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Sample NIC Claim Form

This document is a claim form for Mediclaim insurance from National Insurance Company Limited, intended for submission to FHPL. It requires detailed information about the insured person, patient, hospitalization, and the nature of the illness, along with necessary supporting documents. Additionally, it outlines the mandatory steps for submitting the claim and accessing the E-card online.

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Ganesha G
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46 views2 pages

Sample NIC Claim Form

This document is a claim form for Mediclaim insurance from National Insurance Company Limited, intended for submission to FHPL. It requires detailed information about the insured person, patient, hospitalization, and the nature of the illness, along with necessary supporting documents. Additionally, it outlines the mandatory steps for submitting the claim and accessing the E-card online.

Uploaded by

Ganesha G
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NATIONAL INSURANCE COMPANY LIMITED

MEDICLAIM INSURANCE - CLAIM FORM (To be submitted to M/sFHPL)


POLICY NO: Mentioned On E card INTIMATION NO: Leave Blank DATE:
01 . Name of the Corporate EXL Services.

02. Name of the Insured person (Employee) Amit Kumar

03. Employee No. 1234

04. Contact No. & E-mail ID (if any)

05. Name of the patient


06. ID Card No. of the patient Which mentioned on E card as name of UHID Number

07. Relationship with employee, Age & Sex


08. Bank Name & IFSC code Main Employee Bank details

09. Account No / Payee name Main Employee Bank Details

10. Nature of illness Name Of Treatment

1 1 . Name of the Hospital where treated and Write Proper Name Of Hospital With Address
Address of the Hospital
12. Date of Admission As per Actual Admission Date

13. Date of Discharge As per Actual Discharge Date

14. Cashless / Reimbursement (Specify) Reimbursement

15. Amount Claimed in Rupees As Actual Amount As Per Bill


As er the details below
Bill Date Amount Bill Date Amoun Bi Date Amount
No. No. t ll
No No No No
. . . .
Fill
Details
As Per
Bill

(Please attach a separate sheet for more number of bills and receipts)
TOTAL
I/We hereby declare that the above details are true to the best of my/our knowledge and belief that I/We not suppressed any
information

Leave Blank Below

Signature of the Employer with seal Signature of the Employee NOTE : The following documents all
originals must be sent along with the claim form without fail.
l. Original Discharge Summary. In case of Maternity the member should submit the Gravida Details along with the Discharge
summary if it is not mentioned in the D/S.
2. Final Bill with break up expenses. Detailed Break up for the Final Bill (Break up of Individual drugs
Administered, Lab investigations Carried out etc.,)
3. All Original Lab reports, Medicine bills with Prescription.
4. For Dental Procedures and surgery, Treatment Detail from the Dentist (Should be on the letter head of the
Clinic), Bills with break up of Expenses, Receipt shall be submitted. Please ask your dentist to mention the X-ray findings
in the treatment details.
5. Any Govt Photo id proof of the patient,Fhpl e-card printout of the patient & Employee badge id photocopy
should also be submitted.
6. One cancelled chq

Please Intimation mail drop for hospitalization at


[email protected] it is mandatory.

For E card. Step 1: Log on to FHPL website https://m.fhpl.net/


Step 2: Enter the *Login ID and the *Password.
*Login ID: (EXL employee id no.@exl)
*Password: employee DOB in DDMMYYYY

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