemotherapy
lntent - Adjuvant
Regimen - AC
Cycle - 1st /4
PRESENTING COMPLAINTS
A 66 Year Old Iremale Klc/o Carcinoma Rt Breast admitted for Adiuvant Chemotherapy Cycle 1st (AC)

EVALUATION AND MANAGEMENT

I)atient admitted for ChBmotherapy, receivecl & tolerated it well, no side effects occur & hence planned for Disr:harge & advise lo follow up in

HISTORY OF PRESENT ILLNESS

K/c/oDm II &.ll.TN on Regular Rx
I)iagnoscd Carcinoma'Rt Breast in luly 2023
Underwent Surgery (Rt BCT) on 1.0/OB/2023, HPE - Metaplastic Carcinoma Gr III, pT2N0.
lllC - ER/Pli/ Her2neu Negative.
Planned for Adjuvant Rx - 4 AC f /b t2 weekly Paclitaxel - RT.
2DECHO (11/07 /2023) - LVEF 600/0.

HOSPITAT STAY
Day Care

TREATMENT GIVEN

ffi
RI'CEIVI]D CIIIJMOTHFJRAPY
CAP APRI,]CAI' 125 MG STAT
INJ PAN 40 IV STAT
lNj GIIANISIIT 2MG IV+ INf DEXA 1zMG IV IN 100M1NS OVI"R 15 MIN
tNJ DOXORTJBTCIN 50MG tN 100Mt. NS OVEIT 10MIN
IN] NS IV F'I.USH
rNJ. CYCLOPLIOSPHAMtDE 500MG tN 500Mt. NS OVER 2 HR
rN) oprrNriuRoN 1 AMP IN 500M1 NS IV OVER 1 HOUR
DISCHARGE MEDICATION
SR. MEDICINE DOSAGE INSTRUCTION DURA'I'ION

1. APRIFER KIT 3 TABLET 1 rirfr ,rd-+. solaft ;Irqf,r ir"qufifff 3 fefir

2. PANTA40 MG IOTABIET i,ild c-ct
-6 q-old qradT owflXfr is fi.l.H

3. GRANICIP 20 DT r. me s-dzr rrfi rd ilrdr 6-{uqrgfi is teqsi

 i
J
1n I ti
)I tlt;
j
t-"
,
()N(;()-LIFE (;ANCER CENTRE FVT. LTD TALEGAAN
,.)l f-^0rtril 9 Nr. Roilwoy Siotion Tolegoon Dobhode, Tol. Movol, Dist. pune- 4.l0502

4, S'I'EMIiTIL MD 15 TAtsLI.;'T 9 .hdt k{qEq dlq tr"fl +qunrf,i $ tls

5. OLEANZ 2 5 MG 20 TABTET 1 ffislquorzorffiiery* 3 ft-'l
6, L CIN 5OO MG TAI}I,ET I .rH t-q after meal 0--1--0 oRq
'/, troLoMUs't 650 MG 10'tAB c q'rd RflilE3dr< ilorfiqwqdt tJ Rs
Ii (,ANDID MOI'TIT PAIN'T
9 NoS {t t ilqifr 3-4 times a day ?9 R.l
(] ME'TROGYI DG GEt t 'frR{ifr
9 cEL E{ 3-4 times a day ?eft-q
1I). IIEXIDINE MOUTIIWASTI 160 MI, 9 Nos Eq r, dmiifr i-qlnacn rs Rq
1 I PEGEX 6MG tNIEC',nON l tru; R:+eqt qo-< s/c 1--0--0 on 74 / oe / 2023 'i llq

Nextlleviewtralslotr-!o"?o?3('toMeetDrfayantGawandeinoPDno4withCBc,sCREATINlNE,sELEc'rRoLyTEs,sIJILIRUIrIN,
SG()1; SGP'[ & RBS Report with prior appointment)

INSTRUCTIONS
NO RAW FOOI)
IJIIIiSII& IIOMF] COOKED FOOD.
,IO
t{I.,I'OR]' IN CASIJATTY IN CASE OF FEVER, LOOSE STOOLS, ORAL ULCERS, BLEEDING, BREATHLESSNESS & PAIN.
Ni

(.()N l lN tJ tr ANl'l DlAtstil'lc & AN'II HYPIiR'IENSIVE RX AS PER PREVIOUS.

