ADDITIONAL DOCUMENT REQUEST

WITHOUT PREJUDICE
Date : 07/06/2021 Non Cash Less Claim

Dev. / Agent Code : 038809/9000148772 Policy No. : 281100/50/20/10001375

To, Insurance Co. : National Insurance Company Limited

Varsha Jagdish Raichandani CCN : MDI6330333 MDID No : MDI5-0030376920
Varsha Jagdish Raichandani
Patient Name : Varsha Jagdish Raichandani
F.No. 409, 4Th Floor, Jaideo Apts, Gondwana Sq,
Byramji Town, Employee Code : Varsha Jagdish Raichandani
Nagpur Hospital Name : Wockhardt Hospitals
Maharashtra
440001
Date of Admission : 02/04/2021 Date of Discharge : 02/04/2021
Contact No: 8623990385
Diagnosis : Metastatic Right Breast Ca Grade 3 Kco Systemic
Hypertension Diabetes Mellitus Hypothyroidism
We have received your claim documents. We request you to provide following additional Information / Documents /
Clarifications at the earliest. Please note that your claim document is pending for the same.

Please provide the exact claim amount as mismatch is in claim amount on the claim from & teh amount of bills attach in
claim please confirm & provide details of all bills claim
Regards,

Claims Department
This is a computerized statement. Hence dosen't require signature.

Note : Please note that in case we do not receive the requested information / Documents / Clarifications
within 15 days, your claim file will be closed under "Claim not pursued by Claimant".

In Case you are already submitted the required documents, kindly ignore this communication.

MDINDIA HEALTH INSURANCE TPA PRIVATE LIMITED

Head Office: S.NO.46/1,E-Space, A2 Building, 3rd Floor, Regional Off.: Plot No 265, 1St Floor, Millenium Shopping Mall, Laxmi Nagar
Pune Nagar Rd.,Vadgaonsheri, Pune - 411014 (India) Maharashtra Square, Whc Road, Bajaj Nagar
Reimbursement & Cashless Claims and General enquiries : Nagpur,Pin : 440010 State : Maharashtra
Voice Number 1860-233-4446 Fax Number 1860-233-4447 Tel. No : 07122220824 Fax No: 2420393
Email : info@mdindia.com , customercare@mdindia.com Cashless Authorisation and General enquiries :
Website : www.mdindiaonline.com UAN No (Voice ) 1860-233-4448,Email : authorisation@mdindia.com
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