~r~~~~~ir~~~p~ai~~~~~i~~Tel +91 22 6112312322022147 Toll free No 1800228144 Fax +91 22 22854415 E-mail inforothshieldcoin Websitewwwrothshieldcoin TPA Licence No 030

Date 24~06-2017

To

Ms Manju Choudhary

Assistant Manager (Health Department)

Insurance Regulatory And Development Authority Of India

Parisharam Bhavan 3rd Floor

Bash~er Bagh

Hyderabad - 500004

Sub Annual Report for FY 2016-17 Form TPA-8 as per Regulation 2016

Dear Madam

We are enclosing here with Annual Report for Financial year 2016-17 FORM TPA-8 as per Regulation 19

(9) of IRDAI (TPA - Health Services) Regulations 2016 along with TPA-6C TPA-6D TPA-6E

Quarterly and cumulative claims data in Form TPA - 6B 6F 6G amp 6H have been submitted to IRDAI on

letter dated 25th April 2017

Please find the same along with the covering letter

Thanking you

Yours Faithfully

~r~~~~(~r~~~p~~ai~~r~~~~~bullTel +91 22 6112312322022147 Toll free No 1800228 144 Fax +91 22 22854415E-mail inforothshieldcoin Website wwwrothshieldcoin TPA Licence No 030

Annexure-16

As per Regulations 19 (9) of IRDAI (TPA - Health Services) Regulations 2016

Annual Report by Third Party Administrator

FORM TPA-8

1 PARTICULARS OF THE TPA11 Name of the TPA ROTHSHIELDINSURANCETPA LIMITED

12 (A) Address - Registered Office Corporate office - 402 Raheja Chambers Nariman pointMumbaiPin code 400021Landline No (022) 6112312322022147 22048144E-maillD customercarerothshieldcoinFax No (022) 22854415

13 Financial year 2016-17

14 Board of directors as on2016-17 (end ofconcerned FY)and changein the board since the dateof statement of thepreceding year

Sr Name of Director Age Address with telephone Details of Particulars of Date of

No and DIN No noMobile noE-maii Directorshi Change in changep in other Board in BoardCompanies (Cession

Appointment)

1 MrRitesh 40 31 B Sudha Kalash JMehta Solar Sun NA NA

Mahendra 8hate road Malabar Hill Power

DIN Walkeshwar Mumbai Limited

NOOO203741 400006 BCCSolarTel No022-61123123 PrivateMob No9867665454 Limited ampEmail Rothshieldrbhate rothshieldcoin Medical

ServicesPrivate Ltd

2 Mrs Meera 39 31 B Sudha Kalash JMehta Solar Sun NA NA

Ritesh Bhate road Malabar Hill Power

DIN Walkeshwar Mumbai Limited amp

No01666353 400006 Rothshield

Tel No022-61123123 Medical

Email Services

rbhaterothshieldcoin Private Ltd

3 Mr Mahendra 69 31 B Sudha Kalash JMehta Rohan NA NA

Shivaji Bhate road Malabar Hill Packaging

DIN Walkeshwar Mumbai Products

No01666375 400006 Limited

Tel No022-61123123 Kimaya

Mob No9869400782 Finance

Email andrbhaterothshieldcoin Investment

Pvt LTDSolar SunPowerLimited ampBee SolarPrivate Ltd

4 Mrs Anjana 67 31 B Sudha Kalash JMehta NA NA NA

Bhate road Malabar Hill

DIN Walkeshwar Mumbai

No01666367 400006Tel No022-61123123Mob NoEmail rbhaterothshieldcoin

5 Ms Janki 35 31 B Sudha Kalash JMehta NA NA NA

Mahendra Bhate road Malabar Hill

DIN Walkeshwar Mumbai

No02825780 400006Tel No022-61123123Mob No986954415Email ja nkirothshieldcoin

6 Ms Shruti 34 31 B Sudha Kalash JMehta NA NA NA

Mahendra Bhate road Malabar Hill

DIN Walkeshwar Mumbai

No02825743 400006Tel No022-61123123Email rbhaterothshieldcoin

7 Dr Govind 35 B 104 Gandharvgeet NA NA NA

Mahadu Narke sasanenagar HadpsarPune

DIN 411028NO03222192 Tel No022-61123123

Mob No 9011078989

Details of Chief Executive Officer (CEO)

Sr Name of CEO Age Address with telephone Qualificat Details of Date of

No noMobile noE-maii ions Directors Joining withhip in TPAother Company asCompani aCEOes

1 Ms Janki Mahendra 35 31 B Sudha Kalash Bachelor NA 18-11-2015

Bhate JMehta road Malabar Hill ofWalkeshwar Mumbai Science

400006 inTel No 022-61123123 Business

Mob No 9869254415 Administ

E-mail rationja nkirothshieldcoin

Details of Chief Administrative Officer (CAO)

Sr Name ofCAO Age Address with Qualifications Details of Date of

No telephone no Directorship Joining with

Mobile no e-mail in other TPACompanies Company as

aCAO

1 MrCK 61 B31 Giri Sameep BComamp NA 23042007

Krishnakumar Bldg Near Saibaba LicenciateTemple Shree AssociateshipNagar Wagle Diploma inEstate Thane (W) - System

400604 Management

Tel No 022-61123123Mob No8547628241Email

ckkrishnakumarrothshieldcoin

Details of Chief Medical Officer (CMO)

Sr NameofCMO Age Address with Qua Iifications Details of Date of

No telephone no Directorship Joining with

Mobile no e-mail in other TPACompanies Company as

aCMO

1 DrD Vedhpathak 69 Bunglow NO24 kala MBBS NA 01-04-2014

Nagar Bandra -East Mumbai bull400051Tel No 022-61123123Mob No9323402322

18 Name and Address of Auditors Name Sanghavi Shah amp CoAddress 160DNRoad Office nO2627 Above KelkarVishranti Grah CSTMumbai- 400 001

Enumeration of TPA servicesprovided

Rs2954426-

110 Enumeration of stand We have no Remuneration Revenue sharing with anyarrangements with hospital of our providersand with doctors We have empanelled 2427 Network Hospitals and 845Number of agreements with Diagnostic CenterNetwork ProvidersNumber of agreements withDoctors

111 Summary of TPA Businessa No of insurers with whom agreement entered with 2

b Lives covered under Health Policies (to be reported as per 9767provisions of Reg14 ofTPA Regulations and Circular in thematter issued by the Authority

c Policies Served (to be reported as per provisions of Reg14 of 3800TPA Regulations and Circular in the matter issued by theAuthority)

d Number of Hospitals tied up by the TPA (Beginning of concerned 3053

FY)e Hospital tied up during (For the concerned FY) 219

f Total Hospitals terminated or removed during (concerned FY) 0

g Total Hospitals tied up as on ( end of concerned FY) 3272

1112 0 Summary of TPA services

Sr Particulars of Services No of No of Amount of

No Polices lives Premium ServicedServiced Service wherever

d available (INR inLakh)

