The New India Assurance Company Limited
Registered & Head Office: New India Assurance Building, 87, M.G. Road, Fort, Mumbai - 400 001.
Claim Number
HOSPITALISATION AND DOMICILIARY HOSPITALISATION BENEFIT POLICY
CLAIM FORM
Issuance of this form does not amount to admission of any liability of under the policy on the part of
Please give the following information correctly and completely to enable us process your claim
the claim is under Personal Accident Insurance, please complete a Personal Accident Claim Form.
All dates to be entered as Date / Month / Year
1.
Name of the Insured:
(in whose name policy is issued)
SURNAME
INITIALS
2. Details of the Insured person
:
_
(in respect of whom claim is made)
:
(a) Name & Relationship with the Insured
:
_
(b) Present Completed Age
:
_
(c) Occupation
:
_
(d) Residential Address
:________________________________
________________________________
________________________________
3. Policy Number (in Full)
:
4.
Nature of Disease/Illness contracted or injury sustained
5.
Date on which injury was sustained/Disease
6.
Or illness first detected
(a) Name and Address of the attending
Medical Practitioner
(b)
(c)
(d)
Qualification & Telephone No.
Registration No.
Name & Address of the Hospital/Nursing
Home / Clinic
:________________________________
:________________________________
:________________________________
:________________________________
Pin Code_________________________
State/ U. Territory__________________
:________________________________
:________________________________
:________________________________
the insurers
promptly. If
(b)
(c)
8.
Date of Admission
Date of Discharge
________________________________
Pin Code_________________________
State / U. Territory__________________
:________________________________
:________________________________
If the Claim is for Domiciliary Hospitalisation,
Please indicate
(a) Date of Commencement of treatment
(b) Date of Completion of treatment
(c) Name & Address of attending Medical
Practitioner
(d)
(e)
Telephone No.
Registration No.
:________________________________
:________________________________
:________________________________
:________________________________
:________________________________
Pin Code_________________________
State / U. Territory__________________
:________________________________
:________________________________
9. Are you at present covered under any other similar type of scheme like P.A. Cancer
Insurance, Mediclaim (Individual or Group), Health Insurance, etc. If Yes. Please give
particulars of each
(a) Is this the first year of coverage under Mediclaim Policy? Yes / No.
If no, since when have you been continuously insured under Mediclaim Policy.
Give details
(b) (i) Is this the first claim under this policy ?
(ii) If no, please quote Previous claim number and details
Yes/No
In support of the above claim, I enclose the following original documents (Please
indicated by )
1. Bill, Receipt and Discharge certificate / card from the Hospital.
2. Cash Memos from the Hospitals (s) / Chemists (s), supported by proper
prescriptions.
3. Receipt and Pathological test reports from Pathologist supported by the note from
the attending Medical Practitioner / Surgeon recommending such Pathological
tests.
4. Surgeon's certificate stating nature of operation performed and Surgeons bill and
receipt.
5. Attending Doctor's/ Consultant's/ Specialist's / Anesthetist's bill and receipt, and
certificate regarding diagnosis.
6. In case of Domiciliary Hospitalisation, receipt from a qualified nurse who attended
the patient at his/her residence duly supported by a certificate from attending
Medical Practitioner.
7. Certificate from attending Medical Practitioner giving reasons for allowing
treatment at home.
8.
Certificate from attending Medical Practitioner / Surgeon that the patient is fully
cured.
Summary of expenses incurred for which original bills / receipts / cash memos are
enclosed.
Total of Hospital Bill
Consultant's /Surgeon's /Anesthetist's Fees
Diagnostics Tests
Medicines purchased from chemists
Other expenses not included above
Grand Total
Rs.___________________
Rs.___________________
Rs.___________________
Rs.___________________
Rs.___________________
Rs.___________________
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 or Insurance.
I ALSO CONSENT AND AUTHORISE THE THIRD PARTY ADMINISTRATOR TO SEEK
MEDICAL INFORMATION FROM ANY HOSPITAL / MEDICAL PRACTITIONER WHO
HAS AT ANY TIME ATTENDED ON ME.
I authorize TPA to make payment of the claim admissible as per terms, conditions and
limitations of the policy to the hospital on my behalf for full and final settlement of hospital
bills.
I also authorize TPA to receive payment from insurance company as reimbursement of
hospital bills incurred on my treatment.
Dated at. this day
of2003
Signature of the Claimant
