14-Jul-14

CASHLESS INTIMATION
Sr. No.

Claim No.

Policy
NO

INSURED MEMBER
NAME
NAME

SEX

AGE

RELATIO
SUM
N
INSURED

20140711 190101/4 MR.

SMT.
B006C2A 8/14/97/0 INDERJIT SHARDA
1 5686
0000044 SETHI
SETHI
Female

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

20140711 190400/4 MR.

B006C2A 8/14/41/0 SANJAY KU.
3 5695
0000059 PANCHAL DISHA

11 Daughter

Female

20140712 190404/4 Mr.

B006C2A 8/13/97/0 ANANDI SHUSHIL
4 5708
0000446 LAL JAIN A JAIN
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

20140712 19110228 MR.

MR.
B006C2A 14P10108 CHANDA CHANDA
6 5707
4530
PIYUSH PIYUSH 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

20140711 190300/4 KAMAL

B006R2A 8/13/41/0 KISHORE SUMAN
3 5688
0003180 NEEMA
NEEMA

Female

65 Wife

500000

20140711 190300/4 KAMAL

B006R2A 8/13/41/0 KISHORE SUMAN
4 5689
0003180 NEEMA
NEEMA

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

10:40:06 10/7/2014 12/7/2014

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

13:32:31 11/7/2014 12/7/2014

22000

14:27:18 12/7/2014 12/7/2014

12000

Expected
Claim
discharg
Amount
e date

0 Query

10000 Approved

0 Query

1000

1000

1000

1000

1000

1000

1000

1000