1 IndividualRetail Health Insurance Policies 3800 9767 494766762 Group Health Insurance Policies (other than RSBY NA NA NA

or other similar policies issued by insurers)3 Policies issued under RSBYor other similar policies NA NA NA

issued by insurers4 Pre-Insurance Medical Examination NA NA NA

5 Foreign Travel Policies issued by Foreign insurer NA NA NA6 Foreign Travel Policies issued by Foreign insurer NA NA NA7 Non-insurance healthcare schemes sponsored by NA NA NA

CentralState Government

ROTHSHIELD INSURANCE TPA LTDSchedule -1 FORM TPA-8-RA

Revenue Account for the year ending 31st March 2017

INCOME100260Staff Expenses

IF-I ~===========================~=9F=========================1Directors remuneration NIL

Ii

a) Salariesprovident fund 2028463 a) From insurers 2954426

b) Others benefits b) From non insurance users of services

d) From Doctors

Office Expensesa) Rentrates amp taxes 162000

c) From Hospital 640000

b)

c)

Electricity water

House Keeping and Cleaning

297131

NILe) From others ( please specify )

Audit Feesd) Others NIL

Miscreceipt 96263Operating Expenses

a) Travel 104325 Investment income 1203921

b) Entertainment NIL Profit on sale of Fixed Assets

c) Lease rent of equipments NIL Deffered Tax

d) Post telecommunication and similar expenses 411556

e) Audit fees 10000

f) Legal Expenses NIL

g)

h)

Repairs and maintenance

Depreciation

271875

179278

i) Motor Vehicle Expenses 10432

Other expenses ( Please specity )Taxes

j) Others 901109

167461

Profit for the vear 250720

4894610 4894610

For SANGHAVI SH~~ C~

FIRr REGN

HmEN C SPNGHVlO~1Io 4tA72)

31IosetO)t-

J

ROTHSHIELD INSURANCE TPA LTDSchedule -2 FORM TPA -8-PL

Profit and Loss Appropriation Account for the year ending 31 st March 2017

Loss brought forward

Loss for the year

Dividend for the year

Transfer to reserves

Other allocations from profits

Profit carriedII

FIR~AREGN

1887082

Profit brought forward

Profit for the year

Transfer from reserves

Loss carried forward

1636362

250720

I

ROTHSHIELD INSURANCE TPA LTOSchedule -3 FORM TPA - 8 - BS

Balance Sheet as at 31st March 2017

Liabilities Rs Assets Rs

Authorised capital

Issued capital

Paid up capital

Shares Application Received

Amounts due to

40000000

Properties

ffice Equipments

Sundry Creditors

a)

b)

c)

d)

Capital Reserve

insurers

Hospital

Doctors

Others 4055646

90675

3500000

Cost

Less- Sold during the year

Less-Depreciation

Net

Motor Vehicles

Cost

Less-Depreciation

Net

295392

170335

125057 125057

28636

8943

19693 19693

Investments

Government Securities

(Market value )

Loans and debentures

( Market value )

Other Investments

(Market value )

Loans amp Advances 1701632

Receivables

a) From Insurers 2665002

b) Others

Cash amp bank balances 44702075

Other Assets 319944

495334031 887082

49533403

For SANGHAV SHAH amp CO

~

FIRr REGN No 113382W

Profit amp Loss ac

Hl~EN c SLJGHAVI(M 0 45472)

sllOsl ~o IT

Schedule -4

Schedule of the income received towards various activities during the FY-2016-17

Sr Description Income I RemunerationNo received during the FY (Amt

INR in Lakhs)

1 Towards Health Services of the Individual policies issued by 2954426-Indian Insurers

2 Towards Health Services of the Group Insurance policies NAissued by Indian Insurers

3 Pre-insurance medical examination NA

4 Towards Health Services in the foreign jurisdiction in respect NAof the policies issued by Indian Insurers

5 Towards Non Insurance Services rendered NA

6 Towards Servicing of policies issued by foreign Insurers NA

7 Other income 1300184-(Please specify accounting head wise other income received)

Total 4254610-

Schedule-S

Schedule of apportionment of Expenses to various activities during the FY2016-17

SI Description Expenses incurred during the FYNo (Amt INR in Lakhs)

1 Health services of the policies issued by Indian Insurers 4278927-2 Health services in the foreign jurisdiction in respect of the NA

policies issued by Indian Insurers3 Non Insurance Services rendered NA4 Servicing of policies issued by foreign Insurers NA5 Other Expenses Incurred (to Specify) NA

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Schedule - 6

1 Data of claims received during the year 2016-17

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalNumber of Amount of Number of Amount of Number of Amount of

Number of Claims Amount of Claims Claims Claims Claims Claims Claims Claims0 0 302 19141282 2041 117178740 2343 136320022

2Data of Settled claims in respect of Individual Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 2728841

3Data of Settled claims in respect of Group Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number AmountI of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0Between 1-3 Months 0 0 0 0 0 0 0 01Between 3-6 Months 0 0 0 0 0 0 0 0More than 6 months 0 0 0 0 0 0 0 0

4Data of Settled claims in respect of Total (Individual Policies + Group Policies)

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 272884

5 Data of Claims in respect of Individual Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

6 Data of Claims in respect of Group Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Numberof Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 01

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

7 Data of Claims in respect of Total ( Individual + Group Policies) recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount Iof claim) Claims Claims Claims Claims Claims Claims of Claims of C~aims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

(Note In respect of data on Repudiations amount of claims made by the policyholder to be mentioned as the amount of claim repudiated)

lt~ l~ ~--~

~

-

~ 1

~ ~

8 Data of claims outstanding in respect of Individual PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

9 Data of claims outstanding in respect of Group PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

10 Data of claims outstanding in respect of Total (Individual + Group Policies)Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Numberof Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

(Note In respect of data on claims outstanding amount of claim made by the policyholder to be mentioned as the amount of claim outstanding)

2pthsliied Insurance TP9l Limited ~~Corporate Office 402 Raheja Chambers Nariman Point Mumbai - 400 021 India Tel +9122 6112312322022147 T~IIfree No 1800228144 Fax~9122 22854415 ~tE-mail inforothshieldcoin Website wwwrothshleldcom TPA licence No 030

Schedule-7

1 Directors Report to be attached separately (Note Inter alia (i) to disclose the shareholding structure as at the end of financial year(ii)

Discuss Corporate Governance norms put-in place)

2 Auditors Report including audited financial and all notes schedules to audited financials to be

attached separately

Undertaking from Registered TPA Company

It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in

Form TPA - 8 and schedule 1 to 7 there under towards various activities of the TPA Company during the

