CLAIM_NUMBER MEMBER_CODE FAMILY_CODE PATIENT_NAME INSURED AGE GENDER

HI-BAX-001270479(0) 4760303D 4760303 B DHRUSHITHA MRS BASHETTY NIRUPAMA 18 Female

HI-BAX-001278748(0) 4760283E 4760283 DEVARAJA M N DEVARAJA M N 31 Male
RELATION_NAME EMPLOYEE_CODE EMPLOYEE_LOCATION AGENT_CODE DEV_OFF_CODE GROUP_NAME-Y_NO
Daughter 91 13002301 AJ PACKAGING L-1-13
Employee 82 AJ PACKAGING L-1-13
POLICY_TYPE POLICY_NO VALID_FROM VALID_TILL PRODUCT_NAME
Group 'GHA/Q1702351/13 9/16/2020 9/15/2021 Group Mediclaim-Tailor made
Group 'GHA/Q1702351/13 9/16/2020 9/15/2021 Group Mediclaim-Tailor made
SUB_PRODUCT_NAME MAIN_CLAIM SUM_INSURED BONUS_AMOUNT GROUP_NAME CCN_NO
1 300000 0 AJ PACKAGING LIMITED HI-BAX-001270479
1 300000 0 AJ PACKAGING LIMITED HI-BAX-001278748
CCN_EXT CCN_DATE CCN_TYPE_NAME SUB_CCN_TYPE CCN_AILMENT
0 5/7/2021 Reimbursement Reimbursement LEFT MEDIO TEMPORO OCCIPITAL LOBE CAVERNOMA
0 5/19/2021 Reimbursement Claim Intimation COVID - 19
FINAL_DIAGNOSIS HOSPITAL_NAME
LEFT MEDIO TEMPORO OCCIPITAL LOBE CAVERNOMA Krishna Institute of Medical Sciences Ltd
COVID - 19 Chitradurga Multi Speciality Hospital
HOSPITAL_ADDRESS PROVIDER_NO HOSPITAL_NETWORK_TYPE
MinisterRoad,Secunderabad,,,Secunderabad,AndhraPradesh,500003 66989 Non Network
Plotno.516,HarinakshiLayout,,,Chitradurga,Karnataka,577501 81894 Non Network
PPN_FLAG PPN_DATE HOSPITAL_CITY HOSPITAL_STATE HOSPITAL_PINCODE LIKELY_DOA DATEOF_ADMISSION
NO 12/31/1899 Secunderabad Andhra Pradesh 500003 5/3/2021 5/3/2021
NO 12/31/1899 Chitradurga Karnataka 577501 5/17/2021 5/17/2021
DATEOF_DISCHARGE AL_AMOUNT AL_DATE DL_DATE AL_STATUS LINE_OF_TREATMENT SURG_TYPE
5/7/2021 0 Surgical Major Surgery
0
DISEASE_NAME_LEVEL_I
Congenital malformations,deformations and chromosomal abnormalities
DISEASE_NAME_LEVEL_II DISEASE_NAME_LEVEL_III ICD_CODE_LEVEL_1
Congenital malformations of the circulatory system CONGENITAL STENOSIS OF AORTIC VALVE Q00-Q99
ICD_CODE_LEVEL_2 ICD_CODE_LEVEL_3 LEVEL_OF_CARE ROOM_CATEGORY INTIMATED_AMOUNT
Q20-Q28 Q23 Primary General 25000
Primary General 25000
TOTAL_BILL_AMT_RECD NOT_PAYBLE_AMOUNT DISCOUNT_AMOUNT TDS_AMOUNT SERVICE_TAX
403661 103661 0 0
0 0 0 0 0
AMOUNT_PAID_WITHOUT_TDS PAID_AMOUNT_WITH_TDS AMOUNT_PAYABLE DATE_OF_FILE_RECEIVED
0 0 300000 5/21/2021
0 0 0
REOPEN_DATE BILL_ENTRY_COMPLETE_DATE DEFICIENT_DATE DEFICIENCY_LETTER_SENT_DATE
8/25/2021 5/23/2021 5/25/2021 5/25/2021
FIRST_REMINDER_SENT_DATE SECOND_REMINDER_SENT_DATE DEFICIENCY_RETRIVAL_DATE
6/9/2021 6/24/2021 7/3/2021
MED_SCRUTINY_COMPLETE_DATE RFP_DATE AUTHORISED_DATE PAYMENT_DATE CHEQUE_DISPATCH_DATE
8/31/2021 9/3/2021
CLAIM_CLOSED_DATE CLAIM_REJECT_DATE MED_STATUS CLAIM_STATUS CCN_STATUS
Approval Request Sent Under Process
6/19/2021 Intimated and File not received Repudiated
DO_CODE DO_NAME RO_NAME INSURANCE_CO_NAME CHEQUE_NO
GHA/Q1 Bharti AXA General Insurance Company Limited
GHA/Q1 Bharti AXA General Insurance Company Limited
CHEQUE_CANCEL_STATUS ACCOUNTS_REMARK FLOAT_NO FLOAT_DATE CANCEL_STATUS
CANCEL_REASON_ACCOUNTS PAYEE_NAME OUTSTANDING_AMOUNT INLIAS_OUTSTANDING
300000
25000
DEFICIENCY_DETAILS
Required All Investigation Reports Done During Hospitalisation For Which Bills Attached.
REJECTION_REASON REJECTION_CLOSED_DATE
7/5/2021
Intimation done but claim file not received, hence the claim stands Repudiated. 6/19/2021
IC_CLAIM_NO INS_CODE CLAIMPASSED_DATE STATUS_CODE FLOAT_STATUS NEFT_STATUS FINAL_STATUS DAYS
ARS Outstanding 362
Q0381852 REPU Repudiated 362
FINAL_CLAIM_STATUS SUB_STATUS CLOSED_REASON CLAIMED_AMOUNT PAID_AMT OUT_AMT
OUTSTANDING Approval Request Sent 403661 0 300000
REPUDIATED Repudiated 25000 0 0
INCURRED_AMT AMOUNT PENDING REASON
300000 300000 Approval Request Sent
0 25000
 HEALTHINDIA INSURANCE TPA SERVICES PVT.LTD.
9/13/2021
OVERVIEW SUMMARY Report date 9/13/2021 18:14

INSURANCE CO Bharti AXA General Insurance Company Limited

GROUP NAME AJ PACKAGING LIMITED
POLICY NO 'GHA/Q1702351/13
VALID FROM 9/16/2020 VALID TILL 9/15/2021 362

Incurred Amount Net Premium Amount Claim Ratio (%) Earned Premium Earned Ratio (%)
300000 615003 48.78% 609948 49.18%

CLAIM SUMMARY REPORT

STATUS SUB STATUS TOTAL CLAIM CLAIMED AMT INCURRED AMT

Paid 0 0 0
SETTLED
UTR Awaited 0 0 0
0 0 0
Authorised 0 0 0
AL Issued 0 0 0
Approval Request Sent 1 403661 300000
Deficient Claim 0 0 0
OUTSTANDING
For Repudiation 0 0 0
NEFT Rejected 0 0 0
Intimated File Not Rec 0 0 0
Under Process 0 0 0
1 403661 300000
Closed:Al Issued file Not Rec 0 0 0
Closed:Deficient Claim 0 0 0
Closed:Cashless Denial 0 0 0
CLOSED
Closed:Pre-Auth Requested 0 0 0
Closed:Intimation Closed 0 0 0
Closed:Others 0 0 0
0 0 0
REPUDIATED Repudiated 1 25000 0

TOTAL 2 428661 300000