29-Jan-15

CASHLESS INTIMATION
Sr. No.

Claim No.

Policy
NO

INSURED MEMBER
NAME
NAME

SEX

M/s
BHASKA
R
20150128 19010128 INDUSTR
B006C2A 14P10228 IES
RISHIRAJ
1 8098
4930
LIMITED SHARMA Male

M/s
20150128 19010128 VARDHM
B006C2A 14P10451 AN
2 8096
9524
YARNS
HARDIK

Male

THE
20150128 19010328 DIRECTO
B006C2A 14P10471 R YUVA TARACH
3 8099
9449
SANDHI AND

Male

AGE

RELATIO
SUM
N
INSURED

33 Employee

4 Son

18 Employee

100000

100000

INDIAN
INSTITUT
E OF
20150128 19030028 MANAGE RABI
B006C2A 14P10697 MENT
KUMAR
4 8089
4560
INDORE DEVI

Female

80 Mother

INDIAN
INSTITUT
E OF
20150128 19030028 MANAGE M J
B006C2A 14P10697 MENT
ANDREW
5 8090
4560
INDORE S
Male

79 Father

20150128 190900/4 NAGEND

B006C2A 8/14/06/0 RA
SUDHA
6 8100
0000449 SINGH
SINGH

40 Wife

Female

GENRAL INTIMATION
Sr. No.

Claim No.

Policy
NO

INSURED MEMBER
NAME
NAME

SEX

AGE

RELATIO
SUM
N
INSURED

PRAVEE
20150128 19010328 N
B006R2A 14P10567 CHOUDH
1 8087
6236
ARY

DR.
PRAVEE
N
CHOUDH
ARY
Male

58 Self

300000

SHRI
ARVIND
KUMR
20150128 19040228 MANAK
B006R2A 14P10407 LAL
VIVEK
2 8085
4221
DHAKAD DHAKAD Male

14 SON-2

100000

SHRI
ARVIND
KUMR
20150128 19040228 MANAK
B006R2A 14P10407 LAL
VIVEK
3 8097
4221
DHAKAD DHAKAD Male

14 SON-2

100000

20150128 19040228
B006R2A 14P10787 MR. DILIP DILIP
4 8101
6241
AGAR
AGAR

55 Self

300000

62 SELF

225000

SHRI
GURCHA
20150128 190900/4 RAN
B006R2A 8/13/97/0 SINGH
5 8088
0001540 SALUJA

Male

SHRI
GURCHA
RAN
SINGH
SALUJA Male

20150128 190900/4 NAGEND

B006R2A 8/14/06/0 RA
SUDHA
6 8086
0000449 SINGH
SINGH

Female

40 Wife

250000

20150128 191101/4
B006R2A 8/14/06/0 ANDRE
7 8095
0000006 SUNIL

ANILA
SUNIL

Female

41 Wife

200000

20150128 191501/4 TILOK

B006R2A 8/13/06/0 CHAND
8 8103
0000580 JAIN

PRAKHA
R
Male

20 Son

400000

Period of Period of
Insured
insurance insurance
address
- from
- to

Insured
contact no

15-16, D
SECTOR,
MANDIDE
27/06/201 26/06/201 EP
4
5
,RAISEN

HR
DEPART
MENT,
PLOT
NO.A1A6,
INDUSTR
IAL AREA
PHASE-II
MANDIDE
31/08/201 EP
1/9/2014 5
,BHOPAL ..........

M.P.
STATE
ACADEM
Y, SPORT
AND
YOUTH
WELFAR
22/07/201 21/07/201 E
4
5
,BHOPAL

Hospital
Name

Hospital
Address ICD code
& Phone

Cashless
request
Disease
received Date

B-46,
INDIRA
NAGAR,
MANDIDE
EP,
RAISEN, ,
SAI
RAISEN,
HOSPITA Ph:
0 L
233030
R07.4

Chest
pain,
unspecifie 28/01/201
d
5

23-24,
SATYA
VIHAR
COLONY,
NEAR
NEW
VIDHAM
SABHA,,
LAL
KOTHI,
JAIPUR,
Ph: 0141JAIN ENT 2742541,
HOPITAL 2742828 J35.9

Chronic
disease of
tonsils
and
adenoids,
unspecifie 28/01/201
d
5

30 MIG,
MLA
QTRS.,
OPP. DR.
KATJU
HOSPITA
L,
BHADBH
ADA
ROAD,
BHOPAL,
JASDEEP Ph: 0755 HOSPITA 2779878,
0 L
2779110 S02.2

Fracture
of nasal
bones

28/01/201
5

715 - 716,
VIJAY
SYNDICA
TE,,
ANNAPU
RNA
ROAD,
INDORE,
Ph: 073140992245,279988
1-4
H25

PIGDAMB
EDR
RAU,
INDORE
MADHYA
PRADES
28/11/201 27/11/201 H
4
5
,INDORE

Neema
Hospital
0 (P) Ltd.