FY2016-17 were examined and are true and correct It is also declared that the TPA Company did not

receive any other income or remuneration from any other sources other sources other than the one

that is declared in the above Schedule

Date

Place Mumbai

Forand on behalf of(ROTHSHIELD INSURANCETPA LIMITED)

h~~6d ~Mrs Anjana Bhate Ms Ja~ BhateDirector CEO

---------------------------------------------------------- XX -----------------------------------------------------------

Certificate from the Statutory Auditors of the TPA Company

Certificate that the above information about financials furnished in annual report and Schedule1

to 5 therein by Rothshield Insurance TPA Limited is an extracted from the transactions of the

TPA Company (Rothshield Insurance TPA Limited) for the Financial Year 2016-17

DatePlace Mumbai

Accountant

~HREN C SANGHAVI(MbullNo 45472)

111 Summary of TPA Businessa No of insurers with whom agreement entered with 2

b Lives covered under Health Policies (to be reported as per 9767provisions of Reg14 ofTPA Regulations and Circular in thematter issued by the Authority

c Policies Served (to be reported as per provisions of Reg14 of 3800TPA Regulations and Circular in the matter issued by theAuthority)

d Number of Hospitals tied up by the TPA (Beginning of concerned 3053

FY)e Hospital tied up during (For the concerned FY) 219

f Total Hospitals terminated or removed during (concerned FY) 0

g Total Hospitals tied up as on ( end of concerned FY) 3272

1112 0 Summary of TPA services

Sr Particulars of Services No of No of Amount of

No Polices lives Premium ServicedServiced Service wherever

d available (INR inLakh)

1 IndividualRetail Health Insurance Policies 3800 9767 494766762 Group Health Insurance Policies (other than RSBY NA NA NA

or other similar policies issued by insurers)3 Policies issued under RSBYor other similar policies NA NA NA

issued by insurers4 Pre-Insurance Medical Examination NA NA NA

5 Foreign Travel Policies issued by Foreign insurer NA NA NA6 Foreign Travel Policies issued by Foreign insurer NA NA NA7 Non-insurance healthcare schemes sponsored by NA NA NA

CentralState Government

ROTHSHIELD INSURANCE TPA LTDSchedule -1 FORM TPA-8-RA

Revenue Account for the year ending 31st March 2017

INCOME100260Staff Expenses

IF-I ~===========================~=9F=========================1Directors remuneration NIL

Ii

a) Salariesprovident fund 2028463 a) From insurers 2954426

b) Others benefits b) From non insurance users of services

d) From Doctors

Office Expensesa) Rentrates amp taxes 162000

c) From Hospital 640000

b)

c)

Electricity water

House Keeping and Cleaning

297131

NILe) From others ( please specify )

Audit Feesd) Others NIL

Miscreceipt 96263Operating Expenses

a) Travel 104325 Investment income 1203921

b) Entertainment NIL Profit on sale of Fixed Assets

c) Lease rent of equipments NIL Deffered Tax

d) Post telecommunication and similar expenses 411556

e) Audit fees 10000

f) Legal Expenses NIL

g)

h)

Repairs and maintenance

Depreciation

271875

179278

i) Motor Vehicle Expenses 10432

Other expenses ( Please specity )Taxes

j) Others 901109

167461

Profit for the vear 250720

4894610 4894610

For SANGHAVI SH~~ C~

FIRr REGN

HmEN C SPNGHVlO~1Io 4tA72)

31IosetO)t-

J

ROTHSHIELD INSURANCE TPA LTDSchedule -2 FORM TPA -8-PL

Profit and Loss Appropriation Account for the year ending 31 st March 2017

Loss brought forward

Loss for the year

Dividend for the year

Transfer to reserves

Other allocations from profits

Profit carriedII

FIR~AREGN

1887082

Profit brought forward

Profit for the year

Transfer from reserves

Loss carried forward

1636362

250720

I

ROTHSHIELD INSURANCE TPA LTOSchedule -3 FORM TPA - 8 - BS

Balance Sheet as at 31st March 2017

Liabilities Rs Assets Rs

Authorised capital

Issued capital

Paid up capital

Shares Application Received

Amounts due to

40000000

Properties

ffice Equipments

Sundry Creditors

a)

b)

c)

d)

Capital Reserve

insurers

Hospital

Doctors

Others 4055646

90675

3500000

Cost

Less- Sold during the year

Less-Depreciation

Net

Motor Vehicles

Cost

Less-Depreciation

Net

295392

170335

125057 125057

28636

8943

19693 19693

Investments

Government Securities

(Market value )

Loans and debentures

( Market value )

Other Investments

(Market value )

Loans amp Advances 1701632

Receivables

a) From Insurers 2665002

b) Others

Cash amp bank balances 44702075

Other Assets 319944

495334031 887082

49533403

For SANGHAV SHAH amp CO

~

FIRr REGN No 113382W

Profit amp Loss ac

Hl~EN c SLJGHAVI(M 0 45472)

sllOsl ~o IT

Schedule -4

Schedule of the income received towards various activities during the FY-2016-17

Sr Description Income I RemunerationNo received during the FY (Amt

INR in Lakhs)

1 Towards Health Services of the Individual policies issued by 2954426-Indian Insurers

2 Towards Health Services of the Group Insurance policies NAissued by Indian Insurers

3 Pre-insurance medical examination NA

4 Towards Health Services in the foreign jurisdiction in respect NAof the policies issued by Indian Insurers

5 Towards Non Insurance Services rendered NA

6 Towards Servicing of policies issued by foreign Insurers NA

7 Other income 1300184-(Please specify accounting head wise other income received)

Total 4254610-

Schedule-S

Schedule of apportionment of Expenses to various activities during the FY2016-17

SI Description Expenses incurred during the FYNo (Amt INR in Lakhs)

1 Health services of the policies issued by Indian Insurers 4278927-2 Health services in the foreign jurisdiction in respect of the NA

policies issued by Indian Insurers3 Non Insurance Services rendered NA4 Servicing of policies issued by foreign Insurers NA5 Other Expenses Incurred (to Specify) NA

~---

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Schedule - 6

1 Data of claims received during the year 2016-17

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalNumber of Amount of Number of Amount of Number of Amount of

Number of Claims Amount of Claims Claims Claims Claims Claims Claims Claims0 0 302 19141282 2041 117178740 2343 136320022

2Data of Settled claims in respect of Individual Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 2728841

3Data of Settled claims in respect of Group Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number AmountI of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0Between 1-3 Months 0 0 0 0 0 0 0 01Between 3-6 Months 0 0 0 0 0 0 0 0More than 6 months 0 0 0 0 0 0 0 0

4Data of Settled claims in respect of Total (Individual Policies + Group Policies)

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 272884

5 Data of Claims in respect of Individual Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

6 Data of Claims in respect of Group Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Numberof Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 01

