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Claim Applied Date: 09/11/2024: Medical Reimbursement (Supported by Bills) Application Particulars

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33 views3 pages

Claim Applied Date: 09/11/2024: Medical Reimbursement (Supported by Bills) Application Particulars

hkgklhyftufbkm

Uploaded by

naveen.choragudi1122
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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MEDICAL REIMBURSEMENT (Supported by BILLS)

APPLICATION PARTICULARS
Claim Applied Date : 09/11/2024
Claim Code:24/2024-2025/15989831 Claim Type :Medical Reimbursement Officers
Employee Code :5844673 Employee Name :KATEPOGU MADHURI PRIYANKA
Designation :Deputy Manager Department :RBO SIDDIPET
Branch :RBO SIDDIPET Personnel Sub Area :RBO-IV SANGARED
Cost Centre :RBO, SANGAREDDY Cadre :Officers Cadre
Job :Deputy Manager

Medical/Hospitalization Details
Type Of Reimbursement : Medical Expense Other than Hospital
Type Of Illness : GYNIC ISSUES
Treatment Taken By : KATEPOGU MADHURI PRIYANKA Age : 36 Relationship : Self
Name Of Doctor : N SHOBHA RANI Qualification Of Doctor : MBBS GYNIC

Major Head Wise Details Of Expense Incurred


Bill/Cash Memo Bill Approved
Bill Date Classification Of Expenses Name of Doctor/Chemist/Lab/Hospital
No. Amount Amount
RAINBOW CHILDRENS MEDICARE
30/09/2024 OCS14-00896878 CONSULTATION FEES 900 -
LIMITED
RAINBOW CHILDRENS MEDICARE
02/10/2024 OPH014-318795 COST OF MEDICINE 253 -
LIMITED
SPECIALIZED RAINBOW CHILDRENS MEDICARE
30/09/2024 OCS14-00896868 4200 -
INVESTIGATION LIMITED

Total Claim Amt 5,353.00 Total Approved Amt -


Advance Amount - Total Payable Amt -
Total Payable Amt (In Words) -

Approver Details
Approver Name Action Amount Action Date Remarks Status Signature
Anil Thotapalli (6392075) - Pending for Approver 1

Disclaimer :
I certify that the medical expenses as claimed have been actually incurred by me for my spouse/dependent family members, wholly
dependent on me
I certify that I have not received, nor I am entitled to any reimbursement under any insurance policy or from any other source with
respect to my spouse/dependent family members
I certify that my spouse/dependent family members for whom the medical bill has been claimed is/ are not covered under any medical
insurance or is eligible to claim the said expenses from Government / Other Insurers including schemes such as Ayushman Bharat,
Chiranjeevi etc
I certify that my parent/parent-in-law/family member for whom I am claiming medical expenses is wholly dependent on me and
ordinarily residing with me
I certify that my parent/parent-in-law/family member are not having monthly income (from all sources) exceeding the limits
prescribed by the Bank
I certify that my spouse is not entitled or /and has not claimed or/and will not claim, for reimbursement of such medical expenses
which is being claimed by me
I certify that my spouse has fully availed and exhausted his/her eligible medical benefits from his/her employer for the current
Financial Year and only the residual expenses are being claimed by me
I certify that my spouse for whom the medical bill is being claimed is not getting any medical allowance, as a component of his/her
CTC from employer
In case of claim for Implant/Other transplant, necessary administrative approval has been obtained
This excludes children having a monthly income exceeding the limit prescribed for the purpose and also married children irrespective
of income This undertaking will be taken cognizance of only in case of claim for treatment taken by children
In case of Dental Treatment (applicable in case of officers only) necessary prior approval from the component authority has been
obtained
DATE : 09.11.2024 Signature of Employee
(Authorized doctor's certificate to be obtained where the treatment is taken from a physician other than the Bank's Authorized Doctor in addition to his counter
signature on the respective cash memos and receipts.)

I have scrutinized the bills and have found the claims made herein by the employer to be reasonable.

Place : Date : Signature of the Bank's Authorized Doctor

Certificate from the Forwarding Authority


The bill(s) has / have been scrutinized by me in terms of the instructions laid down in this regard from time to time the claim
may be passed for payment of ₹ 5,353.00 (Five Thousand Three Hundred and Fifty Three Rupees Only /-).

Date : Head of the Department/Branch Manager

For Office Use


Sanctioned for Payment ₹_____________________(Rupees ________________________________
________________________________________________________only) by debit to appropriate
Charges BGL account.

Of the Total Sanctioned Amount Rs.


Amount Taxable
Amount Non-Taxable

Remarks :

Date : Sanctioning Authority


________ Amount Exempted from Income Tax for Treatment of / at Specified Diseases / Hospitals u/s 17 of IT Act is ONLY
required to be mentioned here.

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