POLICY DATA

Policy Number OG-18-2001-8402-00000055 Claim Type

Partner Desc AERON SYSTEMS PRIVATE LTD. Cashless

Risk Inc Date January 10, 2018 Reimburseme

Risk Expiry Date January 9, 2019

Policy Age 363

Policy Period 365

Member Summary
Today's Date January 7, 2019 Member_count

Members_At_Inception

Active_Members

CLAIMS Summary

Cashless Reimbursement

Incurred Claim Incurred

Claim Count Claim Count
Amt Severity Amt

APPROVED 3 116,582 38,861 1 9,620

Sum: 3 116,582 38,861 1 9,620

Mix (%) 75.00% 92.38% 25.00% 7.62%

PREMIUM AND PROFITABILITY

Gross Premium 164613

Net Premium 139,503

Earned Premium 138,739

Incurred Claims (Paid + Ostd) 126202

Incurred Claims Closed w/o pay

IBNR (@ 4%) 5,048

IBNR Included Incurred Claim Amount 131,250
Salvage Amt 0

Claim Ratio on Net Premium 90.47%

Claim Ratio on Earned Premium 90.96%

Claim Ratio on Earned Premium Incl IBNR 94.60%

Claim Frequency 6.49%

 Cashless Vs Reimbursement Claim Summary

Claim Count Claim Count % Incurred Amt Incurred Am

3 75.00% 116582 92.38%

1 25.00% 9620 7.62%

Total 100.00% 100.00%

Member Summary
Member_count 62

Members_At_Inception 52

Active_Members 62

Reimbursement Overall Mix (%)

Claim Claim Claim

Claim Severity Incurred Amt
Count Severity Count(%)

9,620 4 126,202 31,551 100.00%

9,620 4 126,202 31,551 100.00%

100.00% 100.00%
CLaim Locati Sr No Clid Insured Employee Na Patient Sum Insured Doj

1002 8609926 1851798 AERON SYSTE

NISHA PATIL NISHA PATIL 200000 1/10/2018

1002 8933523 2039278 AERON SYSTE

SACHIN KOK SACHIN KOK 200000 1/10/2018

1002 9045326 2118773 AERON SYSTE

RHISHIKESH RHISHIKESH 200000 1/10/2018

1002 9211423 2093402 AERON SYSTE

AKASH DADA AKASH DADA 200000 6/28/2018
Age Gender Relation Id Card Co Empnumb Hat Empcode Policy Rid

32 FEMALE SELF GMC-182001265 65 OG-18-2001-8 1/10/2018

34 MALE SELF GMC-18200124 4 OG-18-2001-8 1/10/2018

26 MALE SELF GMC-182001250 50 OG-18-2001-8 1/10/2018

21 MALE SELF GMC-182001286 86 OG-18-2001-8 1/10/2018

Red Hospital Type Hospital Add1 Add2 City State Pin
Dhankawade
Patil
Township,
1/9/2019 NETWORK ASHWINI MULTBalajinagar,
Autade Hospit - NASIK MAHARASHT 422009
Pune Satara
Road,
1/9/2019 NETWORK SIDDHI HOSPIDhankawadi - PUNE MAHARASHT 411043

1/9/2019 NETWORK JUPITER LIFENEAR PRATHM

NEAR PRATHM
PUNE MAHARASHT 411045

1/9/2019 NON-NETWO ANAND HOSPISr.no.16, Rameshwar Hight, PUNE MAHARASHTRA

Std Phone Fax Pre Auth DatePre Auth Amt Auth Amount Room Catego Auth Date

0253 09822060200 7798424140 6/4/2018 134750 97550 SEMI PRIVAT 6/4/2018

020 24365001\243 24375001 9/17/2018 30000 10944 SEMI PRIVAT 9/18/2018

020 27992799 0 10/15/2018 50000 21106 DELUXE 10/16/2018

Name Dr Expected DoaExpected DodActual Doa Actual Dod Provisional D Claimed Amt Corporate Buf

- 04/06/2018 08/06/2018 04/06/2018 09/06/2018 Intra articular 104000 0

RAJEEV 16/09/2018 18/09/2018 16/09/2018 18/09/2018 Left Leg burn 10944 0

- 14/10/2018 16/10/2018 14/10/2018 16/10/2018 Acute gastroent 21106 0

Dr 22/08/2018 24/08/2018 15276 0

Claim Type Registration Treatment Ty Claim No Claim Status General RemaDocument RecDr Requireme

Cashless 6/4/2018 HOSPITALIZA OC-19-1002-8 CLOSED 7/25/2018

Cashless 9/17/2018 HOSPITALIZA OC-19-1002-8 CLOSED 9/30/2018

Cashless 10/15/2018 HOSPITALIZA OC-19-1002-8 CLOSED 10/25/2018

Reimbursemen 10/8/2018 HOSPITALIZA OC-19-1002-8 CLOSED --NON-SUBMI 10/3/2018 ~We are in receipt of cancel
 Repudiation Final DiagnosIcd Code Disease Cate Medical Or SuHospital Bill Total Bill Pre Hosp Cha

