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OPD Claim Form

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58 views

OPD Claim Form

Opd

Uploaded by

1morebe
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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The New India Assurance Company Limited

Registered & Head Office: New India Assurance Building, 87, M.G. Road, Fort, Mumbai - 400 001.

GROUP MEDICLAIM POLICY (2012)


OPD CLAIM FORM

Issuance of this form does not amount to admission of any liability of under the policy on the part of the Insurers
Please give the following information correctly and completely to enable us process your claim promptly.
All dates to be entered as Date / Month / Year

1. Name of the Employee :- _______________________________________________________

Policy Number : - _____________________________________________________

Employee Code : - _____________________________________________________

TPA Card Number : - _____________________________________________________

Type of Claim: - Consultation Dental Vision Prescribed Diagnostics

Details of Expenses ( Supports annexed) No. Of Bills Total

1. Consultation Fees

2. Tests / X-rays / ECG etc.

3. Others

2. Details of the Paitient : ______________________________


(In respect of whom claim is made) :
(a) Name & Relationship with the Insured : ______________________________
(b) Present Completed Age : ______________________________

3. Nature of Disease contracted / Ailment


Suffered or injury sustained _______________________________

4 Date on which injury was sustained/Disease


Or ailment first detected :_______________________________

5 (a) Name and Address of the attending : ______________________________


Medical Practitioner Location : ______________________________

Grand Total : _________________________

1
DECLARATION

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 of any fact, 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 availed or claimed under any other Medical Scheme or Insurance.

I ALSO CONSENT AND AUTHORISE THE NEW INDIA ASSURANCE COMPANY LIMITED & THIRD
PARTY ADMINISTRATOR TO SEEK MEDICAL INFORMATION FROM ANY HOSPITAL / MEDICAL
PRACTITIONER WHO HAS AT ANY TIME ATTENDED ON ME.

I also authorize TPA to receive payment from the insurance company as reimbursement of hospital bills
incurred on my / the insured person’s treatment.

Date:
Place:

Signature of the Claimant

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