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Inv.14 July 14
Inv.14 July 14
CASHLESS INTIMATION
Sr. No.
Claim No.
Policy
NO
INSURED MEMBER
NAME
NAME
SEX
AGE
RELATIO
SUM
N
INSURED
71 WIFE
150000
MR.
MAST.
20140712 190103/4 SUNIL
ADIT
B006C2A 8/13/97/0 AGRAWA AGRAWA
2 5703
0000453 L
L
Male
14 SON-1
100000
11 Daughter
Female
64 Wife
125000
20140712 190804/4
B006C2A 8/14/41/0 M/s S R F AJAY
5 5706
0000096 LIMITED LAROIA
41 Employee
300000
29 Self
100000
Male
GENRAL INTIMATION
Sr. No.
Claim No.
Policy
NO
INSURED MEMBER
NAME
NAME
SEX
AGE
RELATIO
SUM
N
INSURED
M/s
BHASKA
R
20140711 190101/4 INDUSTR
B006R2A 8/13/41/0 IES
SONU
1 5691
0000491 LIMITED SINGH
Male
27 Employee
50000
MR.
MAST.
20140711 190103/4 SUNIL
ADIT
B006R2A 8/13/97/0 AGRAWA AGRAWA
2 5696
0000453 L
L
Male
14 SON-1
100000
Female
65 Wife
500000
Female
65 Wife
500000
Mr.
20140712 190402/4 LAXMINA
B006R2A 8/13/97/0 RAYAN
NIRMALA
5 5705
0001094 DHARWA DHARWA Female
57 Wife
100000
SHRI
20140712 190404/4 UMESH
B006R2A 8/13/97/0 KUMAR
6 5709
0000474 PARIKH
51 Self
50000
SHRI
UMESH
KUMAR
PARIKH
Male
20140711 190804/4
B006R2A 8/14/41/0 M/s S R F AJAY
7 5704
0000096 LIMITED LAROIA
Male
BRO
20140711 191101/4 ASSISI
JESUDAS
B006R2A 8/13/97/0 PROVINC CHOOND
8 5682
0000213 E
I
Male
41 Employee
67 Self
300000
75000
Period of Period of
insuranc insurance
e - from
- to
Insured
address
Insured
contact
no
Hospital
Name
Hospital
Address ICD code
& Phone
Cashless
request
Disease
received Date
78,
RIZWAN
BAGH,
VIP
ROAD,
26/04/201
BHOPAL ,
4
25/04/2015 BHOPAL
106, OLD
TAJ
MARKET,
NEAR
G.P.O,,
HI - TECH ROYAL
EYE
MARKET,
CARE & BHOPAL,
LASER
Ph: 07550 CENTRE 2531679 H25
SENILE
CATARAC
T LEFT
EYE
11/7/2014
143
SECTOR
A,
INDRAPU
RI BHEL
26/07/201
BHOPAL ,
3
25/07/2014 BHOPAL
E-3/23,
ARERA
COLONY,
BHOPAL,
,
BHOPAL,
NARMAD Ph: 0755A
4040000,
TRAUMA 4040001,
CENTER 4040002,
0 PVT.LTD 4040003 S52.5
Fracture
of lower
end of
radius
12/7/2014
VIRAL
FEVER
11/7/2014
11/6/2014
EWS
111/311INDRA
NAGAR
AGAR
ROAD
10/6/2015 ,UJJAIN
SANJEEV
ANI
HOSPITA
L&
RESEAR
CH
0 CENTRE
45,
UNIVERS
ITY
ROAD,
DASHER
A
MAIDAN
UJJAIN, ,
UJJAIN,
Ph:
