Reimbursement Claim Reference Number: (24893649)

(Please quote this reference number in all future correspondence)

E-card Claims Plan hospitalzation Hospitals

Date : 30 Jun 2021

To,

Bala Murugan,
Sidvin Core-Tech (I) Pvt Ltd
2nd floor, South East Block, Plot No 1,2,3 & 4,
IT & BT Park, KSIIDC Building, Rajajinagar Indl Area,Bengaluru-560044

Dear Member,

Your claim bearing No 24893649 against policy issued by The Oriental Insurance Co. Ltd. has been processed for Rs 60000 against the Amount Claimed for
Rs 90791 towards Medical Expenses incurred for treatment of Encounter for cesarean delivery without indication at Amritakripa Hospital, Mysore for the period
from 24 May 2021 to 26 May 2021. The details of the claim are as follows:

Patient Details

Patient Name Maliny Ramamurthy

Policy Holder Sidvin Core-Tech (I) Pvt Ltd

Primary Beneficiary Bala Murugan

Medi Assist ID 5037994190

Policy No. 421600/48/2021/511

Relationship with Primary Beneficiary Spouse

Employee ID 100637

Procedure / Treatment Planned Caesarean section ( LSCS)

Insurer Claim No 421600/48/2022/00000112

Insurer Member ID

Summary of Approval

Processed Amount (INR) 60000

Mode of Settlement NEFT

Processed Date 30 Jun 2021

Account Holder Name Bala murugan Sundaramoorthy

Bank Name AXIS BANK

Account Number 91**********255

Category-Wise Breakup

Payable Amount Non Pay Amount Reason for

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

gloves-570/-underpad-750/-mop-280/-
Pharmacy & Medicine Charges 18208 15808 2400
gloves-800/-

Consultant Charges 3800 3800 0

Surgery Charges 53533 53533 0

Bill No: 001 dated: 26/05/2021:admission

Miscellaneous Charges 100 0 100
100/-

Investigation & Lab Charges 8050 8050 0 ,,,,

Hospital Charges 7100 7100 0 ,

Total 90791 88291 2500

(LESS)Hospital Discount 0

(LESS)Excess of Defined / Ailment

28291
Limit

(LESS)Copay 0

Net amount recommended for

60000
payment

You will receive the payment advice once the claim is settled by the The Oriental Insurance Co. Ltd..

We assure you the best of our services, always.

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Warm Regards,
Medi Assist Insurance TPA Pvt. Ltd
(Formerly known as Medi Assist India TPA Private Limited)
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