Pre-Auth QueuePRU-PA-2026-001138
Adjudication workspace· PRU-PA-2026-001138

Meera Iyer · Coronary angioplasty with stent

Atherosclerotic heart disease (I25.10) at Medanta — The Medicity · Admission 31 Aug 2026 · 4-night stay
Query Raised
Estimate
₹3,25,000
Raise queryRecommended action
Cataract diagnosis is clinically consistent

Ophthalmologist notes show reduced visual acuity, glare while driving at night, and slit-lamp findings consistent with age-related nuclear cataract in the right eye.

Amount
Against ₹3,25,000 hospital estimate
Confidence64%
Exceptions
0
items need attention
0
Pass
0
Warn
0
Fail
Patient
Meera Iyer
54 · Female · Self
PRU-M-004421-1
Hospital
Medanta — The Medicity
Sector 38, Gurugram
NetworkNABHJCI
Treating doctor
Dr. Rakesh Gupta
Cardiology
DMC-R-11204
Diagnosis & plan
I25.10 · Atherosclerotic heart disease
Planned Emergency · 4 nights · Twin Sharing
AI Assist · Adjudication recommendation
Automated clinical + financial review, grounded in policy wording
RAISE QUERY64% confidence
Suggested approved amount
Model: prudential-adjudicator-v2.3 · 1.4s runtime
₹0
of ₹3,25,000 billed
Reasoning chain
  1. 1
    Cataract diagnosis is clinically consistent

    Ophthalmologist notes show reduced visual acuity, glare while driving at night, and slit-lamp findings consistent with age-related nuclear cataract in the right eye.

    94%
  2. 2
    Day-care eligibility is clean

    Fortis Memorial is a cashless network hospital, cataract with IOL is a listed day-care procedure, and the waiting period is satisfied.

    95%
  3. 3
    Cataract sub-limit caps approval

    Policy pays up to ₹40,000 per eye for cataract. The quoted package is ₹60,000, so the family should expect roughly ₹20,000 at discharge.

    91%
  4. 4
    Lens upgrade must remain transparent

    Base monofocal IOL is admissible within the package. Multifocal or toric premium lens upgrade, if selected, is payable by the family beyond the cataract cap.

    88%
Clinical notes (extracted)
  • Visual acuity: right eye 6/24, improves poorly with refraction.
  • Slit-lamp: nuclear sclerosis grade III, right eye.
  • No diabetic retinopathy noted.
  • Monofocal IOL package selected; premium lens upgrade discussed separately.
Cited policy clauses
Sec 3.2(d) — Cataract Day-care Benefit

Cataract surgery with intraocular lens is covered as a day-care procedure subject to the per-eye sub-limit stated in the policy schedule.

Sec 5.8 — Cataract Sub-limit

The maximum payable for cataract treatment is ₹40,000 per eye, inclusive of surgery, standard IOL, OT, medicines and day-care charges.

Sec 6 — IRDAI List-I Non-Medical Expenses

Items such as admission kits, attendant charges, registration fees and certain consumables are not payable under standard indemnity.

Eligibility & Rule Engine
Deterministic checks against policy wording, network and regulatory rules
0 pass
No rule checks available for this case.
Estimate breakdown
0 line items · submitted by hospital TPA
₹3,25,000
Detailed line items will be uploaded at discharge.
Claim activity
Events, decisions, and operational handoffs
Live
Policy snapshot
Policy
PRU-FF-2024-004421
Case ID
PRU-PA-2026-001138
Procedure code
92920
Admission date
31 Aug 2026
Stay
4 nights
Room
Twin Sharing