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    GAL BillSummaryOtherProducts CLMG 2025 231123 0109777 1714491288004

    Uploaded by

    gopendra garg
    The document is a bill assessment sheet for a hospital payment under a health insurance policy. It provides details of the insured person, hospitalization period and expenses, deductions applied and the net approved payable amount.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    GAL BillSummaryOtherProducts CLMG 2025 231123 0109777 1714491288004

    Uploaded by

    gopendra garg
    17 views4 pages
    The document is a bill assessment sheet for a hospital payment under a health insurance policy. It provides details of the insured person, hospitalization period and expenses, deductions applied and the net approved payable amount.

    Original Description:

    Summary of accounts

    Original Title

    GAL_BillSummaryOtherProducts_CLMG_2025_231123_0109777_1714491288004

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    © © All Rights Reserved

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    The document is a bill assessment sheet for a hospital payment under a health insurance policy. It provides details of the insured person, hospitalization period and expenses, deductions applied and the net approved payable amount.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    17 views4 pages

    GAL BillSummaryOtherProducts CLMG 2025 231123 0109777 1714491288004

    Uploaded by

    gopendra garg
    The document is a bill assessment sheet for a hospital payment under a health insurance policy. It provides details of the insured person, hospitalization period and expenses, deductions applied and the net approved payable amount.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    STAR HEALTH AND ALLIED INSURANCE CO.Ltd.

    ,
    No.15, SRI BALAJI COMPLEX,1st FLOOR, WHITES LANE,ROYAPETTAH,CHENNAI-
    Customer Care Number - 044 6900 6900 | Corporate Customers - 044
    43664666 |
    Chat - +91 9597652225, www.Starhealth.in

    BILL ASSESSMENT SHEET - HOSPITAL PAYMENT


    Intimation No CIR/2025/231123/0108415 Bill Approved Date

    Insured Name SHIVAM GARG Policy No 11240311344600


    Certificate of Insurance
    No.
    Claimant Name SAKSHI GARG Product Name Family Health Optima Insurance Plan
    DOB/Age 20/12/2022 - 0 years
    Policy Period 26-06-2023 to 25-06-2024
    Address : 04 SIRIYA SARAYA GALI,
    SONKH DEHAT, Hospital Name AMAR HEALTHCARE
    SONKH
    NA Hospital Address Radhapuram Crossing, Highway Nh-2
    Pincode : 281123 MATHURA - 281004
    NA Uttar Pradesh
    NA
    Telephone : 7017914438 DOA 23-04-2024

    DOD 26-04-2024
    Sum Insured 500000
    Bonus 0 Final Diagnosis ACUTE GASTROENTERITIS WITH
    Copay % 0.0% SEVERE DEHYDRATION,
    SM Code / Name SH43554 / SANDEEP KUMAR MITTAL

    Intermediary Code / BA0000190975 / SEEMA AGARWAL ICD Codes Desc A09.9,


    Name SECTION

    Hospitalisation Expenses
    Amount Disallowed
    Approve
    Nature of Amount Non Proportionate
    SNo Bill No Bill Date d Disallowance Reasons / Remarks
    Expenditure Claimed Payable Deduction
    Amount
    (A) (B)

    Room Rent(Inclusive
    1 of GST) & Nursing 12000 12000
    charges

    Professional Fees
    (Surgeon, Anastheist,
    2 4000 4000 ,
    Consultation Charges
    etc)

    Investigation &
    3 1950 1950
    Diagnostics

    a.ii) Medicines -
    4 12921 558 12363 thermometer,uro bag,cotton not payable
    outside Hospital

    5 Others 700 700 file,op not payable ,

    IRDAI Registration No: 129 | CIN: L66010TN2005PLC056649 | Ph: 044-28288800 | Email: [email protected]
    Amount Disallowed
    Approve
    Nature of Amount Non Proportionate
    SNo Bill No Bill Date d Disallowance Reasons / Remarks
    Expenditure Claimed Payable Deduction
    Amount
    (A) (B)
    Total 31571

    Deductibles (A + B) 1258

    Hospital Discounts

    Network Hospital Discounts -3637 Refer Note #1

    Deductions

    NET AMOUNT (Total - Deductibles,


    Hospital Discounts 26676
    & Deductions)

    IRDAI Registration No: 129 | CIN: L66010TN2005PLC056649 | Ph: 044-28288800 | Email: [email protected]
    Amount claimed 31571

    Total Deductions 1258

    a. Non payable 1258

    b. Proportionate Deductions 0

    Approved Amount (after Total Deductions) 30313

    Less: Hospital Discounts 0

    Less: Other deductions 0

    Net Amount (Approved amount - Hospital


    26676
    discounts and other deductions )

    Amount considered 26676

    Co-Pay Amount 0

    Amount considered after co pay 26676

    Exceeds sub limit 0

    Less: Amount settled by other Insurer 0

    Exceeds Sum Insured 0

    Amount payable 26676

    Claim Restrictions 0

    Preauth approved amount 26676


    Amount payable to Hospital 26676

    Less: Network Hospital Discount 3637

    Net Amount payable to Hospital 26676

    Consolidation Summary

    Section Amount

    Total amount claimed 31571

    Hospitalisation payable amount 26676

    Pre hospitalisation payable amount 0

    Post hospitalisation payable amount 0


    Add on Benefit(Hospital Cash / Patient
    0
    care)
    Total Claim Payable Amount 26676

    IRDAI Registration No: 129 | CIN: L66010TN2005PLC056649 | Ph: 044-28288800 | Email: [email protected]
    # Remarks

    Note Disallowance Reasons / Remarks


    *12% Discount on final approved amount.w.e.f-31-Mar-2021. Discount will apply on accepted MINI SOC Discount will not
    apply on ANH Package rates.

    #1

    IRDAI Registration No: 129 | CIN: L66010TN2005PLC056649 | Ph: 044-28288800 | Email: [email protected]

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