CLAIM STATUS

Claim No. 9021011123114

Memberid N9010516447
Unique Policy Number 110600/34/10/11/00003764
Insured Name Mr. Brijesh Doshi
Patient Name Mr. Brijesh Doshi
Relation Self
Admission Date/ Discharge Date 03-oct-2010 / 05-oct-2010
For the Treatment of Hill sach’s defect +anterior-inferior labrum tear
Hospital Name The Bhatia General Hospital - null
Claim Received Date 19-NOV-2010
Claim Amount Rs. 147025/-
Document Check List
Claim Processing Date
We are in receipt of your claim documents. As per available documents, patient
was admitted for Hill sachÂ’s defect +anterior-inferior labrum tear had undergone
treatment for the same. Patient was been admitted on 03/10/2010 and was
discharged on 05/10/2010. Now the claim has been submitted to us on
16/11/2010 i.e. more than 30 days after discharge from the hospital. Hence this
claim stands non payable under Exclusion Clause 11.0
Reason for NonPayable:
EXCLUSION CLAUSE 11.0
Final claim along with hospital receipted original Bills/Cash memos, claim form
and documents as listed in the claim form should be submitted to the Policy
issuing Office/TPA not later than 30 days of discharge from the hospital. The
insured may also be required to give the Company/TPA such additional
information and assistance as the Company/TPA may require in dealing with the
claim, from time to time Hill sachÂ’s defect +anterior-inferior labrum tear
Cheque No./ Amount No Cheque Number / 0
Cheque Dispatch Date/Courier Name
Deduction: NA,
Dispatch Date/Courier Name (Latest Dispatch
18-DEC-2010 BLUE BIRD MAIL SERVICES PVT.LTD(Nonpayable Letter)
Details)
 CLAIM STATUS

Claim No. 9021011135603

Memberid N9010676401
Unique Policy Number 110600/34/09/11/00008210
Insured Name Mr. Ashok V. Mittal
Patient Name Mr. Ashok V. Mittal
Relation Self
Admission Date/ Discharge Date 04-nov-2010 / 05-nov-2010
For the Treatment of K/C/O MYOCARDIAL DISEASE WITH BILIARY COLIC
Hospital Name BREACH CANDY HOSPITAL TRUST - null
Claim Received Date 08-DEC-2010
Claim Amount Rs. 63555/-
Document Check List
Claim Processing Date
We are in receipt of your claim documents. As per available documents, patient
was admitted with complaints of K/C/O MYOCARDIAL DISEASE WITH BILIARY
COLIC on 04/11/2010 and was discharged on 05/11/2010. Now the claim has
been submitted to us on 08/12/2010 i.e. more than 30 days after the date of
discharge. Any claim for reimbursement has to be submitted to us within 30 days
after discharge of the patient from the hospital. Hence this claim is not admissible
Reason for NonPayable:
under Clause 11.0.

Clause 11.0:- Final claim along with hospital receipted original Bills / Cash
memos / reports, claim form and list of documents as listed below should be
submitted to the company / TPA within 30 days of discharge from the Hospital /
Nursing Home. K/C/O MYOCARDIAL DISEASE WITH BILIARY COLIC
Cheque No./ Amount No Cheque Number / 0
Cheque Dispatch Date/Courier Name
Deduction: NA,
Dispatch Date/Courier Name (Latest Dispatch
Details)
 CLAIM STATUS

Claim No. 9021011106975

Memberid BN1137797
Unique Policy Number 110600/34/10/11/00001041
Insured Name Mrs Saroj A.Shah
Patient Name Mrs Saroj A.Shah
Relation Self
Admission Date/ Discharge Date 09-oct-2010 / 09-oct-2010
For the Treatment of Right Eye Cataract PCIOL
Hospital Name Forsight Eye Centre - null
Claim Received Date 18-OCT-2010
Claim Amount Rs. 35800/-
The following Document are Requierd to Process Your Claim
Document Check List Kindly provide Tax invoice of IOL used.
Kindly provide Tax invoice of IOL used.
Claim Processing Date
Claim In Query: Query Letter
Cheque No./ Amount No Cheque Number / 0
Cheque Dispatch Date/Courier Name
Deduction:
Dispatch Date/Courier Name (Latest Dispatch
11-NOV-2010 Vichare Couriers(Query Letter)
Details)

CLAIM STATUS
Claim No. 9021011104224
Memberid N9010994252
Unique Policy Number 110600/34/09/11/00011408
Insured Name Mr. Sukesh Solanki
Patient Name Mrs. Krupali S. Solanki
Relation Wife
Admission Date/ Discharge Date 26-aug-2010 / 01-sep-2010
For the Treatment of Dengue fever
Hospital Name Amit Hospital - null
Claim Received Date 11-OCT-2010
Claim Amount Rs. 10932/-
Document Check List
Claim Processing Date
. We are in receipt of your claim documents. As per available documents, patient
was admitted for Dengue fever had undergone treatment for the same. Patient
was been admitted on 26/08/2010 and was discharged on 01/09/2010. Now the
claim has been submitted to us on 11/10/2010 i.e. more than 30 days after
discharge from the hospital. Hence this claim stands non payable under
Exclusion Clause 11.0
Reason for NonPayable:
EXCLUSION CLAUSE 11.0
Final claim along with hospital receipted original Bills/Cash memos, claim form
and documents as listed in the claim form should be submitted to the Policy
issuing Office/TPA not later than 30 days of discharge from the hospital. The
insured may also be required to give the Company/TPA such additional
information and assistance as the Company/TPA may require in dealing with the
claim, from time to time Dengue fever
Cheque No./ Amount No Cheque Number / 0
Cheque Dispatch Date/Courier Name
Deduction: NA,
Dispatch Date/Courier Name (Latest Dispatch
11-NOV-2010 Vichare Couriers(Nonpayable Letter)
Details)

