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27 views

Download (1)

Uploaded by

fyatronbzzqirzuyrn
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We take content rights seriously. If you suspect this is your content, claim it here.
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MEDICAL REIMBURSEMENT (Supported by BILLS)

APPLICATION PARTICULARS

Claim Applied Date : 17/08/2024

Claim Code: 24/2024-2025/12511991 Claim Type: Medical Reimbursement Officers

Employee Code: 1023748 Employee Name: ANKIT YADAV

Designation: Assistant Manager Department: Kutiana

Company / Corporate Centre: State Bank of India Branch: KUTIYANA

Payroll Area: Ahmedabad Personnel Sub Area: KUTIYANA

Cost Centre: Kutiana Cadre: Officers Cadre

Personnel Area: NW-III, AO Rajkot, R-V Job: Assistant Manager

Work Contract: Core Banking NA

Medical/Hospitalization Details
Type Of Reimbursement : Medical Expense Other than Hospital
Type Of Illness : SKIN TINEA CORP
Treatment Taken By : ANKIT YADAV Age : 25 Relationship : Self
Name Of Doctor : BENNY CARDOSO Qualification Of Doctor : MD SKIN

MAJOR HEAD WISE DETAILS OF EXPENSES INCURRED


Bill/Cash Classification Of Name of Bill Approved
Bill Date
Memo No. Expenses Doctor/Chemist/Lab/Hospital Amount Amount
CONSULTATION
14/08/2024 01 BENNY CARDOSO 200 -
FEES
COST OF
14/08/2024 13 SAVIO MEDICAL 680 -
MEDICINE

Total Claim Amount 880.00


Total Approved Amount -
Advance Amount -
Total Payable / Paid Amount -
Total Payable / Paid Amount (In Words) : INR -

Approver Details
Action Action
Approver Name Remarks Status Signature
Amount Date
Ajay Ashwinkumar Raval Pending for Approver
-
(4623428) 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 : 23.08.2024 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 ₹ 880.00 (Eight Hundred and Eighty
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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