IJM 11RGENCY CONTACT DETAILS
I;O}I AI'I)oIN'TMENT CAI,I, ON 8128124067

Consult:

J',\^
c.l
to{ Dr. TAYANi PUNDT,TK GAwANT
Dr..)ayant Gawan
MBBS MD DNB I

tr
ol
cl
,o\
 Onco-Life Cancer Centre Pvt. Ltd.
q9-LIFE Talegaon Chakan Road, Yashwant Nagar,
Talegaon Oabhade - 410506
QFune
'Cancer
Hospital: 8128L24O67 I Pathology: 7410009166
Concer Cenlre DIAGNOSTICS
Department of Pathology

Patient Name : MRS. ZAMBRE CHAAYA SHRIKRUSHNA IMRN-T-2259]

Age / Gender : 66Yr/F
Address: Vishnupuri, Pune, MAHARASHTRA
Req. Doctor: Dr, JAIPAL REDDY
Regn. lD: TL.OPD-23-2 4-2010

HAEMATOLOGY
Request Date : L2-09-2O23 0L:00 PM Reporting Date : L2-09-2023 01:05 PM
Sample No. : HAE-B355 Reporting Status : Finalized
Acceptance Date : L2-O9-2O23 01:03 PM

lnvestigations Result Biological Reference Range

COMPLETE BLOOD
COUNT(CBC/HAEMOGRAM) *[ Whole Blood
Hemoglobin 1O.5 gmolo * 12 - L5 gmo/o
RBC COUNT 3.4O millions/cu.mm * 3.8 - 4.8 millions/cu.mm
Total Leukocyte count (TLC) 10500 /cumm 4000 - 110p0 /cumm
Hematocrit (HCT) 3L.8 o/o * 36 - 45'/"
Platelet Count 286000 /cumm 150000 - 450000 /cumm
MCV 93.53 fL 83 - r.0r" fL
MCH 30.88 Pgms 25 - 33 Pgms
MCHC 33.02 g/dl 31.5 - 34.5 g/dl
Red Cell Distribution Width (RDW-CV) L3.6 o/o
LL.6 - 14 o/o

Neutrophils TLC 63% 40 - 75 o/o

Lymphocytes TLC 27% 2O - 45 o/o

Eosinophils TLC 02 o/o 7--6o/o

Monocytes TLC OB o/o
3-L2%
Basophils TLC 00% 0-lo/o
PERIPHERAL SMEAR
RBC Morphology Normocytic normochromic
WBC Morphology Within normal limits and
morphology
Platelets Adequate
END OF REPORT.

DT. ANIRUDHA PUNTAMBEKAR

Reg. No. : 1.4-15964
MD (Pathology)
Consultant Onco-Pathologist

MRS. ZAMBRE CHAAYA SHRIKRUSHNA

Regn No.: TL.OPD-23-24-2010
/ MRN-T.2259
ffi
 Onco-Life Cancer Centre Pvt. Ltd.
Talegaon Chakan Road, Yashwant Nagar, QPune
'Cancer
9-LIFE Talegaon Oabhade - 410506
Hospital: 8728724067 I Patholoty: 7410009156
DIASNOSTICS
loncer Centre
Department of Pathology

.ient Name : MRS. ZAMBRE CHAAYA SHRIKRUSHNA IMRN-T-2259]

