" >
Claim GMC
Employee details
Employee ID
*
Employee Name
*
Insured Name
*
Relationship
*
Select Relationship
$value) { $selected = (isset($ticket_data) && $ticket_data['relationship'] == $key) ? 'selected' : ''; echo "
$value
"; } } ?>
Policy No
TPA ID
Employee Mobile No
*
Employee Mail ID
*
Employee Personal Mail ID
Corporate Name
*
Insurer
*
Policy
*
Policy
TPA
Account Manager
*
$value) { $selected = (isset($ticket_data) && $ticket_data['acm_id'] == $value['id']) ? 'selected' : ''; echo "
" . $value['first_name'] . "
"; } } ?>
Claim Details
Status
*
$value) { $selected = (isset($ticket_data) && $ticket_data['claim_status_id'] == $value['id']) ? 'selected' : ''; echo "
" . $value['claim_status'] . "
"; } } ?>
Priority
*
$value) { $selected = (isset($ticket_data) && $ticket_data['priority'] == $key) ? 'selected' : ''; echo "
" . $value . "
"; } } ?>
Mode of Submission
*
$value) { $selected = (isset($ticket_data) && $ticket_data['mode_of_intimation'] == $key) ? 'selected' : ''; echo "
" . $value . "
"; } } ?>
Claim Type
*
$value) { $selected = (isset($ticket_data) && $ticket_data['claim_type'] == $key) ? 'selected' : ''; echo "
" . $value . "
"; } } ?>
Hospital Name
*
DOA
*
DOD
*
Claim Amount
*
POD No with Courier Name
Additional Documents
Claim Number
Registration Date
Raised Date
Query Received Date
Denial Reason
Denial Date
Approved Amount
#
Approved Date
Approved Letter
Approved Description
UTR Details
Settled Date
Settle Letter
Payment Initiate Date
Cancel Remark
<?= isset($ticket_data['cancel_remark']) ? $ticket_data['cancel_remark'] : '' ?>
Return Remark
<?= isset($ticket_data['return_remark']) ? $ticket_data['return_remark'] : '' ?>
Return AWB No with Courier Name
Non ID Reason
Select Reason
$value) { $selected = (isset($ticket_data) && $ticket_data['non_id_reason'] == $key) ? 'selected' : ''; echo "
" . $value . "
"; } } ?>
Submit
Approve Claim Rejection
More Information
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