Claim Form – OPD treatment

Corporate: Tata Steel Limited List No (Location/Month/No):

Insurance Company: Bajaj Allianz GIC Ltd Serviced by: Medi Assist Insurance TPA Pvt. Ltd
Employee Name: Sovan Kumar Pattasani Location of posting at Tata Steel: Coke Plant

Personal No / Employee ID: 153694 Patient’s Name & Relation to Employee: Lalmohan Pattasani
(Father)
Policy No: OG-20-1919-8403-00000032 MAID Card No of the patient:

Email ID: sovan.pattasani@tatasteel.com Contact No: 9040096054

Details of the expenses claimed:

Particulars No. of Amount claimed
Bills/Documents in Rs.
enclosed
1. Family Doctors Fees:
(a) Doctor/Consultants/Specialist’s Fees IGKC58473 500.00
(consultation notes mandatory)
(b) Medicine given by Doctor (bills mandatory)
(c) Medicines brought from Chemists IN No 0032368 3700.00
(copy of prescription & original bills mandatory) IN No 0037361
2. Investigation Charges: BIL NO ; BIL79498 3570.00
(a) Blood Test – (copy of the reports mandatory) BIL NO BIL79503 450.00
(b) X-Ray – (copy of the reports mandatory)
(c) Any others – (copy of the reports mandatory)
3. Dental Treatment: (Doctor advice / reports, original` bills mandatory)
Grand Total (1+2+3) 8226.00

Details of the Insured’s Bank Account (Mandatory details for claim processing)
Name of the Account Holder SOVAN KUMAR PATTASANI
Bank Account Number 00871140026720
Bank Name HDFC BANK
Bank Branch address JAMSHEDPUR JHARKHAND
IFSC Code HDFC0000087
Reimbursement to be made to (put a Tick mark as applicable): Tata Steel Limited [ ] or Employee [ ]
If payment is to be made to the employee, please provide the bank details above along with copy of cancelled cheque

Declaration:
I hereby declare that the information furnished in this claim form is true & correct to the best of my knowledge and belief. If I
have made any false or untrue statement, suppression or concealment of any material fact with respect to questions asked in
relation to this claim, my right to claim reimbursement shall be forfeited. I also consent & authorize TPA / insurance company
to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person
against whom this claim is made. I hereby declare that I have included all the bills / receipts for the purpose of this claim & that
I will not be making any supplementary claim, if any.

Signature of Claimant Place & Date:

IMPORTANT NOTES & DETAILS OF CLAIM AND DOCUMENTS TO BE SUBMITTED:

1. Please use separate Claim Form for each member.

2. Copies of Consultation papers (It should have qualifications of the treating doctor)
3. Copies of Prescriptions of tests advised
4. Copies of Prescriptions of medicines advised
5. Copies of Investigation reports
6. Bills and payment receipts (in original)
7. Copies of OPD (Dental X-ray) report in case of dental treatment
8. Any other documents in support of the treatment & expenditure claimed is to be submitted
9. All financial documents should be in original. Photocopies will not be accepted
10. All correspondence should be done with Medicare Help desk representative at your location of posting or
at the below mentioned address:

Medi Assist Insurance TPA Private Limited

Aarpee Chambers, 4th Floor, Shagbaug,
Off Andheri – Kurla Road, Marol, Andheri – East,
Mumbai – 400059
Toll-free No. 1-800-419-1151
Any issues please contact to: Ms. Chaitrali Kondalkar (M) 8433933063
tatasteel.mediclaim@mediassistindia.com