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Claim Details
Name of Insurance Co : Universal Sompo General
Insurance Company Ltd.
U/W Office Name : MUMBAI OFFICE
Policy Number : 2816/55107991/00/000
Group Name : JAIN INTERNATIONAL
ORGANISATION (JIO).
Employee Number : SAH216428

PHS ID : 2949887

Name of Beneficiary : LALITHA

Name of Proposer/Employee : P SURESH JAIN
Policy Period : 21/05/2015 to 20/05/2016

Gender : FEMALE

Address : # 20 Rhenius Street B

Nanjappa Circle Karnataka
Bengaluru Bengaluru 560025

Relation : Wife

Claim Registration
Name of Provider : SELVARANGAM HOSPITAL
Insurer CCN : 0

Processing Branch : 022

Date of Admission : 17/08/2015

FIR Date : 09/09/2015

Date of Discharge : 03/09/2015

FIR Number : 2897058

Al/Denial Date : -

FIR Extention :

Al Amount: 0

Partial Payment Seq: 0

Additional Al Amount: 0

Deficiencies : -

Date of File Received : 09/09/2015

Claim Processing
Bill Received Date : 09/09/2015

Amount Cleared : 131258

Provider Bill Amount : 222723

Amount Cleared Beneficiary : 131258

Pre/Post Provider Bill Amount

2924
:

Amount Cleared Provider : 0

Total Amount Claimed : 225647

Discharge Voucher Sent Date : 08/10/2015

Processing Status : Ready for Settlement

Discharge Voucher received
08/10/2015
Date:
Service Tax : 0

Claim Processed Date : 01/10/2015

Not Payable Expenses : 94389

TDS Amount : 0

Deduction Reasons : Rs 8500/- AC charges, Rs 6000/- Extra Attender , Rs 600/- TV Charges, RS 1000/- Monitor
charges part of ICU, RS 3000/- Special Nurse charges not payable, Rs 4100/- Excess ICU Room
charges as per policy, Rs 54211/- Incremental charges as per policy, RS 14584/- Deducted as
co-pay 10% applied on pre existing diseasesRS 660/- pre and post charges not payableRs 90/Drink charges not payableRS 120/- Drink charges not payableRs 150/- Drink charges not
payableRS 90/- Drink charges not payableRS 68/- skin blade, RS 453/- Resporometer , Rs
290/-nebulizer mask charges not payableRs 133/- under pad charges not payableRs 65/- plain
sheet , Rs 150/- Chest lead, RS 125/- under pad charges not payable

Payment
Lot No :
Date of Payment to Provider : -

Date of Payment to Beneficiary : -

Amount Paid to Provider : -

Amount Paid to Beneficiary : -

Cheq. No of Payment to
Provider:

Cheq. No of Payment to Beneficiary :

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12/4/2015 10:12 AM