Medi Assist India TPA Pvt Ltd Claim Payment Advice Claim No: 12704549 (PA:12704548 )
Claim Type : Cashless
Payment Date: 13-Jun-2016
To: Rajas Eye Hospital 152, Kanchan Bag, Opp. Airtel Office
Mode of settlement: Cheque
Indore-452018 Cheque no: Dated: '166754330OFO0L14 07-Jun-2016 Drawn on: Direct settlement Policyholder Name: Claimant Name: J P Sethiya(6617) J P Sethiya Relationship: Age: Self 67 Policy No: Period of Insurance 500100/48/15/41/00000533 From:01-Nov-2015 Date Of Admission: Date of Discharge: 21-May-02016 22-May-2016 Hospital Name & City:Rajas Eye Hospital,Indore Amount Settled:Rs Amount Claimed:Rs 37000 21600
Charge Type Package Total (Less) Copay(Rs) (Less) Excess of Defined / Ailment Limit(Rs) (Less) Hospital Discount(Rs) (Add) Ser Tax (if Applicable)(Rs) (Less) Tax Deducted at Source(Rs) (Less )TDS arrears(Rs) Net Paid/Transferred(Rs)
Bill Amount 37000 37000
Amount: Rs 21600
MAID: 5021370212
To:31-Oct-2016
Category Break Up Payable Non Pay Amount Amount 37000 0 37000 0
Non Payable Reason
0 13000 0 0 2400 0 21600
As per the instructions of the insurer United India Insurance Co. Ltd, the payment for claim has been Initiated for Rs 21600, through Cheque NO : '166754330OFO0L14 dated 13-Jun-2016 on account of Senile cataract LE (Left Eye) IDC Description. For any clarifications, you may directly contact the insurer United India Insurance Co. Ltd. Please note that amount will be credited to your above referred A/C No. within 24 HOURS or may take maximum 72 hours. In case of failure of credit to your A/C within the timeline, please write to
[email protected] The payment made is full and final and Insurer/MediAssist are discharged from any financial liability by settlement of the claim. Note: Tax will be deducted at source where ever applicable by Insurer /Medi Assist as per the prevailing rules. This is a Computer generated Settlement advice and signature is not required. Regd office: Tower D, 4th Floor, IBC Knowledge Park, 4/1, Bannerghatta Road, K.M.Layout, Bengaluru,Karnataka 560029. Toll free Nos:1800 425 9449 Website:www.mediassistindia.com ,CIN:U85199KA1999PTC025676
