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