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

7 Data of Claims in respect of Total ( Individual + Group Policies) recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount Iof claim) Claims Claims Claims Claims Claims Claims of Claims of C~aims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

(Note In respect of data on Repudiations amount of claims made by the policyholder to be mentioned as the amount of claim repudiated)

lt~ l~ ~--~

~

-

~ 1

~ ~

8 Data of claims outstanding in respect of Individual PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

9 Data of claims outstanding in respect of Group PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

10 Data of claims outstanding in respect of Total (Individual + Group Policies)Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Numberof Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

(Note In respect of data on claims outstanding amount of claim made by the policyholder to be mentioned as the amount of claim outstanding)

2pthsliied Insurance TP9l Limited ~~Corporate Office 402 Raheja Chambers Nariman Point Mumbai - 400 021 India Tel +9122 6112312322022147 T~IIfree No 1800228144 Fax~9122 22854415 ~tE-mail inforothshieldcoin Website wwwrothshleldcom TPA licence No 030

Schedule-7

1 Directors Report to be attached separately (Note Inter alia (i) to disclose the shareholding structure as at the end of financial year(ii)

Discuss Corporate Governance norms put-in place)

2 Auditors Report including audited financial and all notes schedules to audited financials to be

attached separately

Undertaking from Registered TPA Company

It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in

Form TPA - 8 and schedule 1 to 7 there under towards various activities of the TPA Company during the

FY2016-17 were examined and are true and correct It is also declared that the TPA Company did not

receive any other income or remuneration from any other sources other sources other than the one

that is declared in the above Schedule

Date

Place Mumbai

Forand on behalf of(ROTHSHIELD INSURANCETPA LIMITED)

h~~6d ~Mrs Anjana Bhate Ms Ja~ BhateDirector CEO

---------------------------------------------------------- XX -----------------------------------------------------------

Certificate from the Statutory Auditors of the TPA Company

Certificate that the above information about financials furnished in annual report and Schedule1

to 5 therein by Rothshield Insurance TPA Limited is an extracted from the transactions of the

TPA Company (Rothshield Insurance TPA Limited) for the Financial Year 2016-17

DatePlace Mumbai

Accountant

~HREN C SANGHAVI(MbullNo 45472)

ROTHSHIELD INSURANCE TPA LTDSchedule -1 FORM TPA-8-RA

Revenue Account for the year ending 31st March 2017

INCOME100260Staff Expenses

IF-I ~===========================~=9F=========================1Directors remuneration NIL

Ii

a) Salariesprovident fund 2028463 a) From insurers 2954426

b) Others benefits b) From non insurance users of services

d) From Doctors

Office Expensesa) Rentrates amp taxes 162000

c) From Hospital 640000

b)

c)

Electricity water

House Keeping and Cleaning

297131

NILe) From others ( please specify )

Audit Feesd) Others NIL

Miscreceipt 96263Operating Expenses

a) Travel 104325 Investment income 1203921

b) Entertainment NIL Profit on sale of Fixed Assets

c) Lease rent of equipments NIL Deffered Tax

d) Post telecommunication and similar expenses 411556

e) Audit fees 10000

f) Legal Expenses NIL

g)

h)

Repairs and maintenance

Depreciation

271875

179278

i) Motor Vehicle Expenses 10432

Other expenses ( Please specity )Taxes

j) Others 901109

167461

Profit for the vear 250720

4894610 4894610

For SANGHAVI SH~~ C~

FIRr REGN

HmEN C SPNGHVlO~1Io 4tA72)

31IosetO)t-

J

ROTHSHIELD INSURANCE TPA LTDSchedule -2 FORM TPA -8-PL

Profit and Loss Appropriation Account for the year ending 31 st March 2017

Loss brought forward

Loss for the year

Dividend for the year

Transfer to reserves

Other allocations from profits

Profit carriedII

FIR~AREGN

1887082

Profit brought forward

Profit for the year

Transfer from reserves

Loss carried forward

1636362

250720

I

ROTHSHIELD INSURANCE TPA LTOSchedule -3 FORM TPA - 8 - BS

Balance Sheet as at 31st March 2017

Liabilities Rs Assets Rs

Authorised capital

Issued capital

Paid up capital

Shares Application Received

Amounts due to

40000000

Properties

ffice Equipments

Sundry Creditors

a)

b)

c)

d)

Capital Reserve

insurers

Hospital

Doctors

Others 4055646

90675

3500000

Cost

Less- Sold during the year

Less-Depreciation

Net

Motor Vehicles

Cost

Less-Depreciation

Net

295392

170335

125057 125057

28636

8943

19693 19693

Investments

Government Securities

(Market value )

Loans and debentures

( Market value )

Other Investments

(Market value )

Loans amp Advances 1701632

Receivables

a) From Insurers 2665002

b) Others

Cash amp bank balances 44702075

Other Assets 319944

495334031 887082

49533403

For SANGHAV SHAH amp CO

~

FIRr REGN No 113382W

Profit amp Loss ac

Hl~EN c SLJGHAVI(M 0 45472)

sllOsl ~o IT

Schedule -4

Schedule of the income received towards various activities during the FY-2016-17

Sr Description Income I RemunerationNo received during the FY (Amt

INR in Lakhs)

1 Towards Health Services of the Individual policies issued by 2954426-Indian Insurers

2 Towards Health Services of the Group Insurance policies NAissued by Indian Insurers

3 Pre-insurance medical examination NA

4 Towards Health Services in the foreign jurisdiction in respect NAof the policies issued by Indian Insurers

5 Towards Non Insurance Services rendered NA

6 Towards Servicing of policies issued by foreign Insurers NA

7 Other income 1300184-(Please specify accounting head wise other income received)

Total 4254610-

Schedule-S

Schedule of apportionment of Expenses to various activities during the FY2016-17

SI Description Expenses incurred during the FYNo (Amt INR in Lakhs)

1 Health services of the policies issued by Indian Insurers 4278927-2 Health services in the foreign jurisdiction in respect of the NA

policies issued by Indian Insurers3 Non Insurance Services rendered NA4 Servicing of policies issued by foreign Insurers NA5 Other Expenses Incurred (to Specify) NA

~---

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Schedule - 6

1 Data of claims received during the year 2016-17

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalNumber of Amount of Number of Amount of Number of Amount of

Number of Claims Amount of Claims Claims Claims Claims Claims Claims Claims0 0 302 19141282 2041 117178740 2343 136320022

2Data of Settled claims in respect of Individual Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 2728841

3Data of Settled claims in respect of Group Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number AmountI of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0Between 1-3 Months 0 0 0 0 0 0 0 01Between 3-6 Months 0 0 0 0 0 0 0 0More than 6 months 0 0 0 0 0 0 0 0

4Data of Settled claims in respect of Total (Individual Policies + Group Policies)

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 272884

5 Data of Claims in respect of Individual Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

6 Data of Claims in respect of Group Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Numberof Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 01

