Patient Name ATIEN RACHMAN Record Calc ID 20-JKT014985-GOP01-02

Policy No. PRU-IND Client Name Prudential Life Assurance

Certificate No. 12107740 Product Name Prudential Individual
Claim No. 20-JKT014985 Plan Code H1TRB
Claim Type MED Plan Name H1TRB - HS Conventional (PLUS)
LOS Period 28-Aug-2019 to 31-Aug-2019 User Create Voltino Ardyan Putra

Benefit
Benefit Name Units Amount Actual Cost Discount Excess
Max Used Benefit Amount Max Benefit Used To Date

OVERALL PLAN LIMIT Per Year

0 0 200,000,000.00 200,000,000.00 6,291,964.00

Room & Board Days Per Year Per Day x 4

150 6 425,000.00 1,700,000.00 2,000,000.00 0.00 -300,000.00
Benefit Code Qty Actual Amount Discount
Room & Board - Utama ROOM9 4 500,000.00 0.00

GP Visit Per Visit x 1

0 2 150,000.00 150,000.00 50,000.00 0.00 0.00
Benefit Code Qty Actual Amount Discount
GP Visit 1 MED88 1 50,000.00 0.00

Specialist Visit Per Visit x 3

H1TRB 0 6 175,000.00 525,000.00 750,000.00 0.00 -225,000.00
Benefit Code Qty Actual Amount Discount
SP Consultation 1 MED83 3 250,000.00 0.00

Miscellaneous Hospital
Per Diagnosis Per Year x 1
Expenses
H1TRB 0 0 7,500,000.00 7,500,000.00 1,847,335.00 0.00 -10,000.00
Benefit Code Qty Actual Amount Discount
Pharmaceutical / Medicine (Prescription) MED009 - A15 1 1,002,335.00 0.00
In Hospital Nursing Charges MED011 - A15 1 280,000.00 0.00
X-Rays MED013 - A15 1 225,000.00 0.00
Laboratory - Blood MED24 - A15 1 155,000.00 0.00
General Administration Costs MED65 - A15 1 125,000.00 0.00
Emergency Treatment MED66 - A15 1 50,000.00 0.00
Uncovered Medical Expense MED74 1 -10,000.00 0.00
 Miscellaneous Benefit Accumulation per Diagnosis
Diagnosis Max Benefit Current Total Used To Date
A15 7,500,000.00 1,837,335.00 1,837,335.00

Total Hospital Fee 4,647,335.00

Discount 0.00
Paid By Patient -535,000.00
Paid By PSJ 4,112,335.00
NOTES
Curcuma : Rp. 10.000