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:-
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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 acceptance of the settled amount as full & final settlement towards the above claim.
Sincerely,
(Authorized Signatory)
For IFFCO TOKIO GENERAL INSURANCE CO. LTD.
Enclosures:
1. Cheque/DD No.-585678
2. Annexure-I
3.