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01S l No 30531A1~7
I I:!
AFFIDAVIT FOR MEDICAL CLAIM
I, . ASHWATHI .A D/o. K.Anandan, resident of No.129, Sholinghur Road,
Arf konam, Ranipet District, Pin: 631 001, Tamil Nadu, do hereby solemnly affirm
ani state as follows :
1 . A I do hereby declare that the claim preferred only Medi Assist TPA. ·
2. No other TPAare involved in claiming the Medical Insurance for K. ANANDAN.
i
3. I am assuring that details of insured person hospitalized K.ANANDAN working
I in Tube Products of India at No.18, Mth Road, Avadi Camp, Chennai
I 600 054. He does not have any insurance enrolled in the company or any
1 otherTPA.
• .l0GAB IRA ·~ - M.A. t3 .
Advocate & otary Put>ii;
Govt. of India
A_rakk,w.arn Vellorc Di$tr1c:;
.. 2 ..
The Medical Reimbursement claim is only preferred at Medi Assist TPA. The
details of claim are Policy No.97000034210400000061_NON SEZ
Insurance Claim No.TP00397000022900077755.
(
VERIFICATION
Verified that the contents of my above said affidavit are true and correct to the
best of my knowledge and belief and nothing has been concealed therein.
Verified at Arakkonam on 23.11 .2022
1-..! -J-\~-
t- - ~L
•. U JG ABI RA Al'li . M .A . o
Advocate otary Publ ie:
DEPONENT
Govt . of Ind ia
Arakkonam Vellnre OistrtCI
Tube Products of India
(A Unit o f Tube lnvestment.s of Ind ia Ltd.
formerly Known as Tl Financial Holdings Limited}
Po st Box No. 4 & 18. CTH Road . Ava d i,
Chennai 600 054, India.
IND IA Tel: 91 .44.42291999
Fax: 91.44.42291990/42291991/42291992
Website : www.tubeproductsindia.com
GST IN : 33AADCT1398N1ZX
CIN : l351 00TN2008PLC069496
November 25, 2022
TO WHOMSOEVER IT MAY CONCERN
This is to certify that Mr.K.A.nandan, CI.No.3121, CDW Maintenance
Department was admitted for Covid pneumonia and was taking
treatment at SIMS hospital, Chennai. The total expenses incurred for his
treatment is Rs.3,46,534.50.
As per company practice, the bill amount is paid to Hospital and the
same will be recovered from the wages of Mr.Anandan in EMls. We will
not claim the bill amount from any insurance agency.
This certificate is being issued to him on his request for the purpose of
obtaining health insurance claim.
Yours faithfully
For TUBE P ODUCTS OF INDIA
I
Regd. Office: 'Dare House'
234 N.S.C. Bose Road,
Chennai 600 001.
Tel: 91 .44.42177770 - 76
Fax: 91.44.42110404
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