DATE : 27-Jan-2021 WITHOUT PREJUDICE

SHORTFALL LETTER
CLAIM No.: MUM-0121-CL-0003367

To

Ms. SHARDA HIRALAL RAMANI

NAMAN B WING BLDG NO 305/303, CHARPETH RD, AGASHI, VASAI,
THANE,Maharashtra-401301
Phone No: 9833795212 Agent Code: AGD0085935
Email ID: mr.amitramani@gmail.com Dev Officer Code:

Dear Madam,

Sub: Claim Number: MUM-0121-CL-0003367 , Policy Number: 120100/28/20/P1/03678007 , Policy Holder: SHARDA HIRALAL
RAMANI , Patient Name: SHARDA HIRALAL RAMANI , Card Number: MUM-UI-00000-000-0087817-A , Hospital Name: DISHAN
LIFE CARE , Hospital IP Number: 0453 , DOA: 02-Jan-2021 , Ailment: COVID-19 POSITIVE, PNEUMONIA, INFECTION,
ISOLATION
We acknowledge receipt of claim documents in the above connection.
On a scrutiny of the papers received we notice that we require the following documents to proceed further:
1. SF:- 1) KINDLY PROVIDE THE ORIGINAL CANCEL CHEQUE, PASSBOOK FRONT PAGE COPY AND DULY FILLED ECS
FORM OF INSURED/POLICY HOLDER ACCOUNT.
We shall be able to proceed further with the matter only on your submission of the above requirements along with copy of this
letter.
You can submit the soft copy of the document at 'claimsdocuments@vidalhealthtpa.com' and send the hard copy within 15 days to the
below mentioned address.

We seek your compliance as above within 7 days from the date of this letter.

Assuring you our best services at all times.

Thanking you,

Yours faithfully,

Authorized Signatory
Note: This is a system generated letter does not require signature.

Vidal Health Insurance TPA Pvt.Ltd, 413-422, 4TH FLOOR, CHINTAMANI PLAZA, MOHAN STUDIO COMPOUND,CHAKALA, ANDHERI KURLA
ROAD ANDHERI - EAST, MUMBAI-400099 Phone: +91-1800221717 Fax: 1800 22 1919 Email: Website: www.vidalhealthtpa.