Subject: Fw: Payment processed for claim no 220202676399 against Account reference number ACC11092200420 in the name of ASHISH DABRAL.
From: "Swati Shukla (LSM ACCOUNTS)" <[email-masked]>
To: Ashish Dabral <[email-masked]>
Date: Tue, 13 Sep 2022 05:08:56 +0000

Best Regards,

Swati Shukla

Asst. Manager (Accounts)

8882991655

________________________________
From: [email-masked] <[email-masked]>
Sent: Monday, September 12, 2022 8:13 PM
To: Swati Shukla (LSM ACCOUNTS) <[email-masked]>
Subject: Payment processed for claim no 220202676399 against Account reference number ACC11092200420 in the name of ASHISH DABRAL.

[IL Logo]       [IL_iHC_Logo_New]
SETTLEMENT LETTER

Date : 12-SEP-22

To,

ASHISH DABRAL
A-72 SECTOR 2 NOIDA GAUTAM BUDH NAGAR,,,NOIDA,Uttar Pradesh,201301 Tel: 0 Mob:
Dear ASHISH DABRAL,
CLAIM NO        AL NO   EMPLOYEE/MEMBER ID      EMPLOYEE NAME   MEMBER NAME     UHID
220202676399            CPU13   ASHISH DABRAL   ASHISH DABRAL   IL20144984600
DOA     HOSPITAL NAME   REQUESTED AMOUNT        NET SANCTIONED AMOUNT   CO-PAYMENT AMOUNT       DISALLOWED AMOUNT       DISALLOWED REASONS      Sub Bill Breakup
11-JUL-2022     Health Point Polyclinic 31119   29563   0       1556    Rs.1556 Please refer Sub Bill Breakup
Rs.1556 /- deducted towards excess charges as these are not justified and incidental with the treatment taken. Please get clarification from Hospital/treating doctor for further consideration of this amount  1556
Note: If there are any deductions due to non-submission of reports or bills, the same will be re-considered upon submission of required documents. Please submit the required documents within 30 days from the receipt of this letter.
On behalf of ICICI Lombard General Insurance Co. Ltd, we thank you for preferring ICICI Lombard as your health insurance partner.
We write to you with reference to above health claim Number, we wish to inform you that we have received the papers & documents submitted by you. We have perused the documents and your claim is being settled for an amount of Rs. 29563 . We enclose a Cheque/ EFT vide ref. no. CMS2825981801 dated 12-SEP-22 towards the full and final settlement of the claim. This includes an amount of 0 towards the service tax & education Cess, against the claimed amount of 0. The amount deducted under TDS is 0.The Company hereby stands discharged of liabilities arising out of this claim...

Thank you for having given us an opportunity to be of service to you. In case of any further clarification, please feel free to write to us at the below mentioned address, or e-mail us at [email-masked]<mailto:[email-masked]> according to your preference, quoting the above claim No, and we shall be pleased to assist.

In case you are not satisfied with the resolution provided, you may visit our website https://www.icicilombard.com/content/ilom-en/ServiceCouncil/SQindex.html<http://delivery.icicilombard.com/SMCYEUDARQ?id=131301=eh8ACAZSUgcBHg5aCAVaBFFWWwVWUwELV1cGUAFRAQINWgQNVFEEBAcHCQoKUVZXVQ1ERRYAEFFxWFhEVBIDXFwQXVhbTQJYXR4JDw8CWgNSDQ4PU1FVAAcFBE5ZFRZAA0wfXVAPCEFVEEEXUFMKUgpYV1sDABZcH1deXx4yL3NgJmV9dDEwCFkGRE8K&fl=URdESUZZThhHFU8XUFMKUgpYV1sDABZcH1deXx4CDV5NBl5NGgoNWF1PXVcWYwZDFV1bUyIOEVZSXV0dYjALXl0GSBddFwxb> for Grievance Redressal procedure and Insurance Ombudsman office details for the resolution of your grievance.

[i_Signature]

Associate Vice President- Health Claims

For ICICI Lombard General Insurance Company Ltd
ICICI LOMBARD HEALTH CARE
Contact Details:        Email: [email-masked]<mailto:[email-masked]>
Address:
ICICI Lombard GIC,
ICICI Lombard Health Care,
ICICI Bank Tower,
Plot No 12, Financial District,
Nanakram Guda, Gachibowli,
Hyderabad – 500032,
Telangana
IRDA Registration No. 115
;

        [IL Logo]

ANNEXURE  I  :  220202676399

 Claim No :        220202676399  AL No :
 UHID NO :         IL20144984600         Relationship :            SELF
 Name of the Patient :     ASHISH DABRAL         Policy No :       4016/X/195525873/02/000
 Policy Start Date :        20-APR-22    Polic y End Date :         19-APR-23
 Type Of Claim :           FRESH CLAIM   Requested Amount in Rs :&nb sp;            31119
 Name Of Hospital :        Health Point Polyclinic       Address of the Hospital :         D-178,New Ashok Nagar,New Delhi
Delhi,New Delhi-110096
 Date Of Admission :       11-JUL-22     Date Of Discharge :        13-JUL-22
 Policy Name :     CHERRY E COMMERCE SERVICES P LTD

SR No   Charges Details Claimed Deductions      Paid    Reason for Deductions
1       Consultation Visit Charges      6000    0       6000
2       Others  13119   0       13119
3       Room Charges    6000    1556    4444    Rs.1556 Please refer Sub Bill Breakup
4       Room Nursing Charges    6000    0       6000
        Total   31119   1556    29563

 Diagnosis :     Infectious gastroenteritis and colitis, unspecified
 Final Amount Settled in Rs. :

 29563

 Claim Status :          PAID

[http://delivery.icicilombard.com/SMCYEUDARQ?id=131301=dh8ACAZSUgcBHhgZGRBDEUMUGBZBQUQYERQREhFBQhAZQxAZFUNBFxBCGBkZEEMRQwRERRYAEFFxWFhEVBIDXFwQXVhbTQJYXR4JDw8CWgNSDQ4PU1FVAAcFBE5ZFRZAA0wfXVAPCEFVEEEXUFMKUgpYV1sDABZcH1deXx4yL3NgJmV9dDEwCFkGRE8K]