ketut stitha prajna sugi hari_1977138
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7/25/2019 Ketut Stitha Prajna Sugi Hari_1977138
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Client : PRUhospital & surgical
Group : Prudential Individual
Patient : KETUT STITHA PRAJNA SUGI HARI
Member No. : 1977138 A
Client No. : Open
Claim Ref. : 267572 / 3652436 / 1
Provider : RSU KERTHA USADA SingarajaClaim Type : Inpatient
Date of Service : 15-Jun-2016 - 18-Jun-2016 Polis No. : 18527203
Item Charge Approved Benefit Paid Excess Charge
Biaya Aneka Perawatan 2,596,200 2,596,200 2,596,200 0
Biaya Dokter Spesialis 390,000 390,000 390,000 0
Biaya Dokter Umum 80,000 80,000 80,000 0
Biaya Kamar 900,000 900,000 900,000 0
Operasi Type I 4,820,500 4,820,500 4,820,500 0
Sub Total : 8,786,700 8,786,700 8,786,700 0
GRAND TOTAL : 8,786,700 8,786,700 8,786,700 0
Claim Details
This Report is provided by PT. JLT Gesa, your Plan Administrator & Risk Manager.
Page 1 of 1Report Printed: 18-Jun-2016 12:43:19