MDIndia Healthcare Services (TPA) Pvt. Ltd.

First Floor, Karnavat Tower (Maral Heights),Paud Phata,

Behind Dashbhooja Ganapati Temple, Pune 411 038. (Maharashtra)

UAN Voice No. 1860-233-4446. UAN Fax No. 1860-233-4447

E-mail ID: pune@mdindia.com .Website: www.mdindiaonline.com

CLAIM FORM
National Insurance Company Ltd.

The New India Assurance Company Ltd.

Oriental Insurance Company Ltd.

The United India Insurance Company Ltd.

1. Current Policy No.

2. MDIndia ID No.: MDI5-

Employee Code :

3. Corporate Name :

Name of Patient :

4. Present Contact Address :

5. Contact No.(M)

Email ID :

6. Have you preferred any claim for the same Insured and for same hospitalization under any other Mediclaim scheme
earlier, if so (Enclose claim settlement letter)
7.

Since when the person covered under the policy without break ______Years. (Enclose Policy Photo Copies)

8. If the claim is of Hospitalization please provide

a. Date of Commencement / first consultation of the treatment
b. Date of Completion of treatment
c. Name of referring doctor or Family physician
Address:
d. Contact No.

Registration No.

9. Details of Expenses incurred by the claimant Sr. No.

DATE
BILL NO.
1
2
3
4
5
6
7
8
9
10

Qualification
PARTICULARS

AMOUNT CLAIMED

GRAND TOTAL
I/We hereby declare that the above details are true to the best of my / our knowledge and belief that I/We have not
suppressed any information.

(1) Signature of the Policy Holder.

Policy holder should Sign of all pages of the claim form at Designated Numbered spaces.

Check List of Documents: Please put a

mark in the box

Total Number of Claim Documents Pages Submitted: __________

1) Duly Filed Claim Form signed by Policy Holder (Fill the claim amount in Signed Claim Form)
2)
3)
4)
5)

& Previous Years Mediclaim policy photo copies.

Original Hospital Bill with break up. (Detailed Breakup of various heads like Room & Nursing
Charges, Investigation, and Medical Consumables etc.)
Original All Hospital Payment Receipts with serial number. (Advance paid receipts & Final
amount paid receipts)
Original Discharge Summary / Card from the hospital. (Should have diagnosis, cause of
illness, complete treatment details in the Hospital)
Death Certificate or Summary in case of a death claims. (Mentioning the cause of the death)

6) Original Receipts with serial number (For Consultation/Surgeon charges if charged outside the
main hospital bill)

7) Original Investigation bills and reports (Along with referral Note / prescriptions with reports
for all tests done along with x-ray film or images)
8) Police FIR/ Medico Legal Certificate (Mandatory for all road traffic accidents If not done
kindly provide self-explanatory note detailing cause of accident in detail)

9) Original Pharmacy bills with original Doctors Prescriptions (On doctors letterhead
mentioning duration and dosage for medicines)
10) Patients Valid Photo ID Proof (Like MDIndia Photo ID card, Passport, Driving License,
Employee Card, Aadhar Card, PAN Card, Election Card, Bank Passbook with Photograph Etc.)
11) Bank cheque leaf (cancelled) with printed name of A/C Holder, A/C No., IFSC Code or Bank
Passbook copy with IFSC and MICR Code.
Important Points to remember:
Please retain a copy of all documents submitted to us for further reference
Please retain POD copy of the courier for tracking your consignment in case of any delay etc.
For implants used in Cataract, Heart Valve Surgeries, CABG, Abdominal Surgeries, Knee replacement
surgeries. Please submit the bill (in case purchased outside) from the vendors for the prosthetic devices
used along with Sticker. (BARCODES)
Please arrange the claim documents as per the above checklist.

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No Objection Declaration to M/s MDIndia Healthcare Services (TPA) Pvt. Ltd.

To
(Name and address of Hospital)
____________________________________
____________________________________
I wish to inform you that I have undergone treatment for ______________________________ailment from (date of admission)
________________ to (date of discharge) ________________in your hospital as an inpatient bearing Hospital Inpatient No:
_______________ . I hereby authorize M/s MDIndia Healthcare Services (TPA) Pvt. Ltd., who are my TPA for servicing the
Health Insurance Policy, to seek any medical information/ records from your Hospital or from the Medical Practitioners
who have attended on me in connection with the above ailment.
I have no objection to your furnishing any such information/ records sought by them.

