Reimbursement Claim Reference Number: (98437000)

(Please quote this reference number in all future correspondence)

E-card Claims Plan hospitalzation Hospitals

Date : 13 Jun 2019

To,

Shraddha Mandge,
Tata Consultancy Services Ltd
NIRMAL BUILDING, 9TH FLOOR,
NARIMAN POINT,Mumbai-400021

Dear Member,

Your claim bearing No 98437000 against policy issued by The New India Assurance Co. Ltd has been processed for Rs 51338 against the Amount Claimed for
Rs 55581 towards Medical Expenses incurred for treatment of Single delivery by caesarean section at Chobe Nursing Home, Aurangabad for the period from
13 May 2019 to 16 May 2019. The details of the claim are as follows:

Patient Details

Patient Name Shraddha Mandge

Policy Holder Tata Consultancy Services Ltd

Primary Beneficiary Shraddha Mandge

Medi Assist ID 4022524750

Policy No. 92000034190400000001

Relationship with Primary Beneficiary Self

Employee ID 1576508

Procedure / Treatment Planned Caesarean section ( LSCS)

Insurer Claim No TP00392000019900314939

Insurer Member ID MEMBER900617

Summary of Approval

Processed Amount (INR) 51338

Mode of Settlement NEFT

Processed Date 13 Jun 2019

Account Holder Name SHRADDHA SAMEER MANDGE

Bank Name HDFC BANK

Account Number 24*********583

Category-Wise Breakup

Payable Amount Non Pay Amount Reason for

Charge Type Bill Amount (INR)
(INR) (INR) Non-Payment

cotton60gauze500cord clamp36betadine
Pharmacy & Medicine Charges 5081 4338 743
97dettol50

Consultant Charges 37000 35000 2000 ,break up not enclosed of others rs.2000

Surgery Charges 4000 4000 0

prenumbered receipt not enclosed for

Investigation & Lab Charges 1500 0 1500
rs.1500

Hospital Charges 8000 8000 0 ,

Total 55581 51338 4243

(LESS)Hospital Discount 0

(LESS)Copay 0

Net amount recommended for

51338
payment

You will receive the payment advice once the claim is settled by the The New India Assurance Co. Ltd.

We assure you the best of our services, always.

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Warm Regards,
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(Formerly known as Medi Assist India TPA Private Limited)
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