LIST OF ENCLOSURES

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9.

Claim Form.
Medical certificate from the Doctor treating the patient.
Authorisation letter to M/s. Medi Assist India Pvt. Ltd.,
Copy of Oriental Mediclaim policy schedule, Policy
No.421504/48 /2016/890
ID card No. MA-ID : 5019294535 My father Mr
Seetharam and MA-ID : 5019294536 My mother Smt.
K.R. Vijayalakshmi.
Crossed cheque of OBC Bank bearing No.502308.
Copy of OBC Bank S.B. Account pass book of P. Seetharam.
Adhaar Card Nos. of my father Mr. Seetharam 8429 0357
4452 and Mother Smt. K.R. Vijayalaksmi 8983 7757
3794.
Discharge summery.

10. Cash bill 530 dated 29.04.2016 for the total amount of
Rs.56,640/11. Cash receipt No. 343 dated 25.04.2016 for Rs.10,000/- as
advance
Cash receipt.
12. Cash receipt No. 387 dated 29.04.2016 for Rs.46,640/- as
final cash
receipt.
13. Laboratory report dated 25.04.2016
14. Laboratory report dated 27.04.2016
15. Laboratory report dated 28.04.2016
16. Pharmcy bill dated 25.04.2016
18,440/-

to 29.04.2016 for Rs.

17. Cash receipt No. 826 dated 25.04.2016 for Rs. 800/- as
cash
Receipt of Radocs Associates Imaging Pvt. Ltd. For USG
abdomen and
pelvis
18. Abdomen Pelvic Ultrasound report dated 25.04.2016.

19. Cash receipt No. 193 dated 27.04.2016 for Rs. 7,500/- as
cash
Receipt of Radocs Associates Imaging Pvt. Ltd. For CT
abdomen and
pelvis
20. MDCT Scan report of abdomen and Pelvis
21. Cash receipt No. 891 dated 27.04.2016 for Rs. 2,300/- as
cash
Receipt of Radocs Associates Imaging Pvt. Ltd. For
ECHO, ECG and Xray
22. ECHOCARDIOGRAM Report and scan copy
23. ECG chart
24. CHEST Cardiograph PA View report
25. Copy to ; Request letter addressed to The Oriental
Insurance Company Ltd.
26. CT and X-ray reports
27. Death certificate
28. Adhar Card of self with 8496 6886 4186

Signature

(S. Nagaraj)
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