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

7 Data of Claims in respect of Total ( Individual + Group Policies) recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount Iof claim) Claims Claims Claims Claims Claims Claims of Claims of C~aims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

(Note In respect of data on Repudiations amount of claims made by the policyholder to be mentioned as the amount of claim repudiated)

lt~ l~ ~--~

~

-

~ 1

~ ~

8 Data of claims outstanding in respect of Individual PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

9 Data of claims outstanding in respect of Group PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

10 Data of claims outstanding in respect of Total (Individual + Group Policies)Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Numberof Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

(Note In respect of data on claims outstanding amount of claim made by the policyholder to be mentioned as the amount of claim outstanding)

2pthsliied Insurance TP9l Limited ~~Corporate Office 402 Raheja Chambers Nariman Point Mumbai - 400 021 India Tel +9122 6112312322022147 T~IIfree No 1800228144 Fax~9122 22854415 ~tE-mail inforothshieldcoin Website wwwrothshleldcom TPA licence No 030

Schedule-7

1 Directors Report to be attached separately (Note Inter alia (i) to disclose the shareholding structure as at the end of financial year(ii)

Discuss Corporate Governance norms put-in place)

2 Auditors Report including audited financial and all notes schedules to audited financials to be

attached separately

Undertaking from Registered TPA Company

It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in

Form TPA - 8 and schedule 1 to 7 there under towards various activities of the TPA Company during the

FY2016-17 were examined and are true and correct It is also declared that the TPA Company did not

receive any other income or remuneration from any other sources other sources other than the one

that is declared in the above Schedule

Date

Place Mumbai

Forand on behalf of(ROTHSHIELD INSURANCETPA LIMITED)

h~~6d ~Mrs Anjana Bhate Ms Ja~ BhateDirector CEO

---------------------------------------------------------- XX -----------------------------------------------------------

Certificate from the Statutory Auditors of the TPA Company

Certificate that the above information about financials furnished in annual report and Schedule1

to 5 therein by Rothshield Insurance TPA Limited is an extracted from the transactions of the

TPA Company (Rothshield Insurance TPA Limited) for the Financial Year 2016-17

DatePlace Mumbai

Accountant

~HREN C SANGHAVI(MbullNo 45472)

ROTHSHIELD INSURANCE TPA LTDSchedule -2 FORM TPA -8-PL

Profit and Loss Appropriation Account for the year ending 31 st March 2017

Loss brought forward

Loss for the year

Dividend for the year

Transfer to reserves

Other allocations from profits

Profit carriedII

FIR~AREGN

1887082

Profit brought forward

Profit for the year

Transfer from reserves

Loss carried forward

1636362

250720

I

ROTHSHIELD INSURANCE TPA LTOSchedule -3 FORM TPA - 8 - BS

Balance Sheet as at 31st March 2017

Liabilities Rs Assets Rs

Authorised capital

Issued capital

Paid up capital

Shares Application Received

Amounts due to

40000000

Properties

ffice Equipments

Sundry Creditors

a)

b)

c)

d)

Capital Reserve

insurers

Hospital

Doctors

Others 4055646

90675

3500000

Cost

Less- Sold during the year

Less-Depreciation

Net

Motor Vehicles

Cost

Less-Depreciation

Net

295392

170335

125057 125057

28636

8943

19693 19693

Investments

Government Securities

(Market value )

Loans and debentures

( Market value )

Other Investments

(Market value )

Loans amp Advances 1701632

Receivables

a) From Insurers 2665002

b) Others

Cash amp bank balances 44702075

Other Assets 319944

495334031 887082

49533403

For SANGHAV SHAH amp CO

~

FIRr REGN No 113382W

Profit amp Loss ac

Hl~EN c SLJGHAVI(M 0 45472)

sllOsl ~o IT

Schedule -4

Schedule of the income received towards various activities during the FY-2016-17

Sr Description Income I RemunerationNo received during the FY (Amt

INR in Lakhs)

1 Towards Health Services of the Individual policies issued by 2954426-Indian Insurers

2 Towards Health Services of the Group Insurance policies NAissued by Indian Insurers

3 Pre-insurance medical examination NA

4 Towards Health Services in the foreign jurisdiction in respect NAof the policies issued by Indian Insurers

5 Towards Non Insurance Services rendered NA

6 Towards Servicing of policies issued by foreign Insurers NA

7 Other income 1300184-(Please specify accounting head wise other income received)

Total 4254610-

Schedule-S

Schedule of apportionment of Expenses to various activities during the FY2016-17

SI Description Expenses incurred during the FYNo (Amt INR in Lakhs)

1 Health services of the policies issued by Indian Insurers 4278927-2 Health services in the foreign jurisdiction in respect of the NA

policies issued by Indian Insurers3 Non Insurance Services rendered NA4 Servicing of policies issued by foreign Insurers NA5 Other Expenses Incurred (to Specify) NA

~---

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Schedule - 6

1 Data of claims received during the year 2016-17

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalNumber of Amount of Number of Amount of Number of Amount of

Number of Claims Amount of Claims Claims Claims Claims Claims Claims Claims0 0 302 19141282 2041 117178740 2343 136320022

2Data of Settled claims in respect of Individual Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 2728841

3Data of Settled claims in respect of Group Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number AmountI of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0Between 1-3 Months 0 0 0 0 0 0 0 01Between 3-6 Months 0 0 0 0 0 0 0 0More than 6 months 0 0 0 0 0 0 0 0

4Data of Settled claims in respect of Total (Individual Policies + Group Policies)

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 272884

5 Data of Claims in respect of Individual Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

6 Data of Claims in respect of Group Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Numberof Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 01

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

7 Data of Claims in respect of Total ( Individual + Group Policies) recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount Iof claim) Claims Claims Claims Claims Claims Claims of Claims of C~aims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

(Note In respect of data on Repudiations amount of claims made by the policyholder to be mentioned as the amount of claim repudiated)

lt~ l~ ~--~

~

-

~ 1

~ ~

8 Data of claims outstanding in respect of Individual PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

9 Data of claims outstanding in respect of Group PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

10 Data of claims outstanding in respect of Total (Individual + Group Policies)Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Numberof Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

(Note In respect of data on claims outstanding amount of claim made by the policyholder to be mentioned as the amount of claim outstanding)

2pthsliied Insurance TP9l Limited ~~Corporate Office 402 Raheja Chambers Nariman Point Mumbai - 400 021 India Tel +9122 6112312322022147 T~IIfree No 1800228144 Fax~9122 22854415 ~tE-mail inforothshieldcoin Website wwwrothshleldcom TPA licence No 030

Schedule-7

1 Directors Report to be attached separately (Note Inter alia (i) to disclose the shareholding structure as at the end of financial year(ii)

Discuss Corporate Governance norms put-in place)

