Domiciliary Claim Reference Number: (26114978)

(Please quote this reference number in all future correspondence)

E-card Claims Plan hospitalzation Hospitals

Date : 05 Oct 2021

To,

Balasubramanya K,
COGNIZANT TECHNOLOGY SOLUTIONS INDIA PVT. LTD
No 165, 6th,7th & 8th Floor,,
Menon Eterenity,St Mary's Road,Chennai-600018

Dear Member,

Your claim bearing No 26114978 against policy issued by COGNIZANT TECHNOLOGY SOLUTIONS INDIA PVT. LTD has been processed for Rs 1410
against the Amount Claimed for Rs 1410 for the period from 08 Jul 2021 to 08 Jul 2021. The details of the claim are as follows:

Patient Details

Patient Name Balasubramanya K

Policy Holder COGNIZANT TECHNOLOGY SOLUTIONS INDIA PVT. LTD

Primary Beneficiary Balasubramanya K

Medi Assist ID 5063882344

Policy No. SFS001/48/21/Cognizant_Covid Vaccine Policy

Relationship with Primary Beneficiary Self

Employee ID 850484

Procedure / Treatment Planned

Insurer Claim No

Insurer Member ID

Summary of Approval

Processed Amount (INR) 1410

Mode of Settlement NEFT

Processed Date 05 Oct 2021

Category-Wise Breakup

Payable Amount Non Pay Amount Reason for

Charge Type Bill Amount (INR)
(INR) (INR) Non-Payment

Covid Vaccination 1410 1410 0

Total 1410 1410 0

Net amount recommended for

1410
payment

You will receive the payment advice once the claim is settled by the COGNIZANT TECHNOLOGY SOLUTIONS INDIA PVT. LTD.

We assure you the best of our services, always.

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Medi Assist Healthcare Services
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