Bajaj Allianz General Insurance Co.

Ltd
Claim Approval Letter Date: 25-OCT-2018
Insured Details
Policy Number OG-18-1919-8403-00000288
Claim Number OC-19-1901-8403-00010826
Claim ID 2124405
Policy Period From: 01-JAN-18 To: 31-DEC-18
Name Of The Company MSCI SERVICES PRIVATE LIMITED.
Joining Date 01-JAN-2018
Name Of The Employee/ Insured NILESH JAIN
ID Card No GMC-18191930288-211E
Employee No 211
Name Of The Patient SHANTI JAIN
Age 54
Relation MOTHER
Hospital Name Criticare Multispeciality and Researchg Center Andheri
Period Of Hospitalisation DOA: 05-SEP-2018 DOD: 08-SEP-2018
Final Diagnosis Urinary tract infection with left renal Koch's
Claimed Amount Details
Note: **** Field are to be considered as a deduction and should not be added in the Bill Amount.
Particular Bill Amount Disallowed Approved Amount Disallowance Reason
Amount
Room Rent differential co- 14975 14975 --- Eligible per day non ICU rent is INR 5000) , Availed
pay*** per day Room rent INR (6000).As per policy terms &
condition proportionate co-payment (83.33%) is applic-
able on all bill heads excluding medicines consumables
& non medical expenses. ( Copay calculation :
5000/6000*100) = (83.33)%.100 %- (83.33)% = Co-
payment 16.67%
OT Charges 12000 0 12000
Nursing Charges 4400 0 4400
Pharmacy Charges 18412 2165 16247 Rs 350/- pad, Rs 180/- gloves, Rs 500/- bed bath, Rs
10/- cap, Rs 175/- gauze, Rs 152/- cap, Rs 135/- sheet,
Rs 143/- wokadine, Rs 250/- bed bath , Rs 90/- gloves,
Rs 180/- gloves not payable
Pathology Charges 450 0 450
Pre Hospitalisation 17949 0 17949
Post Hospitalisation 1072 0 1072
Non-Medical Charges 6123 6123 0 rs 500/- Reg. fee , Claimed amount as per claim form
is INR(135906), submitted bills are amounting to
INR(130283) only . Hence INR(5623) difference
amount deducted.
Miscellaneous 7500 2500 5000 Rs 2500 Require detailed costwise breakup of dispos-
able material
Room Charges 24000 0 24000
Doctor Charges 19000 0 19000
Surgeon Charges 25000 0 25000
Payment Details
Claimed Amount 135906

Total Approved Amount 110143

Disallowed Amount 25763

Beneficiary Name Health Administration Team

NILESH- BajajJAIN
Allianz General Insurance Company Limited.
2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune. Maharashtra-411014
* Said approved amount will be remitted in Toll
the Free:
account within 2-3
1800-103-2529 working
Phone: days
(020) 30305858 Fax: (020) 30512224/6/7
Email: hat@bajajallianz.co.in Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-233-7272 Email: customercare@bajajallianz.co.in
CIN No.: U66010PN2000PLC015329
In case of any query, kindly contact us at hat@bajajallianz.co.in or 020-30305858
With warm regards,

Authorised Signatory
For Bajaj Allianz General Insurance Co. Ltd
Health Administration Team

Health Administration Team - Bajaj Allianz General Insurance Company Limited.

2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune. Maharashtra-411014
Toll Free: 1800-103-2529 Phone: (020) 30305858 Fax: (020) 30512224/6/7
Email: hat@bajajallianz.co.in Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-233-7272 Email: customercare@bajajallianz.co.in
CIN No.: U66010PN2000PLC015329