4066177 R50
NAVKAR
APARTM
ENT, KALI
DAS
PATH
BARNAG
AR
DISTT,
MANDSA
26/03/201
UR
4
25/03/2015 ,UJJAIN
MALANP
27/04/201
UR
4
26/04/2015 ,BHIND
S/O SHRI
DHIRAJ
CHANDA
BUNGLO
W NO.5,
SOUMYA
ESTATE
KHAJURI
21/04/201
KALAN
4
20/04/2015 ,BHOPAL
Period of Period of
insuranc insurance
e - from
- to
Insured
address
SAHAJ
HOSPITA
LS
ENDOSC
OPIC
SUPER
SPECIALI
TY
CENTRE
0 PVT. LTD.
15/2,
SOUTH
TUKOGA
NJ
INDORE,
,
INDORE,
Ph:
2510200 M51.9
20 B/3
D.B.GUP
TA ROAD
KAROL
BAGH, ,
NEW
DELHI,
Ph:
28716363
,
28717474
,
BALI
41547041
NURSING ,4154704
9.0E+009 HOME
0
N20
CITY
HOSPITA
L&
RESEAR
CH
CENTRE
0 PVT. LTD.
Insured
contact
no
Hospital
Name
21/2,
NORTH
CIVIL
LINES , ,
JABALPU
R, Ph:
0761 4033111,4
044111,26
25171,26
25172
M23.2
Hospital
Remarks
address
Interverte
bral disc
disorder,
unspecifie
d
12/7/2014
Calculus
of kidney
and ureter 12/7/2014
Derange
ment of
meniscus
due to old
tear or
injury
12/7/2014
Date Of
Disease Admissio
n
15-16, D
SECTOR,
INDUSTR
IAL
AREA,MA
13/12/201
NDIDEEP
3
12/12/2014 ,RAISEN
NATIONA
L
HOSPITA
L~
BHOPAL
E - 3/61,
ARERA
COLONY,
,BHOPAL
11/7/2014
143
SECTOR
A,
INDRAPU
RI BHEL
26/07/201
BHOPAL ,
3
25/07/2014 BHOPAL
NARMAD
A
TRAUMA
CENTER
PVT.LTD
~
0 BHOPAL
E-3/23,
ARERA
COLONY,
BHOPAL ,
BHOPAL
10/7/2014
80 INDRA
LOK
COLONY
RTO
27/12/201
ROAD
3
26/12/2014 ,INDORE
93036686
60
NIHAR
93036686 NETRALA
60
YA
,
80 INDRA
LOK
COLONY
RTO
27/12/201
ROAD
3
26/12/2014 ,INDORE
93036686
60
NIHAR
93036686 NETRALA
60
YA
,
12/3/2014
B-119ALKAPU
RI
11/3/2015 ,RATLAM
KACHOT
TA
COMPLE
X
NAYAPU
RA ROAD
MANDSA
UR
28/03/201
,MANDSA
4
27/03/2015 UR
11/7/2014
cancel the
General
intimation
11/7/2014
CHL JAIN
DIWAKA
R
HOSPITA SAGOD
L~
ROAD
0 RATLAM ,RATLAM
12/7/2014
NO. 1,
TULSIBA
UG
SOCIETY,
OPP.
DOCTOR
HOUSE,
ELLISBRI
APOLLO DGE,
HOSPITA AHMEDA
L~
BAD
AHMEDA ,AHMEDA
0 BAD
BAD
12/7/2014
MALANP
27/04/201
UR
4
26/04/2015 ,BHIND
ASSISI
PROVINC
IALATE,
P.B.NO.5, PATEL
NAGAR,
15/12/201
BHOPAL ,
3
14/12/2014 BHOPAL
BALI
NOURISH
ING
HOME
NEW
9.0E+009 DELHI
,
94250040
97
PUSHPA DALLI 94250040 HOSPITA RAJHARA
97
L ~ DURG ,DURG
11/7/2014
10/7/2014
Cashless
Date Of
Expected
request
Approve
Claim Approved
Admissio
discharg
STATUS
received Date
Amount Amount
n
e date
Time
16/07/201
13:03:11 4
11/7/2014
27000
74000
0 Query
17/07/201
16:25:39 4
12/7/2014
17250
8000 Approved
27000 Approved
13/07/201
15:32:11 4
12/7/2014
120000
22000
12000
Expected
Claim
discharg
Amount
e date
0 Query
10000 Approved
0 Query
1000
1000
1000
1000
1000
1000
1000
1000