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Raksha Health Insurance TPA Pvt.Ltd.

C/o Escorts Corporate Center, 15/5 Mathura Road,


Faridabad, Haryana-121 003
Phone: 0129-4289999,18001801444 Fax: Cashless-011-
66173411, 45823411
Date: 12-Jun-2017 Email:crcm@rakshatpa.com

9021718087491
TO,
MRS.SHREEDEVI V. CHINAI
DARIA MAHAL, VARSOVA ROAD , ANDHERI (W) , DIST. : GREATER MUMBAI, MAHARASHTRA
MUMBAI , MAHARASHTRA- 400061

Claim Settlement Voucher

Dear Sir/Madam,

As per the instructions of The New India Assurance Co. Ltd. the claim is being settled for Rs.56173 on
account of pneumonia, as per the Terms & Condition for New MediClaim 2012.

The details of payment as follows:

Claim No 9021718087491 Insurance Company Claim No. TP015131500179023072


Member Id N9010730939 Policy Number 13150034162500009087
Dev/AgentCode 1D13699518 Policy Period 15/01/2017 to 14/01/2018
Insured/Employee MRS.SHREEDEVI V. CHINAI Period of Hospitalization DOA 21/05/2017 DOD: 24/05/2017
Claimant/Patient MRS.SHREEDEVI V. CHINAI Corporate Name Individual
Claim Amount 76960 Deduction 23187
Pass Amount 56173 TDS* 0
Net Payable Amount 56173 Neft-Ref/Cheque No. 'CITIN17789711008
Payment 56173 Neft-Ref/Cheque Date 07-Jun-2017
Disease PNEUMONIA As per Clause 3.1 (a) Room rent and Nursing charges payable upto 1% of SI
per day hence deducted Rs.9000 /-,As per Clause 3.1 Doctor Fees charges
payable as per Room rent Proportionate deduction on Rs.17150 /- hence
deducted Rs.4677 /-,As per Clause 3.1 Investigation charges payable as per
Room rent Proportionate deduction on Rs.1030 /- hence deducted Rs.281 /-
,DATED 20/5/2017 RS 950/- RELATED INVESTIGATION
PRESCRIPTION NOT ATTCHED,DATED 18/5/2017 RS 600/- RELATED
INVESTIGATION PRESCRIPTION NOT ATTCHED,DATED 17/5/2017 RS
1500/- REALTED INVESTIGATION PRESCRIPTION NOT
ATTCHED,DATED 16/5/2017 RS 4500/- CT SCAN INVESTIGATION
PROPER NUMBER BILL NOT ATTCHED,RS 254/- MASK +RS 80/-
GLOVES +RS 200/- BED BATH +RS 200+ RS 150/- RUB+ RS 42/- FACE
MASK NOT PAYABLE ,RS 453/- SPIROMETER NOT PAYABLE,RS 500/-
REGISTRATION CHARGES NOT PAYABLE,0.0% TDS Deduction,
Details Of Deduction

Expense Name Billed Deduction Approved Reason of Deduction (If any)


Amt(Rs) Amt(Rs) Amt(Rs)
Single Room 33000 9000 24000 As per Clause 3.1 (a) Room rent and Nursing charges payable upto 1% of SI
per day hence deducted Rs.9000 /-,
Doctor Fees 17150 4677 12473 As per Clause 3.1 Doctor Fees charges payable as per Room rent
Proportionate deduction on Rs.17150 /- hence deducted Rs.4677 /-,
Investigation Charges 1030 281 749 As per Clause 3.1 Investigation charges payable as per Room rent
Proportionate deduction on Rs.1030 /- hence deducted Rs.281 /-,
Lab Charges 7550 7550 0 DATED 20/5/2017 RS 950/- RELATED INVESTIGATION PRESCRIPTION
NOT ATTCHED,DATED 18/5/2017 RS 600/- RELATED INVESTIGATION
PRESCRIPTION NOT ATTCHED,DATED 17/5/2017 RS 1500/- REALTED
INVESTIGATION PRESCRIPTION NOT ATTCHED,DATED 16/5/2017 RS
4500/- CT SCAN INVESTIGATION PROPER NUMBER BILL NOT
ATTCHED,
Medication Charges 17730 1179 16551 RS 254/- MASK +RS 80/- GLOVES +RS 200/- BED BATH +RS 200+ RS
150/- RUB+ RS 42/- FACE MASK NOT PAYABLE ,RS 453/-
SPIROMETER NOT PAYABLE,
Registration Fees 500 500 0 RS 500/- REGISTRATION CHARGES NOT PAYABLE,
Hospital Cash 2400 0 2400
Total 76960 23187 56173

This is full and final settlement of your claim and for any further clarification,you may directly contact the insurer.
(The New India Assurance Co. Ltd.)

We wish you to stay healthier with us.


For Raksha Health Insurance TPA Pvt.Ltd.
Authorized Signatory