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Claim Form

1) The document is a claim form from United India Insurance Co. for an individual medical insurance policy. 2) It requests information about the insured, policy details, illness/injury details, treating doctors, hospitalization dates and expenses incurred. 3) A schedule of expenses section lists the various medical costs being claimed and amounts payable after deductions based on policy terms.

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ppghoshin
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128 views

Claim Form

1) The document is a claim form from United India Insurance Co. for an individual medical insurance policy. 2) It requests information about the insured, policy details, illness/injury details, treating doctors, hospitalization dates and expenses incurred. 3) A schedule of expenses section lists the various medical costs being claimed and amounts payable after deductions based on policy terms.

Uploaded by

ppghoshin
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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United India Insurance Co. Ltd.

(Subsidiary of General Insurance Company)


Registered & Head Office: 24, Whites Road, Chennai – 600 014.
REVISED MEDICLAIM INSURANCE POLICY
(Individual)

CLAIM FORM
Claim No. Date:
Issuance of this form does not amount to admission of any liability under the claim on the part of the insurers. Please give the
following information correctly and completely to enable the Company to process your claim promptly.
FOR OFFICE USE ONLY
1. Name of the Insured:

(In whose name policy is issued) SUR NAME INITIALS

2. Details of the Insured person : ………………………………………


(In respect of whom claim is made)
(a) Name & relationship to the insured : ……………………………………..
(b) Present Completed Age : ……………………………………..
(c) Occupation : ……………………………………..
(d) Residential Address : ……………………………………..
3. Policy No.

4. Nature of Disease / Illness contracted or injury suffered : ………………………………………

5. Date of injury sustained or Disease / illness first detected:

Date Month Year


6. (a). Name and Address of the attending Medical Practitioner: ………………………………….
………………………………………
Pin Code ……………………………
State / U. Territory………………….
(b). Qualification & Telephone No. : ………………………
(c). Registration No.

7. (a). Name and Address of the attending Medical Practitioner :…………………………………..


………………………………………
Pin Code ……………………………
State / U. Territory………………….

(b). Date of Admission:


Date Month Year
(c). Date of Discharge:

Date Month Year


8. If the claim is for Domiciliary Hospitalisation Please indicate:

(a). Date of Commencement of treatment

Date Month Year

(b). Date of completion of treatment (a).(b). (e).(f). (c).(d).


Date Month Year
(c). Name & Address of attending Medical Practitioner: …………………………………….
…………………………………….
Pin Code…………………………..
State / U. Territory………………... (g).(h).
(d). Telephone No. :……………………………………
(e). Registration No. :..…………………………………..
POLICY NUMBER …………………… SUM INSURED OPTED ……………………………
ADD CUMULATIVE BONUS ALLOWED …………………...……….. CLAIM NO.

SCHEDULE OF EXPENSES INSURRED BY THE CLAIMANT


Details of Expenses claimed under Amount Amount (1)-(2) Amount Payable
Hospitalisation / Domiciliary / Hospitalisation Claimed not payable
(To be supported by Bills / Receipts, Cash Memos etc.) (1) (2) (3) (4)
1. (a). HOSPITALISATION BENEFITS:
(1). Room, Board, Nursing expenses
For ………… days @ Rs. ……….. Per day
(2). I.C. Unit
For ………… days @ Rs. ……….. Per day
(b). HOSPITALISATION BENEFITS: OTHER THAN ABOVE
(Including Pre. & Post Hospitalisation)
(1). Surgeon, Anaesthetist, Medical Practitioner
Consultants, Specialists fees.
(2). Anaesthesia, Blood, Oxygen, Operation Theatre Charges,
Surgical Appliances, Medicines & Drugs, Diagnostic
Materials & X-Ray, Dialysis, Chemotherapy, Radiotherapy,
Cost of pacemaker, artificial limbs & cost of Organs
and similar other expenses
TOTAL
II. DOMICILIARY HOSPITALISATION BENEFITS:
(Non-surgical treatment)
(a). Medical Practitioner, Consultants, Specialists fees for visits etc.
(b). Blood, Oxygen, Diagnostic Materials & X-Ray, Employment of
qualified Nurses, Medicines and Drugs and similar expenses.
TOTAL
SCHEDULE OF EXPENSES INCURRED BY THE CLAIMANT FOR OFFICE USE ONLY

Details of Expenses claimed under Amount Claimed Amount Not (1)-(2) Amount payable
Hospitalisation / Domiciliary Hospitalisation. Payable
(To be supported by Bills / Receipts, Cash, Memos etc.) (1) (2) 3) (4)

III. MATERNITY EXPENSES BENEFIT EXTENSION


(a). Room, Board and Nursing expenses
For days @……………. .Per day.
(b). Gynaecologists / Obstetrician / Surgeon
Physician / Anaesthetist fees…
Normal delivery, Miscarriage and Abortion, Caesarian Section /
Abdominal Opening for extra uterine pregnancy
(c). Diagnostic Materials, X-Ray, Medicines and Drugs,
Injections etc.

TOTAL:

Signature of the Claimant: Less: Amount paid since inception of the policy
………………………………………………
Date : Net payable
Place:
FOR OFFICE USE ONLY
Prepared by : Total amount payable under the claim Rs ……………… in case entire claim is
Checked by : Less: part payment if any Rs………………not admissible, reasons
Approved by : Rs……………..thereof
Passed for payment of Rs. ……………….. Net amount payable
COMPETENT AUTHORITY
I have incurred on the treatment of Disease / illness / Accident referred to above the
expenses as per the detail given to me in the Schedule of Expenses given overleaf.

In support of the above claim, I enclose following documents (please indicate by)

1. Bill, Receipt and Discharge certificate / card from the Hospital.


2. Cash Memos from the Hospital / Chemist(s) supported by the proper prescription.
3. Receipt and Pathological test reports from a pathologist supported by the note from
the attending Medical practitioner / Surgeon demanding such pathological test.
4. Surgeon’s certificate stating nature of operation performed and Surgeon’s bill and
receipt.
5. Attending Doctor’s / Consultant’s / Specialist’s / Anesthetist’s bill, receipt and
certificate regarding diagnosis.
6. In case of Domiciliary Hospitalisation, Receipt from qualified nurse who attended the
patient at his / her residence duly supported by a certificate from attending Medical
Practitioner.
7. Certificate from the attending Medical Practitioner giving reasons for treatment under
domiciliary Hospitalisation clause of policy.
8. Certificate from the attending Medical Practitioner / Surgeon that the patient is fully
cured.
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 of Insurance.

Dated at ………………… this……………….day of…………………..20

(Signature of the Claimant)

FOR OFFICE USE


Date of Claim

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