Cashless Claim Reference Number: (18891386)

(Please quote this reference number in all future correspondence)

E-card Claims Plan hospitalzation Hospitals

Date :04 Feb 2019

To,

The Administrator / Medical Superintendent,

Prasad Hospitals,
44-617/12, Ida Nacharam, Behind Telephone Exchange,
Hospital ID: (142980)

Dear Partner,

With reference to your request (18891386) for final cashless pre authorization, we here by approve INR (22500) against your final bill amount INR (25000). The
details of the claim are as follows:

Patient Details

Patient Name Anitha

Insurance Company United India Insurance Co. Ltd

Medi Assist ID 5038923586

Policy Holder TechMahindra LTD

IP No. NULL

Policy No. 021700/28/17/P1/19045393

Primary Beneficiary Gittaboina Sravan Kumar

Employee ID 547855

Insurer Claim No

Insurer Member ID 637242

Treatment Details

Provisional Diagnosis Other noninflammatory disorders of uterus, except cervix

Expected Date of admission 02 Feb 2019

Treating Doctor DR TELASWINI

Procedure / Treatment Planned Other procedures on uterus

Estimated Date of Discharge 04 Feb 2019

Room Category Occupied General Ward (Economy Ward)

Summary of Authorisation

Total bill amount (INR) 25000

Initial Amount Authorised (INR) 13500

Enhanced Amount Authorised (INR) 9000

Deductions (INR) 2500

Amount to be paid by the patient 2500

Final Amount Authorized (INR) 22500

Deductions

Deduction Type Deduction Amount (INR) Remarks

Copay 2500 10% Co payment

Non-Medical Expenses 0

Total Deductions 2500

Terms and conditions for authorization

Full and final approval, approved as per package. 10% co pay deducted.

Please note that the amount authorised is provisional and is subject to change based on the final bill and discharge summary, and deduction of TDS, as
applicable.

QUICK LINKS:

For partner hospital

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Warm Regards,

Medi Assist Insurance TPA Pvt. Ltd

(Formerly known as Medi Assist India TPA Private Limited) CIN: U85199KA1999PTC025676. Regd Off: Tower "D", 4th floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore - 560
029.
Helpline: 080-22068666 | Email: hospital.medibuddy@mediassistindia.com

Disclaimer: The TPA extends the cashless facility subject to the standard terms & conditions of the policy and the information provided in the cashless request form. We suggest that the
patient continues with the treatment as advised by the treating doctor, irrespective of the pre-authorization/cashless facility.

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