Discharge queue
Shree Sai Multispeciality Hospital (fictional), Nashik. Six cashless claims with discharge advised today, all with Sahyog General Insurance (fictional). Start with C-103: it shows the desk approval gate.
| Claim and patient | Bill | What the agent will meet | Designed outcome | Latest result | Action |
|---|---|---|---|---|---|
| C-103 Imran Shaikh45 male, symptomatic cholelithiasis | Rs 64,200 | Hospital code and a kit billed outside the package Clause C7.1. The agent maps the surgery code to the insurer package, then asks the desk before removing a Rs 6,200 consumables kit. | Auto-approved after desk approval | Not run yet | Open claim |
| C-102 Sunita Desai52 female, dengue fever with thrombocytopenia | Rs 42,250 | Pharmacy bill not itemised Clause C8.2 needs an itemised pharmacy bill. The agent fetches it and finds Rs 690 of non-payable items. | Auto-approved; patient told about Rs 690 | Not run yet | Open claim |
| C-106 Kiran Patil29 male, viral fever | Rs 28,200 | MRI with no record; reused lab report An Rs 9,500 MRI has no order or report, and a lab report matches another patient’s claim. The agent flags both and does not try to fix them. | Flagged to adjudicator | Not run yet | Open claim |
| C-104 Meena Iyer67 female, community-acquired pneumonia | Rs 92,900 | ICU note missing; senior citizen co-pay The day-3 ICU note is in hospital systems but not in the file. Age 67 triggers a 10% co-pay (C5.4). | Clean, above Rs 75,000 cap: adjudicator | Not run yet | Open claim |
| C-105 Arjun Mehta41 male, acute gastroenteritis with dehydration | Rs 38,600 | Deluxe room above the room-rent cap Rs 8,000 a day against a Rs 5,000 cap (C3.1). The agent computes the proportionate deduction and tells the desk before discharge. | Auto-approved; Rs 10,463 deduction disclosed | Not run yet | Open claim |
| C-101 Ravi Kumar34 male, acute appendicitis | Rs 48,750 | Clean claim (control) Nothing to fix. Shows that a complete file passes straight through. | Auto-approved | Not run yet | Open claim |