ERICSON INSURANCE TPA PVT. LIMITED.

11-C, Corporate Park, S.T.Road, Chembur, Mumbai-400071

Website: www.ericsontpa.com, E mail: - care@ericsontpa.com
Call Centre: 022-25280234 Fax No.: 022-25270200

Settled Letter –cum- Discharge Voucher

To, Date : 28-05-2021

IOB
CENTRAL OFFICE, 763,
ANNA SALAI, CHENNAI
CHENNAI
CHENNAI
TAMIL NADU
TAMILNADU
600002
Dear Sir/Madam,

Please find below the payment details towards the claim settled as submitted by you
Card No. : 1472590 Patient name : DEEPA SACHIN BASTAWAD
Insurer Co. : National Insurance Co. Ltd. Policy No. : 251100502010000268
Claim ID : 139037 InstNo: 1 Emp Code : 56334
Hospital : GUNJIGAVI MULTI-SPECIALITY HOSPITAL
Primary Diagnosis : Unknown and unspecified causes ICD Code : R69
of morbidity
Date of Discharge: 26-03-2021 D. O. A. : 24-03-2021
Claimed Amount : 22812.00
 SNo. Sub_Service Claimed_Amount Approved_Amount DeductAmt Remarks Details

ICU (INTENSIVE CARE UNIT) CHARGES

1 Monitor Charges 500 500 0
2 Oxygen Charges 1900 1900 0
3 Ventilator Charges 3000 3000 0
5400 0
5400

LAB INVESTIGATION
4 LAB INVESTIGATION 400 400 0
5 LAB INVESTIGATION 500 500 0
6 LAB INVESTIGATION 600 600 0
7 LAB INVESTIGATION 650 650 0
8 LAB INVESTIGATION 750 750 0
9 LAB INVESTIGATION 800 800 0
10 LAB INVESTIGATION 2900 2900 0
6600 0
6600

MEDICINES
11 MEDICINES 682 682 0
12 MEDICINES 3930 2166 1764 Non Medical items RS.1764/- DEDUCTED
AS NON MEDICAL
ITEMS NOT PAYABLE.
4612 1764
2848

MISCELLANEOUS CHARGES
13 Others 400 400 0
14 Registration Charges 500 0 500 Registration charges RS.500/- DEDUCTED
not payable AS REGISTRATION
CHARGES NOT
PAYABLE.
15 Service Charge/ Surcharge/ Taxes 500 0 500 Service charge not RS.500/- DEDUCTED
payable AS SERVICE CHARGES
NOT PAYABLE.
1400 1000
400

PROFESSIONAL CHARGES
16 Consultation Charges 500 500 0
17 Consultation Charges 1500 1500 0
18 Duty Doctors/RMO Charges 700 700 0
2700 0
2700

ROOM and NURSING CHARGES

19 Room Rent and Nursing Charges 2100 2100 0
2100 0
2100
Grand Total: 22812 20048 2764
Sum Insured : 300000.00 Less Claim Passed for : 20048.00 Balance Sum Insured : (42393.00)
Details of Payment Made to Insured Person :

Insured Name : SACHIN SHANKAR BASTAWAD

Cheque Amount : 20048.00 UTR No : KKBK211466862429 Dated: 26-05-2021
Flat Discount : 0.00 Discount Amt : 0.00 Net Bill : 20048.00

Thanking You,

Your claim bearing No 139037 against policy issued by National Insurance Co. Ltd. has been settled for 20048.00 against the Amount
Claimed for Rs 22812.00 towards Medical Expenses insured for treatment of Unknown and unspecified causes of morbidity at GUNJIGAVI
MULTI-SPECIALITY HOSPITAL And Icu for the period from 24-03-2021 to 26-03-2021. For any further clarifications, you may directly contact
the insurer

For ERICSON INSURANCE TPA PVT. LIMITED.

Authorized Signatory
If you are not satisfied with our settlement, you may approach the Grievance Cell of the Insurer at their Underwriting Office or Controlling
Offices. If you are not satisfied with the resolution of the Grievance Cell, you may approach the jurisdictional Insurance Ombudsman,
address of which are available in website of the Insurer (www.nationalinsuranceindia.com)

DISCLAIMER: This is an auto generated email. Please do not reply to this email.

