STAR HEALTH AND ALLIED INSURANCE CO.LTD.
,
SRI BALAJI COMPLEX,15,WHITES ROAD,CHENNAI 600014.
Customer Care Number - 044 6900 6900 / Corporate Customers - 044 43664666
Chat - +91 9597652225, www.Starhealth.in
DENIAL OF PREAUTHORISATION REQUEST FOR CASHLESS TREATMENT
TO, DATE : 28-DEC-2022
HOSPITAL : Arsh Super Specialty Hospital
ADDRESS : A P Colony Gaya Bihar
GAYA - 823001
Bihar
Name of Insured Patient : ARTI Age / Sex : 50 / Female
Date of admission : 28-DEC-2022 Diagnosis : UROSEPIS
Room category : Super Deluxe Product Name : Family Health Optima Insurance Plan
Policy Number : 11230218016703 Policy Start Date : 11-DEC-2022
Claim intimation No. : CIR/2023/231214/1280923 Policy End Date : 10-DEC-2023
Dear Sirs,
We have scrutinized your request for approval for cashless treatment of the above insured patient for the diagnosed disease of
UROSEPIS.
The required documents/ details are not submitted to us inspite of our request/s. We are therefore not able to decide the admissibility of
the claim.
1. usg and all other investigation documents pertaining to the diagnosis ( urosepsis)
Hence we deny the approval for cashless treatment of the above diagnosed disease.
The insured may however submit the documents to us seeking reimbursement of the expenses incurred relating to the treatment
of the above disease.
A letter addressed to the insured is attached. Please hand over a copy of this letter to the insured.
Thanking you,
Yours faithfully,
SH059162
28-DEC-2022 08:15 PM
Authorized Signatory.
IRDA Regn.No.129
Corporate Identity Number L66010TN2005PLC056649
Email ID : [email protected]
STAR HEALTH AND ALLIED INSURANCE CO.LTD.,
SRI BALAJI COMPLEX,15,WHITES ROAD,CHENNAI 600014.
Customer Care Number - 044 6900 6900 / Corporate Customers - 044 43664666
Chat - +91 9597652225, www.Starhealth.in
DENIAL OF PREAUTHORISATION REQUEST FOR CASHLESS TREATMENT
TO, DATE : 28-DEC-2022
Mr./ Ms.MR.JAI PRAKASH
S/O- MADAN RAM
ROYAL COLONY, MURALI PAHADI,
RAJENDRA PATH, R.S GAYA
NA
Pincode : 823002
NA
NA
Telephone : 9470418150
Name of Insured Patient :ARTI Age / Sex : 50 / Female
Date of admission : 28-DEC-2022 Diagnosis :UROSEPIS
Room category : Super Deluxe Product Name :Family Health Optima Insurance Plan
Policy Number : 11230218016703 Policy Start Date : 11-DEC-2022
Claim intimation No. : CIR/2023/231214/1280923 Policy End Date : 10-DEC-2023
Hospital & Location : Arsh Super Specialty Hospital, GAYA, Bihar
Dear Customer,
We refer to your request for approval for cashless treatment at the above referred hospital for the above diagnosed disease of the
insured patient.
The required documents/ details are not submitted to us by the hospital inspite of our request/s. We are therefore not able to decide the
admissibility of the claim.
1. usg and all other investigation documents pertaining to the diagnosis ( urosepsis)
Hence we deny the approval for cashless treatment of the above diagnosed disease.
You may however submit the documents to us seeking reimbursement of the expenses incurred relating to the treatment of the
insured patient.
You are therefore requested to submit the following original documents in this regard:
1. Enclosed claim form duly completed and signed by the insured.
2. Discharge summary.
3. Hospital final bill with break up details.
4. All other bills and receipts.
5. Investigation reports,X ray, scans etc.,
6. Prescription of the treating doctor.
7. Earlier treatment records, if any.
8. A copy of a cancelled cheque to enable us to remit the amount in settlement of the admissible claim amount to your
Bank account.
9. In case the claimed amount exceeds Rs.1,00,000 a copy of your PAN card as required by the provisions of the Prevention of
Money Laundering Act.
IRDA Regn.No.129
Corporate Identity Number L66010TN2005PLC056649
Email ID : [email protected]
STAR HEALTH AND ALLIED INSURANCE CO.LTD.,
SRI BALAJI COMPLEX,15,WHITES ROAD,CHENNAI 600014.
Customer Care Number - 044 6900 6900 / Corporate Customers - 044 43664666
Chat - +91 9597652225, www.Starhealth.in
On receipt of the above documents, your claim for reimbursement of expenses will be processed and the admissibility of the claim
will be decided as per the policy terms and conditions of the policy issued to you. A copy of this letter together with a claim form is
being mailed to your residential address as appearing on the policy.
In case you are not satisfied with the above decision, you may represent to our Grievance Department at the following address:
Mrs. Radha Vijayaraghavan,
Grievance Redressal Officer,
Corporate Grievance Department,
4th Floor, Balaji Complex, No. 15, Whites Lane,
Whites Road, Royapettah, Chennai- 600014.
(Land mark: In the lane next to Satyam Theatre Parking Area)
Telephone : 044-4366 4600,Exclusive Number for Senior Citizen : 044-6900 7500
E-mail id:-
[email protected]Thereafter if you wish to pursue the matter further, you may represent to the Office of the Insurance Ombudsman whose address
is given below:
Office of the Insurance Ombudsman,
1st Floor,Kalpana Arcade Building,
Bazar Samiti Road,
Bahadurpur,
Patna - 800 006.
Tel : 0612-2680952
[email protected]Thanking you,
Yours faithfully,
SH059162
28-DEC-2022 08:15 PM
Authorized Signatory.
CC : Branch Office - Gaya
STAR HEALTH AND ALLIED INSURANCE CO.LTD.
2nd Floor, Nandan Niketan,Nagmatia Road, Gaya,Bihar-823001
IRDA Regn.No.129
Corporate Identity Number L66010TN2005PLC056649
Email ID : [email protected]
