Section 21(3)(a) in Insurance Regulatory and Development Authority of India (Third Party Administrators - Health Services) Regulations, 2016
(a)"Your claim bearing No (Claim No) against policy issued by (name of the insurer) has been settled for Rs (Amount Paid) against the Amount Claimed for Rs (Claimed Amount) towards Medical Expenses incurred for treatment of (name of the Ailment) at (Name and City of the Hospital) for the period from (Date of Admission) to (Date of Discharge)":