Medical Claim - Hospitalisation / Non-Hospitalisation

Claim Submitted Date 21.12.2018

Employee Name : Debobrata Das Employee Number : 60065027

Region : Eastern Region - II Location : Birpara
Department : S/S-O&M Designation : Jr Engr Gr-II

Claim Detail

Non-Hospitalisation
Request ID Patient's Name Treatment Date Consultation Amt Injection Amt Medicine Amt Patho Amt Total Amount T/NT

180000223896 Debobrata Das 05.08.2018 0.00 0.00 737.80 0.00 Rs.737.80 T

180000223897 Debobrata Das 09.09.2018 0.00 0.00 957.00 0.00 Rs.957.00 T

180000223898 Debobrata Das 14.09.2018 500.00 0.00 907.00 1580.00 Rs.2,987.00 T

180000223899 Debobrata Das 11.12.2018 600.00 0.00 943.00 0.00 Rs.1,543.00 T

Total Amount Rs.6,224.80

Note: Claim form and supporting medical documents need to be submitted in concerned Finance Department.

Declaration

Certified that the particulars mentioned in this claim are true to best of my knowledge and belief and that the person for
whom medical expenses were incurred is wholly dependent upon me and residing with me.

Signature of the Employee Signature of the Approving Officer

Mob. No. - 9563637306

Approving Authority :
At CC .
E3 - Upto Rs.200/- , E4/E5 - Upto Rs.1000/-, E6/E7/E7A - Upto Rs.1,500/- (including own claims),
GM & above -Full powers (including own claims).
In relaxation of Normal Rules : GM(HR) - Upto Rs.2,000/-, D(P) - Full powers

At RHQ and Sites.

As per normal Rules : DM - Upto 500, CM/MGR Upto Rs.1500/-, DGM & above - Rs.1501 & above
Self Approving : DGM/CM/MGR - Upto Rs.1000/-, ED/GM - All claims.
In relaxation of Normal Rules : GM - Upto Rs.2000/-, ED - Full powers.