The Oriental Insurance Co. Ltd.

Policy No. 233300/48/2018/5512 Member ID O55618011053 TPA ID YA0000000338

SH. MANJIT SINGH RANA Retired S.S. MASTER GHS Gate Hakima (Amritsar), had undergone
treatment at the PGI CHANDIGARH Hospital from 28/8/2018 to 02/10/2018. He was suffering
from Degenrative Atlanto Axial dislocation with O-G Instability. Period of treatment from 28-08-
2018 to 02-10-2018

Original Discharge certificate issued by PGI Chandigarh is attached.

Copy of Death Certificate attached.

List of Original Bills signed by Senior Resident Department of Neurosurgery PGIMER Chandigarh
are attached.

Original main hospital bill at Serial No. 110 is attached.

Copy of ADHAR Card of Sh. Manjit Singh is attached.

Copy of ADHAR Card of Smt. Krishna Kumari w/o Manjit Singh is attached.

Copy of PAN Card of Smt. Krishna Kumari is attached.

DATE ON
SERIAL WHICH
NO. PURCHASED PARTICULARS BILL NUMBER AMOUNT
INCLUDED IN SERIAL NO. 110
1 28/8/2018 BILL NO. 4180174543
2 28/8/2018 RADIODIGNOSIS 2181233534/1 1425.00
3 28/8/2018 RADIODIGNOSIS 21881234458/1 825.00
4 28/8/2018 MEDICINE 99213 100.00
5 28/8/2018 MEDICINE 99211 1768.00
6 29/8/2018 MEDICINE 85398 127.00
7 29/8/2018 MEDICINE 84993 148.00
8 29/8/2018 MEDICINE 85535 150.00
9 30/8/2018 MEDICINE 232100 2339.00
10 31/8/2018 MEDICINE 86565 436.00
11 31/8/2018 MEDICINE 86900 710.00
INCLUDED IN SERIAL NO. 110
12 1/9/2018 BILL NO. 4180174543
13 1/9/2018 MEDICINE 86951 75.00
14 2/9/2018 MEDICINE 102297 422.00
15 3/9/2018 MEDICINE 101362 420.00
16 4/9/2018 MEDICINE 88900 161.00
17 4/9/2018 CT SCAN 91840 5000.00
18 5/9/2018 MEDICINE 104031 190.00
19 5/9/2018 MEDICINE 89784 136.00
20 5/9/2018 MEDICINE 102808 117.00
21 6/9/2018 MEDICINE 104394 269.00
22 7/9/2018 MEDICINE 91183 97.00
23 7/9/2018 MEDICINE 90847 275.00
24 7/9/2018 MEDICINE 90695 132.00
25 7/9/2018 MEDICINE 91270 494.00
26 7/9/2018 MEDICINE GKC-203549 4248.00
27 7/9/2018 MEDICINE GKC-203517 480.00
28 7/9/2018 MEDICINE 2181288869/1 300.00
29 7/9/2018 MEDICAL SUPPLY 90864 105.00
30 8/9/2018 MEDICINE 106108 655.00
31 8/9/2018 MEDICAL SUPPLY 105669 3381.00
32 8/9/2018 MEDICINE 105845 1691.00
33 8/9/2018 MEDICINE 105491 533.00
VERTEX MAS SCREWS , BONE
34 8/9/2018 SCREWS 255 95164.00
35 9/9/2018 MEDICINE 92244 55.00
36 9/9/2018 LAB TEST 2181294866/1 100.00
37 9/9/2018 MEDICINE 106567 370.00
38 9/9/2018 MEDICINE 106173 675.00
39 9/9/2018 MEDICAL SUPPLY 106607 150.00
40 10/9/2018 MEDICINE 106772 101.00
41 10/9/2018 LAB TEST 2181297396/1 150.00
42 11/9/2018 MEDICINE 107800 118.00
43 11/9/2018 MEDICINE 107780 118.00
44 11/9/2018 MEDICINE 107400 174.00
45 11/9/2018 LAB TEST 2181302171/1 300.00
46 12/9/2018 MEDICINE 108424 276.00
