Date : 10/03/2021 Claims Payment Statement

Cash Less Claim

Dev./Agent Code : 0/59000033 Policy No. : 565200/H0599875

To, Insurance Co. : IFFCO-TOKIO GENERAL INSURANCE CO. LTD.

Name : Sukruthi Eye Care Microsurgical Centre
CCN : MDI6162046
Address : 148, Vyalikaval, 11th Cross, near
Vyalikaval Police Statrion Malleshwaram Bangalore Patient Name : Zahida Khanum
Karnataka 560003
MD ID No. : MDI5-0012499804
Contact No:09986900209 / 962020248,0
Date of Admission : 03/03/2021 Date of Discharge 03/03/2021

Diagnosis : RIGHT EYE CATARACT WITH GLAUCOMA

EMP.No. : 743748

Employee Name : Afzal Ahmed

DEDUCTION DETAILS
BILL NO. BILL DATE DED. AMT REMARKS
2149-1 03/03/2021 8000.00 OTHER PROCEDURES Charges Are Not Payable
N/A 03/03/2021 3330.00 CO-Payment : As per policy terms & condition 10 % Co-payment
deduction is applicable for Parantel Claims on Payable amount
DISCOUNT DETAILS
PARTICULARS SETTLED AMT DIS. AMT REMARKS
Hospital Discount - TOTA 0.0000 3700.0000 HOSPITAL DISCOUNT AS PER AGREED TARIFF :- 10% ON THE TOTAL
BILL EXCLUDING MEDICINE AND CONSUMABLES OTHER THAN THE
PACKAGES.

Lodge Amt 40000.00 Deduction Amt 11330.00 Discount Amt 3700.00

Authorized Amt 29970.00 Settled Amt 24970.00 NetPayable 24970.00

TDS in % 0.00 TDS Amt 0.00 Final Payable 24970.00

Remarks:
Group Medishield Insurance Policy

Payment Details:

Particular Details Remarks

Beneficiary Bank Name STATE BANK OF MYSORE

Beneficiary A/C Number 54033820809

Beneficiary Name Sukruthi Eye Care Microsurgical Centre

Cheque No

Cheque Date

Your claim bearing No MDI6162046 against policy issued by IFFCO-TOKIO GENERAL INSURANCE CO. LTD. has been
settled for Rs 24,970.00 against the Amount Claimed for Rs 40,000.00 towards Medical Expenses incurred for treatment of
RIGHT EYE CATARACT WITH GLAUCOMA at Sukruthi Eye Care Microsurgical Centre for the period from
03-Mar-2021 to 03-Mar-2021. For any further clarifications, you may directly contact the insurer.

Regards,

Authorized Signatory

Claims Department

"Acceptance of this cheque by the Insured / Claiment / Beneficiary is in full and final settlement of the claim and company
stands fully discharged of it's liability under the Mediclaim / Health Insurance policy".

MDINDIA HEALTH INSURANCE TPA PRIVATE LIMITED

Head Office: Regional Off.: 216, Lalita Towers, Behind Railway Station, Near Hotel Rajpath, Dinesh
S.NO.46/1,E-Space, A2 Building, 3rd Floor, Mills Road,
Pune Nagar Rd.,Vadgaonsheri, Pune - 411014 (India) Maharashtra Baroda,Pin : 390005 State : Gujarat
Tel. No : 02652320602 Fax No: 2323244
Reimbursement & Cashless Claims and General enquiries :
Email Id: baroda@mdindia.com WebSite:www.mdindia.com
Voice Number 1860-233-4446 Fax Number 1860-233-4447
Cashless Authorisation and General enquiries :
Email : info@mdindia.com , customercare@mdindia.com
UAN No (Voice ) 1860-233-4448,Email : authorisation@mdindia.com
Website : www.mdindiaonline.com

10/03/2021 6:17:10PM Auto Email Print