Intra articular S82 Injury, poison MEDICAL ~0 104000

Left Leg burn T24.1 Injury, poison MEDICAL ~1 10944

Acute gastroentA09,J06.9 Certain infect MEDICAL ~0 21106

~We are in receipt of cancel Enteric Fever R50.9 Symptoms, signMEDICAL ~0 15276
Room ChargeDoctor Charg Ot Charges Pharmacy Pathology Radiology Cardiology Equipement

1550 19900 11200 10663 1500 3400 150

1877

3750 1500 6026 650

 incurred
during
hospitalizatio
n shall be
settled as per
the agreed
negotiated
tariff with
Bajaj Allianz
General
Ambulance Non Medical Discount Miscellaneou Post Hosp ChApproval Dat Approved AmAuthorizatio
Insurance
Co. Ltd. ~
~Authorization issued with tota
Previous
Authorization
8459 800 8/4/2018 86794 stands
~ Kindly send invoice / barcod
revised to
Rs.10944/-
1039 8517 10/9/2018 9355

20433 10/31/2018 20433 ~ Expenses incurred during ho

0 12/4/2018 9620
 Dr Requiremen
Dr RequiremePayable To HoHospital Disa Hospital Disa Payable To In Insured Disal Insured Disa

~Authorization issued with total deductions (INR 6450/-) as:;~Tariff excess deduction - [ICU (1300*1)-1300,NURSING (850*1)-850,VISIT (800*1)-800,N

~ Kindly send invoice / barcode / sticker for implant used

86794at the time17206
of discharge.
~Tariff excess deduction~providine, gauze, , cotton, opsite , ecg lead, fi

9355 1589 ~Diet charges , ward material ~10% Discount On Total Bill

~ Expenses incurred during hospitalization s 20433 673 ~admission, registration , tegaderm

9620 5656 ~IV Fluid/ IV Bottle will be paid

 Payable To In Asssement DaMedical Mgt DAssessment EPreauth Excl Denial Reaso Denial Date Pay Status

cotton, opsite , ecg lead, fi 8/4/2018 With Pay

10/8/2018 With Pay

10/31/2018 With Pay

~IV Fluid/ IV Bottle will be paid upto

10/8/2018
INR. 50/- per bottle or whichever is less. Eg (RL Ringer Lactate, NS: Normal Saline,With
D5 Dextrose
Pay 5%, DNS: Dextr
Reserve Amt Claim Close SClose Date Orphan RemaOrphan ClaimTelephone Patient Addre Cheque No

97550 APPROVED 8/4/2018

10944 APPROVED 10/9/2018

21106 APPROVED 10/31/2018

16000 APPROVED 12/4/2018

Cheque Date Cheque Rec DCheque Dis D Mobile No Bank Name Bank Ac No Debit Card NoProcessor

9371229570 abhijeet.kudre

7066815165 abhijeet.kudre

9689491931 abhijeet.kudre

7066815165 abhijeet.kudre
Imd Code Dr Intimation Dr Reply DateDiagnosis DetDig Procedur Updated On Other Deduct Premium

10009185 8/8/2018

10009185 10/11/2018

10009185 11/2/2018

10009185 10/10/2018 12/1/2018 12/7/2018 3206 0

Co Payment Surgeon CharNursing Char Icu Charges Repudiation DOrphan IntimaHospital Id Irda Unique I

36400 5700 1155 422009002

1641 411043007

67538 0

900 72426
Partner Id Utr No Tds Amount Pan No Service Tax Account No Bank Name Service Tax

29250499

29251695

98109394

107076313
Tds Rate Doc Receive Reopen Date Eligible RoomEligible RoomAvailed RoomAvailed RoomCriti Unit Ro

7/25/2018

9/30/2018

10/25/2018

12/4/2018 11/30/18 OTHER OTHER 1250

Non Network Member Co P Room Rent DiImplant Char Package CharNeo Natal Ch Cause Of Los Pcs Code

3990
Pcs Descripti Pcs Id Eligible RoomEligible RoomAvailed RoomAvailed RoomCriti Unit Ro Irda Unique I

SINGLE ROO SINGLE ROOM 422009002

OTHER SEMI PRIVATE 411043007

OTHER PRIVATE A/C 0

OTHER OTHER 1250

Medical Ass DPolicy Loc Approved Qc Hospital QualiPpn Type Discount 1 Discount On1 Room Desc

2001 NON PPN NA 10 10% Discount On Total Hospital Bill Excluding

2001 NON PPN NA 10 10% Discount O

SEMI PRIVATE

2001 NON PPN NA 0 0

2001 NA
 Bonus Si Sp Condition Ip No Query Remar Orphan Date P Master Poli Salvage Amt Incurred_Amt

On Total Hospital Bill Excluding Consumable 0 0 86794

SEMI PRIVATE 1 0 9355

0 0 20433

0 0 9620
Rev'd Claim CIC_Amt

APPROVED 86794

APPROVED 9355

APPROVED 20433

APPROVED 9620