To,

Medi Assist Insurance TPA Pvt Ltd,

Bannerghatta Road, Bangalore.

Subject: Regarding your Request for additional information/documents for CCN 30674620 under policy
l 63600/48/2023/852

Sir/Ma'm

With ref to above subject, on 07.12.2022, some additional information/documents were requested you for
reimbursement claim no. 30674620 under policy 163600/48/2023/852. Below are the details requested by you.

1. Kindly provide attested copies of indoor case papers containing admission notes, daily doctor's notes,
surgery notes, treatment sheets, nurse notes and tpr chart etc. with detailed line of treatment given
----Scanned Copies are attached.

2. Kindly provide letter from the hospital stating the exact time of admission and time of discharge
----Scanned Copy is attached.

3. Kindly provide ID proof of the patient (ID and address proof), Kindly provide reason for delayed
submission
---Copy of Aadhar Card as ID & Address proof is attached.
- - - - I t is to inform that there is no delay in submission. A claim file for reimbursement
was already submitted to Medi-assist representative posted at CSTPS Chandrapur in the month of
June 2022 (Claim ID: 29335109) in the employee name of Sagar Shankar Mitta, who is also
working in MSEB as an Assistant Engineer. Same was processed and was ready for payment
since 14.09.2022 but payment was NOT DONE. After Continuous follow-ups by us , we received
a call from one of your representative on 18.11.2022, asking to submit Part A of claim form in my
name i.e. Shrinath Shankar Mitha and accordingly I have submitted the Part A of claim form.

Thanking you

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Address: C/O : Shankar Mitha, Behind Pragati
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Chandrapur, Maharashtra, 442401
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