UIIC17-Jan-14CASHLESS INTIMATIONSr. No.Claim No.Policy NOINSUREDNAMEMEMBERNAMESEXAGERELATIONSUM INSUREDPeriod of insurance - fromPeriod of insurance - toInsured addressInsured contact noHospital NameHospital Address & PhoneICD codeDiseaseCashless request received - DateCashless request received - TimeDate Of AdmissionApprove DateExpected discharge dateClaim AmountApproved AmountSTATUS120140115B006C2A3500190101/48/13/41/00000406M/s UNITED HOTELS LIMITEDINDU AGNIHOTRIFemale73Mother02/11/131/11/14THE AMBASSADOR HOTELS LIMITED SUJAN SINGH PARK ,NEW DELHI..........FORTIS MEMORIAL RESEARCH INSTITUTE (A UNIT OF FORTIS HEALTH MANAGEMENT (NORTH) LTD.)SECTOR-44, OPPOSITE HUDA CITY METRO STATION, , GURGAON, Ph: 0124-4386666G45.9Transient cerebral ischaemic attack, unspecified15/01/201414:07:5414/01/201415/01/20145325020000Approved220140116B006C2A3511190101/48/13/41/00000406M/s UNITED HOTELS LIMITEDMOHINI DEVIFemale68Mother02/11/131/11/14THE AMBASSADOR HOTELS LIMITED SUJAN SINGH PARK ,NEW DELHI9871768738DR. KAPURS THE HEALING TOUCH EYE CENTRED-8, VIKAS PURI, , NEW DELHI, Ph: 28535083h 25CATARACT RT EYE16/01/201414:05:5218/01/201416/01/20143000025000Approved320140116B006C2A3519190300/48/13/41/00000641MR.SUBHASH PORWALRENUKAFemale40Wife013/05/201312/5/14253,KALANI NAGAR INDORE ,INDORE0CITY NURSING HOME PVT. LTD.209, JAWAHAR MARG, RAJMOHALLA ,NEAR MALGANJ, , INDORE, Ph: 0731-3243396, 2340666, 2340777, 2340888K92.2Gastrointestinal haemorrhage, unspecified16/01/201417:39:2915/01/201416/01/2014180008000Approved420140116B006C2A3507191102/48/12/97/00000513MR. SUBHASH CHANDER MADANMR. SUBHASH CHANDER MADANMale70SELF15000027/01/201326/01/2014H.NO. A-60 JAI BHAVANI HOUSISNG SOCIETY PHASE-I BAWADIA KALAN , BHOPAL ,BHOPAL0HI - TECH EYE CARE & LASER CENTRE106, OLD TAJ MARKET, NEAR G.P.O,, ROYAL MARKET, BHOPAL, Ph: 0755-2531679H 25CATARACT RT EYE16/01/201411:49:0520/01/201416/01/2014270000RejectedGENRAL INTIMATIONSr. No.Claim No.Policy NOINSUREDNAMEMEMBERNAMESEXAGERELATIONSUM INSUREDPeriod of insurance - fromPeriod of insurance - toInsured addressInsured contact noHospital NameHospital addressRemarksDiseaseDate Of AdmissionExpected discharge dateClaim Amount120140116B006R2A3516190101/48/13/41/00000324M/s ANANT SPINNING MILLS (A UNIT OF VARDHMAN TEXSANGITAFemale23Daughter7500031/08/201330/08/2014HR DEPARTMENT, PLOT NO.1-A, NEW INUSTRIAL AREA-1 MANDIDEEP ,SEHOREVARDHAMAN MEDICARE C-37 VIDHYA NAGAR BHOPAL,16/01/20141000220140116B006R2A3514190101/48/13/41/00000431M/s BHASKAR INDUSTRIES LIMITEDSARWATI