Claim Approval Letter Date: 11-JAN-2023

To,
Abhishek Singh
B 59A SECTOR 60, PO Area - NOIDA GAUTAM
BUDDHA NAGAR, GAUTAM BUDDHA NAGAR,
UTTAR PRADESH, 201301,
Insured Details
Policy Number OG-23-1901-8403-00000011
Claim Number OC-23-1002-8403-00204591
Claim ID 5564490
Policy Period From: 05-MAY-22 To: 04-MAY-23
Name Of The Company EBIXCASH LIMITED
Joining Date 05-JUL-2022
Name Of The Employee/ Insured ABHISHEK SINGH
ID Card No GMC-23190130011-B001578
Employee No B001578
Name Of The Patient ABHISHEK SINGH
Age 24
Relation SELF
Hospital Name R N HOSPITAL PVT LTD
Period Of Hospitalisation DOA: 10-DEC-2022 DOD: 16-DEC-2022
Final Diagnosis Acute Viral Illness
Claimed Amount Details
Note: **** Field are to be considered as a deduction and should not be added in the Bill Amount.
Particular Bill Amount Disallowed Approved Amount Disallowance Reason
Amount
Non-Medical Charges 200 200 0 File Charges/Admission-200
Pharmacy Charges 15463 130 15333 Cannula-Fixtr-130
Room Charges 17500 0 17500
Doctor Charges 6500 0 6500
Nursing Charges 2100 0 2100
Pathology Charges 6650 0 6650
Payment Details
Claimed Amount 48413

Total Approved Amount 48083

Disallowed Amount 330

Beneficiary Name Abhishek Singh

* Said approved amount will be remitted in the account within 2-3 working days
In case of any query, kindly contact us at hat@bajajallianz.co.in or 020-30305858
If you are still not satisfied with the claim decision of the Insurance Company, you may approach the Insurance Ombudsman, established by the
Central Government for redressal of grievance. The Insurance Ombudsman is empowered to adjudicate on personal line insurance claims up to
Rs.20 lacs. Detailed process along with list of Ombudsman offices are available at http://www.policyholder.gov.in/Ombudsman.aspx

Health Administration Team - Bajaj Allianz General Insurance Company Limited.

2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune. Maharashtra-411014
Toll Free: 1800-103-2529 Phone: (020) 30305858 Fax: (020) 30512224/6/7
Email: hat@bajajallianz.co.in Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-209-5858 Email: bagichelp@bajajallianz.co.in
CIN No.: U66010PN2000PLC015329 UIN No.: BAJHLIP21536V022021
With warm regards,

Authorised Signatory
For Bajaj Allianz General Insurance Co. Ltd
Health Administration Team

Health Administration Team - Bajaj Allianz General Insurance Company Limited.

2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune. Maharashtra-411014
Toll Free: 1800-103-2529 Phone: (020) 30305858 Fax: (020) 30512224/6/7
Email: hat@bajajallianz.co.in Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-209-5858 Email: bagichelp@bajajallianz.co.in
CIN No.: U66010PN2000PLC015329 UIN No.: BAJHLIP21536V022021
 Health Administration Team - Bajaj Allianz General Insurance Company Limited.
2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune. Maharashtra-411014
Toll Free: 1800-103-2529 Phone: (020) 30305858 Fax: (020) 30512224/6/7
Email: hat@bajajallianz.co.in Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-209-5858 Email: bagichelp@bajajallianz.co.in
CIN No.: U66010PN2000PLC015329 UIN No.: BAJHLIP21536V022021
 Health Administration Team - Bajaj Allianz General Insurance Company Limited.
2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune. Maharashtra-411014
Toll Free: 1800-103-2529 Phone: (020) 30305858 Fax: (020) 30512224/6/7
Email: hat@bajajallianz.co.in Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-209-5858 Email: bagichelp@bajajallianz.co.in
CIN No.: U66010PN2000PLC015329 UIN No.: BAJHLIP21536V022021
 Health Administration Team - Bajaj Allianz General Insurance Company Limited.
2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune. Maharashtra-411014
Toll Free: 1800-103-2529 Phone: (020) 30305858 Fax: (020) 30512224/6/7
Email: hat@bajajallianz.co.in Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-209-5858 Email: bagichelp@bajajallianz.co.in
CIN No.: U66010PN2000PLC015329 UIN No.: BAJHLIP21536V022021
With warm regards,

Authorised Signatory
For Bajaj Allianz General Insurance Co. Ltd
Health Administration Team

Health Administration Team - Bajaj Allianz General Insurance Company Limited.

2nd Floor, Bajaj Finserv Building, Survey No: 208/1B, Behind Weik Field IT Park, Viman Nagar, Pune. Maharashtra-411014
Toll Free: 1800-103-2529 Phone: (020) 30305858 Fax: (020) 30512224/6/7
Email: hat@bajajallianz.co.in Website: www.bajajallianz.com
Regd. & Head Office: GE Plaza, Airport Road, Yerawada, Pune 411006. Toll Free: 1800-209-5858 Email: bagichelp@bajajallianz.co.in
CIN No.: U66010PN2000PLC015329 UIN No.: BAJHLIP21536V022021