Page 2 of 5
List of Insurance Ombudsmen

CONTACT DETAILS JURISDICTION

AHMEDABAD
Office of the Insurance Ombudsman,
2nd floor, Ambica House,
Near C.U. Shah College, State of Gujarat and Union Territories of Dadra & Nagar Haveli and Daman and Diu.
5, Navyug Colony, Ashram Road,
Ahmedabad - 380 014
Tel.:- 079-27546150/139
Fax:- 079-27546142
Email:- bimalokpal.ahmedabad@gbic.co.in

BENGALURU
Office of the Insurance Ombudsman,
Jeevan Soudha Building,
PID No.57-27-N-19, Karnataka.
Ground Floor, 19/19, 24th Main Road,
JP Nagar, 1st Phase,
Bengaluru-560 078.
Tel.:- 080-26652048 / 26652049
Email:- bimalokpal.bengaluru@gbic.co.in

BHOPAL
Office of the Insurance Ombudsman,
Janak Vihar Complex,
2nd Floor, 6, Malviya Nagar,
Opp.Airtel Office, States of Madhya Pradesh and Chattisgarh.
Near New Market,
Bhopal - 462 033.
Tel.:- 0755-2769200/201/202
Fax:- 0755-2769203
Email:- bimalokpalbhopal@gbic.co.in

BHUBANESHWAR
Office of the Insurance Ombudsman,
62, Forest park,
Bhubneshwar - 751 009. State of Orissa.
Tel.:- 0674-2596461 / 2596455
Fax:- 0674-2596429
Email:- bimalokpal.bhubaneswar@gbic.co.in

CHANDIGARH
Office of the Insurance Ombudsman,
S.C.O. No. 101, 102 & 103, 2nd Floor,
Batra Building, Sector 17 - D, States of Punjab, Haryana, Himachal Pradesh, Jammu & Kashmir and Union territory of
Chandigarh - 160 017. Chandigarh.
Tel.:- 0172-2706196/5861 / 2706468
Fax:- 0172-2708274
Email:- bimalokpal.chandigarh@gbic.co.in

CHENNAI
Office of the Insurance Ombudsman,
Fatima Akhtar Court,
4th Floor, 453 (old 312), Anna Salai, State of Tamil Nadu and Union Territories - Pondicherry Town and Karaikal
Teynampet, (which are part of Union Territory of Pondicherry).
CHENNAI - 600 018.
Tel.:- 044-24333668 / 24335284
Fax:- 044-24333664
Email:- bimalokpal.chennai@gbic.co.in

DELHI
Office of the Insurance Ombudsman,
2/2 A, Universal Insurance Building,
Asaf Ali Road, State of Delhi
New Delhi - 110 002.
Tel.:- 011-23239611/7539/7532
Fax:- 011-23230858
Email:- bimalokpal.delhi@gbic.co.in

Page 3 of 5
ERNAKULAM
Office of the Insurance Ombudsman,
2nd floor, Pulinat Building,
Opp. Cochin Shipyard,
M.G. Road, Kerala, Lakshadweep, Mahe-a part of Pondicherry
Ernakulum - 682 015.
Tel.:- 0484-2358759/2359338
Fax:- 0484-2359336
Email:- bimalokpal.ernakulum@gbic.co.in

GUWAHATI
Office of the Insurance Ombudsman,
'Jeevan Nivesh’, 5th Floor,
Nr. Panbazar over bridge, S.S. Road, States of Assam, Meghalaya, Manipur, Mizoram, Arunachal Pradesh, Nagaland and Tripura.
Guwahati - 781001(ASSAM).
Tel.:- 0361- 2132204 / 2132205
Fax:- 0361-2732937
Email:- bimalokpal.guwahati@gbic.co.in