CLAIM STATUS

Claim No. 902101184020

Memberid BN1151912
Unique Policy Number 110600/34/09/11/00005657
Insured Name Suryakant Shah
Patient Name Suryakant Shah
Relation Self
Admission Date/ Discharge Date 22-jul-2010 / 28-jul-2010
For the Treatment of Severe anaemia-AV fistula done k/c/o HTN,DM
Hospital Name Arihant Heart Clinic - null
Claim Received Date 08-SEP-2010
Claim Amount Rs. 61372/-
Document Check List
Claim Processing Date
We are in receipt of your claim documents. As per available documents, patient
was admitted with Severe anaemia-AV fistula done k/c/o HTN,DM from 22/07/10
to 28/7/10. The claim was submitted to us on 8/09/10 i.e.. more than 30 days
after the date of discharge. The reason provided for delay in submission of claim
is not acceptable
This claim therefore stands non admissible under clause 11.0. Severe anaemia-
AV fistula done k/c/o HTN,DM
Reason for NonPayable:
As per policy clause 11.0
Final Claim along with hospital receipted original bills/cash memos, calim from
and documents as listed in the claim from should be submitted to the Policy
issuing Office/TPA not later than 30 days of discharge from the hospital. The
insured may also be required to give the Company/TPA such additinal
information and assistance as the Company/TPA may require in dealing with the
claim
Cheque No./ Amount No Cheque Number / 0
Cheque Dispatch Date/Courier Name
Deduction: NA,
Dispatch Date/Courier Name (Latest Dispatch
27-NOV-2010 Vichare Couriers(Query Letter)
Details)

CLAIM STATUS

Claim No. 9021011108137

Memberid BN1151912
Unique Policy Number 110600/34/09/11/00005657
Insured Name Suryakant Shah
Patient Name Suryakant Shah
Relation Self
Admission Date/ Discharge Date 13-sep-2010 / 16-sep-2010
For the Treatment of CRF with IHD,HTN
Hospital Name Arihant Heart Clinic - null
Claim Received Date 21-OCT-2010
Claim Amount Rs. 42182/-
Document Check List
Claim Processing Date
We are in receipt of your claim documents. As per available documents, patient
was admitted with CRF with IHD,HTN from 13/09/10 to 16/09/10. The claim was
submitted to us on 21/10/10 i.e.. more than 30 days after the date of discharge.
The reason provided for delay in submission of claim is not acceptable
This claim therefore stands non admissible under clause 11.0.
As per policy clause 11.0
Reason for NonPayable:
Final Claim along with hospital receipted original bills/cash memos, calim from
and documents as listed in the claim from should be submitted to the Policy
issuing Office/TPA not later than 30 days of discharge from the hospital. The
insured may also be required to give the Company/TPA such additinal
information and assistance as the Company/TPA may require in dealing with the
claim CRF with IHD,HTN
Cheque No./ Amount No Cheque Number / 0
Cheque Dispatch Date/Courier Name
Deduction: NA,
Dispatch Date/Courier Name (Latest Dispatch
26-NOV-2010 Vichare Couriers(Query Letter)
Details)

CLAIM STATUS

Claim No. 9021011141513

Memberid BN1151912
Unique Policy Number 110600/34/10/11/00005601
Insured Name Mr.Shah Suryakant
Patient Name Mr.Shah Suryakant
Relation Self
Admission Date/ Discharge Date 23-nov-2010 / 27-nov-2010
For the Treatment of CAPD CANNULA INSERTED
Hospital Name SHRI BALA HANUMAN MATERNITYAND SURGICAL HOSPITAL - null
Claim Received Date 22-DEC-2010
Claim Amount Rs. 39004/-
Document Check List
Claim Processing Date
AS PER AVAILABLE DOCUMENTS THE PATIENT WAS ADMITTED WITH
CAPD CANNULA INSERTED WHICH IS NOT COVERED UNDER THE SCOPE
Reason for NonPayable:
OF THE POLICY AS PER CLAUSE 4.4.15 HENCE THIS CLAIM STANDS NON
PAYABLE. CAPD CANNULA INSERTED
Cheque No./ Amount No Cheque Number / 0
Cheque Dispatch Date/Courier Name
Deduction: RS.39004/- NON PAYABLE ,
Dispatch Date/Courier Name (Latest Dispatch
Details)