5/30/13

Paramount Health Services (TPA) Pvt. Ltd.

+91-022-66620808

contact.phs@paramounttpa

Detailed Claim Information Claim Details

Name of Insurance C o : New India Assurance Company PHS ID : 20009088

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U/W Office Name : MUMBAI DO

Name of Beneficiary :

SHRIKANT PURUSHOTTAM KULKARNI

Policy Number : 112700/34/12/04/00000014 Group Name :

Name of Proposer/Employee : MANISH SHRIKANT KULKARNI Policy Period : 23/04/2012 to 22/04/2013

PAN INDIA NETWORK LTD

Employee Number : Address : 135, Continental Building, Dr Annie Beasant Road, Mumbai 400018

Gender : MALE Relation : Father

Claim Registration
Name of Provider : Nityaseva Maternity And General Surgical Nursing Home Insurer C C N : 0 FIR Date : 20/04/2013 FIR Number : 2228746 FIR Extention : Partial Payment Seq: 0 Deficiencies : Processing Branch : 022

Date of Admission : 04/04/2013 Date of Discharge : 06/04/2013 Al/Denial Date : Al Amount: 0 Additional Al Amount: 0 Date of File Received : 19/04/2013

Claim Processing
Bill Received Date : 19/04/2013 Provider Bill Amount : 6400 Pre/Post Provider Bill Amount : 625 Total Amount C laimed : 7025 Discharge Voucher received 29/05/2013 Date: Service Tax : 0 Amount C leared : 6400 Amount C leared Beneficiary : 0 Amount C leared Provider : 0 Discharge Voucher Sent Date : 29/05/2013

Not Payable Expenses : 625

TDS Amount : 0

Deduction Reasons : 235 Medicine Not Covered Within Pre-Post Hospitalization390 Medicine Not Covered Within Pre-Post Hospitalization

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