Ref No.

:58122223553323/24 (Confidential without prejudice)

Dated:27-10-2022

To,
Sreekanth Rayachoti
Sector - 10, Plot No. 4 Dwarka, City: South West Delhi,
New Delhi , Delhi- 110075
Sub: Query Letter for Claim No: 58122223553323

MemberId : M58323754PNBA
Policy No : 251100502110000169
Policy Period : 01/10/2021 to 30/09/2022
Insured Name : Sreekanth Rayachoti
Corporate Name : IBA Account - Punjab National Bank
Company Name : National Insurance Co. Ltd.
Employee Number : 323754
Claim in respect of : Smt. Rukmini
Relation : Mother
Claim Ref No : 58122223553323
Dev Officer/Agent Code :NA/
Insurance Company Number :251100502299370713-001
Hospital Name : SAI BALAJI NURSING HOME
Claim Amount : 1240
Diagnosis : 13. Diabetes and its complications
Date of admission/Date of Discharge : 04-JUN-2022/04-JUN-2022
Claim Type : MAIN CLAIM

Dear Sir/Madam,
We have received claim documents pertaining to captioned claim no. 58122223553323 to avail the benefits of the
policy251100502110000169(issued by National Insurance Co. Ltd. ) for the hospitalization date 04-JUN-2022.
We have scrutinized the documents and the information gathered during the course. We observe that following documents/information
is/are not provided :

1 Treating doctor prescription is required mentioning the chief complaints with diagnosis for undergoing the
investigations mentioned on the OPD prescription card.
You are requested to submit the original documents as mentioned above within 15 days from the receipt of this letter for us to enable the
processing of claim.

Please note that the conclusion regarding the eligibility of coverage/admissibility of amount can only be arrived at, once we have the full
set of the requested documents.
Kindly quote the Claim number for all future correspondence regarding this claim or attach this letter with your reply.

In case of any grievance related to this claim, you may contact Regional Office OR Head Office of the insurance company.
You may also contact insurance ombudsman for unresolved Grievance. The updated list of Office of Insurance Ombudsman is available
on IRDA website www.irda.gov.in and on the website of General Insurance Council www.gicouncil.in

Regards,
For Raksha Health Insurance TPA Pvt.Ltd..
Authorized Signatory

This is Computer Generated Letter, does not require Signature.

SCO 39, 1st Floor, Sector 26, Madhya Marg, Above Barbeque Nation, Chandigarh – 160019, PHONE: 0172-5008705, 5008716,
FAX: Cashless Email:cashless@rakshatpa.com,
EMAIL: contact@rakshatpa.com

58122223553323