47 12/9/2018 MEDICINE 107915 118.00
48 12/9/2018 MEDICINE 107972 758.00
49 12/9/2018 MEDICINE 108052 646.00
50 13/9/2018 MEDICINE 109010 566.00
51 14/9/2018 MEDICINE 109190 270.00
52 14/9/2018 MEDICINE 109637 200.00
53 14/9/2018 MEDICINE 180088300123001 49.00
54 15/9/2018 MEDICINE 109880 527.00
55 16/9/2018 MEDICINE 257513 253.00
 56 16/9/2018 MEDICAL SUPPLY 110674 100.00
57 17/9/2018 MEDICINE 110809 1898.00
58 17/9/2018 MEDICINE 110865 124.00
59 17/9/2018 MEDICAL SUPPLY 110912 451.00
60 17/9/2018 MEDICINE 111125 1920.00
61 17/9/2018 MEDICINE 111096 1199.00
62 18/9/2018 MEDICINE 111462 1950.00
63 19/9/2018 MEDICINE 111787 1124.00
64 20/9/2018 MEDICAL SUPPLY & MEDICINE 120695 248.00
65 20/9/2018 MEDICINE 112473 7139.00
66 20/9/2018 MEDICINE 112253 910.00
67 20/9/2018 MEDICINE 112332 1669.00
68 21/9/2018 MEDICAL SUPPLY 112758 282.00
69 21/9/2018 MEDICINE 112884 7144.00
70 21/9/2018 MEDICINE 113145 9534.00
71 21/9/2018 MEDICINE 180078300140634 183.00
72 22/9/2018 MEDICINE 113775 3900.00
73 22/9/2018 MEDICINE 113611 118.00
74 22/9/2018 MEDICINE 113482 5285.00
75 23/9/2018 RADIODIGNOSIS 2181370947/1 25.00
76 23/9/2018 MEDICINE 101607 70.00
77 23/9/2018 LAB TEST 611 2870.00
78 23/9/2018 MEDICINE 113966 188.00
79 23/9/2018 MEDICINE 113926 195.00
80 23/9/2018 MEDICAL SUPPLY 113925 497.00
81 23/9/2018 MEDICINE 113924 620.00
81 A 23/9/2018 LAB TEST 612 2830.00
82 24/9/2018 LAB TEST 2181376683/1 150.00
83 24/9/2018 MEDICINE 114807 250.00
84 24/9/2018 MEDICINE 114348 85.00
85 24/9/2018 MEDICINE 114485 3291.00
86 24/9/2018 MEDICINE 114347 8389.00
87 25/9/2018 LAB TEST ICR080180026437 400.00
88 25/9/2018 MEDICINE 114994 7574.00
89 25/9/2018 MEDICINE 115196 193.00
90 25/9/2018 LAB TEST 2181379896/1 250.00
91 25/9/2018 LAB TEST 2181379887/1 475.00
92 26/9/2018 LAB TEST 2181387197/1 125.00
93 26/9/2018 MEDICINE 115737 8177.00
94 26/9/2018 LAB TEST ICR080180026611 168.00
95 26/9/2018 MEDICINE 272179 7614.00
 96 27/9/2018 MEDICINE 116283 15521.00
97 27/9/2018 MEDICINE 116404 2312.00
98 27/9/2018 MEDICINE 116821 5485.00
99 27/9/2018 MEDICINE 116279 510.00
100 28/9/2018 MEDICINE 274739 10550.00
101 28/9/2018 MEDICINE 53453 6294.00
102 28/9/2018 LAB TEST 2181400633/1 150.00
103 28/9/2018 LAB TEST 2181402624/1 300.00
104 29/9/2018 MEDICINE 53648 801.00
105 29/9/2018 MEDICAL SUPPLY 117882 1870.00
106 29/9/2018 MEDICINE 275395 3900.00
107 30/9/2018 MEDICINE 118454 1832.00
108 1/10/2018 MEDICINE 118575 1116.00
109 1/10/2018 MEDICINE 118913 133.00
HOSPITAL INDOOR CHARGES
110 12/10/2018 FROM 28/08/18 TO 2/10/2018 4180174543 108800.00
TOTAL 3,77,535.00

Three Lakh seventy

seven thousand five
TOTAL (IN hundred thirty five
WORDS) only