RESTRICTED 11901006

Final Worksheet

Claim No : 24015181

Life Assured : GAN SENG KIAN

NRIC : 621211106393,6939652

Hospital Name : KPJ Klang Specialist Hospital

Admission Date : 11/01/2024 Discharge Date : 14/01/2024

: Pulmonary embolism without mention of acute cor
Diagnosis Description pulmonale : (Pulmonary embolism)(Pulmonary (artery)
(vein) : infarction/thromboembolism/thrombosis

Total Amount Paid By PAMB (MYR) : 12,619.17

Amount Payable By Policy Holder / Self-Pay
: 1,063.73
(MYR)
Policy No : 33476526

Effective Date : 04/04/2012

Medical Plan : PRUHealth

Room & Board Entitlement : MYR 200.00 / day

Paid By Policy
Benefit Item Actual Incurred Paid By PAMB
Holder / Self-Pay
Room & Board (3.0 days) 567.15 567.15 0.00

Hospital Charges 11,270.75

12,052.02 1,063.73
Surgical Benefit 1,845.00

Total Self-Pay Amount 1,063.73

Itemised Self-Pay Amount

Non Coverable Expense 63.73

Coinsurance 1,000.00

Grand total Actual Incurred (MYR) 13,682.90

Grand total paid by PAMB (MYR) 12,619.17

Grand total paid by Policy Holder / Self-
1,063.73
Pay (MYR)

Breakdown of Non Coverable Expenses(MYR)

Hospital & Surgical Benefits

Administrative / Registration / Admission / Service / Hospital Ancillary Fees -
60.00
REGISTRATION INPATIENT
Amount not payable under HAS - ID BAND ADULT WHITE 3.73

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*Disclaimer:
Prudential Assurance Malaysia Berhad (PAMB) reserves the right to exclude payment for
Charges that are deemed unnecessary / unrelated, as stipulated in our Hospital Alliance
Services Agreement.
ONLY VALID FOR ONE INPATIENT ADMISSION / DAY SURGERY
Print Date : 14/01/2024

Healthcare - Claims

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