STAR HEALTH AND ALLIED INSURANCE CO. LTD.

NO.15, SRI BALAJI COMPLEX, 1 ST FLOOR, WHITES LANE, 
ROYAPETTAH, CHENNAI­ 600014 Toll Free No: 1800 425 2255/ Toll Free Fax: 1800
425 5522, www.starhealth.in

Authorization Letter to the Hospital for the Treatment Cost Payment

Kindly quote the Claim Intimation No ­­­ for all communications. 

          HOSPITAL :  K.S. Hospital                                                                                          DATE: 03/05/2018

          ADDRESS          : CHENNAI
  We are in receipt of the Admission/Authorization request note with the following information / Documents.

NAME OF PATIENT :   Gopinath Annan Ramachandran  Age        : 64  YEARS              Sex: M

POLICYNO : PRICE WATER HOUSE
Duration of Stay : Room category :  
DATE OF : 01/05/2018 Product : GMC POLICY
ADMISSION 

Diagnosis :   RSD­UROSEPSIS

Rs. 26885 /-Auth (TWENTY SIX THOUSAND EIGHT HUNDRED AND EIGHTY FIVE Only). SUBJECT TO VERIFICATION:

MAXIMUM PAID AFTER DEDUCTING NON-PAYABLE.

NOTE: 5% COPAY APPLIED.

1. Valid for admission within 10 days from issuance of this letter or the expiry of the current policy whichever is earlier. 

2. If the hospital bill estimated to be higher than the approved amount, an request letter for additional amount needs
to be sent to Star Health and Allied Insurance on Toll Free number with due justification. 

3. If no further authorization is given by us in response to the request or otherwise,  the hospital to collect the excess 
amount which is over and above the authorized amount directly from the beneficiary prior to discharge form the hospital, as
per hospital rules and regulations. 
4. Duration of hospitalization for the above treatment is considered for      days. 
5. Quantum of claim authorized is inclusive of professional fees, namely Doctors, Surgeons, Anesthetists, for
the above treatment. 
6. Room, Boarding inclusive of nursing charges eligibility per day shall be AS PER POLICY conditions. Difference in room
rent charges to be borne by the insured. 
7. The authorization of the treatment is for the room charges eligible as provided in the policy. In case the insured opts for room
category above the entitlement under the policy the claim shall be proportionately limited for the following expenses:­
Surgeon, Anesthetist, Medical Practitioner, consultants Specialist fees. 
Nursing charges, Anesthesia, Blood, Oxygen, 
Operation Theatre Charges, Surgical Appliances, 
Medicines, Dialysis, Chemotherapy, Radiotherapy, Consumables, implants, Mesh, Relevant Laboratory/Diagnostic test,
X­ray  and other medical expenses related to the treatment. 
8. The change in the admissibility of the claim due to discrepancies in the information provided by the Hospital in the
preauthorization form and discharge summary woulld be the liability of the hospital. 
9. Hospitilization for treatment of the following conditions is not payable by the Company :­
Convalescence, General debility, Run down condition, 
Congential External Disease, 
Sterility, STD, intentional self injury & 
use of Alcohol / intoxication drugs. 
10. All Post Hospitalization expenses to be paid by the insured. 
 STAR Health and Allied Insurance Co. Ltd.

KRM Centre, VI Floor,No.2, Harrington Road,Chetpet,Chennai-600031

Toll Free No: 1800 425 2255/ Toll Free Fax: 1800 425 5522, www.starhealth.in

Exclusions : Not payable by the Company 
1. Telephone / Fax / Barber / Toiletries / TV / Laundry 
2. Food and Beverages for the relatives / attendant. 
3. Dental Treatment if not pertains to the ailment 
4. External implants, supports accessories such as Crutches, Spectacles etc 
5. Shaving blade / Razaor sets 
6. Service / Maintenance / Documentation / Registration Charges. 
7. Attendant Pass 
8. Antiseptic creams 
9. Cosmetic treatment for eyes /  teeth including their accessories 
10. Water purifiers and Energy drinks like Glucose C/D and Glycerin. 

11. Nutritional supplements like Vitamins, Pro­biotic, Hepotic tonics(Udiliv, LIv52, Hepamerz etc.)
& digestive   ( Aristozyme etc.) 

Documents to be submitted For settlement:

1. Pre auth Request Form 
2. Copy of the Authorization / Enhancement Letter 
3. Discharge Summary 
4. Hospital Final bill showing details of units of each service with Insured / Patient Signature 
5. Original Investigation reports 
6. Pharmacy Bill with Prescriptions 
7. AR / MLC /  Self Declartions in case of Accidental injury 
8. Copy of  ID Card 
9. X­Ray / CT / MRI Film ­ Originals or Scanned Copies 

Approved by 

SH47305
Medical Officer

Star Health And Allied Insurance Co Ltd. Signature of Patient / Insured
03­MAY­ 2018­  07:45PM  

Note: Please hand-over the copy of the letter to the Insured Patient.