Patient Name I WAYAN SUGRIYA Record Calc ID 17-JKT006274-GOP01-02

Policy No. PRU-IND Client Name Prudential Life Assurance

Certificate No. 76242273 Product Name Prudential Individual
Claim No. 17-JKT006274 Plan Code H1G1A
Claim Type MED Plan Name H1G1A
LOS Period 25-Jul-2016 to 28-Jul-2016 User Create Hendra Kurniawan

Benefit
Benefit Name Units Amount Actual Cost Discount Excess
Max Used Benefit Amount Max Benefit Used To Date

Overall Plan Limit Per Year

0 0 86,000,000.00 86,000,000.00 2,898,210.00

Room & Board Days Per Year Per Day x 3

120 3 200,000.00 600,000.00 600,000.00 0.00 0.00
Benefit Code Qty Actual Amount Discount
Room & Board MED001 3 200,000.00 0.00

Specialist Visit Per Visit x 3

H1G1A 0 3 150,000.00 450,000.00 225,000.00 0.00 0.00
Benefit Code Qty Actual Amount Discount
SP Consultation 1 MED83 3 75,000.00 0.00

Miscellaneous Hospital
Per Diagnosis Per Year x 1
Expenses
H1G1A 0 0 3,900,000.00 3,900,000.00 2,123,210.00 0.00 -50,000.00
Benefit Code Qty Actual Amount Discount
Pharmaceutical / Medicine (Prescription) MED009 - A91 1 298,210.00 0.00
Medical Supply MED066 - A91 1 750,000.00 0.00
Laboratory - Blood MED24 - A91 1 505,000.00 0.00
General Administration Costs MED65 - A91 1 250,000.00 0.00
Emergency Treatment MED66 - A91 1 120,000.00 0.00
Other Specialist or GP - 1 MED73 - A91 1 150,000.00 0.00
Doctor Fees - Not Cover MED81 1 -50,000.00 0.00
 Miscellaneous Benefit Accumulation per Diagnosis
Diagnosis Max Benefit Current Total Used To Date
A91 3,900,000.00 2,073,210.00 2,073,210.00

Total Hospital Fee 2,948,210.00

Discount 0.00
Paid By Patient -50,000.00
Paid By SOS 2,898,210.00
NOTES