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    GobinderSinghSidhu
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    RELIGARE CLAIM DOCS

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    © All Rights Reserved
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    10 views29 pages

    Religare Claim Docs

    Uploaded by

    GobinderSinghSidhu

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Flag for inappropriate content
    of 29
    To, ‘The Religare health insurance company limited Gurgaon.122001 Subject: FRACTURE ON LEFT WRIST Dear Sir/Madam, |/am writing this in regards to explain my injury on left wrist. | got wrist fracture while taking bath in the: morning around 9'o clock on 17.07.2020 owing to slipped my feet. | fell down into my left wrist and got injury. Yours sincerely, eS Manpreet singh Fotity Norte 272118 6) CLO MINIT Mes Nos- RAR VF02202 \ ore eqD ee Claim Form - "CARE" Part A 1. Tobemtedinby tetas rerun atinfurm ents bettenat natn olla 2) Currently covered by ary other Melee surance »b) Dato of commencement of fist insurance without bres: 9) yes, Company Name i. Policy Number Tae 2) Ne ©) Gender oe i 9 Age: | | ©) Felatnship wie Prva hae er f ‘Chis [ 1 ‘Others (Pease Speci) Homemser SRE ere re nm, compe ae Ex womens UN Hae oe IRDA Repose a Lehane Senco Sn, 301 ae) anaes = 2) Nome of Hospital where Aomtted: KG M0, 1) Room Category cccpied : |_| Day Care ©) Mospitaeaton dueto —: | Whur Gone Wosti Tar TALA woHOR Se Occpuey Twnstarng dormers inde ati tess — ) Date of ry Date Disease frst detectedtDate of Delvery: | 1H 019 1//>. o 2Ie) js nen ©) DuteofAdmsson 1H O/Pi\D 0 ae * 1) Time of Admission ® Diteof Discharge VW Hilo Riis! © alo) van 1h) Time of Discharge “ 4) Hlaury give cause | Set inicted Road Tralfe Accident 1 Substance AbusefAkohol Consumption 9) Meco Legs ws [Wie 1) Reportedioreke: | Js [eRe 1) MC Report &Polce FR tached: | | Yes 2 Sytem of Meine 8) Detaiof the treatment expensesclamed © Preosptalaaton Expenses : Rs HorpitaanionEwenies Re (i) Posthospitateatonperses: Re (2) Heath Checleup cost Rs, 6) Ambulance Changes Bs [L ») CammtorDomiclaryHorptazation: | Yes (yes revise detalsinannexire) ©) DetatsofLumpsuenicah benef chimed (Hosp DayCash Re © Sapedcan Rs, (i) Citadines Bane: () Convaescence me (_] b) ClimDocuments Spmited-Chectst Qaim Form Dutra (9 Copyofthe chim iimstion ifany i) Hospital Main at (0) HosptaBres (6) HosptalBilPaymert Recent (9) HospitalDschanse Summary (si, Others at ec No ou 0 oy Tr wi) 9 ” ~~ « (9) Others (code) Total (4) Prehospitateation period | (6) Postchositleation period Othe : Re | Total Rs. CLES Pharmacy (Operation Thontre Notes foc Doctors requestor vestigation lovestigation Reports nehcing CTIMRVUSGPE) Doctor's Presrigtions nee Bate art egal le 9 Chow ne Ah PN A N9 Cap. "at tr Fn Tour tc ah P Site ® Gru 20 ny) TRDA Registration No. = 148 ‘ ‘Neb wo cigs f ON" econ OPIS iN RUM PION Festal | ‘Section F - Details of Bills Enclosed ‘SNo. Bill No, Date Issued by Towards { Amour (NR) | 1 dora WAfpj20 KOM Boe Hostal Main Bal 5 Hooj— = }o24 2) }yJa0 ” Prechosptalzation Bal:__Nos 3 DAS 29)H 0 o Posthospkalation Bis ne Yoke i 214% 4 [or|z0 Pharrpacy bils 6 AJO'S. 1qupeas/= 5 eRe Malze ” GION) @2 20) 22 V0 Z 104, 29/fa)r oy R213S > 17]7]20 2 listys lepappe Te Raszisyfepo 2B. Re 1/1/20 i R269 5 lao in %as ep gpie | 4 Raizy= N9]20, a8 : R272 21)9/22 ‘Section G - Detals of Primary Insured’s Bank Account a 2) PAN CRP $e 94sia I 2) Account Number O24 recooYollosizi189 | ©) Bank Name & Branch PuINTeR NaATiow nL AWK ie ) ChequeiDD parable det C WIE Alu E [ ©) ISCCode PeNBoorAYro0o0 [ ‘Section H Declaration by the Insured formis te & correct tothe best ef my kiowledge and beSet hare made any fae or untrue with respect to questions asked in retin to ths ci, my right to clan remoursement shal be TPA/Comparyto sck necessary meal information/documets from; hospital Medea Prectticcer whoa atindedon the person aginst whom thi cls made. hereby dele that Ihave inched a he bikirecepts or the purpose of ths clam tha wl not bi apy upplernertarycimexcept the prefposheapalztionclamifany. owe (12) [[o lize 2b Siatre ofthe ned a fe OAR NO WAE ESESOR Bs et con, coc a kn en ak Se, en le) aoc aces oe eno ne Sa aS ie ON UesomDLUMPLCIBISS LIN" RNBLIDIONVeSNE! 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