2 Auditors Report including audited financial and all notes schedules to audited financials to be

attached separately

Undertaking from Registered TPA Company

It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in

Form TPA - 8 and schedule 1 to 7 there under towards various activities of the TPA Company during the

FY2016-17 were examined and are true and correct It is also declared that the TPA Company did not

receive any other income or remuneration from any other sources other sources other than the one

that is declared in the above Schedule

Date

Place Mumbai

Forand on behalf of(ROTHSHIELD INSURANCETPA LIMITED)

h~~6d ~Mrs Anjana Bhate Ms Ja~ BhateDirector CEO

---------------------------------------------------------- XX -----------------------------------------------------------

Certificate from the Statutory Auditors of the TPA Company

Certificate that the above information about financials furnished in annual report and Schedule1

to 5 therein by Rothshield Insurance TPA Limited is an extracted from the transactions of the

TPA Company (Rothshield Insurance TPA Limited) for the Financial Year 2016-17

DatePlace Mumbai

Accountant

~HREN C SANGHAVI(MbullNo 45472)

ROTHSHIELD INSURANCE TPA LTOSchedule -3 FORM TPA - 8 - BS

Balance Sheet as at 31st March 2017

Liabilities Rs Assets Rs

Authorised capital

Issued capital

Paid up capital

Shares Application Received

Amounts due to

40000000

Properties

ffice Equipments

Sundry Creditors

a)

b)

c)

d)

Capital Reserve

insurers

Hospital

Doctors

Others 4055646

90675

3500000

Cost

Less- Sold during the year

Less-Depreciation

Net

Motor Vehicles

Cost

Less-Depreciation

Net

295392

170335

125057 125057

28636

8943

19693 19693

Investments

Government Securities

(Market value )

Loans and debentures

( Market value )

Other Investments

(Market value )

Loans amp Advances 1701632

Receivables

a) From Insurers 2665002

b) Others

Cash amp bank balances 44702075

Other Assets 319944

495334031 887082

49533403

For SANGHAV SHAH amp CO

~

FIRr REGN No 113382W

Profit amp Loss ac

Hl~EN c SLJGHAVI(M 0 45472)

sllOsl ~o IT

Schedule -4

Schedule of the income received towards various activities during the FY-2016-17

Sr Description Income I RemunerationNo received during the FY (Amt

INR in Lakhs)

1 Towards Health Services of the Individual policies issued by 2954426-Indian Insurers

2 Towards Health Services of the Group Insurance policies NAissued by Indian Insurers

3 Pre-insurance medical examination NA

4 Towards Health Services in the foreign jurisdiction in respect NAof the policies issued by Indian Insurers

5 Towards Non Insurance Services rendered NA

6 Towards Servicing of policies issued by foreign Insurers NA

7 Other income 1300184-(Please specify accounting head wise other income received)

Total 4254610-

Schedule-S

Schedule of apportionment of Expenses to various activities during the FY2016-17

SI Description Expenses incurred during the FYNo (Amt INR in Lakhs)

1 Health services of the policies issued by Indian Insurers 4278927-2 Health services in the foreign jurisdiction in respect of the NA

policies issued by Indian Insurers3 Non Insurance Services rendered NA4 Servicing of policies issued by foreign Insurers NA5 Other Expenses Incurred (to Specify) NA

~---

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Schedule - 6

1 Data of claims received during the year 2016-17

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalNumber of Amount of Number of Amount of Number of Amount of

Number of Claims Amount of Claims Claims Claims Claims Claims Claims Claims0 0 302 19141282 2041 117178740 2343 136320022

2Data of Settled claims in respect of Individual Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 2728841

3Data of Settled claims in respect of Group Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number AmountI of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0Between 1-3 Months 0 0 0 0 0 0 0 01Between 3-6 Months 0 0 0 0 0 0 0 0More than 6 months 0 0 0 0 0 0 0 0

4Data of Settled claims in respect of Total (Individual Policies + Group Policies)

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 272884

5 Data of Claims in respect of Individual Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

6 Data of Claims in respect of Group Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Numberof Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 01

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

7 Data of Claims in respect of Total ( Individual + Group Policies) recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount Iof claim) Claims Claims Claims Claims Claims Claims of Claims of C~aims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

(Note In respect of data on Repudiations amount of claims made by the policyholder to be mentioned as the amount of claim repudiated)

lt~ l~ ~--~

~

-

~ 1

~ ~

8 Data of claims outstanding in respect of Individual PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

9 Data of claims outstanding in respect of Group PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

10 Data of claims outstanding in respect of Total (Individual + Group Policies)Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Numberof Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

(Note In respect of data on claims outstanding amount of claim made by the policyholder to be mentioned as the amount of claim outstanding)

2pthsliied Insurance TP9l Limited ~~Corporate Office 402 Raheja Chambers Nariman Point Mumbai - 400 021 India Tel +9122 6112312322022147 T~IIfree No 1800228144 Fax~9122 22854415 ~tE-mail inforothshieldcoin Website wwwrothshleldcom TPA licence No 030

Schedule-7

1 Directors Report to be attached separately (Note Inter alia (i) to disclose the shareholding structure as at the end of financial year(ii)

Discuss Corporate Governance norms put-in place)

2 Auditors Report including audited financial and all notes schedules to audited financials to be

attached separately

Undertaking from Registered TPA Company

It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in

Form TPA - 8 and schedule 1 to 7 there under towards various activities of the TPA Company during the

FY2016-17 were examined and are true and correct It is also declared that the TPA Company did not

receive any other income or remuneration from any other sources other sources other than the one

that is declared in the above Schedule

Date

Place Mumbai

Forand on behalf of(ROTHSHIELD INSURANCETPA LIMITED)

h~~6d ~Mrs Anjana Bhate Ms Ja~ BhateDirector CEO

---------------------------------------------------------- XX -----------------------------------------------------------

Certificate from the Statutory Auditors of the TPA Company

Certificate that the above information about financials furnished in annual report and Schedule1

to 5 therein by Rothshield Insurance TPA Limited is an extracted from the transactions of the

TPA Company (Rothshield Insurance TPA Limited) for the Financial Year 2016-17

DatePlace Mumbai

Accountant

~HREN C SANGHAVI(MbullNo 45472)

Schedule -4

Schedule of the income received towards various activities during the FY-2016-17

Sr Description Income I RemunerationNo received during the FY (Amt

INR in Lakhs)

1 Towards Health Services of the Individual policies issued by 2954426-Indian Insurers

2 Towards Health Services of the Group Insurance policies NAissued by Indian Insurers

3 Pre-insurance medical examination NA

4 Towards Health Services in the foreign jurisdiction in respect NAof the policies issued by Indian Insurers

5 Towards Non Insurance Services rendered NA

6 Towards Servicing of policies issued by foreign Insurers NA

7 Other income 1300184-(Please specify accounting head wise other income received)

Total 4254610-

Schedule-S

Schedule of apportionment of Expenses to various activities during the FY2016-17

SI Description Expenses incurred during the FYNo (Amt INR in Lakhs)

