INSURANCE THIRD PARTY ADMINISTRATOR
REIMBURSEMENT CLAIM APPROVAL LETTER
Date Generated: 04/09/2025
To
SOMASUNDARAM MUTHUKUMARESAN
N/A
NA - 201301
Tel No: -
Dear Sir/Madam,
Sub: Your Claim No: DEL-0925-CL-0246641 under Policy No: 2-81-25-00003897-000 our ID Card No: DEL-AB-H0351-103-0002860-A Patient:
SOMASUNDARAM MUTHUKUMARESAN on 09/08/2025
On scrutiny of the claim papers submitted by you and other relevant documents collected by us, we are pleased to inform you that as per
the instructions of your Insurer M/s ADITYA BIRLA HEALTH INSURANCE COMPANY LTD the claim is being settled as per the Mediclaim
Computation Sheet attached.
You shall be intimated on the settlement details, including payment information, in a separate email within the next 7 to 15 business days.
For any further assistance, please feel free to contact us at 1860-425-0255 or 0806-426-7022, or raise an SSD by following these steps:
Log in to the MyHCL portal
Search for SSD
Select 'HR Benefits & Policy Clarification'
Choose 'Medical Insurance policy'
Thanking you,
Yours faithfully,
Authorised Signatory
VIDAL HEALTH INSURANCE TPA PVT LTD
Note: This is a System Generated Letter.
Copy to:
ADITYA BIRLA HEALTH INSURANCE COMPANY LTD
MUMBAI-400013
Maharashtra
Vidal Health Insurance TPA Pvt.Ltd, SJR iPark,1st Floor,Tower 2,EPIP Zone, Whitefield Road, Opp.Sathya
Sai Hospital, BANGALORE - 560066, Fax No:080-25204296
INSURANCE THIRD PARTY ADMINISTRATOR
Claim No.: DEL-0925-CL-0246641 Claim File No.: DEL-0925-FL-0238569
Claim Settlement No.: DEL-0925-CR-0148499 Approval Date: 04/09/2025
Claim Type: Member Insurance Company: ADITYA BIRLA HEALTH INSURANCE
COMPANY LTD
Policy No.: 2-81-25-00003897-000 Insurer Claim No.: -
Policy Type: Corporate Policy Start Date: 01/10/2024
Corporate Name: HCL TECHNOLOGIES LIMITED Policy End Date: 30/09/2025
Enrollment No.: DEL-AB-H0351-103-0002860-A Payee Name: SOMASUNDARAM
MUTHUKUMARESAN
Claimant: MUTHUKUMARESAN Relationship: Father
MUTHUKUMARESAN
Date of Treatment: 09/08/2025 Address: N/A
NOIDA
NA - 201301
Insured Person: SOMASUNDARAM Emp No./Ref No.: 51921592
MUTHUKUMARESAN
DOB/Age: 68 Sum Insured (Rs.): 44000.0
IP No.: Balance (Rs.): 27089.0
Settled Amt (Rs.): 869
Final Diagnosis: OPD
ICD Codes: PERSONS ENCOUNTERING HEALTH SERVICES IN OTHER CIRCUMSTANCES - ISSUE OF REPEAT
PRESCRIPTION
Last Doc Received Date: 03/09/2025
Remarks: As per policy terms and condition
MEDICLAIM COMPUTATION SHEET
Bill
Sl Bill Nature of Disallowed / Non-Medical Amount
Bill Date Amount Remarks
No. No. Expenditure Expenses Rs. Settled Rs.
Rs.
1 869 09/08/2025 pharmacy 869 0 869
Total: 869 869
Sum of Rupees: Rupees EIGHT HUNDRED SIXTY NINE Only
COPAY BREAKUP DETAILS
Settled By: : 15215
Total Bill Amt (Rs.) : 869
Discount Allowed Amt (Rs.) : 0
Allowable Amt (Rs.) : 869
Other Deduction Amt (Rs.) : 0
Co-Pay Amt (Rs.) : 0
Co-Pay Buffer Amt (Rs.) : 0
Vidal Health Insurance TPA Pvt.Ltd, SJR iPark,1st Floor,Tower 2,EPIP Zone, Whitefield Road, Opp.Sathya
Sai Hospital, BANGALORE - 560066, Fax No:080-25204296
INSURANCE THIRD PARTY ADMINISTRATOR
Deductible Amt (Rs.) : 0
Exceeds Policy Limit Amt (Rs.) : 0
Policy Deductible Amt (Rs.) : 0
Deposit Amt (Rs.) : 0
Total Approved (Rs.) : 869
Vidal Health Insurance TPA Pvt.Ltd, SJR iPark,1st Floor,Tower 2,EPIP Zone, Whitefield Road, Opp.Sathya
Sai Hospital, BANGALORE - 560066, Fax No:080-25204296
