Covering letter

To Date : 14th Aug 2020.

The Claim manager,

Accenture service Pvt ltd,
Plant 3, Godrej & Boyce Complex, LBS Rd, Pirojshanagar,
Vikhroli West, Mumbai, Maharashtra 400079.

Sub : Submission of Mediclaim billing for Reimbursement.

Respected sir/madam,

I am attaching following document for Mediclaim bill submission.

List of documents.

1. Discharge summary
2. Hospital bill summary with break up.
3. Claim Form A.
4. Claim Form B.
5. Electronic clearing service form.
6. Declaration of Electronic submission of claim document.
7. Medical shop bills (amounting to Rs. 16,156/- along with medical shop attested).
8. Doctor’s prescriptions
9. Blood, Scan and Uterine reports and
10. Vidal claim intimation ID # CLM-A1243-652639.

Kindly do the needful in processing my claims. Let me know if you have any question.

Thanking you and assuring you our best services.

Selvaraj.

9962503124
EMP : 11508975
Accenture India Pvt ltd. Chennai
list of “Original Invoices” amounting to Rs. 16,156/- along with medical shop attested.

Bill no Date Amount

C01024291 03.08.2020 3614
C01021235 22.05.2020 2277
C01018079 26.02.2020 1635
C01014929 25.12.2019 1131
C01021260 23.05.2020 803
C01020183 16.04.2020 784
C01022692 26.06.2020 771
C01024325 04.08.2020 720

C01024376 05.08.2020 679

C01024398 06.08.2020 677
C01022202 13.06.2020 632
C01024525 08.08.2020 630
C01023222 09.07.2020 608
C01023590 18.07.2020 375
C01015274 02.01.2020 325
C01017986 25.02.2020 130
C01024051 28.07.2020 128
C01024487 07.08.2020 107
C01024426 06.08.2020 86
C01024289 03.08.2020 44
Total 16156

The Vidal health insurance TPA claim intimation ID # CLM-A1243-652639.