" >
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 "
" . $value . "
"; } } ?>
Hospital Name
*
Hospital Address
*
<?= isset($ticket_data['hospital_address']) ? $ticket_data['hospital_address'] : '' ?>
Hospital City
*
Hospital State
*
Hospital Pincode
*
Hospital Phone
*
DOA
*
DOD
*
Claim Amount
*
POD No with Courier Name
Additional Documents
Claim Number
Registration Date
Raised Date
Query Received Date
Denial Reason
Denial Date
Approved Amount
# REF : SVR
Approved Date
Approved Letter URL
Approved Letter PDF
Only PDF allowed.
Approved Description
UTR Details
Settled Date
Settle Letter URL
Settle Letter PDF
Only PDF allowed.
Payment Initiate Date
Cancel Remark
<?= isset($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 . "
"; } } ?>
Approve Claim Rejection
More Information
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