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PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED(IRDAI Lic no.

006)
[formerly known as PARAMOUNT HEALTH SERVICES(TPA)PVT.LTD]

Icmard Building, 8th Floor, 14/2, C.I.T Road,Scheme- Viii M, Ultadanga,Kolkata-700067 Tel-(033)-23567005 / 08 ,Fax-(033)-23567014,E-mail -
kolkata.phs@paramounttpa.com

Deficiency Letter
Without Prejudice

To, Date : 28/03/2019


INDIAN INSTITUTE OF MANAGEMENT
CALCUTTA,
C/O GANESHPRASAD RAVINDRA
PAVASKAR,

Email id:
Mobile No. :

Policy & Member Details Claim Details

Insurance Company : United India Insurance Company Ltd. CCN No. : 4226121 Ext: Partial :

Policy No. : 030800/28/18/P1/04156716 Name of Patient :GANESHPRASAD RAVINDRA PAVASKAR

Policy Validity : 19/06/2018 to 18/06/2019 Date of Admission :23/02/2019

Employee Name : GANESHPRASAD RAVINDRA PAVASKAR Date of Discharge :28/02/2019

PHS ID.No. : 24640459 Employee No. : PGP/PGDM/0249/54


Provider Name:KASTURI MEDICAL RESEARCH CENTRE (P) LTD
Insurance Claim No:

Ailment : Lower Respiratory Tract Infection

Dear Sir/Madam,
We are in receipt of the documents forwarded by you pertaining to the captioned claim. On scrutinizing the documents,it is observed that the following
documents / information are required to process your claim:

Sr.No Deficiency Type Mandatory Status

1 DELAY: Letter from insured, stating reason for both delayed intimation & submission. Yes Pending

INDOOR CASE PAPERS: Duly attested and paginated Xerox copies of the indoor case
2 papers with history sheet and nursing chart /TPR/ BP /RBS of KASTURI hospital. ** Doctor's Yes Pending
advice for hoapitalization

3 Hospital Requirement: Provide reason for not availing cashless facility. Yes Pending

PSU PPN Declaration Form: As per the instruction from the Insurance company; we require
the attached (hard copy) of the PPN declaration form, to be filled by the hospital, and counter
4 Yes Pending
signed by the (Patient/Patient's attendant) also. Note: This form can be downloaded from
(link / Paramount website)

IRDA CLAIM FORM: IRDA claim form Part 'A' & 'B' filled and signed by the Insured and the
5 Yes Pending
Hospital respectively. NOTE : This form can be downloaded from (link / Paramount website)

You are requested to submit the original documents as mentioned above within 14 days from the receipt of this letter,so that we can proceed further and
process the claim.Please note that the conclusion regarding the eligibility of coverage/admissibility amount can only be decided once we have a full set of
original documents. Your co-operation in this regard shall be highly appreciated.
Kindly quote the CCN for all future correspondence regarding this claim.

Thanking You,

Dr.
For Paramount Health Services & Insurance TPA Private Limited (Kolkata)

Please Provide your Email Id. & Contact No. for future correspondence.

For complete guidance on your current claim status,please log on to our website www.paramounttpa.com