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Authorization Letter to the Hospital for the Treatment and Guarantee of Payment

Date : 20-MAR-13

To,

SRI SAI HOSPITALS (N9164/AWSP/I) AL Number 110300245061

H. NO: 3/1396, SRI SAI HOSPITALS, PRODDATUR,KADAPAProddatur,Andhra Pradesh-516360Tel:Mob:

Date of Admission 20-MAR-13

Dear Sir/Madam,We hereby authorize and guarantee for payment up to Rs 3200 (in words) Rupees THREE THOUSAND TWOHUNDRED only for Admission/ Pre-Authorization request note sent by you with the following information:

Name of the patient LAKSHUMMA

UHID Number W/6/Z1/AP/00716453/M2/01

Class of Accomodation

For provisional diagnosis Senile cataract

Previous Authorised Limit Rs. Additional Sum Sanctioned Rs.

Co-Payment Amount Rs.0 Total Sanctioned Amount Rs.3200

P.S.: Effective June 01, 2011 ICICI Lombard Health Care office would be shifted to new location, please findcommunication address details below.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 isavailable, 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 thehospital 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) Pleasecollect 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 collecteddirectly 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 attendingdoctor 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 certifyingcharges.

Remarks : APPROVED AS PER CATARACT SUBLIMIT AND FURTHER ENHANCMENT IS NOTPOSSIBLE.

Chief - Underwriting & Claims

For ICICI Lombard General Insurance Company Ltd

ICICI LOMBARD HEALTH CAREImportant 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 Authorizationbecomes 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 inMOU/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.

Address:Email:ihealthcare@icicilombard.com

Old Address: New Address: Contact Us

ICICI Lombard GIC,ICICI Lombard Health Care,TGV Mansion, 6th Floor,Plot No. 6-2- 1012

Khairatabad,Hyderabad - 500004,Andhra Pradesh

ICICI Lombard GIC,ICICI Lombard Health Care,ICICI Bank Tower,Plot No 12, Financial District,Nanakram Guda, Gachibowli,Hyderabad 500032,Andhra Pradesh

Toll Free Helpline No.:Toll Free Fax No.:

Fax No. Line 1:Fax No. Line 2:

1800 209 88881800 209 8880

040-66989160040-66989161

mailto:ihealthcare@icicilombard.commailto:ihealthcare@icicilombard.com