date: 12/14/2017 claims payment statement

Non Cash Less Claim

dev. / agent code : 1D7804981/1D7797856 policy no. 150704/34/16/28/00001087

to, insurance co. The New India Assurance Company Limited
Harshal Kashinath Patil ccn MDI3685734 md id no. MDI5-0012532792
patient name Shreeraj Harshal Patil
Harshal Kashinath Patil
employee code NULL Harshal Kashinath Patil
Plot No 1 Rajpal Colony Saheb Appt Makhmalabad date of admission 9/8/2017 1 date of discharge 9/11/2017
Naka Panchavti hospital name VASU CHILDREN HOSPITAL
Nashik
diagnosis Myositis
MAHARASHTRA
422101
sum insured 500,000.00 cumulative bonus 0.00
DEDUCTION DETAILS
BILL NO. BILL DATE DED. AMT REMARKS
228-4 11/09/2017 275.00 Bmw Charges Are Not Payable
228-5 11/09/2017 275.00 Registration charges are not payable.
balance sum insured before claim 500,000.00
lodge amt 19,283.00 deduction amt 550.00 discount amt 0.00 tds amount 0
authorized amt 0.00 settled amt 18,733.00 netpayable 18,733.00
balance sum insured after claim 481,267.00
remarks: Rs. 1500/- has been released under the Daily Cash Benefit.
payment details:
particular details remarks
bank name BANK OF INDIA
bank a/c number 081410510000266
cheque in favour of Harshal Kashinath Patil
ECS Tran No. CITIN17862689916
ECS Tran Date 12/6/2017 12:00:00 AM
regards,

authorized signatory
claims department
This is a computerized statement. Hence dosen't require signature.
"acceptance of this cheque by the insured / claiment / beneficiary is in full and final settlement of the claim and company stands
fully discharged of it's liability under the mediclaim / health insurance policy".
discharge voucher
(please send signed discharge voucher at the earliest. kindly note that your reimbursement is pending for the same.)
policy no. 150704/34/16/28/00001087 insured name: Harshal Kashinath Patil
mdi id no. MDI5-0012532792 patient name: Shreeraj Harshal Patil
ccn MDI3685734 net payable amount 18,733.00
In consideration of such payment, I/We here by absolve the company from all liabilities present or future arising directly or
indirectly out of the saved lose or damage under the said policy.
revenue
i/we also agree that the sum insured under the said policy
stamp
stand reduce by the amount paid untill the next renewal.
rs1/-
signature / thumb impression of insured / patient / nominee.

MDIndia Health Insurance TPA Private Limited

Head Office:
S.NO.46/1,E-Space, A2 Building, 3rd Floor,
Pune Nagar Rd.,Vadgaonsheri, Pune - 411014 (India) Maharashtra
Reimbursement & Cashless Claims and General enquiries :
Voice Number 1860-233-4446 Fax Number 1860-233-4447
Email : info@mdindia.com , customercare@mdindia.com Cashless Authorisation and General enquiries :
Website : www.mdindiaonline.com UAN No (Voice ) 1860-233-4448,Email : authorisation@mdindia.com

12/14/2017 2:55:03PM