ADDITIONAL DOCUMENT REQUEST

WITHOUT PREJUDICE
Date : 07/05/2019 Non Cash Less Claim

Dev. / Agent Code : 3791/0 Policy No. : 253200/48/19/00866

To, Insurance Co. : The Oriental Insurance Company Ltd

Mohd Zahid CCN : MDI4875028 MDID No : MDI5-0033016268
Mohd Zahid
Patient Name : Mohd Zahid
H. No 84, Shekhpuri, Bhola
Meerut Employee Code : Mohd Zahid
Uttar Pradesh Hospital Name : S HARI RATTAN KIRTI HOSPITAL
250501
Contact No: 9997019470
Date of Admission : 20/03/2019 Date of Discharge : 03/04/2019
Diagnosis : Acute Bacterial Meningitis

We have received your claim documents. We request you to provide following additional Information / Documents /
Clarifications at the earliest. Please note that your claim document is pending for the same.

Please provide Original Authentic Final hospital bill (with printed bill no.& date) Of Rs-115300

Please provide Initial Case Papers, clinical summary or first consultation papers, showing the nature/duration/history of
Illness along with referral letter for investigation or specialist’s consultation paper.

Please provide attested Photocopy of Indoor Case Papers, Patient’s health history/ Personal information /Pre operative
anesthesia information along with the day-to-day treatment chart from the hospital along with daily doctor’s visit notes.
Please note that only the nursing chart or daily order sheet will not be accepted.

As per claim documents received, it has been observed that Date of Discharge was 03-Apr-2019 The claim documents
were submitted on 23-Apr-2019 Therefore, there was a delay in submission of 5 days. The last consultation date is
03/04/2019 The claim documents were not submitted to us within 15 Days of date of discharge from the hospital.
Hence, we request you to provide us with a clarification for the delay in submission of the documents. The
reconsideration of the claim is subject to approval from Branch Authority once we receive an explanation from you.

As per claim documents received, it has been observed that the Claim Intimation was not given to us within [ 48 ] hours
after admission in hospital. Hence, we request you to provide us with a clarification for non-compliance to the mandatory
requirement of the policy terms and conditions. The reconsideration of the claim is subject to approval from Branch
Authority once we receive an explanation from you.

please provide the following documents.

1. Typed and certified indoor case papers and day to day clinical conditions with room number, bed number,
attending nursing staff name as the handwritten copies of the indoor case papers are not legible. Typed copy of discharge
card with details of complaint on admission, treatment given during the hospitalization period and advise on discharge.
2. Nursing chart confirming injection/drip/medicines given to patient as per advice in indoor case papers with
name of nursing staff and qualification who attended the patient.
3. Typed prescription for the medicines prescribed.Certified copy of Indoor Case register from hospital.
4. Payment confirmation - if paid by cash or cheque to the hospital and laboratory.
5. Treatment details taken initially before hospitalization with duration of complaints.
6. Who has referred the case to hospital for hospitalization? Please submit reference note of family doctor. Post
hospitalization details and fitness certificate.
7. Previous hospitalization details if patient admitted within one year - if admitted then submit copy of discharge
summary of said hospitalization.
8. Any outside consultant called for the reference or not - if yes then confirm the name of doctor and his advice
after consulting the patient during hospitalization.
9. Please confirm who has sent intimation, filled the claim form and who has signed the claim form.
10. Policy holder's income proof and estimated monthly income/type of employment/self-employment.Certificate
from school/employer for the medical leaves during the hospitalization period.
11. Copy of residential address proof. If the proof is not on name of the policy holder then copy of the rental
agreement/declaratio n with identification of the owner of the residential property.

MDINDIA HEALTH INSURANCE TPA PRIVATE LIMITED

Head Office: S.NO.46/1,E-Space, A2 Building, 3rd Floor, Regional Off.: Plot No - 18/13, Wea, Ground Floor, Ganga Plaza, Karol Bagh
Pune Nagar Rd.,Vadgaonsheri, Pune - 411014 (India) Maharashtra – 110005
Reimbursement & Cashless Claims and General enquiries : New Delhi,Pin : 110005 State : Delhi
Voice Number 1860-233-4446 Fax Number 1860-233-4447 Tel. No : 01128757061 Fax No: 28757063
Email : info@mdindia.com , customercare@mdindia.com Cashless Authorisation and General enquiries :
Website : www.mdindiaonline.com UAN No (Voice ) 1860-233-4448,Email : authorisation@mdindia.com
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Regards,

Claims Department
This is a computerized statement. Hence dosen't require signature.

Note : Please note that in case we do not receive the requested information / Documents / Clarifications
within 15 days, your claim file will be closed under "Claim not pursued by Claimant".

In Case you are already submitted the required documents, kindly ignore this communication.

MDINDIA HEALTH INSURANCE TPA PRIVATE LIMITED

Head Office: S.NO.46/1,E-Space, A2 Building, 3rd Floor,
Pune Nagar Rd.,Vadgaonsheri, Pune - 411014 (India) Maharashtra
Reimbursement & Cashless Claims and General enquiries :
Voice Number 1860-233-4446 Fax Number 1860-233-4447
Email : info@mdindia.com , customercare@mdindia.com
Website : www.mdindiaonline.com
Regional Off.: Plot No - 18/13, Wea, Ground Floor, Ganga Plaza, Karol Bagh
– 110005
New Delhi,Pin : 110005 State : Delhi
Tel. No : 01128757061 Fax No: 28757063
Cashless Authorisation and General enquiries :
UAN No (Voice ) 1860-233-4448,Email : authorisation@mdindia.com
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