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Domiciliary Claim Form Instructions

This document is a domiciliary claim form for an insurance company provided by Medi Assist India TPA Pvt. Ltd. It requests details about the insured, patient, treatment expenses, and bank account. The insured must provide the name and nature of illness, original bills and documents for doctor fees, medicines, and investigations. Copies of investigation reports must be included. Separate claim forms for each family member are required, and all correspondence should be sent to the specified Medi Assist India address.

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712 views1 page

Domiciliary Claim Form Instructions

This document is a domiciliary claim form for an insurance company provided by Medi Assist India TPA Pvt. Ltd. It requests details about the insured, patient, treatment expenses, and bank account. The insured must provide the name and nature of illness, original bills and documents for doctor fees, medicines, and investigations. Copies of investigation reports must be included. Separate claim forms for each family member are required, and all correspondence should be sent to the specified Medi Assist India address.

Uploaded by

anjna
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

Insurance Company:

Service by: MEDI ASSIST INDIA TPA PVT. LTD.


Domiciliary Claim Form
¾ Details of the Insured: *Please Note: Below mentioned columns are mandatory:
*Employee’s Name: *Employee Code: *MAID No:

*Patient’s Name in full: *Complete Residential Address & Contact No.:

*Emergency Contact No.: *E-Mail ID :

¾ Details of the Treatment Expenses :


Name/ Nature of Ailment:

1. Family Doctors Fees: No. of Total Amount


Bills/documents
(a) Doctor/Consultants/Specialist’s Fees (Consultation Notes
Mandatory)
(b) Medicine given by Doctor (Prescription Mandatory)
(c) Medicines brought from Chemists (Prescription Mandatory)
2. Investigation Charges:
(a) Blood Test – (Copy of the Reports Mandatory)
(b) X-Ray – (Copy of the Reports Mandatory)
(c) Others – (Copy of the Reports Mandatory)
3. Dental Treatment : (Doctor Advice, Report, original Bills Mandatory)
Grand Total (1+2+3)

¾ Details of the Insured’s Bank Account (Mandatory details for claim processing)
Name of the Account Holder
Bank Account Number
Bank Name
Bank Branch address
IFSC Code
*Please attach cancelled cheque along with the claim form for ready reference.
Signature of Claimant : Date :

Important Notes/Guidelines to be strictly followed :


1. Name/Nature of illness has to be mentioned in the claim form along with prescription and doctor’s consultation
notes or claim will be rejected.
2. All doctors’ consultation Bills/Chemists Bills/Investigation Bills have to be submitted in original.
3. Copy/Duplicate of claim form to be attached at the end after all other relevant documents are attached.
4. Please use separate claim form for each member i.e. self and spouse.
5. Copies of all the investigation reports have to be enclosed along with the claim form
6. All correspondence should be done at the below mentioned address.
*For further details please contact : Medi Assist India TPA Pvt. Ltd. 1st floor, North Wing, Plot No.7, Excom House,
Saki Vihar Road, Saki Naka, Andheri (E), Mumbai -400 072. Tel: 022-30843800/01/02/03.

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