R

Medi Assist
a) Policy No.: c) Company / TPA ID (MA ID)No: d) Name: e) Address:
S U R N A M E

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: b) Sl. No/ Certificate no.

REIMBURSEMENT CLAIM FORM

(To be Filled in block letters)

SECTION A

City: Pin Code a) Currently covered by any other Mediclaim / Health Insurance: c) If yes, company name: Sum insured (Rs.) Diagnosis: f) If yes, company name: Phone No: Yes No

State: Email ID: DETAILS OF INSURANCE HISTORY: b) Date of commencement of first Insurance without break: D Policy No. d) Have you been hospitalized in the last four years since inception of the contract? Yes No Date: M M Y Y Yes No D M M Y Y Y Y

SECTION B

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

DETAILS OF INSURED PERSON HOSPITALIZED: a) Name: b) Gender S Male U R N A M E c) Age years Spouse Y Child Y F I R S M T N A M E D M M M I Y D Y D Y L Y E N A M E Female Self Self Employed Months M Father Student d) Date of Birth Mother Retired

D
Other Other

e) Relationship to Primary insured: f) Occupation Service

(Please Specify) (Please Specify)

SECTION C

Home Maker

g) Address (if diffrent from above) :

City: Pin Code Phone No:

State: Email ID: DETAILS OF HOSPITALIZATION: Day care Illness M M Y Y Single occupancy Maternity f) Time H H Twin sharing 3 or more beds per room D D Y Y Yes M M h) Time: No Y H Y H Y : Y M H

a) Name of Hospital where Admited: b) Room Category occupied: c) Hospitalization due to: e) Date of Admission: ii) Reported to Police
a) Details of the Treatment expenses claimed I. Pre -hospitalization expenses iii. Post-hospitalization expenses v. Ambulance Charges: Rs. Rs. Rs. D Injury D

SECTION D

d) Date of injury / Date Disease first detected /Date of Delivery: M H g) Date of Discharge: D D M M

I) If injury give cause: Self inflicted

Road Traffic Accident iii. MLC Report & Police FIR attached

Substance Abuse / Alcohol Consumption Yes No j) System of Medicine: DETAILS OF CLAIM: ii. Hospitalization expenses Rs. iv. Health-Check up cost: vi. Others (code): Rs. Rs. Rs.

I) If Medico legal

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
Rs. Rs. Rs. Rs.

Total
vii. Pre -hospitalization period: b) Claim for Domiciliary Hospitalization: c) Details of Lump sum / cash benefit claimed: i. Hospital Daily cash: Rs. iii. Critical Illness benefit: Rs. days Yes No (If yes, provide details in annexure) ii. Surgical Cash: iv. Convalescence: vi. Others: Total

SECTION E

viii. Post -hospitalization period: days

v. Pre/Post hospitalization Lump sum benefit: Rs.

Operation Theater Notes ECG Doctor s request for investigation Investigation Reports (Including CT / MRI / USG / HPE) Doctor s Prescriptions Others Amount (Rs)

Sl. No. Bill No.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. a) PAN:

Date
D D D D D D D D D D D D D D D D D D D D M M M M M M M M M M M M M M M M M M M M Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y

Issued by

DETAILS OF BILLS ENCLOSED:

Towards

Hospital main Bill Pre-hospitalization Bills: Post-hospitalization Bills: Pharmacy Bills Nos

SECTION F

Nos

SECTION G

DETAILS OF PRIMARY INSUREDS BANK ACCOUNT: b) Account Number: c) Bank Name and Branch: d) Cheque / DD Payable details: e) IFSC Code:

DECLARATION BY 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. Date D D M M Y Y Y Y Place: Signature of the Insured

(IMPORTANT: PLEASE TURN OVER)

SECTION H