Date: ___/_____/_20____ Contact No.:____________________________

(2) Signature of the Insured
Disclaimer: All the statements made above and the answers given on my behalf of the family members are wholly true and correct to the
best of my knowledge and belief. I have disclosed all particulars/materials to the risk. It is hereby understood and agreed that the
statements, answers and particulars are basis on which the insurance is being granted. If, after the insurance is effected, it is found that the
statements, answers of particulars are incorrect or untrue in any respect, the company shall have no liability under this insurance in respect
of myself and my family member proposed for insurance and event of any legalities insurance company reserve the rights to recover any
such amount from my side.

MEDICLAIM MEDICAL REPORT (MMR)

CERTIFICATE FROM ATTENDING DOCTOR OF PATIENT FROM THE NURSING HOME/HOSPITAL
1. Name of Patient :
2. Age

Date of Birth:-

3. Are you a family doctor of patient? Yes / No

Sex : M

Since:-

yrs.

4. Who referred the case to you?

5. When did the patient approach you for the first time in connection with present disease suffered?
Date of First Consultation:

6. Details of previous history of disease / surgery (if any) of patient?

7. Is the patient suffering from Diabetes, Hypertension (Blood Pressure), Kidney problems, Cancer, T.B., Heart Problem
and AIDS or other disease? If yes (Since how long he or she may be suffering from the same):

8. Present disease suffered (Diagnosis):9. Duration of present disease suffered (i.e. since how long he or she may be suffering from present disease before
approaching you) :-

10. Is the present disease suffered connected to previous disease or Diabetes, Hypertension (Blood Pressure), Surgery or
other existing disease?

11. Is disease suffered Acute or Chronic? :12. Whether the disease is caused due to any congenital defects (Yes/No)?
13. Whether the patient had any complications during or after pregnancy (Yes/No)?
14. Whether the disease/injury is caused directly or indirectly due to the use of alcohol or drugs (Yes/ No)
15. Is the disease suffered requires hospitalization? :- Yes / No
a) Nature of treatment given : Operative / I V Fluid / Injection / Oral Treatment / other Parenteral Treatment
b)
Date of Admission
16.
Date of Discharge

____/_____/ 20____
____/_____/ 20____

Time Of Admission
Time Of Discharge

:
:

AM/PM
AM / PM

16. Hospital Registration No.____________________No. of Total Beds in your Hospital :_________________________

Certified that the details furnished above are true to the best of my knowledge and as per the records available at this hospital.

Doctors Name:___________________________Qualification:________________Registration No.______________

Contact No. ___________________
Date: _____/_____/20____

Signature of Attending Doctor

(With Rubber stamp and registration no. of your Nursing Home / Hospital)
Name of Policy Holder: ______________________________________________
Date: ____/_____/ 20____
(3) Signature of Policy Holder

Mandate Form for Electronic Clearance System

Name of Account
Holder
Name of Bank

Branch Name

Branch Address

Type of Account

Account No.

IFSC Code

Important Information to the Policy Holder / Claimants option for NEFT:

1. All the information mentioned above mandate form should be filled correctly.
2. The account of the policy holder should be operational at the time of receipt of policy payment.
3. Before submitting the mandate form, the policy holder / claimant should confirm from his bank that it is NEFT
enabled.
4. Policy holders / claimants name under the policy should match with that of Bank A/C, else it is likely to be
rejected.
Declaration
1. I hereby declare that the information furnished in this ECS Form is true & correct to the best of my knowledge &
belief. If I have made any false or untrue statement, suppression or concealment of any material fact, my right to
claims reimbursement shall be forfeited.
2. I agree that I shall not hold TPA/ Insurance Company responsible for delay or non-receipt of the payment for any
reason whatsoever after issue of the instructions for payment by Insurer/TPA based on the above.
3. As per the revised RBI guidelines, Canceled Cheque should have pre-printed name of Account holder.
Date:
(4) Signature of the Policy Holder

Place:

Attach Photocopy of Cheque leaf or the photocopy of the page of the passbook / Cheque book where details of the
Account Holder Name, IFSC, Account Number are mentioned.
SAMPLE CHEQUE FORMAT
Note: Claims Number / Policy number / MDID number to be mentioned on cancel cheque and Please enclose the cancelled cheque of your bank account for
our record; your banker should be a participant of NEFT/RTGS Facility.