HYDERABAD
Office of the Insurance Ombudsman,
6-2-46, 1st floor, "Moin Court"
Lane Opp. Saleem Function Palace, States of Andhra Pradesh, Telangana and Union Territory of Yanam - a part of the Union
A. C. Guards, Lakdi-Ka-Pool, Territory of Pondicherry.
Hyderabad - 500 004.
Tel.:- 040-65504123/23312122
Fax:- 040-23376599
Email:-bimalokpal.hyderabad@gbic.co.in

JAIPUR
Office of the Insurance Ombudsman,
Jeevan Nidhi-II Bldg.,
Ground Floor, State of Rajasthan.
Bhawani Singh Marg,
Jaipur - 302005.
Tel.:- 0141-2740363
Email:- bimalokpal.jaipur@gbic.co.in

KOLKATA
Office of the Insurance Ombudsman,
Hindustan Building Annexe,
4th floor, 4, CR Avenue, States of West Bengal, Bihar, Sikkim and Union Territories of Andaman and Nicobar Islands.
Kolkata - 700 072.
Tel.:- 033-22124339 / 22124340
Fax:- 033-22124341
Email:- bimalokpal.kolkata@gbic.co.in

LUCKNOW
Office of the Insurance Ombudsman,
6th Floor, Jeevan Bhawan,
Phase-II, Nawal Kishore Road,
Hazratganj,
Lucknow-226 001.
Tel.:- 0522-2231330 / 2231331
Fax:- 0522-2231310.
Email:- bimalokpal.lucknow@gbic.co.in
District of Uttar Pradesh: Lalitpur, Jhansi, Mahoba, Hamirpur, Banda, Chitrakoot, Allahabad,
Mirzapur, Sonbhabdra, Fatehpur, Pratapgarh, Jaunpur, Varansi, Gazipur, Jalaun, Kanpur,
Lucknow, Unnao, Sitapur, Lakhimpur, Bahraich, Barabanki, Raebareli, Sravasti, Gonda,
Faizabad, Amethi, Kaushambi, Balrampur, Basti, Ambedkarnagar, Sulanpur, Maharajganj,
Santkabirnagar, Azamgarh, Kaushinagar, Gorkhpur, Deoria, Mau, Chandauli, Ballia,
Sidharathnagar.

MUMBAI
Office of the Insurance Ombudsman,
3rd Floor, Jeevan Seva Annexe,
S. V. Road, Santacruz (W), States of Goa, Mumbai Metropolitan Region excluding Navi Mumbai & Thane
Mumbai - 400 054.
Tel.:- 022-26106928/360/889
Fax:- 022-26106052
Email:- bimalokpal.mumbai@gbic.co.in

Page 4 of 5
NOIDA
Office of the Insurance Ombudsman,
Bhagwan Sahai Palace,
4th Floor, Main Road,
Naya Bans, Sector-15,
Gautam Budh Nagar, Noida
Email:- bimalokpal.noida@gbic.co.in
States of Uttaranchal and the following Districts of Uttar Pradesh:. Agra, Aligarh, Bagpat,
Bareilly, Bijnor, Budaun, Bulandshehar, Etah, Kanooj, Mainpuri, Mathura, Meerut,
Moradabad, Muzaffarnagar, Oraiyya, Pilibhit, Etawah, Farrukhabad, Firozabad, Gautam
Budh Nagar, Ghaziabad, Hardoi, Shahjahanpur, Hapur, Shamli, Rampur, Kashganj,
Sambhal, Amroha, Hathras, Kanshiramnagar, Saharanpur.

PATNA
Office of the Insurance Ombudsman,
1st Floor, Kalpana Arcade Building,
Bazar Samiti Road, States of Bihar and Jharkhand.
Bahadurpur,
Patna - 800 006.
Email:- bimalokpal.patna@gbic.co.in

PUNE
Office of the Insurance Ombudsman,
Jeevan Darshan Building, 3rd Floor,
CTS Nos. 195 to 198, States of Maharashtra, Area of Navi Mumbai and Thane excluding Mumbai Metropolitan
NC Kelkar Road, Narayan Peth, Region.
Pune - 411 030
Tel: 020 -32341320
Email:- bimalokpal.pune@gbic.co.in

Page 5 of 5