MEDI ASSIST INDIA TPA PVT LTD
YESHASVINI COOPERATIVE FARMERS HEALTH SCHEME
AUTHORIZATION LETTER
Preauhorization No.:  H_154501552456-2 Date:  20-SEP-2013 12:05:24 PM
Institute of Nephro Urology, Bangalore-KA
Victoria Hospital Campus
Karnataka,Bangalore-560002

MPCS HEMMIGE


Dear Sir,
Please extend Cashless Facility to the Following Insured / Patient, as per detailed below,
1. Name of the Patient CHIKEERA
2. Membership ID # 0763226
3. Reason for Hospitalization STRICTURE URETHRA ON SPC
4. Medical Consultant DR.C.S.RATKAL
5. Insurance Company Yeshasvini Trust
6. Estimated Cost of Treatment (in Figures) 15000
7. Current Approved/Enhanced Amount 15000
7.1 Total Payment Guarantee Amount Up to (Figures) 15000
8. Payment Guarantee Amount Up to (in Words) Fifteen Thousand, Only
9. Remarks Approved.

Note:
  • This preauthorization is given by Medi Assist India TPA Pvt Ltd on behalf of Yeshasvini Trust based on information provided by the hospital in pre authorisation request. In case any information provided is incomplete/incorrect, the authorisation is liable to be cancelled at the discretion of Medi Assist.
  • The primary liability to make payment to the hospital providing services based on the Pre authorization is that of the Yeshasvini Trust & not Medi Assist India TPA Pvt Ltd.
  • Denial of Pre authorization does not mean denial of treatment. Medi Assist India TPA Pvt Ltd. shall not be held responsible for any consequences arising from not extending necessary medical care/assistance by the hospital to the patient/member.
  • MediAssist is not liable to make any payments in excess of the authorized amount.
  • Non Medical Expenses incurred at the hospital like TV, Telephone, Fax, Video Cassettes, Medicine not related to Diagnosis/Ailment, Food & Beverages, Attendant's Expenses, Transportation etc. should be collected from the Insured/Patient at the time of discharge.
  • This Authorization letter is valid only for 30 days from the date of Authorization.
  • MediAssist will not be liable for payment to the hospital in the event of any of the facts presented by the hospital/ insured in PA are found to be incorrect/revised.

Formal claim has to be submitted by the Hospital to Medi Assist India TPA Pvt Ltd. within 30 days from the date of discharge along with all the supporting documents as required in terms of the Protocol between the Hospital and the Trust. Medi Assist India TPA Pvt Ltd reserves the right to call for any other relevant document which may be required to process the claim. Any claim submitted after 30 days from the date of discharge shall attract penalty as per the Protocol between the Hospital and Yashaswini Trust. The authorisation is governed by the Protocol between the Hospital and Yashaswini Trust and the Protocol would always prevail.

This is a Computer generated statement so no signature is required.
Note : Please quote our Authorization Number in all your correspondence and bills
Medi Assist India Pvt Ltd
No, 41, 16th Main, 2nd cross, 2nd stage
1st phase, BTM Layout, Bangalore-560076
Contact Numbers: 080–26783111; 080–26784111
Website: www.mediassistindia.com