\ a [REQUEST FOR CASHLESS HOSPITALIS ATION FOR MEDICAL INSURANCE POLICY Moa: nas en GALAN At a dosept 4 U ES REP a MotatPhone no OG coc a LI eS Aesceky J] ox nncncoro: Medi ASSN¢ India TPA Pvt Ltd wares menounos: 1800 425 9449 warm 1900425 9559 To Beniedin ylnsued/ patent sumeiietae ZIRINY AL! MINAS 0 nie re ‘ce Yrs Monts) tomas 2G BF TA ST Onilividsa imanenonnn SO(08 06340 9 Paeyrmeenanstegete Ua Moms ur MOG OOOO 1 wmeif oojouhoes inyptyicon [] Neca mkt J a 7 vomeneer OOO OOOO (REISE CONALFEBECLARATONGN THE REVERSE SEE CF TH FOR PEON TT attereersoc SEAT AY (DES ST oO icomamenie (8 6 S733) Osteo oN ons wee Porn, h4te Oy Krewesler Ry Bethe £4 bom - Osteo lth © mci venegment (Rca Pee eld won PR Selle, Re plement} —— Winmddewneer | A Somanimson (BE [RDN [AGT tame cere adm eat epRRR Re 400 000 [ > NN mee eee : aa 3! ?PAGE 2: NOT TO BE FAXEDISCANNED DECLARATION BY THE PATIENT / REPRESENTATIVE |-ogae a lowe spa sib a ogi Soameresonang fesse oe hese PA are che lage anf ne Deca Suman, ibe my cece £2 Peyent ep ged by bets a con le pole ncaa me oar TPA abe stb esp i undsha ate e il a perh e 2 orators on gcy 3 Abner-eides wees ances ol val re) Mga ae anon eB toe ao tye TPA ol gow By ems ans censtons prey mB a om. ‘aby oe abi ty Me lars an inate of pay a at ny Sacked yr ae oa a borin! ly Cin ad ae ry ine rarer TPA 5. ayer an undead a TPA. ero may maraing ese oa espa & Nate eu TAs may aang Rat owes proved yh ost al 26 2 far quater santas, 8 ines aon! bef ote psa pats in uy ese! at a8 MO Rew mao al ke ay abe eran Benen! Spon or concaran hresec) tote dam my ra 9 ca errant ol Pes exenes sal be cy eed 71a mt hop! gsi expres nc on my baa ich ay ol ites by ha ayer TPA gram inenesvon___Neaanebinad Sanyal vena T6OU8 TT 29 nego HOSPITAL DECLARATION 1. Wane meee eae asteroad Th vce Coney oa ering aman pra Fea 2. Aid gna cures ay cautery hina pt 8 pro eck! bw wile Se! TPA Inaanc Company wn Ti che ples Sache 2 Sinan made eganes Ragas treet epson ofthe, OR exert talon 5 erat Later o TAK swans Co, OR arg a of amet oton Pa pearson fo wl bla Fan eon 4 WE AGREE THA TPAJ NSURANCE COMPANY WL NOT BE LABLE TO MAME THE PAYMENT THE EVENT OF ANY CGCREPANCY BETWEEN THE FACTS aM HS FORD [ND USCHARGE SULMIAY or er dxwens 5 Th palo tetanus bon sted ye ant o by his etm eter {8 We ame rove datcaton tr ha quran rs hsitain ar wea te sk epunsty rary Se noe cans 7 re wt 2008 yt ams a conor agen MOL gS roe Sree ae Sie DOCUMENTS TO BE PROVIDED BY THE HOSPITAL IN SUPPORT OF THE CLAIM |. uid Dechage Summary rd aH om et 2. Wane fone Hepa (Chants spas pope pescgton 4: Rac ns Pahl fet prs fon Paes. Sager yn on tw ted scl Paior Supe ecommerce Tess 4 Sag Conf sting na of nen gets and Sons at Racor 5 Cents fam tee Masel Pacner Sugita by conPEPE Om ze. general insurance MAID: 010806370 Name Nandini Sanyal Relation: Mother PriBenef — : Devraj Sanyal Polkidr ——_: Universal Music India Pvt Lid Emp. No. 001 MemberID: Q008372000004 @ Medi Assist Serviced by- MED! ASSIST INDIA TPA PVT LTD 24 Hour Toll Free Call Centre 180-425-9449 - This card is only for identification urgose and is not an authoasaion to proceed wih the tTeatrent or a guarantee for payment S"Subject to the terms and conditions of the underlying Insurance policy, this non transferable identification card valid at selected hospitals will enable you 10 avail Cashless hospitalisation only on the basis of preauthorisation issued by Medi Assist = in Case preauthorisation is not igsued,the