EIffilEI
ge / Gender :
Address :
66Yr/F
Vishnupuri, Pune, MAHARASHTRA ffi
Req. Doctor:
Regn. lD:
DT. JAIPAL REDDY
TL.OPD-23-2 4-20L0 ffiffi
BIOCHEM!STRY
Request Date : 12-09-2023 01:00 PM Repofting Date : L2-O9-2023 01105 PM
Sample No. : BioB554 Repofting Status : Finalized
Acceptance Date : L2-O9-2O23 01:03 PM
Result Biological Reference
Serum Creatinine 0.73 0.5 - 0.9
Elecirolytes
Sodium Serum 136.8 mmol/L 135 - 150 mmol/L
Potassium Serum 4.46 mmol/L 3.5 - 5 mmol/L
in

Chloride Serum 104,5 mmol/L 98 - 108 mmol/L

RANDOM BLOOD SUGAR (RBS) 2OO.8 mg/dL 70 - 140 mg/dl
END OF REPORT.

F
DT. ANIRUDHA PUNTAMBEKAR
Reg. No. : 14-15964
MD (Pathology)
Consultant Onco-Pathologist

ffi
MRS. ZAMBRE CHMYA SHRIKRUSHNA / MRN-T-2259
Regn No.: TL.OPD-23-24-2010
 _-

Onco-Life Cancer Centre Pvt. Ltd. QPune

Talegaon Chakan Road, Yashwant Nagar, 'Cancer
9LIFE
Cenlre
Talegaon Dabhade - 410506
Hospital: 8728124067 I Pathobgy 7410009166
DIAGNOSTICS
Asncer Department of Pathology

zient Name : MRS. ZAMBRE CHMYA SHRIKRUSHNA IMRN-T'2259]

ge / Gender : 66Yr/F
Vishnupuri, Pune, MAHARASHTRA

ffffi
Address :
Req. Doctor: DT. JAIPAL REDDY

Regn. lD: TL.OPD-23-24-2010

BIOCHEMISTRY
L2-O9-2023 01:02 PM Reporting Date : ]-2-09-2023 01:06 PM
Request Date :
Bio8554 RePorting Status : Finalized
Sample No. :
Acceptance Date : ]-2-09-2023 01:03 PM

Result Biological Reference Range

lnvestigations
SERUM BILLIRUBIN
0.2 mg/dL 0.1- 1.2 mg/dl
Billirubin Total
0.1 mg/dL 0 - 0.3 mg/dl
Billirubin Direct
Billirubin lndirect 0.1
L6,7 UIL 0-41 U/L'o
SGOT
29.0 U/L 0-40u/L
SGPT
END OF REPORT.

w DT. ANIRUDHA PUNTAMBEKAR

Reg. No. : 14-15964
MD (Pathology)
Consultant Onco-Pathologist

ffi

MRS. ZAMBRE CHMYA SHRIKRUSHNA / MRN'T-2259

Regn No.: TL.OPD-23-24-2O10
 !
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 CASE SHEET Date : 01-09-2023
MRS. ZAMBRE CHAAYA SHRIKRUSHNA MRN-T-2259
Age : 66 Yr / Female
Address : Pune, Maharashtra, India, 410507
Mobile No. : 8329412291 Reg. No : TL.OPD-23-24-1911
Category : Paying
Department : Medical Oncology
Consultant : Dr. Jayant Pundlik Gawande

HISTORY OF PRESENT ILLNESS

K/c/o DM on Insulin
HTN

F/H/O Elder sister Ca Breast @ 47 Years.

& Elder Sister GI Carcinoma @ 50 Years.

Carcinoma Rt Breast
Rt BCT 10/08/2023
HPE - Metaplastic Carcinoma Gr II, pT2N0
TNBC
EF 60% (11/7/2023) -

Discharge from Wound + -Review Oncosurgeon

Treatment Plan -

Adjuvant AC 4 # - 12 # Weekly Paclitaxel - RT.