1 Health services of the policies issued by Indian Insurers 4278927-2 Health services in the foreign jurisdiction in respect of the NA

policies issued by Indian Insurers3 Non Insurance Services rendered NA4 Servicing of policies issued by foreign Insurers NA5 Other Expenses Incurred (to Specify) NA

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Schedule - 6

1 Data of claims received during the year 2016-17

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalNumber of Amount of Number of Amount of Number of Amount of

Number of Claims Amount of Claims Claims Claims Claims Claims Claims Claims0 0 302 19141282 2041 117178740 2343 136320022

2Data of Settled claims in respect of Individual Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 2728841

3Data of Settled claims in respect of Group Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number AmountI of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0Between 1-3 Months 0 0 0 0 0 0 0 01Between 3-6 Months 0 0 0 0 0 0 0 0More than 6 months 0 0 0 0 0 0 0 0

4Data of Settled claims in respect of Total (Individual Policies + Group Policies)

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 272884

5 Data of Claims in respect of Individual Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

6 Data of Claims in respect of Group Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Numberof Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 01

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

7 Data of Claims in respect of Total ( Individual + Group Policies) recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount Iof claim) Claims Claims Claims Claims Claims Claims of Claims of C~aims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

(Note In respect of data on Repudiations amount of claims made by the policyholder to be mentioned as the amount of claim repudiated)

lt~ l~ ~--~

~

-

~ 1

~ ~

8 Data of claims outstanding in respect of Individual PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

9 Data of claims outstanding in respect of Group PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

10 Data of claims outstanding in respect of Total (Individual + Group Policies)Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Numberof Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

(Note In respect of data on claims outstanding amount of claim made by the policyholder to be mentioned as the amount of claim outstanding)

2pthsliied Insurance TP9l Limited ~~Corporate Office 402 Raheja Chambers Nariman Point Mumbai - 400 021 India Tel +9122 6112312322022147 T~IIfree No 1800228144 Fax~9122 22854415 ~tE-mail inforothshieldcoin Website wwwrothshleldcom TPA licence No 030

Schedule-7

1 Directors Report to be attached separately (Note Inter alia (i) to disclose the shareholding structure as at the end of financial year(ii)

Discuss Corporate Governance norms put-in place)

2 Auditors Report including audited financial and all notes schedules to audited financials to be

attached separately

Undertaking from Registered TPA Company

It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in

Form TPA - 8 and schedule 1 to 7 there under towards various activities of the TPA Company during the

FY2016-17 were examined and are true and correct It is also declared that the TPA Company did not

receive any other income or remuneration from any other sources other sources other than the one

that is declared in the above Schedule

Date

Place Mumbai

Forand on behalf of(ROTHSHIELD INSURANCETPA LIMITED)

h~~6d ~Mrs Anjana Bhate Ms Ja~ BhateDirector CEO

---------------------------------------------------------- XX -----------------------------------------------------------

Certificate from the Statutory Auditors of the TPA Company

Certificate that the above information about financials furnished in annual report and Schedule1

to 5 therein by Rothshield Insurance TPA Limited is an extracted from the transactions of the

TPA Company (Rothshield Insurance TPA Limited) for the Financial Year 2016-17

DatePlace Mumbai

Accountant

~HREN C SANGHAVI(MbullNo 45472)

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Schedule - 6

1 Data of claims received during the year 2016-17

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalNumber of Amount of Number of Amount of Number of Amount of

Number of Claims Amount of Claims Claims Claims Claims Claims Claims Claims0 0 302 19141282 2041 117178740 2343 136320022

2Data of Settled claims in respect of Individual Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 2728841

3Data of Settled claims in respect of Group Policies

Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number AmountI of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0Between 1-3 Months 0 0 0 0 0 0 0 01Between 3-6 Months 0 0 0 0 0 0 0 0More than 6 months 0 0 0 0 0 0 0 0

4Data of Settled claims in respect of Total (Individual Policies + Group Policies)

Bebefit Based Policies Cashless Claims Reimbursement Claims TotalDescription (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claimswithin 1 months from date of receipt of claims 0 0 60 1970430 370 11379613 430 13350043

Between 1-3 Months 0 0 198 9390130 1171 47284853 1369 56674983Between 3-6 Months 0 0 9 358037 88 5460756 97 5818793More than 6 months 0 0 1 64019 10 208865 11 272884

5 Data of Claims in respect of Individual Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

6 Data of Claims in respect of Group Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Numberof Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 01

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

7 Data of Claims in respect of Total ( Individual + Group Policies) recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount Iof claim) Claims Claims Claims Claims Claims Claims of Claims of C~aims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

(Note In respect of data on Repudiations amount of claims made by the policyholder to be mentioned as the amount of claim repudiated)

lt~ l~ ~--~

~

-

~ 1

~ ~

8 Data of claims outstanding in respect of Individual PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

9 Data of claims outstanding in respect of Group PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

10 Data of claims outstanding in respect of Total (Individual + Group Policies)Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Numberof Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

(Note In respect of data on claims outstanding amount of claim made by the policyholder to be mentioned as the amount of claim outstanding)

2pthsliied Insurance TP9l Limited ~~Corporate Office 402 Raheja Chambers Nariman Point Mumbai - 400 021 India Tel +9122 6112312322022147 T~IIfree No 1800228144 Fax~9122 22854415 ~tE-mail inforothshieldcoin Website wwwrothshleldcom TPA licence No 030

Schedule-7

1 Directors Report to be attached separately (Note Inter alia (i) to disclose the shareholding structure as at the end of financial year(ii)

Discuss Corporate Governance norms put-in place)

2 Auditors Report including audited financial and all notes schedules to audited financials to be

attached separately

Undertaking from Registered TPA Company

It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in

Form TPA - 8 and schedule 1 to 7 there under towards various activities of the TPA Company during the

FY2016-17 were examined and are true and correct It is also declared that the TPA Company did not

receive any other income or remuneration from any other sources other sources other than the one

that is declared in the above Schedule

Date

Place Mumbai

Forand on behalf of(ROTHSHIELD INSURANCETPA LIMITED)

h~~6d ~Mrs Anjana Bhate Ms Ja~ BhateDirector CEO

---------------------------------------------------------- XX -----------------------------------------------------------

Certificate from the Statutory Auditors of the TPA Company

Certificate that the above information about financials furnished in annual report and Schedule1

to 5 therein by Rothshield Insurance TPA Limited is an extracted from the transactions of the

TPA Company (Rothshield Insurance TPA Limited) for the Financial Year 2016-17

DatePlace Mumbai

Accountant

~HREN C SANGHAVI(MbullNo 45472)

