Ms.

Lee Pui Chi

c/o Miss Ferice Wong
Oursky Limited
Flat/Room B 10/F
Great Wall Factory Building
11 Cheung Shun Street
Cheung Sha Wan Kowloon
Staff No.: 032

Confidential 密件

Claim Statement 賠償單 Issue Date 發出日期 : 30 DEC 21

Contract No. 合約編號 : 01402900

The claim(s) shown below has been processed. Please refer to the Summary for the total claim reimbursement.
以下索償已完成處理。請參閱「 賠償摘要」了解可獲賠償的總金額。

Employee name 僱員姓名 : Lee Pui Chi 李珮芝

Staff number 職員編號 : 032

Member name 會員姓名 : Lee Pui Chi 李珮芝

Membership number 會員編號 : 01402900 00010114
Eligible
Incurred Deducted Maximum benefit
Voucher Days expenses
Incurred date Benefit item expenses amount limit Remarks
number paid 合資格
治療日期 保障項目 申請索償金額 自費金額 最高保險限額 備註
索償表編號 日數 賠償金額
(HK$) (HK$) (HK$)
(HK$)
52760649 10 DEC 2021 Chiropractor 001 800.00 500.00 500.00 - A
脊醫
52760649 10 DEC 2021 Diag. Imaging & Lab Tests 001 400.00 0.00 1,500.00 - B 18,45
診斷影像及化驗
52760649 14 DEC 2021 Chiropractor 001 700.00 500.00 500.00 - A
脊醫
52760649 14 DEC 2021 Diag. Imaging & Lab Tests 001 400.00 0.00 1,500.00 - B 18,45
診斷影像及化驗

Subtotal of eligible expenses 合資格賠償金額小計 (HK$) 1,000.00

Claim reimbursement賠償金額 (HK$) 1,000.00

Summary 賠償摘要
Total claim reimbursement 賠償總金額 (HK$) 1,000.00

Remarks 備註:
18 : Maximum amount per year exhausted. 超過全年最高賠償金額限制
45 : Maximum amount for sub-limit per year exhausted 超過每年最高金額之次限制
A : Maximum amount per visit 每日每次之最高賠償金額
B : Maximum amount per year 每年之最高賠償金額

You will be reimbursed by autopay to your designated bank account 2 working days from the date of this claim statement.
賠償金額將於本賠償單發出日兩個工作天後自動轉賬至閣下之指定銀行戶口。

Bupa (Asia) Limited 保柏（ 亞洲 ）有限公司

18/F, Berkshire House, 25 Westlands Road, Quarry Bay Hong Kong
香港鰂魚涌華蘭路25號栢克大廈18樓
Telephone 電話: (852) 2517 5388 Facsimile 傳真: (852) 2548 1848 Website 網址: www.bupa.com.hk

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The terms and policy descriptions used on our website, myBupa, customer forms and letters may be different from the
VHIS plans. For details, please refer to the glossary on Bupa’s website or myBupa.
保柏網站、myBupa、客戶表格及信件上使用的部份詞彙及保單用詞，可能與自願醫保計劃有所不同。詳情請查閱保柏網
站或myBupa上的詞彙表。

This document is computer-generated. No signature or official stamp is required.

此文件由電腦列印，無須簽署或公司蓋印作實。

Bupa (Asia) Limited 保柏（ 亞洲 ）有限公司

18/F, Berkshire House, 25 Westlands Road, Quarry Bay Hong Kong
香港鰂魚涌華蘭路25號栢克大廈18樓
Telephone 電話: (852) 2517 5388 Facsimile 傳真: (852) 2548 1848 Website 網址: www.bupa.com.hk

2 of 2
BH-AT-A01149/M CLFSTM01/31122021/2