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    ADDITIONAL DOCUMENT REQUEST

    WITHOUT PREJUDICE

    Date: 14/08/2024 Non Cash Less Claim

    Dev. / Agent Code:0/0 Policy No : 251100/50/23/10000172


    To, Insurance Co : National Insurance Company Limited
    Dipika Mukherjee CCN : MDI8740785
    HR DEPARTMENT, STAR HOUSE-1 C-5, G MDI ID No : MDI5-0039724997
    BLOCK , BANDRA KURLA COMPLEX BANDRA
    (EAST) GREATER Patient Name : Dipika Mukherjee
    MUMBAIMAHARASHTRA400051
    Contact No: 7980372575 Employee Code : 212807
    Date of Admission : 13/07/2024 Date of Discharge : 14/07/2024
    Diagnosis : Dyselectrolytemia With Hypertension

    Dear Sir/Madam,

    We have received your claim documents. We request you to provide the following additional Information / Documents / Clarifications at the
    earliest. Please note that your claim document is pending for the same.

    Please provide a Certificate from hospital authorities stating:exact time of admission and discharge in am /pm

    Thanks & Regards,

    Claims Department

    Authorized signatory,

    For & on behalf of MDIndia Health Insurance TPA Private Limited

    For more information please log on to www.mdindiaonline.com

    OR Contact on Toll Free number : 1800-209-7777, 1800-209-7800

    Track your Claim details from MDIndia Mobile app @ http://goo.gl/WG4UnF

    This is a computerised statement and hence dosen't require signature.

    Note : For & on behalf of MDIndia Health Insurance TPA Private Limited Please note that in case we do not receive the requested
    information / Documents / Clarifications within 15 days, your claim file will be closed under "Claim not pursued by Claimant".

    In Case you have already submitted the required documents, kindly ignore this communication.

    ECS form with cancelled cheque is mandatory for funds transfer. Please ignore this communication if the same has already
    been submitted. Please be informed that you can update the ECS details by logging on www.mdindiaonline.com for transfer
    of funds and can also download the ECS forms from our website.

    MDINDIA HEALTH INSURANCE TPA PRIVATE LIMITED

    Head Office: Regional Off.: Bungalow No. 8, 9th Cross, Wilson Garden,
    S.NO.46/1,E-Space, A2 Building, 3rd Floor, Bangalore 452027 Karnataka
    Pune Nagar Rd.,Vadgaonsheri, Pune - 411014 (India) Maharashtra Fax No: 22111070
    Reimbursement & Cashless Claims and General enquiries : [email protected], www.mdindiaonline.com
    Voice Number 1860-233-4446 Fax Number 1860-233-4447
    Email : [email protected] , [email protected] Cashless Authorisation and General enquiries :
    Website : www.mdindiaonline.com UAN No (Voice ) 1860-233-4448,Email : [email protected]

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