REIMBURSEMENT CLAIM APPROVAL LETTER

Date Generated : 02/04/2019

To
M A BAGAVAN
SYNDICATE BANK BUILDING, 2ND CROSS ROAD GANDHINAGAR

BANGALORE - 560009
Tel No:8939320810

Dear Sir/ Madam,

Sub: Your Claim No: BLR-0319-CL-0008767 under Policy No: 500100/28/18/P1/09893572/EMPLOYEE POLICY
our ID Card No: BLR-UI-I0580-001-0002875-C Patient: S NANDHINI Hospitalisation at: SUNDARAM MEDICAL
FOUNDATION on 06/03/2019
On scrutiny of the claim papers submitted by you and other relevant documents collected by us, we are
pleased to inform you that as per the instructions of your Insurer M/s UNITED INDIA INSURANCE COMPANY
LTD the claim is being settled as per the Mediclaim Computation Sheet attached.

We shall advise you the settlement particulars shortly.

For any further clarification in this regard, kindly contact us.

Thanking you,
Yours faithfully,
Authorised Signatory
VIDAL HEALTH INSURANCE TPA PVT LTD

Note: This is a System Generated Letter.

Copy to:
UNITED INDIA INSURANCE COMPANY LTD
UIIC, CORPORATE CELL, GROUND FLOOR,
VULCAN INSURANCE BUILDING,
V N ROAD, CHURCHGATE
MUMBAI-400021
Maharashtra

Vidal Health Insurance TPA Pvt.Ltd, SJR iPark,1st Floor,Tower 2,EPIP Zone, Whitefield Road, Opp.Sathya
Sai Hospital, BANGALORE - 560066, Fax No:080-25204296
Claim No. : BLR-0319-CL-0008767 Claim File No. : BLR-0419-FL-0000377
Claim Settlement No. : BLR-0419-CR-0000363 Approval Date: 02/04/2019

Claim Type : Member Insurance Company : UNITED INDIA INSURANCE

COMPANY LTD
Policy No. : 500100/28/18/P1/09893572/EM Policy Start Date : 01/10/2018
PLOYEE POLICY
Policy Type : Corporate Policy End Date : 30/09/2019

Corporate Name : SYNDICATE BANK (IBA) - Payee Name : M A BAGAVAN

EMPLOYEES
Enrollment No. : BLR-UI-I0580-001-0002875-C Relationship : Spouse

Claimant : S NANDHINI DOD : 09/03/2019

DOA : 06/03/2019 Hospital : SUNDARAM MEDICAL
FOUNDATION
Address : SYNDICATE BANK BUILDING, Hospital Address : SHANTHI COLONY
2ND CROSS ROAD ANNANAGAR
GANDHINAGAR CHENNAI-600040

Insured Person : M A BAGAVAN DOB/Age : 22

Emp no./Ref-no. : 675868 IP No. : 45898
Sum Insured (Rs.) : 300,000.00
Settled Amt (Rs.) : 39,737.00
Balance (Rs.) : 247,055.00 ICD Codes : O80.9,Z37.0

Final Diagnosis : G2 A139+6 WEEKS WITH NVD WITH RMLE, SINGLE LIVE BORN
Remarks : PIAD AS PER BABY EXPENCES ALSO UNDER MOTHER ID

MEDICLAIM COMPUTATION SHEET

Sl Bill No. Bill Date Nature of Amt Claimed Disallowed / Non Amount Settled Remarks
No. Expenditure Rs. Medical Expenses Rs.
Rs.
1 2241 09/03/2019 DELIVERY 2,420.00 2,420.00
CHARGES
2 2241 09/03/2019 ECG 1,270.00 1,270.00

3 2240 09/03/2019 LABORATORY 375.00 375.00

INVESTIGATIONS
4 2241 09/03/2019 LABORATORY 325.00 325.00
INVESTIGATIONS
5 2240 09/03/2019 MISCELLANEOUS 1,048.00 1,048.00 NOT PAYABLE
CHARGES
6 2241 09/03/2019 MISCELLANEOUS 4,771.00 4,771.00 NOT PAYABLE
CHARGES
7 2241 09/03/2019 NURSING 13,684.00 13,684.00
CHARGES
8 8230 06/03/2019 PHARMACY 2,720.00 2,720.00

9 2240 09/03/2019 PROFESSIONAL 2,250.00 2,250.00

10 2241 09/03/2019 PROFESSIONAL 26,950.00 18,319.00 8,631.00 EXCEEDS MATERNITY

11 2240 09/03/2019 ROOM/BOARDING 250.00 250.00

EXPENSES
12 2241 09/03/2019 ROOM/BOARDING 5,864.00 5,864.00
EXPENSES
13 2240 09/03/2019 DRUGS FEE 70.00 70.00

14 2241 09/03/2019 DRUGS FEE 1,878.00 1,878.00

Total : 63,875.00 24,138.00 39,737.00

Sum of Rupees : Rupees Thirty Nine Thousand Seven Hundred and Thirty Seven Only

COPAY BREAKUP DETAILS

Settled By : 3540 Allowable Amt (Rs.) : 39,737.00

Discount allowed (Rs.) : 0.00
Deductible Amt (Rs.) :
Total Co-pay Amt (Rs.) : 0.00
Total Approved (Rs.) : 39,737.00
: