Letter Page 1 of 2

Corporate Office: Plot No. 577, Udyog Vihar,

Phase V, Gurgaon, Haryana - 122016
Phone : 0124 - 4980555, Fax No : 0124 - 4466677
E-Mail : customercare@emeditek.com
Pre - Approval Certificate
PAC No. :EMSL/PAC/OICL/550703/2018 Claim No. : 108051800011 Date : May 10 2018 9:50PM

Medical Superintendent,
S. K. D. Hospital
63- A, Krishna Nagar , Lucknow - 226023 , Uttar Pradesh
(Note : Please quote your NSP Code (HO00002832) for future cashless request/references. )
Ref no:-Claim No 108051800011, under policy no:-221112/48/2018/185.
Subject: PAC Approved
Dear Sir/Madam,
We hereby authorize you to admit DEEPIKA BAJPAI (Wife) having ID Card Number : 10809160000227D and Policy No :
221112/48/2018/185 (Silver Plan - Happy Family Floater Policy 2015) for THE ORIENTAL INSURANCE CO. LTD. as per the
following authorization specifications:
Nature Of Illness : # BB forearm
ICD 10 Code : Fracture of forearm, part unspecified (S52.9)
Name Of Treating Doctor : DR
Proposed Date Of Hospitalisation : May 5 2018 12:00PM - May 10 2018 12:00PM
Approved Maximum duration of stay : 6
Class Of Accomodation : Single Room From 05/05/2018 12:00 PM To 10/05/2018 12:00 PM
Estimated Expenses : 94327.00
Admissible Limit : 71921.00
Amount Payable by Insured on the admissible limit
Compulsory Deduction :
Co Payment : 7192.00
NSP Discount :
Authorised Limit : Rs. 64729.00
Remarks : HOSPITAL ROOM RENT @ 1500/DAY, ELIGIBLE ROOM RENT @ 1000/DAY HENCE PROPORTIONATE
DEDUCTIONS DONE ON ASSOCIATED CHARGES - SURGERY CHARGES AND INVESTIGATION CHARGE. FULL AND FINAL
AUTHORIZATION.PLEASE MUST SEND INVOICE AND STICKER OF IMPLANT FOR FINAL SETTLEMENT.
Note: PAC stands for the active treatment only. Non-medical and Non-payable expenses are not payable.
Note: "As per the instructions of the insurer THE ORIENTAL INSURANCE CO. LTD., the claim is being Authorized for Rs. 64729.00/-
on account of treatment for # BB forearm. For any further clarifications, you may directly contact the insurer.

Dr. Riyaz Ullah

( Medical Officer )
Note : HOSPITAL TO SEND DETAILED FINAL BILL AND DISCHARGE SUMMARY TO TAKE FINAL AUTHORIZATION BEFORE
DISCHARGE OF PATIENT FROM THE HOSPITAL.
Special Conditions :
1. If the hospitalization expenses exceed the authorized limit and / or change in primary diagnosis / or change in line of treatment /
or prolonged hospitalization of more than 3 days, an updated case summary along with explanation of the same supported by
IPD records shall be provided before discharge of the patient to EMSL.
2. The authorization given is as per agreed package/ GIPSA PPN rates, inclusive of all the charges, no additional amount shall be
charged from the patient/insured in excess. For any further authorization, above agreed package/ GIPSA PPN rates, proper
justification from the treating doctor along with IPD records is mandatory.
3. In case, the insured opts for a higher room category or any advance procedure/modalities/services which does not fall under
reasonable and customary, the difference of such amount shall be charged from the insured after obtaining a proper undertaking
that the same will not be payable by the insurance company.
4. This certificate is valid for the treatment mentioned above and is valid for a period of 15 days from the expected date of
hospitalization or the expiry of the Insurance Policy of the member whichever is earlier.
5. Expenses in respect of All non medical expenses/items as per IRDAI notifications must be collected from the patient at the time
of discharge; otherwise, it shall be deducted from the hospital bill at the time of final settlement. Expenses incurred on materials
& services, investigations irrelevant to the cause of hospitalization shall be directly collected from the insured.
6. In the event of any variation in the information provided in the cashless request form and the treatment papers, this pre-approval
certificate stands void ab initio and hospital / nursing home shall be solely responsible for any loss and / or damage to them on
this account.
7. This PAC is valid only if full & final authorization is issued from EMSL.

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Letter Page 2 of 2

PLEASE ENSURE THAT THE FOLLOWING DOCUMENTS ARE RECIEVED BY EMSL WITHIN 7 DAYS OF THE DISCHARGE OF
THE BENEFICIARY. OTHERWISE THE CLAIM SHALL BE MARKED NO CLAIM AS PER THE INSTRUCTIONS OF THE
INSURERS.
1. A copy of the pre-approval certificate(s) with undertaking duly signed by the beneficiary.
2. Hospital bill with complete breakup. (Authenticated by patient's signature) & All investigation reports, doctors prescriptions and
pharmacy bills / cash memos.
3. Original detailed discharge summary.
4. Original sticker/ invoices wherever implants, stents, mesh, lenses have been used.
5. Duly filled and signed claim form.
Insured's Undertaking
I confirm that the information provided in my application for authorization letter is true and correct to the best of my knowledge and
belief. Any deviation from the course of treatment and / or information as mentioned by me in my application form shall render this
authorization letter null & void unless E- Meditek Insurance TPA Ltd. has expressly in writing agreed to the deviation. I undertake to
inform the deviation to E-Meditek Insurance TPA Ltd. immediately. I further undertake to reimburse E-Meditek Insurance TPA Ltd. /
Network Service Provider for any loss caused to them by non-payment of the claim by my Insurers on account of non-disclosure of
material information by me.
(Signature of the Insured)
Note for Hospital / Nursing Home :
1. Kindly take the undertaking from the member as per above format and send the same along with the bills for reimbursement
2. It shall be the duty of the hospital / nursing home to handover all the correspondence exchanged with EMSL for this cashless to
the insured person.

Send Fax

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