Genetic Counselling & Testing

Authorised By

Dr. JAYANT PUNDLIK GAWANDE

Dr. Jayant Gawande
MBBS MD DNB DM

MRS. ZAMBRE CHAAYA SHRIKRUSHNA / MRN-T-2259 / TL.OPD-23-24-1911 Page 1 of 1

 Cashless Authorization Letter (115739001)
(Please quote this reference number in all future correspondence)

E-card Claims Plan hospitalzation Hospitals

Date :11 Aug 2023

To,

The Administrator / Medical Superintendent,

Deenanath Mangeshkar Hospital,
Near Mhatre Bridge, Erandwane, Erandwane Pune - 411004
Hospital ID: (50242)
Rohini Id: 8900080349858

Dear Partner,

With reference to your request (115739001) for final cashless pre-authorization, we here by authorize INR 63872 against your final bill amount INR 81066. The
details of the pre-authorization are as follows:

Patient Details

Patient Name Chaaya

Relation to Primary Beneficiary Mother

Age 66

Gender F

Insurance Company The New India Assurance Co. Ltd

Medi Assist ID 4021191899

Policy Holder Ultratech Cement Limited-Unit-Awarpur Cement Works

IP No. -

Policy No. 12120034230400000247

Policy Period 01 Apr 2023 to 31 Mar 2024

Primary Beneficiary Shantanu Zambre

Primary Beneficiary Employee ID 127282

Insurer Claim No TP00312120023900020192

Insurer Member ID MEMBER97

Treatment Details

Provisional Diagnosis Malignant neoplasm of nipple and areola, right female breast

Expected Date Of Admission 09 Aug 2023

Treating Doctor Dr. KURLEKAR UTKRANT ANANT

Procedure / Treatment Planned Chemotherapy infusions - Cycle 2

Estimated Date of Discharge 11 Aug 2023

Room Category Occupied Single private room

Length Of Stay 2

Eligible Room Category Single Ward ( Private / Special / Executive Ward)

Authorization Details

# Status Received Date Cumulative Amount Cumulative Authorized

1 Pre-Auth Processed 08 Aug 2023 18:08 90000 59500

2 Pre-Auth Processed 11 Aug 2023 16:08 81066 65956

3 Pre-Auth Processed 11 Aug 2023 18:08 81066 63872

Total Authorized amount Rs 63872 (Sixty Three Thousand Eight Hundred and Seventy Two).

Authorization Remarks :

FINAL AL

Note: If Top Up is available and applicable, as per policy conditions, Top Up claims will be processed and additional amounts will be approved along with base
amount as per your benefit.
Hospital Agreed Tariff :

I. Package Case

Agreed Package Rate NA

Package charges exclude cost towards implants/co-morbidity/extended stay

II. Non Package Case

Room Type Room Rent Nursing

Private D AC 2500 0

Consultation Visit Charges/ Surgeon's fee/ OT/ Anaesthetist : As per customary and reasonable charges

Authorization Summary

Total bill amount (INR) 81066

Other Deductions(INR)* 1870

Hospital Discount (INR) 4053

Copay (INR) 11271

Deductibles (INR) 0

Total Authorized Amount(INR) 63872

Amount to be paid by Insured (INR) 13141

*Deduction Details

Deducted Admissible
Bill Amount
S.no Description Amount Amount Deduction Reason
(INR)
(INR) (INR)

NME CATHERER MOUNT:-170.00,NME ALCOHOL

SWABES:-3.00,NME BED UNDER PAD CHARGES:-45.00,
NME ECG ELECTRODES:-50.00,NME EXAMINATION
1 medicines/drugs 12541 1870 10671
GLOVES:-1202.00,NME MASK:-84.00,NME OXYGEN
MASK:-310.00,NME SURGICAL BLADES,HARMONIC
SCALPEL, SHAVER:-6.00

Terms and conditions for authorization

1. Cashless authorization letter issued on the basis of information provided in pre authorization form. In case of misrepresentation/concealment of facts,
any material difference/deviation/ discrepancy in information is observed in discharge summary / IPD records then cashless authorization stand null &
void. At any point of claim processing Insurer or TPA reserves right to raise queries for any other document to ascertain the admissibility of claim.
2. KYC (know your customer) details of proposer/employee/beneficiary are mandatory for claim payout above Rs.1 lakh.
3. Network provider shall not collect any additional amount from the individual in excess of Agreed Package Rates except cost 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 the cost 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 policy holder from the network provider and/or take necessary action as
provided under the MOU.
6. Where treatment / procedure 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 the policyholder.
7. Differential cost borne by the policyholder may be reimbursed by Insurer subject to terms and conditions of the policy.

DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM

1. Detailed discharge summary and all bills from the Hospital

2. Cash memos from the Hospitals / Chemists supported by proper prescriptions
3. Diagnostic Test Reports and Receipts supported by note from the attending Medical Practitioner / Surgeon recommending such diagnostic tests.
4. Surgeon's Certificate stating nature of operation performed and Surgeon's Bill and Receipt.
5. Certificates from attending Medical Practitioner / Surgeon giving patient's condition and advice on discharge
6. Please send cashless documents to address mentioned in last page of letter. (Beneath signature)
7. Final hospital bills should be issued in the name of The New India Assurance Co. Ltd as a payer for payment of cashless claims. This is a mandatory
requirement for claim settlement.

Cashless Checklist

1. Photo ID Card
2. Address Proof
3. Discharge Summary (Mandatory)
4. Final Bill (Mandatory)

Also note that

The following expenses will not be payable:

Expenses on investigations / diagnostic tests, etc. which are not related to the condition for which admission is sought
Expenses related to medicines/drugs incurred post discharge
Expenses not covered / not payable as per health insurance policy terms and conditions
The following documents must be submitted in full within 7 days from date of discharge to enable settlement of claim:
Settlement of claim, failing which Authorization(s) issued for this hospitalization would be treated as void
Original cashless claim form in IRDAI format
Original bill in IRDAI format, duly signed by the patient / representative
Original discharge summary in IRDAI format, duly signed by the patient / representative
Break-up of the bill amount being claimed, including pharmacy, investigations, etc.
All original investigation reports and X ray films etc
 Original letter/s of clarification provided during the authorization
Original sticker for all the implants & high value consumables
Attested copy of the receipt for the amount settled by the patient / representative.
Attested copy of the OT notes for surgical cases
Self-attested copy of photo id card of the patient is mandatory; any one of these documents will be accepted - (a) Driving Licence (b) PAN Card
(c)Voter ID Card (d) School/College Id card for students (e) Passport (f) ID card issued by present employer
If the bill amount exceeds INR 1 lakh, it is mandatory to collect the address proof of the Primary Beneficiary; any of these documents will be
accepted - (a)Driving Licence (b) Passport (c) Voter ID Card (d) Aadhar Card

Please note that the amount authorised is provisional and is subject to change based on the final bill and discharge summary, and deduction of TDS, as
applicable.

Note: As per Modified Guidelines on Standards and Benchmarks for Hospitals in the Provider Network issued by IRDAI vide Circular Ref:
IRDA/HLT/REG/GDL/114/07/2018 dated 27th July 2018, your Hospital is mandatorily required to Register with ROHINI and obtain either Pre-entry level
Certificate (or higher level of certificate) issued by NABH or State Level Certificate (or higher level of certificate) under NQAS, issued by National Health
Systems Resources Centre (NHSRC) on or before July 26, 2019.

QUICK LINKS:

For partner hospital

View this claim on IHX. Not on IHX yet? Sign Up now.

View important notes related to cashless claims

For member beneficiary

Pre- and post-hospitalization expenses? Raise a reimbursement claim on MediBuddy.

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Warm Regards,

Medi Assist Insurance TPA Pvt. Ltd

CIN: U85199KA1999PTC025676.
Cashless Processing Centre
#58/1A, Singhasandra.
Hosur Main Road,
Begur Post.
Bangalore. PIN - 560068.
Helpline: 1800 425 9449

Disclaimer: The TPA extends the cashless facility subject to the standard terms & conditions of the policy and the information provided in the cashless request form. We suggest that the
patient continues with the treatment as advised by the treating doctor, irrespective of the pre-authorization/cashless facility.

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