MediAssist
MEDLASSIST INDIA TPA PVT LTD.
INVESTIGATION REPORT
(NEW INDIA ASSURANCE LTD)
Policy Details
Belef of the case As per lnsured As per investigation Verified or NO,
Not
Name of the Insured patient comments
. D o s a aDoei
Date of Birth/Age
Age proof
|Occupation
Poicy No
CCN/PA
Policy holder Name and Relation
Policy Type
Calm details
Date and Time of Admission
Date and Time of Discharge
ICU Admission/Details
|Cashless/Non-cashless hlos cada w )
Pre-Auth
Details(Amount,Estimates, Medical
History etc)
lihi
Diagnosis Aute tanenea
Treatment Paratelyos oleebamy
Hospital Name and Address
Registration and Other
details(Attach hospital
information sheet and related
documents
Allment detalls
Onset of symtoms Beatlexsnen Veit Aelpmn
Fist consutation Velammal enilal
Referal Doctor's detail
intial treatment Details Nedtia (odnte
Pre Hosp Inv and Treatment
details
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O Scaned with CKEN SCanner
O Scanned with CKEN Scanner
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Medi Assist
Post Hosp Inv and ([Link])
details treatment
Ivestigations
Diagnosis
Suggesting
(Attach relevant copies)
Outcome
INSURED'S ADDRESS
DETAILS al above qelals a
OPINION
INSURED'S INTERVIEW
uST OF DOCUMENTS COLECTED
() Photography/copy of Pan Card/Noter lD of the claimant
() Copy of different pathology test ete
(i) Copy of Indoor case papers/investigation papers/discharge summary
Signature |Date: Place
TNKH NU
to
wa el,
Vfis. skl
Patt 2
teow
O canned with OKEN Scaner
CHARITYFUND O Scanped with OEN SCanner
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Reg. Nq64/1985 O Scanned with OKEN Scanner
THEM O Scanned with OKEN SCanner
