5/29/23, 11:09 AM SETTLEMENT LETTER

Print
HERITAGE HEALTH INSURANCE TPA PVT. LTD
203, Second Floor, Sakar - II,B/H Sanyash Ashram,Ashram Road, Opposite Ellisebridge
State: Gujarat CITY : AHMEDABAD PIN : 380009
PHONE NO. : 079 26402373/59 40272801 to 05 FAX: 079 26402341,26424489 EMAIL:
CIN: U85195WB1998PTC088562
Date :

To,
KIRANBHAI PRABHUBHAI PARMAR
A- 27, SOHAM APARTMENT 301, MANGAL GROUP SOCIETY,Surat,Surat,Gujarat,India
State : Fax :
City : Tel.No.:
Pin : 395004

Dear Sir/Madam,
SUB : Claim Settlement Advice(CCN :HH792400499 / 310600502390322612)
Proposer/Employee Name : KIRANBHAI PRABHUBHAI PARMAR
Patient Name : MAAN Age : 11
I-Card No. : HHS7.0900825085 Relation : Son
Policy No. : 310600502210003821 Policy Validity : 12/03/2023 to 11/03/2024
Agent ID/Dev-Officer ID : 9000182927 / 310600
Hospital Name: VR Group Of Hospitals
DOA : 02/05/2023 DOD : 04/05/2023
Illness : PREPUCEAL LACERATION DUE TO ZIP TRAUMA Amount Claimed : 46384.00 Amount Settled : 22054.00

As per the instructions of the insurer National Insurance Company, the claim being settled for Rs. 22054.00
on account of PREPUCEAL LACERATION DUE TO ZIP TRAUMA. For any further clarifications, you may
directly contact the insurer.

Payment Details:
In Favour of: KIRANBHAI PRABHUBHAI PARMAR
The successful transter of the amount in your bank account will be considered as as full and final Payment against
above claim and your agreeing to suborgate both us and the insurer from further claims and/or liabilities realting
thereto.
Deduction Details :
Tot. of all Bills submitted - Rs. 46384.00
Bill Amount Deduction Amount Settled Amount
Heads
(Rs.) (Rs.) (Rs.)
Room Rent (Including Nursing Charges) 4500.00 1500.00 3000.00
ICU 0.00 0.00 0.00
Surgeon, Anesthetist, Medical Practitioner,
7550.00 0.00 7550.00
Consultation/Doctor Fees
Medicine 13180.00 7253.00 5927.00
Pathology/Radiology/Investigation 10081.00 7500.00 2581.00
Package 0.00 0.00 0.00
Implant 0.00 0.00 0.00
Others 4564.00 3761.00 803.00
Hospital Daily Cash Benefit 0.00 0.00 0.00
Pre-Post Hospitalization Bill 6509.00 4316.00 2193.00
NA Bill 0.00 0.00 0.00
Deposited at Hospital 0.00 0.00 0.00
Total 46384.00 24330.00 22054.00
Co-pay 0.00
Discount 0.00
Payable Amount 22054.00

223.31.103.204/HeritageHealthTPA/HOME/SettlementLetterNew.aspx?HOSPBILLID=wsjCFW6sZxxk3HrGrKOe3A==&Insco=NIC&letter=SETTLEMENT 1/2
5/29/23, 11:09 AM SETTLEMENT LETTER

Details of deductions:
Rs. 1500.00 on Bill No 111 dated 04/05/2023 (Room Rent) - ROOM+NURSING CHARGES 1% OF SUM INSURED AS
PER TERMS AND CONDITION
Rs. 289.00 on Bill No 246 dated 04/05/2023 (Medicines by Shop) - NON MEDICAL EXPENCE NOT PAYABLE
Rs. 6964.00 on Bill No 234 dated 02/05/2023 (Medicines by Shop) - NON MEDICAL EXPENCE NOT PAYABLE
Rs. 452.00 on Bill No 308 dated 16/05/2023 (Medicines by Shop) - NON MEDICAL EXPENCE NOT PAYABLE
Rs. 460.00 on Bill No 289 dated 11/05/2023 (Medicines by Shop) - NON MEDICAL EXPENCE NOT PAYABLE
Rs. 452.00 on Bill No 270 dated 08/05/2023 (Medicines by Shop) - NON MEDICAL EXPENCE NOT PAYABLE
Rs. 452.00 on Bill No 256 dated 06/05/2023 (Medicines by Shop) - NON MEDICAL EXPENCE NOT PAYABLE
Rs. 200.00 on Bill No 111 dated 04/05/2023 (Registration) - REGISTRATION CHARGE NOT PAYABLE
Rs. 3561.00 on Bill No 111 dated 04/05/2023 (OT Charges) - 10% CO- PAYMENT FOR NON NETWORK HOSPITAL
Rs. 7500.00 on Bill No 1231 dated 04/05/2023 (Pathology Reports) - NON REQUIRED REPORT EXPENCE NOT PAYABLE
Rs. 2500.00 on Bill No 1569 dated 02/05/2023 (OTHERS) - OTHERS DEDUCTION EXPENCE NOT PAYABLE

Sincerely yours,
TEAM
Heritage Health Insurance TPA Pvt. Ltd.
[NB:This is a computer generated letter and no signature is required.]

P.S.

In Case you are not satisfied with the above decision, you may wish to represent to the Grievance Department of the insurer at the
following address :

1st Floor, Godavari Bhavan, Above Handloom House, Chowki Sheri, Nanpura SURAT Gujarat 395001 Phone - 02612474416

Thereafter if you wish to pursue the matter further, you may represent to the office of the Insurance Ombudsman whose address is given
below:

AHMEDABAD Office of the Insurance Ombudsman, Jeevan Prakash Building, 6th floor, Tilak Marg, Relief Road, Ahmedabad – 380 001.
Tel.: 079 - 25501201/02/05/06 Email: bimalokpal.ahmedabad@cioins.co.in

223.31.103.204/HeritageHealthTPA/HOME/SettlementLetterNew.aspx?HOSPBILLID=wsjCFW6sZxxk3HrGrKOe3A==&Insco=NIC&letter=SETTLEMENT 2/2