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CLAIM FORM
NationalInsuranceComPanY I I The New India Assurance ComPanY
g. Have you preferred any claim for the same Insured under the Mediclaim scheme earlier, if so give details
, aiz.
Sr. Particulars Claim 1 Claim 2 Claim 3 Claim 4
No.
(a) Policy Number
(b) Date of Admission
(c) Date of Discharge
(d) Diagnosis
(e) Whether settled / rePudiated
(0 Clairn Amount (if settled) : Rs'
9. Since when the person covered under the policy without break YIS.
Xerox copy of Pievious year's policies MUST be inclosed
GRANDTOTAL
NOTE : Pieaseattach the sheetsif Necessary
In support of the claim, I enclose the iollowing documents
Sr. Particulars Yes/ No Sr. Particulars Yes / No
No. Tick No. Tick
1 Policy Schedule / Policy Copy 8 Prescriptions*
2 Discharge Card / Summary" 9 Pre Hospitalization Medical Bills*
3 Final Hospital Bill* 10 Post Hospitalization Medical Bills*
4 Surgeon s Certificate (In all cases 1l MedicalReports*& MLC / FIR
of surgeryexplaining the procedure) -' (for accidenlcases)
AtienArn;r
odCr.ilIC.i'irit"il1t
5 Speciali.t s/ Anesthetist s bill recerpr
' 12 HospitalPaymentReceipt*
ahd certificateregarding diamosis*
Certif icate from a-"ttendiieNfedical
6 Practihonergiving reasonsfor allowing 13 Indoor CasePaper>(preferablvfor
treatment atlomd* all claims above 1 lakh)
Certificdlefrom attending Medical.
7 Practitioner/ Surgeonthat the patient is Previous Policy Copies, if any
tully cured.'
I hereby declarethat the aboveinJormationis true & conect to the best of my knowledge and belief. If I have made any false,fraud or untrue
statement suppressionor concealment,my ght to claim reimbursementof the expensesshall be forfeited.
I alsoconsentand authorize MDINDIA / InsuGnce Company to seekmedical information Irom any Hospital Medical practitionerwho has any
time ;ttended on the insured person.
I herebydeclarethat I have included all bills / receiptsfor purpose o{ this claim and that t will not be making any supplementaryclaim in
' respectthercof,exceptthe post Hospitalization claim if any.
5. When did the patient approach you for the first time in connection with present diseasesuffered ?
7. Is the patient suffering from Diabetes, Hypertension (Blood Pressure),Kidney problems,Cancer,T. 8.,
Heart Problem and AIDS or other disease? If yes (Sincehow long he or she may be suffering from the
same) :
9. Duration of present diseasesuffered (i.e. since how long he or she may be suffering from present disease
befpre approaching you) :
10 Is the present diseasesuffered connected to previous diseaseof Diabetes, Hypertension (Blood Pressure),
Surgery or other existing disease ? _
12. \A/hetherthe diseaseis caused due to any congenital defects (Yes / No) ?
13. \t\rheiherthe patient had any complications during or after pregnancy (Yes / No) ?
14. V\ihetherthe disease/ injury is caused directly or indirectly due to the use of alcohol or drugs
( Y e s / N o ): _
15. Could the patient have been aware the illness or diseaseof which keatment is being taken now ?
a) Nature of treatment given : -Operative/ I. V. Fluid / Injection / Oral Treatment / Othef Pareilteral
Treatment
19. Is your hospital registered with local authority? If yes, please attach xerox copy of certificate
Regiskation Number of Hospital :
21. Qther commentsyou would like to make (iI any) connectedto present diseasesuffered by the
Patient :
Contact No.:
(With rubber stamp and registration no. o{ your Nursing Home / Hospital )
Signatureof PolicYHolder