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  • Date Submitted: 02/11/2013 04:32 AM
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CLAIM PAYMENT LETTER

Date   7/3/2012

|VINOD KUMAR PHULWANI                                 |Claim Incident FIR No           : 20111291291.C2O                                       |
|80/1, VARUCHI MARG, NEAR A.K.BUILDING FREEGANJ,     |Member Code                         : 11-00004566-02                                   |
|UJJAIN, Madhya Pradesh                               |Employee Number                 : NA                                                   |
|                                                     |Employee/Proposer Name   : Mr. VINOD KUMAR PHULWANI                                     |
|                                                     |Corporate Name                     : NA                                                 |
|                                                     |Policy No                                 : 52191568                                   |


Dear Sir/Madam

This has reference to the Claim received by us on 09-Dec-11 with following details:-



        1. Patient name : Mr. NEERAJ PHULWANI   Age: 18 yrs Gender: M

        2. Name of the Hospital : Patidar Hospital and Research Centre

        3. Period of Hospitalization : From 30-Oct-11 to 01-Nov-11

        4. Diagnosis : E10.69:Type 1 diabetes mellitus with other specified complication

        5. Line of Treatment : ITGIDI129:DIABETES MELLITUS



We are pleased to inform you that your claim has been approved for Rs. 6381.00. Please find enclosed Cheque/DD No. 585678 dated 7/2/2012 on Deutsche Bank payable at par, towards Full & Final settlement of the claim. The details are as under:-

Billed Amount : Rs.8429.00

Claimed Amount : Rs. 8429.00

Less: Deductions (Details as per Annexure I) : Rs. 2048.00

Add: Service Tax : Rs. 0.00

Less: Tax deducted at Source : Rs. 0.00

Payment Amount : Rs. 6381.00

Please note that presentation of this Cheque/DD for realization will be deemed to be your...

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