PARAMOUNT HEALTHCARE MANAGEMENT PRIVATE LIMITED(IRDA License No.

006) Validity: From 21-03-2020 to 20-03-2023

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

401-402, Sumer Plaza, Marol Maroshi Road, Marol, Andheri(e), Mumbai - 400059,

FIRST REMINDER LETTER

Without Prejudice

To, Date : 18/12/2020

PIDILITE INDUSTRIES LTD,

Email id :
Mobile No. : 8828298974

Policy & Member Details Claim Details

Insurance Company : Self Funded CCN No. : 4809703 Ext: Partial :

Policy No. : PIDI-20-21-NEW1 Name of patient :SADASHIV SHINDE

Policy Validity : 01/04/2020 to 31/03/2021 Date of Admission :03/11/2020

Employee Name : MAYURESH SADASHIV SHINDE Date of Discharge :05/11/2020

PHS ID.No. : 26725709 Employee No. : 28331

Provider Name:DESAI HOSPITAL
Insurance Claim No:

Ailment : Lt Inguinal Hernia

Dear Sir / Madam,

With reference to the above mentioned claim and earlier deficiency letter sent to you on 02/12/2020, we regret to inform you that the below mentioned
documents have not been received by us till date.

Sr.No Deficiency Type Status

1 DETAILS FROM ATTENDING DOCTOR: Duly signed & stamped certificate from the treating doctor stating etiology of ailment. Pending

2 CONSULTATION CHARGES Particular Bill No Bill Date Amount

a Consultation notes corresponding to the submitted bills. 1 12/11/2020 1 Pending

3 INVESTIGATION REPORTS Particular Bill No Bill Date Amount

a Investigation reports against the submitted bills 1 27/10/2020 1100 Pending

Please note that we are required to pay, partially pay or deny the claim based on the documents received. In case of non receipt of the documents within 14
days of this letter the claim will be dealt accordingly.

Thanking you for your anticipated cooperation.

Yours faithfully,

Medical Officer
For Paramount Health Services & Insurance TPA Private Limited

Disclaimer: This is an E-notification, generated automatically. Please ignore, if you have already submitted all the requirement / required documents.

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