5 Data of Claims in respect of Individual Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

6 Data of Claims in respect of Group Policies recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Numberof Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 01

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

7 Data of Claims in respect of Total ( Individual + Group Policies) recommended for repudiationBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount Iof claim) Claims Claims Claims Claims Claims Claims of Claims of C~aims

within 1 months from date of receipt of claims 0 0 0 0 123 5471895 123 5471895

Between 1-3 Months 0 0 6 559742 131 5876606 137 6436348

Between 3-6 Months 0 0 1 151000 3 273519 4 424519

More than 6 months 0 0 0 0 1 3114 1 3114

(Note In respect of data on Repudiations amount of claims made by the policyholder to be mentioned as the amount of claim repudiated)

lt~ l~ ~--~

~

-

~ 1

~ ~

8 Data of claims outstanding in respect of Individual PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

9 Data of claims outstanding in respect of Group PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

10 Data of claims outstanding in respect of Total (Individual + Group Policies)Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Numberof Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

(Note In respect of data on claims outstanding amount of claim made by the policyholder to be mentioned as the amount of claim outstanding)

2pthsliied Insurance TP9l Limited ~~Corporate Office 402 Raheja Chambers Nariman Point Mumbai - 400 021 India Tel +9122 6112312322022147 T~IIfree No 1800228144 Fax~9122 22854415 ~tE-mail inforothshieldcoin Website wwwrothshleldcom TPA licence No 030

Schedule-7

1 Directors Report to be attached separately (Note Inter alia (i) to disclose the shareholding structure as at the end of financial year(ii)

Discuss Corporate Governance norms put-in place)

2 Auditors Report including audited financial and all notes schedules to audited financials to be

attached separately

Undertaking from Registered TPA Company

It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in

Form TPA - 8 and schedule 1 to 7 there under towards various activities of the TPA Company during the

FY2016-17 were examined and are true and correct It is also declared that the TPA Company did not

receive any other income or remuneration from any other sources other sources other than the one

that is declared in the above Schedule

Date

Place Mumbai

Forand on behalf of(ROTHSHIELD INSURANCETPA LIMITED)

h~~6d ~Mrs Anjana Bhate Ms Ja~ BhateDirector CEO

---------------------------------------------------------- XX -----------------------------------------------------------

Certificate from the Statutory Auditors of the TPA Company

Certificate that the above information about financials furnished in annual report and Schedule1

to 5 therein by Rothshield Insurance TPA Limited is an extracted from the transactions of the

TPA Company (Rothshield Insurance TPA Limited) for the Financial Year 2016-17

DatePlace Mumbai

Accountant

~HREN C SANGHAVI(MbullNo 45472)

8 Data of claims outstanding in respect of Individual PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

9 Data of claims outstanding in respect of Group PoliciesBebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Number of Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 0 0 0 0 0 0

Between 1-3 Months 0 0 0 0 0 0 0 0

Between 3-6 Months 0 0 0 0 0 0 0 0

More than 6 months 0 0 0 0 0 0 0 0

10 Data of claims outstanding in respect of Total (Individual + Group Policies)Bebefit Based Policies Cashless Claims Reimbursement Claims Total

Description (to be reckoned from the date of receipt Number of Amount of Numberof Amount of Number of Amount of Number Amount

of claim) Claims Claims Claims Claims Claims Claims of Claims of Claims

within 1 months from date of receipt of claims 0 0 17 618024 93 3560655 110 4178679

Between 1-3 Months 0 0 8 572043 44 1884686 52 2456729

Between 3-6 Months 0 0 2 150554 5 276662 7 427216

More than 6 months 0 0 0 0 2 98761 2 98761

(Note In respect of data on claims outstanding amount of claim made by the policyholder to be mentioned as the amount of claim outstanding)

2pthsliied Insurance TP9l Limited ~~Corporate Office 402 Raheja Chambers Nariman Point Mumbai - 400 021 India Tel +9122 6112312322022147 T~IIfree No 1800228144 Fax~9122 22854415 ~tE-mail inforothshieldcoin Website wwwrothshleldcom TPA licence No 030

Schedule-7

1 Directors Report to be attached separately (Note Inter alia (i) to disclose the shareholding structure as at the end of financial year(ii)

Discuss Corporate Governance norms put-in place)

2 Auditors Report including audited financial and all notes schedules to audited financials to be

attached separately

Undertaking from Registered TPA Company

It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in

Form TPA - 8 and schedule 1 to 7 there under towards various activities of the TPA Company during the

FY2016-17 were examined and are true and correct It is also declared that the TPA Company did not

receive any other income or remuneration from any other sources other sources other than the one

that is declared in the above Schedule

Date

Place Mumbai

Forand on behalf of(ROTHSHIELD INSURANCETPA LIMITED)

h~~6d ~Mrs Anjana Bhate Ms Ja~ BhateDirector CEO

---------------------------------------------------------- XX -----------------------------------------------------------

Certificate from the Statutory Auditors of the TPA Company

Certificate that the above information about financials furnished in annual report and Schedule1

to 5 therein by Rothshield Insurance TPA Limited is an extracted from the transactions of the

TPA Company (Rothshield Insurance TPA Limited) for the Financial Year 2016-17

DatePlace Mumbai

Accountant

~HREN C SANGHAVI(MbullNo 45472)

2pthsliied Insurance TP9l Limited ~~Corporate Office 402 Raheja Chambers Nariman Point Mumbai - 400 021 India Tel +9122 6112312322022147 T~IIfree No 1800228144 Fax~9122 22854415 ~tE-mail inforothshieldcoin Website wwwrothshleldcom TPA licence No 030

Schedule-7

1 Directors Report to be attached separately (Note Inter alia (i) to disclose the shareholding structure as at the end of financial year(ii)

Discuss Corporate Governance norms put-in place)

2 Auditors Report including audited financial and all notes schedules to audited financials to be

attached separately

Undertaking from Registered TPA Company

It is hereby declared that the particulars furnished with respect Annual Report of our TPA Company in

Form TPA - 8 and schedule 1 to 7 there under towards various activities of the TPA Company during the

FY2016-17 were examined and are true and correct It is also declared that the TPA Company did not

receive any other income or remuneration from any other sources other sources other than the one

that is declared in the above Schedule

Date

Place Mumbai

Forand on behalf of(ROTHSHIELD INSURANCETPA LIMITED)

h~~6d ~Mrs Anjana Bhate Ms Ja~ BhateDirector CEO

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Certificate from the Statutory Auditors of the TPA Company

Certificate that the above information about financials furnished in annual report and Schedule1

to 5 therein by Rothshield Insurance TPA Limited is an extracted from the transactions of the

TPA Company (Rothshield Insurance TPA Limited) for the Financial Year 2016-17

DatePlace Mumbai

Accountant

~HREN C SANGHAVI(MbullNo 45472)