PIGDAMB
EDR
RAU,
INDORE
MADHYA
PRADES
28/11/201 27/11/201 H
4
5
,INDORE

LIG
SQUARE,
A.B
ROAD, ,
CONVENI INDORE,
ENT
Ph: 0731HOSPITA 4220247,
0 LS LTD. 4220243 N11.0

Nonobstru
ctive
refluxassociate
d chronic
pyeloneph 28/01/201
ritis
5

123,
RAMDAS
PETH B/H
SOMALW
AR HIGH
SCHOOL
NAGPUR,
RAMADA
SPETH,
ARNEJA NAGPUR,
HEART
Ph:
INSTITUT 2548721,
E
2560848, I74

Arterial
embolism
and
thrombosi 28/01/201
s
5

7/7/2014

H NO 175
B SHAKTI
NAGAR
GUPTES
HWAR
,JABALP
6/7/2015 UR

Period of Period of
Insured
insurance insurance
address
- from
- to

Insured
contact no

Hospital
Name

Hospital
Remarks
address

CATARAC 28/01/201
T LT. EYE 5

Date Of
Disease Admissio
n

C-23,BDA
COLONY
KOHE
FIZA
22/10/201 21/10/201 BHOPAL ,
4
5
,BHOPAL

ASIAN
HEART
INSTITUT
E~
NO.
MUMBAI ,MUMBAI

7/9/2014

86,
JAGDEV
GANJ,
ALOTE,
DIST:
RATLAM
DIST. :
RATLAM,
MADHYA
PRADES
H,
6/9/2015 ,RATLAM 9993121872

GRATER
KAILESH
HOSPITA
L
,

7/9/2014

86,
JAGDEV
GANJ,
ALOTE,
DIST:
RATLAM
DIST. :
RATLAM,
MADHYA
PRADES
H,
6/9/2015 ,RATLAM 9993121872

Greater
Kailash
11/2, OLD
Hospital ~ PALASIA ,
INDORE INDORE

CHL JAIN
DIWAKA
76-78,
R
SAMTA
0000000000 HOSPITA SAGOD
31/12/201 PARISAR 9229572249 L ~
ROAD
1/1/2015 5
,RATLAM 0000000000 RATLAM ,RATLAM
H.NO 529
NAPIER
TOWN
BEHIND
GORAKH
PUR
GURUDA
WAR
JABALPU
R
,JABALP
12/3/2014 11/3/2015 UR

WISDOM
DENTAL
CLINIC
JABALPU
R
,

27/01/201
5

CANCLE
THE
GENERA
L
INTIMATI
ON

28/01/201
5

28/01/201
5

28/01/201
5

24/01/201
5

7/7/2014

MYRTE
VILLA 68CONVEN
T
NAGAR,
THEKKU
M
BHAGAM,
ERAVIPU
30/06/201 RAM
1/7/2014 5
,KOLLAM

7/2/2014

123,
RAMDAS
PETH B/H
ARNEJA SOMALW
HEART
AR HIGH
INSTITUT SCHOOL
E~
NAGPUR
NAGPUR ,NAGPUR

H NO 175
B SHAKTI
NAGAR
GUPTES
HWAR
,JABALP
6/7/2015 UR

27/01/201
5

(KIMS)
KERALA
INSTITUT
E OF
MEDICAL
0 SCIENCE ,

S/O. MR.
PUKHRAJ
KANKARI
YA,KAILA
SH
NAGAR
RAJNAN
DGAON ,
RAJ
NANDGA
6/2/2015 ON
9770690001

BM
SHAH
HOSPITA
L
,

29/01/201
5

Add;- B M
SHAH
HOSPITA
L BHILAI
CONTAC
T NO;NOT
MENTION
DISEASE;
- HIGH
FEVER
ESTIMAT
E
AMOUNT
NOT
CONFRM

26/01/201
5

Cashless
Date Of
Expected
request
Approve
Claim Approved
Admissio
discharg
STATUS
received Date
Amount Amount
n
e date
Time

28/01/201 28/01/201
16:08:49 5
5

34700

29/01/201 28/01/201
15:04:09 5
5

25300

29/01/201 28/01/201
16:21:53 5
5

7500

0 Query

15000 Approved

0 Query

29/01/201 28/01/201
12:37:35 5
5

16000

16000 Approved

27/01/201 28/01/201
13:06:55 5
5

25000

15000 Approved

27/01/201 28/01/201
17:11:28 5
5

175000

100000 Approved

Expected
discharg
e date

Claim
Amount

1000

1000

1000

1000

1000

1000

1000

1000