Group mediclaim - Associate, Family & Parents

Tracking No : H150420191046544383

Employee Details

Employee name Lakavath Ramesh Employee number 109690

Employee's location Contact number 8610818383

Employee Bank A/c Information

Account holder name Lakavath Ramesh Bank Name SHAMIRPET

A/c Number 41*********05 IFSC Code C*********1

Branch Address CANA**************************************************************************0078

Claiment Details - Details of the insured person in respect of whom claim is made

Name Vangdoth Priyanka Relationship Spouse

Claim Details

Nature of illness CAESARIAN SECTION Duration of illness 5 Day

Name of the Hospital SYAMALA HOSPITAL Location Telangana

Date of Admission 06-Mar-2019 Total amount 41415

Medical Expencess breakup

No Bill No. Bill Date Bill Amount Remarks

1 4609 11-Mar-2019 34000 IP BILL

2 CT18292 17-Jan-2019 1086 MEDICAL

3 CT21099 04-Feb-2019 1064 MEDICAL

4 CT20390 20-Feb-2019 839 MEDICAL

5 CT21098 02-Mar-2019 540 Hospital / Bill Charges

6 CT21698 11-Mar-2019 1047 MEDICAL

7 CT21700 11-Mar-2019 399 MEDICAL

8 88 20-Feb-2019 700 Hospital / Bill Charges

9 345 07-Mar-2019 732 Hospital / Bill Charges

10 346 07-Mar-2019 186 Hospital / Bill Charges

11 347 07-Mar-2019 205 Hospital / Bill Charges

12 348 07-Mar-2019 617 Hospital / Bill Charges

Declaration
I hereby declare that the information furnished in this Claim Form is true & correct to the best of my knowledge & belief. If I have made any false or untrue statement,
suppressed or concealed any material fact, my right to claim reimbursement shall be forfeited. I also consent & authorize the TPA or the insurance company to seek
necessary medical information from any hospital / Medical Practitioner who has attended to the person for whom the claim is made. I hereby declare that I have included all
the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except that of Post - hospitalisation claim, if any.

Please note that online claim submission only registers the claim in the system and is the first step in the claims process. However, as per the mandate from IRDA and
insurance company original documents/hard copies are required for complete processing of the claims. Would request you to forward the original documents within 10 days
for the completion of claims process. Unless receiving the original documents, claim will not be considered for processing.

Date Employee Signature

Date of Submission