Bharat Petroleum Corporation Limited

Medical Claim Form CLM20231100022454001

KARTHIKEYAN VINOD (22454 ) JG/Grade : Job Group A1

Cadre : Management Region/Location : KR / POWER & UTILITY

Claim For : VINOD KUMAR Ailment : BP / DIABETES / HYPERTENSION

Relationship : Father Treatment Type : Allopathy

Age : 46 Claim Amount : 3572.00

Claim Type : Domiciliary (Non Hosp) Adv Settled : 0.00

Remarks : AS I JOINED IN JUNE I DINT KNEW ABOUT PRESCRIPTION, SO PLEASE KINDLY CONSIDER FOR MO

Expense Type Amount

Medicines / Injections 3572.00

Claim For : VINOD KUMAR Ailment : FEVER / COLD / COUGH / URTI

Relationship : Father Treatment Type : Allopathy

Age : 46 Claim Amount : 740.00

Claim Type : Domiciliary (Non Hosp) Adv Settled : 0.00

Remarks :

Expense Type Amount

Pathology / Lab Test Charges 740.00

Claim For : PRATHIMA Ailment : BP / DIABETES / HYPERTENSION

Relationship : Mother Treatment Type : Allopathy

Age : 47 Claim Amount : 1929.00

Claim Type : Domiciliary (Non Hosp) Adv Settled : 0.00

Remarks :

Expense Type Amount

Medicines / Injections 1929.00

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 Bharat Petroleum Corporation Limited
Medical Claim Form CLM20231100022454001

Claim For : SELF Ailment : OPTICALS / OPTHAL & CATARACT

Relationship : SELF Treatment Type : Allopathy

Age : 22 Claim Amount : 350.00

Claim Type : Domiciliary (Non Hosp) Adv Settled : 0.00

Remarks : EYE CHECKUP

Expense Type Amount

Consultation Fee 300.00

Others 50.00

Claim Amount : 6591.00 Date :Jan 29, 2024 Signature :

Administrator Use Only

Sanctioned Amt: Date : Deduction :

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