Cashless Claim Reference Number: (97606351)

(Please quote this reference number in all future correspondence)

E-card Claims Plan hospitalzation Hospitals

Date :31 Jan 2019

To,

The Administrator / Medical Superintendent,

Chaya Super Speciality Hospital,
#6, 5th Main, B Channasandra Main Road, Kasturi Nagar,,
Hospital ID: (144033)

Dear Partner,

With reference to your request (97606351) for final cashless pre authorization, we here by approve INR (20706) against your final bill amount INR (24682). The
details of the claim are as follows:

Patient Details

Patient Name Madamanchi Naga Subbulu

Insurance Company National Insurance Co. Ltd.

Medi Assist ID 4016982790

Policy Holder Nvidia Graphics Pvt Ltd

IP No.

Policy No. 604100501810001034

Primary Beneficiary Parabrahmam Madamanchi

Employee ID NVD_20303

Insurer Claim No

Insurer Member ID

Treatment Details

Provisional Diagnosis Diaorrhoea & gastroenteritis of presumed infectious origin

Expected Date of admission 29 Jan 2019

Treating Doctor DR OBUL REDDY

Procedure / Treatment Planned Medical management

Estimated Date of Discharge 31 Jan 2019

Room Category Occupied Single Ward ( Private / Special / Executive Ward)

Summary of Authorisation

Total bill amount (INR) 24682

Initial Amount Authorised (INR) 0

Enhanced Amount Authorised (INR) 20706

Deductions (INR) 3976

Amount to be paid by the patient 3276

Final Amount Authorized (INR) 20706

Deductions

Deduction Type Deduction Amount (INR) Remarks

Hospital Discount 700

Copay 1089 5% copay

Non-Medical Expenses 2187 NME

Total Deductions 3976

Terms and conditions for authorization

NME deducted 5% copay deducted Hospital discount deducted Post discharge medication not payable

Please note that the amount authorised is provisional and is subject to change based on the final bill and discharge summary, and deduction of TDS, as
applicable.

QUICK LINKS:

For partner hospital

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Warm Regards,

Medi Assist Insurance TPA Pvt. Ltd

(Formerly known as Medi Assist India TPA Private Limited) CIN: U85199KA1999PTC025676. Regd Off: Tower "D", 4th floor, IBC Knowledge Park, 4/1, Bannerghatta Road, Bangalore - 560
029.
Helpline: 080-22068666 | Email: hospital.medibuddy@mediassistindia.com

Disclaimer: The TPA extends the cashless facility subject to the standard terms & conditions of the policy and the information provided in the cashless request form. We suggest that the
patient continues with the treatment as advised by the treating doctor, irrespective of the pre-authorization/cashless facility.

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