Date : 22/12/2023

To,
Mr. Rahul Kori

Subject : Claim not payable for Claim ID 1579256 of Mr. Rahul Kori with Member ID 16937108.

Details of the submitted claim

Hospital Name SMJ TRUST HOSPITAL ( SETH MANNULAL JAGANNATH DAS TRUST HOSPITAL)

Date of admission 11/26/2023 12:00:00 AM

Date of Discharge 11/29/2023 12:00:00 AM

Claimed amount 24132

Diagnosis AFI

Dear Rahul,

We regret to inform that your claim has not been approved due to following reason (s).

As per submitted documents, patient was admitted primarily for diagnostic and evaluation purpose. Therefore, We regret the
claim is not payable policy clause 6.4
In case you believe that we have overlooked any details for evaluation, please let us know by writing to us at
https://bit.ly/3lr44xb

In case you are still not satisfied with our decision, you may approach the Insurance Ombudsman. The contact details
of the insurance ombudsman based on your location have been provided in your policy document, and are also available
on our website www.nivabupa.com

Warm Regards,

Authorized Signatory

For and on behalf of Niva Bupa Health Insurance

(Formerly known as Max Bupa Health Insurance)

Disclaimer: Insurance is the subject matter of solicitation. Niva Bupa Health Insurance Company Limited (formerly known as Max
Bupa Health Insurance Company Limited) (IRDAI Registration Number 145). ‘Bupa’ and ‘HEARTBEAT’ logo are registered
trademarks of their respective owners and are being used by Niva Bupa Health Insurance Company Limited (formerly known as
Max Bupa Health Insurance Company Limited) under license. Registered office:- C-98, First Floor, Lajpat Nagar 1, New
Delhi-110024, Customer Helpline: 1860-500-8888. Fax: 011-41743397. Website: www.nivabupa.com.
CIN: U66000DL2008PLC182918. * Niva Bupa processes pre-auth within 30 min for all active policies, subject to receiving all
documents and information(s) up to Niva Bupa’s satisfaction. The above commitment doesn’t include pre-authorization settlement
at the time of discharge or system outage. # Number of network hospitals shown is an approximate figure and is subject to
change without prior notice, please visit our website to access latest and updated list of network hospitals.