To,

Management Director

VERMA HOSPITAL AND MATERNITY CENTER

Near Vishawkarma Mandir, Tosham Road BHIWANI

Haryana, 127046

Admin Contact Phone : 9254875014,9896904331

Provider Code : 31894.

Claim Number : 88581.

Date : - 23/08/2014 TPA Name :

Subject : Claim Settlement Voucher for Preauth Id 47336 , Invoice No 1709 and Invoice Date 07/06/2014.

Dear Sir/Madam

This is with reference to the claim filed with us. Below mentioned are the det

Patient Name : : Ms. POONAM RANI

Customer Number : 0000310209

Contract Number : 30283555

Company Name / Proposer Name : ROHTASH KUMAR

Bill No. / Invoice No. : 1709

Please find below the payment details:

Claim Number : 88581

Hosptial Name : VERMA HOSPITAL AND MATERNITY CENTER

Date of Admission : 07/06/2014

Date of Discharege : 11/06/2014

Diagnosis / Treatment : SHOCK WITH INFECTIOUS DISESASES

Claim Status : Approved

Preauthorization Approval Number : 47336

Payment Details *

Bill No / Invoice No. Bill Date / Invoice Dat Billed Amount Denied Amount Settled Amount Discount Amount

1709 07/06/2014 18,450.00 450.00 8,576.00 1,514.00

Paid Amount TDS Amount Cheque No / NEFT No Payment Acct. No.

7,718.00 858.00 300010953;300010953

Payee Name Payment Date

VERMA HOSPITAL AND MATERNITY CENTER 14/07/2014;14/07/2014

Particular Bill Amount Disallowed Amount Approved Amount Disallowance Reason

Accommodation 18,450.00 450.00 8,576.00 Provider Discount
Critical Care/ICU 18,450.00 750.00 8,576.00 Provider Discount
Laboratory 18,450.00 164.00 8,576.00 Provider Discount
Doctor's Visits 18,450.00 150.00 8,576.00 Provider Discount
Medicines 18,450.00 0.00 8,576.00 Provider Discount
Medicines 18,450.00 8,360.00 8,576.00 Break-up not given
Total 110,700.00 9,874.00 51,456.00

(*)All Taxes under Income Tax Act 1961 will be deducted in the final settlement

Looking forward to a mutual beneficial relationship.

With warm regards,

Somesh Chandra,
Director - Customer Service, Operations, Technology and Chief Quality Officer
For and on behalf of
Max Bupa Health Insurance Company Limited

Note: Please review the enclosed statement and send justification for items you disagree with so that we can resolve any disagreement.
Customer Service Helpline: 1800-3010-3333 or 33003333 or email: customercare@maxbupa.com

Confirmed: VERMA HOSPITAL AND MATERNITY CENTER herewith accepts the amount of Rs. 7,718.00 as full and final settlement for the claim su

Provider Stamp with Signature of Designated Signatory

Name of Signatory: