Beeassist health insurance -- claim form (reimbursement)
-------------------------------------------------------
policy no : POL-1003
Insured ID - M-1003-01
Pt Name: Ravi K Sharma
DOB: 15-07-1990
Type of claim: inpatient / hospitalisation
Hospital: CityCare Multispeciality Hosp.
Admitted on: 12/08/2026
Discharged on: 15 Aug 2026
Diagnosis: Community acquired pneumonia
ICD code: J18.9
Amount claimed: INR 84500/-
Submitted on: 24-Sep-2026

sign: R.K.Sharma
