Form No.

3
CLAIM FORM
( Issuance of this form does not amount to admission of any liability under the policy on the part of the Insurers )

Vipul ID No. : __________________

Name & Address of the Insured : _____________________________________________________
(in whose name policy is issued)
Details of Insured Person :
(in respect of whom claim is made)
a) Name & relationship of the Insured : _____________________________________________________
b) Present completed Age : _____________________________________________________
c) Contact Address : _____________________________________________________
e) Mobile / Phone No. : _____________________________________________________
f) Bank A/C No. : _____________________________________________________
g)Bank Name. : _____________________________________________________
h) E-mail Address : _____________________________________________________
i) I.P. No. : _____________________________________________________
j) File No. : _____________________________________________________
Name of Insurance Company :
Policy No. :__________________________________ Serial No. of the Schd./Certificate No.: _______________________________

AILMENT / DISEASE / INJURY

Date of Injury sustained of disease / illness first detected :- _______________________________________________________________

Name of the Hospital : _______________________________________________________________

a) Have you been Insured under any Mediclaim Scheme

earlier (held with any Insurance Co.) If yes
Xerox copies of Previous years’ policies MUST be
enclosed. : _______________________________________________________________

b) Date of Commencement of very first Insurance for this

Insured person with continuous Insurance coverage: _______________________________________________________________

Have you proffered any claim for the same insured under
the Mediclaim scheme earlier, if so give details viz :
(a) Previous Claim File Ref. No. / Office : _______________________________________________________________
(b) Diagnosis : _______________________________________________________________
(c) Whether Settled / Repudiated : ___________________________
(d) Amount (if settled) : Rs. ___________________________
PRESENT HOSPITALISATIN DETAILS:
Admitted On : Date _______________ Time _______________ Discharged On : Date_______________ Time ________________

Total Amount Claimed Rs.: ________________________

If the claim is of Domiciliary Hospitalization please indicate

a) Date of Commencement of the treatment: ___________________________
b) Date of Completion of treatment: ___________________________
c) Name & Address of attending Medical Practitioner with Telephone No. & Registration No.: _____________________________
_____________________________________________________________________________________________________________

Signature of the Claimant

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I have incurred the above expenses for the treatment of the disease / illness / accident and herewith as per schedule mentioned below:-

Schedule of Expenses incurred by the Claimant

CLAIM TYPE ( PRE-HOSPITALIZATION /

POST-HOSPITALIZATION /
HOSPITALIZATION )
DATE BILL NO. DESCRIPTION AMOUNT CLAIMED

GRAND TOTAL
* If required, additional sheet to be attached

In support of the claim, I enclose the following documents

Yes / No Yes / No
Claim Form Duly Signed Pre-Hospitalization Bills : No(s)____ Bill Amount ______
Vipul Pre-Authorization Form Post-Hospitalization Bills : No(s)____ Bill Amount ______
Claim Notification Hospital Payment Receipt
Discharge Summary Investigation Report with Dr’s request
Hospitalization Bills 1. MRI Yes / No 2. CT Scan Yes / No
Doctors Surgery Certificate if any 3. ECG Yes/ No 4. X-ray Yes / No 5. US Scan Yes / No
Surgery / Consultation Bills if any Lab Reports with Dr’s request No (s)_____ of Rep _______
Operation Theatre Pharmacy Bills Others if any
Medicines Bills with Dr’s prescription

Previous Policy Numbers if any :

I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made or shall make any false
or untrue statement, suppression or concealment, my right to claim reimbursement of the said expenses shall be absolutely
forfeited. I further declare that, in respect of the above treatment, no benefits are admissible under any other Medical Scheme
or insurance

I also consent and authorize Vipul MedCorp / Insurance Company to seek the treatment papers/medical information from any
Hospital / Medical Practitioner who has any time attended on the insured person.

I hereby declare that I have included all bills / receipts for purpose of this claim and that I will not be making any
supplementary claim in respect thereof, except the post Hospitalization claim if any.

Date : Signature of the Claimant

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 MEDICAL CERTIFICATE TO BE FILLED IN BY THE DOCTOR

1. Name of the Patient & Age

2. Admission Date and Time Discharge Date and Time

3. Name of Surgeon / Physician

4. Diagnosis

5. Date of first consultation

(Prior to hospitalisation)

6. (a) With what complaints was the patient

admitted for:

(b) Since when was the patient suffering from

the said complaints

7. Past History of the Patient (if any) with the

duration of illness

8. Whether the present ailment is a complication of

Pre-existing disease?
If yes, please specify the disease (or)
complication of any previous Surgery done?
If yes, please specify details.
9. Whether the disease/disorder is congenital in
nature?

10. Nature of Surgery/treatment given for present

ailment

11. (a) Whether Hospital/Nursing Home is

Registered, if yes, Regn. No.

(b) No. of in-patient beds in the Hospital

(including ICU)

(c) Whether the hospital is having fully equipped

Operation Theatre of its own/ qualified nurses
Round the clock / Qualified doctors round the
clock?

Signature of the Doctor with seal Date

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