PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED

(IRDA License No.006) Validity: From 21-03-2020 to 20-03-2023

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

Plot No.A-442,Road No-28.M.I.D.C Industrial Area,Wagale Estate,Ram Nagar, Vitthal Rukhumani Mandir,Thane-400604 Tel-66620808 ,Fax-68342454 / 55,E-mail -
[email protected]

Deficiency Letter
Without Prejudice

To, Date : 19/07/2021

GODREJ & BOYCE MFG.CO.LTD,
C/O HIREN KANTILAL PANCHAL,

Email id:
Mobile No. : 9819932678

Policy & Member Details Claim Details

Insurance Company : The Oriental Insurance Company Ltd. CCN No. : 5079642 Ext: Partial :

Policy No. : 112500/48/2022/601 Name of Patient :BHAVIKA H PANCHAL

Policy Validity : 01/04/2021 to 31/03/2022 Date of Admission :19/06/2021

Employee Name : HIREN KANTILAL PANCHAL Date of Discharge :22/06/2021

PHS ID.No. : 22046608 Employee No. : 11020

Provider Name:YASHWANT HOSPITAL - VIKHROLI
Insurance Claim No:

Ailment : Pregnancy

Dear Sir/Madam,
We are in receipt of the claim documents from your end 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 Provide registration certificate of Hospital/ Nursing home Yes Pending

2 CONSULTATION CHARGES Particular Bill No Bill Date Amount

Kindly provide justification of hospitalization- from

a 1 Yes Pending
treating doctor

You are requested to kindly provide the original documents as mentioned above within 7 days from the receipt of this letter, enabling us to proceed further and
to process the claim. Please note that the conclusion regarding the eligibility of coverage/admissibility of 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,

Medical Officer
For Paramount Health Services & Insurance TPA Private Limited

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
 PARAMOUNT HEALTH SERVICES & INSURANCE TPA PRIVATE LIMITED
(IRDA License No.006) Validity: From 21-03-2020 to 20-03-2023
[formerly known as PARAMOUNT HEALTH SERVICES(TPA)PVT.LTD]

Plot No.A-442,Road No-28.M.I.D.C Industrial Area,Wagale Estate,Ram Nagar, Vitthal Rukhumani Mandir,Thane-400604 Tel-66620808 ,Fax-68342454 / 55,E-mail -
[email protected]

CLAIM ACKNOWLEDGMENT SHEET

Name of Insurer : The Oriental Insurance Company Ltd. CCN NO : 5079642

Insured Name : HIREN KANTILAL PANCHAL Policy No : 112500/48/2022/601
PHS ID : 22046608 Patient Name : BHAVIKA H PANCHAL
Mobile No : 9819932678 Employee No : 11020

Name of Corporate :

Type of Claim (To be ticked) : Main Hospitalisation / Pre-Post Hospitalisation / OPD Claim
Total no of documents received 24
Sr No. Category Document received Yes/no No of documents
1 claim Form YES 5
2 KYC DOCUMENTS NO 0
3 NEFT DOCUMENTS YES 1
4 DELAY INTIMATION / SUBMISSION DOCUMENTS NO 0
5 DISCHARGE CARD /DEATH SUMMARY /TRANSFER SUMMARY YES 2
6 Indoor Case Paper NO 0
7 FINAL HOSPITAL BILL YES 1
8 FINAL HOSPITAL CASH RECEIPT NO 0
9 CONSULTATION CASH RECEIPT NO 0
10 INVESTIGATION CASH RECEIPT NO 0
11 INVESTIGATION REPORT NO 0
12 MEDICINE CASH RECEIPT YES 5
13 MEDICINE PRISCRIPTION YES 7
14 IMPLANT STICKER NO 0
15 64 VB DOCUMENTS NO 0
16 POLICY COPY NO 0
17 PAN CARD NO 0
18 AADHAR CARD NO 0
19 CKYC NO 0
20 Other YES 3