policy holder / beneficiary will be required to make payments to hospital and submit the cisien to Medi Assist for a possible reimbursement = All preauthorisation andlor seitlement of claims is subject to the terms and conditions of the relevant policy, Please note the following {. This soft copy of Medi Assist Identity card is valid for identification when printed and presented with'a valic proof of identity at any Medi Assist Network Hospital ZAI non admissible expenses Incurred have to bo paid directly to the hospital by tha Employee. 3. Thi card is valid only for hospitalization in india 4. Please take a print out of this e-card, sign it and hend aver the same to the hospital authorities. while availing the cashless hospitalisation facilly, 5. Along with this card acceptable proof of identity such as Id card issued by the employer [Passport / Driver's Licence / Ration Card / Voters ID Card / PAN Card shoulc be presented at the Hospital For Claim Forms & Complete List of Network Hospitals, visit the following URL: hitps://wwwmediassistindia.convinfo_desk.aspx (MEDI ASSIST INDIA TPA PVT.LTD. Tower D, 4th Floor, IBC Knowledge Park, 4/1 Sannerghatta Road, Bangalore - 560028 Call center: 1800 425 9449 | Fax: 1800 425 9559 www mediassistindia.comarcane. ‘MING TORTS REPUBLIC OF INDIA wor een gait & ari ny nna oF nes Pees sence arent it fe sed (A 0 Pa dis ety pei ond ae, TRE TOIGG REPUBLIC OF INDIA rin Ey ee TR eine —— eae J8882055 ———— ‘WANDINT oe 29/88/1951 qm. Se - “RouRATA VEST semen ed "nONBAT {hace opt | =inanan= sraR PXINDSANYAL< 64Yrs /FEMALE Reported on : 31-10-2015 \ Patient Type + OPD Ward / Bed : | A plain Scan of the right shoulder joints has been performed. | Clinical Details : pain {R} shoulder | | ‘Advanced degenerative changes are seen in the right shoulder joint with presence of large marginal osteophytes, reduced joint space, bony eburnation, ligamentous and soft tissue calcification/ossification Similar changes of marked degenerative changes are also noted in the right acromioclavicular joint. ‘There is mild superior subluxation of the right humeral bead. | There are no fractures. ‘The anatomical neck is intact. There is no fracture of the bony glenoid, acromion or the caracoid process. No fractures are seen involving the scapula. ‘The visualized humeral shaft is normal. IMPRESSION : Severe advanced degenerative changes of the glenohumeral and actomioclavicular joints. __DRNAJASHANANDA = Rage FoF 9° Hiranandani Hospital, Hillside Avenue, Hiranandani Gardens, Powai, Mumbai - 400 074 tala. 91-22-2576 9988, 2574 2952 F 91-22-2576 3346Orthopaedic Surgeon & Arthroscopist DR. SANJAY S. DESAI Tae ton no feed Spa Hospital 2 tel) Ag To, Admission Breach Candy / Jestok / Bhatia / Lilevati Hospital Kindly admit Mr. / Ms. caecae Sen _f Serge] geen rll ¢ (+ oy prs} under my careon_____ for @® cL. Sah Sue. . QoS Secqred Pepleen at nie; 11a Saigry, 16 French Bdge, OF, Hughes Rood, mba - 40 07. © 22646390 20685318 hander Plc, Mena, Ata Lane, Near Stoppers Stop Ande (W), @ 25205581 Res. @ ZBET2588, 2693450 Fax: 2569350DR. SANJAY S. DESAI ana oni era er 1 emi Men eaten ot ei emesco/anmeragne te Sere Athecsopy &JontRepacement Sugiag | — + sack Reece ta Pebee meena at tnd rh Ses ch rs + ena ‘e maossor puree cae) — yolo Na_Seogel Cc T Scan Ri— Beeler us ZD Qe cone hers} \ecdkly Cleo Crew A Socket Pie subtershrs Ysera St Heed | An 2 Erma sonaesalgnen www sheuldern nsec — Rag. No: NNC $6051