DENIALOFCASHLESSACCESS

Date:08OCT16
To,
SukhmaniHospital.
B7,Extension126A,SafedarjungEnclave
NEWDELHI,Delhi110029
Tel:Mob:
DearSir/Madam,
Claimof SUKHBIRKAURBHATIA
UHID IL00671552101
PolicyNumber 4016/66719457/05/000
26SEP2016to25SEP
PolicyPeriod
2017
ALNumber 1102006306501

Werefertothepreauthorizationrequestdated08OCT16.Weareinreceiptofthedocumentssubmittedbyyouinsupport
ofyourclaim.Onperusalofthesame,weregrettoinformyouthatyourpreauthorizationrequestisdeniedforthereason(s)
mentionedhereinbelow

SrNo Reason Remarks

1 Others MaximumamountapprovedasperMOU.Hencefurther
enhancementisnotpossible.Chargestowards
CHROMOSOMALINTERPHASEPROFILLINGisnot
payable.Initialapprovedamountstandsvalid.Pleasenote
anyexcessamountapprovedatthetimeof
AL/Enhancement,discountsandexpensesincurredonnon
medicalswillbedeductedatthetimeofclaims.Finalclaim
settlementstrictlyasperMOUandPolicyT&C

Foranycashlessqueries,writeoncashlessrequest@icicilombard.com

ChiefUnderwriting&Claims
ICICILombardGeneralInsuranceCompanyLtd,

Important:Pleasenotethatatthedenialofauthorizationforcashlessaccessdoesnotimplydenialofthetreatment
anddoesnotinanywaypreventtheinsuredfromseekingnecessarymedicalattentionorhospitalization/claimingfor
reimbursementissues.

ForRealtimeUpdatelogonto:https://24x7.icicilombard.com/ghi/provider/providerlogin.aspx

Address:ICICILombardGIC,ICICILombardHealthCare,ICICIBankTower,PlotNo12,FinancialDistrict,NanakramGuda,
Gachibowli,Hyderabad,500032,Telangana,TollFreeHelplineNo:18002666,TollFreeFaxNo:18002098880,
FaxNo.Line:04066989160/61,Email:ihealthcare@icicilombard.com
IRDARegistrationNo.115