DEVIFemale65Mother10000027/06/201326/06/201415-16, D SECTOR, INDUSTRIAL AREA MANDIDEEP ,RAISENCHIRAYU MEDICAL COLLEGE & HOSPITAL ~ BHOPALBHOPAL-INDORE HIGHWAY, NEAR BAIRAGARH ,BHOPAL12/1/141000320140115B006R2A3499190300/48/12/41/00004024MR.CHAMPALAL PATELSMT.NARMADAFemale41Wife1000007/3/136/3/14VILL.PO-GUDIKHEDA DIST KHANDWA ,KHANDWA9752207878 07332286424PRAKASH HOSPITAL ~ KHANDWAINDORE ROAD KHANDWA ,KHANDWA11/1/141000420140115B006R2A3498190401/48/12/97/00001525Mr. BAL KRISHNA NAGARSULOCHANA NAGARFemale61Wife1500006/3/135/3/14A-109, V.D. CLOTH MARKET ,UJJAIN9444378910MEDICARE CENTRE ~ INDORE4/5 OLD PAIASIA RAVINDRA NAGAR ,INDORE14/01/20141000520140116B006R2A3521190402/48/13/97/00000027Mr. LAXMINARAYAN KHANDELWALLAXMINARAYAN KHANDELWALMale53Self12500013/04/201312/4/14BLOCK NO.9, SUPER MARKET, OPP. MEHARA NARSIG HOME, KATJU NAGAR, RATLAM ,RATLAMRAJAS EYE & RETINA RESEARCH CENTRE INDORE ~ INDORE152, KANCHANBAG OPP AIRTEL OFFICE ,INDOREDisease:cataract15/01/201430000620140115B006R2A3497190702/48/12/06/00000445KIRTI SHAHKIRTI SHAHMale48Self3000002/2/131/2/14MILL ROAD GANJ BASODA ,VIDISHAADARSH HOSP. SAHAJAHANABAD THANE KE SAMNE BHOPAL,15/01/20141000720140115B006R2A3522190900/48/12/97/00001674Mr. DEVENDER SINGH MATHRURAJENDERFemale74Mother12500024/03/201323/03/2014AWADHPURI COLONY GWARIGHAT RD JABALPUR ,JABALPURBHANDARI HOSPITAL JABALPUR,16/01/20141000820140116B006R2A3504191005/48/13/06/00000133ANKIT KUMARETISH JAINMale2Son20000017/09/201316/09/2014PANDIT COLONY, SANAWAD ,KHARGONE9926068801UNIQUE HOSPITAL INDORE,15/01/20141000920140116B006R2A3515191005/48/13/97/00000014Mr. VIKAS KUMAR JAGDISHCHANDRA GOYALVIKAS KUMAR JAGDISHCHANDRA GOYALMale34Self5000017/04/201316/04/2014MAIN ROAD, KARAHI ,KHARGONEROBART NURSING HOME INDORE,16/01/201410001020140115B006R2A3503191100/48/12/41/00001794VIMAL KISHOREVIMAL KISHOREMale57Self50000027/03/201326/03/2014H NO. E-1, ORIENT PAPER MILLS COLONY, P.O. AMLAI PAPER MILL S ,ANANDPUR0SHROFF EYE HOSPITAL ~ MUMBAIGOBIND MAHAL, 86-B, ,MUMBAI17/01/201410001120140115B006R2A3502191101/48/13/97/00000064SOCIETY OF BENEDICTINE SISTERS OF ST LIOBASISTER VINEETAFemale43Self1000004/6/133/6/14ASHIR BHAWAN AYODHYA NAGAR AHINSA VIHAR COLONY BHOPAL ,BHOPALST. JAMES HOSPITAL, CHALAKUDDY, TRICHUR, KERALA,15/01/201410001220140116B006R2A3520191103/48/13/14/00000004PRASANNA GANGRADEBHARTI GANGRADEFemale63Mother5000013/04/201312/4/1419, NEHRU GANJ, ITARSI ,HOSHANGABAD8989506035 9981123686JABALPUR HOSPITAL & RESEARCH CENTRE ~ JABALPURNO ,JABALPURdisease;-cataract16/01/20141000