Preview Reimbursement Claim Form

REIMBURSEMENT CLAIM FORM

TO BE FILLED BY THE INSURED

The issue of this Form is not to be taken as an admission of liablity

DETAILS OF PRIMARY INSURED:

a) Policy No.:

(To be Filled in block letters)

SECTION A SECTION B

b) Sl. No/ Certificate no.

c) Company / TPA ID (MA ID)No:

e) Address:

DETAILS OF INSURANCE HISTORY:

a) Currently covered by any other Mediclaim / Health Insurance: b) Date of commencement of first Insurance without break:

c) If yes, company name: Policy No.

Sum insured (Rs.) d) Have you been hospitalized in the last four years since inception of the contract?

Diagnosis:

e) Previously covered by any other Mediclaim /Health insurance : :

Date:

M M

f) If yes, company name:

DETAILS OF INSURED PERSON HOSPITALIZED:

DETAILS OF HOSPITALIZATION:

DETAILS OF CLAIM:

DETAILS OF BILLS ENCLOSED:

Sl. No. Bill No. Date Issued by Towards Amount (Rs)

DETAILS OF PRIMARY INSURED’S BANK ACCOUNT:

SECTION C SECTION D SECTION E SECTION F SECTION G SECTION H

D YMD YM

10.

D YMD YM

City: State:

Pin Code Phone No: Email ID:

City: State:

Pin Code Phone No: Email ID:

D D

M M

Y Y

Yes No

d) Name:

S U R N A M E F I R S T N A M E M I D D L E N A M E

a) Name:

S U R N A M E F I R S T N A M E M I D D L E N A M E

b) Gender Male Female c) Age years

M M Y Y Y YMonths d) Date of Birth

e) Relationship to Primary insured: Self Spouse Child Father Mother Other (Please Specify)

(Please Specify)OtherRetiredStudentHome MakerSelf EmployedServicef) Occupation

g) Address (if diffrent from above) :

a) Name of Hospital where Admited:

b) Room Category occupied:

Day care

D D

M M Y Y H H

H H

M H

D M M Y Y Y Y

D M M

Y Y

Single occupancy Twin sharing 3 or more beds per room

c) Hospitalization due to:

Injury Illness Maternity d) Date of injury / Date Disease first detected /Date of Delivery:

e) Date of Admission: f) Time g) Date of Discharge: h) Time: :

NoYesI) If Medico legal

j) System of Medicine:

Substance Abuse / Alcohol Consumption

I) If injury give cause: Self inflicted Road Traffic Accident

iii. MLC Report & Police FIR attached

ii) Reported to Police NoYes

a) Details of the Treatment expenses claimed

I. Pre -hospitalization expenses

iii. Post-hospitalization expenses

v. Ambulance Charges:

Rs.

ii. Hospitalization expenses Rs.

iv. Health-Check up cost:

vi. Others (code):

Rs.

Total

vii. Pre -hospitalization period:

days

viii. Post -hospitalization period:

days

b) Claim for Domiciliary Hospitalization:

NoYes (If yes, provide details in annexure)

c) Details of Lump sum / cash benefit claimed:

i. Hospital Daily cash: Rs.

Rs.

iii. Critical Illness benefit:

v. Pre/Post hospitalization Lump sum benefit:

ii. Surgical Cash:

iv. Convalescence:

vi. Others:

Rs.

Total

Claim Documents Submitted - Check List:

Claim form duly signed

Copy of the claim intimation, if any

Hospital Main Bill

Hospital Break-up Bill

Hospital Bill Payment Receipt

Hospital Discharge Summary

Pharmacy Bill

Operation

Theater Notes

ECG

Doctor’s request for investigation

Investigation Reports (Including CT

/ MRI / USG / HPE)

Doctor’s Prescriptions

Others

Hospital main Bill

Pharmacy Bills

Post-hospitalization Bills: Nos

Pre-hospitalization Bills: Nos

a) PAN:

c) Bank Name and Branch:

d) Cheque / DD Payable details:

b) Account Number:

e) IFSC Code:

(IMPORTANT: PLEASE TURN OVER)

Medi Assist

DECLARATION BY THE INSURED:

Date

Y YD D M M Y Y

Place: Signature of the Insured

I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression or concealent of any material

fact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA / insurance Company, to seek necessary medical information /

documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim &

that I will not be making any supplementary claim except the pre/post-hospitalization claim, if any.

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