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Atien Rachman - Calc

This document is an insurance claim summary for patient ATIEN RACHMAN for treatment from August 28-31, 2019. It details benefits paid and remaining for room and board, doctor visits, specialist visits, and miscellaneous hospital expenses. The patient received treatment for diagnosis A15 totaling Rp. 1,837,335, which was applied to the Rp. 7,500,000 annual miscellaneous benefit limit. The total hospital fees were Rp. 4,647,335, with Rp. 535,000 paid by the patient and Rp. 4,112,335 paid by the insurance provider.

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Qonita Luthfia
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89 views2 pages

Atien Rachman - Calc

This document is an insurance claim summary for patient ATIEN RACHMAN for treatment from August 28-31, 2019. It details benefits paid and remaining for room and board, doctor visits, specialist visits, and miscellaneous hospital expenses. The patient received treatment for diagnosis A15 totaling Rp. 1,837,335, which was applied to the Rp. 7,500,000 annual miscellaneous benefit limit. The total hospital fees were Rp. 4,647,335, with Rp. 535,000 paid by the patient and Rp. 4,112,335 paid by the insurance provider.

Uploaded by

Qonita Luthfia
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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

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