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

Claim Payment cum Discharge Voucher

Claim Lodgement No: 529706 Policy No: 311500/48/2017/5435
Nature of Claim: Hospitalization Period of Insurance: 10/09/2016 09/09/2017
Name of the Insured : S C KAYAL Name of Ins Co.: The Oriental Insurance Company Ltd.
Beneficiary No:
Name of the Patient : PRATIMA KAYAL Corporate : INDIAN INSTITUTE OF MANAGEMENT
CALCUTTA
FIR No. : 3455808
Date of Admission : 26/02/2017 Agent :
Date of Discharge : 04/03/2017 DV Sent Date : 22/03/2017
Final Diagnosis : Carcinoma In Situ Of Breast, Unspecified,, Name of Hospital : NETAJI SUBHASH CHAND BOSE GOVT. MEDICAL
COLLEGE HOSPITAL,JABALPUR

Less :Total Claim submitted : Rs.: 73483

Less :Deductions Rs.: 12674

Total Claim Settled : Rs.: 60809

PHS Paid : Rs.: 0

Member Paid : Rs.: 60809

Received from Paramount Health Services (TPA) Pvt.Ltd on behalf of The Oriental Insurance Company Ltd.
Rupees :Rupees Sixty Thousand Eight Hundred Nine and Zero Paise
In full and final settlement of My /Our claim as detailed herein above.
Rs: 60809 Neft Transaction No.:
Affix 1 Re. Revenue
Bank : Stamp for Claim
above Rs.5000
Date : 23/03/2017
Place : MUMBAI Signature of the claimant
*Reasons for Deductions.:
Inadmissible medicine( handcare,cotton,diaper,etc) Rs.4624/- not payable.Private nursing ch Rs.3000/- not payable.Accucheck
Rs.5050/- not payable.

This is a computer generated post settlement advice and thus does not require any signature.
To,
S C KAYAL
Joka, Diamond Harbour Road, Kolkata - 700104

In case of any discrepancy in payment and deductions there on you may send your query in writing to Paramount Health
Services TPA Pvt Ltd in the above mentioned address else register your query by e-mail at kolkata.phs@paramounttpa.com