Reimbursement Claim Reference Number: (34259888)

(Please quote this reference number in all future correspondence)

E-card Claims Plan hospitalzation Hospitals

Date : 25 Sep 2023

To,

Apurva Ashok Muley,

Freecharge Payment Technologies Pvt Ltd
Axis bank limited, 11th Floor, Corporate park, Sion Trombay Road. Chembur, Mumbai,
,Mumbai-400007

Dear Member,

Your claim bearing No 34259888 against policy issued by The Oriental Insurance Co. Ltd. has been settled for Rs 57965 against the Amount Claimed for Rs
57965 towards Medical Expenses incurred for treatment of Acute anal fissure at Namo Multispeciality Hospital, Pune for the period from 23 Aug 2023 to 24 Aug
2023. The details of the payment are as follows:

Patient Details

Patient Name Apurva Ashok Muley

Policy Holder Freecharge Payment Technologies Pvt Ltd

Primary Beneficiary Apurva Ashok Muley

Medi Assist ID 5094850767

Policy No. 124500/48/2023/2760

Relationship with Primary Beneficiary Self

Employee ID FC_D19918

Procedure / Treatment Planned Fissurectomy and sphincterotomy

Insurer Claim No 124500/48/2024/00146801

Insurer Member ID

Summary of Settlement

Settled Amount (INR) 57965

Settlement Date 22-09-2023 00:00:00

UTR Number AXISCN0355293654

Account Holder Name Apurva Ashok Muley

Bank Name INDUSIND BANK

Account Number 15*******194

Current balance SI is Rs.342035 for Policy Period 01 Oct 2022 to 30 Sep 2023.

Category-Wise Breakup

Payable Amount Non Pay Amount Reason for

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

Investigation & Lab Charges 31600 31600 0 ,

Miscellaneous Charges 15465 15465 0

Consultant Charges 3900 3900 0

Hospital Charges 7000 7000 0

Total 57965 57965 0

Net amount recommended for

57965
payment

The successful transfer of the amount into your bank account will be considered as full and final discharge of this claim under the above mentioned policy.

If you are not satisfied with the resolution provided by the Medi Assist team, as per the regulatory process, you may contact the Insurer through:

Website: www.orientalinsurance.org.in
Toll free: 1800118485 Or 011- 33208485
E-mail: csd@orientalinsurance.co.in
Insured person may also approach the grievance cell at any of the company's branches with the details of grievance.

If Insured person is not satisfied with the redressal of grievance through one of the above methods, insured person may contact the grievance officer at:
Customer Service Department 4th Floor, Agarwal House Asaf Ali Road,
New Delhi-110002.

For updated details of grievance officer, kindly refer the link https://orientalinsurance.org.in/documents/10182/7605007/List+of+Nodal+Officer+.pdf/992a7f9b-
aef7- 5cac-c613-ffc05d578a3e

Insurance Ombudsman -If Insured person is not satisfied with the redressal of grievance through above methods, the insured person may also approach the
office of Insurance Ombudsman of the respective area/region for redressal of grievance.

The contact details of the Insurance Ombudsman offices have been provided as and when amended as available in the website
http://www.cioins.co.in/ombudsman.html

Grievance may also be lodged at IRDAI Integrated Grievance Management System - https://igms.irda.gov.in/

We assure you the best of our services, always.

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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: 0120-6937324 | Contact: mediassist.in/contactus/| WhatsApp: mediassist.in/WhatsApp/

If you are not satisfied with our settlement, you may approach the Grievance Cell of the Insurer at their Underwriting Office or Controlling Offices. If you are not satisfied with the resolution of
the Grievance Cell, you may approach the jurisdictional Insurance Ombudsman, address of which is available on the website of the Insurer.

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