Cashless Claim Reference Number: (31965374)

(Please quote this reference number in all future correspondence)

E-card Claims Plan hospitalzation Hospitals

Date :09 Mar 2023

To,

The Administrator / Medical Superintendent,

R G Stone Urology And Laproscopy Hospital,
B-1, Vishal Enclave, Rajouri Garden, Opp. Police Station,
Hospital ID: (99782)

Dear Partner,

This is with reference to the Cashless claim (31965374) submitted with the following details:

Patient Details

Patient Name Simmi Kalra

Insurance Company Manipal Cigna Health Insurance Company Limited

Medi Assist ID 5034172561

Policy Holder Simmi Kalra

Treating Doctor DR R S GANDHI

IP No. 34.93.40.101

Policy No. PROHLR410013127_2023

Primary Beneficiary Simmi Kalra

Employee ID 1

Insurer Claim No

Insurer Member ID 1000372416

Provisional Diagnosis Acute cholecystitis

We require the following additional information to proceed with the processing of the claim:

1. Doctor certificate detailing about the etiology ( cause) of ailment

2. Kindly provide letter from treating doctor stating the significant past medical/surgical history of patient with duration and supporting papers
3. Kindly provide the revised medical bill as per agreed schedule of charges /tariff -PLEASE SUBMIT ESTIMATED COST OF HOSPITALIZATION

These documents must be submitted as early as possible to speed up the process of cashless claim pre authorization. Any response received post discharge of
the beneficiary may lead to denial of cashless facility.

QUICK LINKS:

For partner hospital

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For member beneficiary

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We assure you the best of our services, always.

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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