MEDICLAIM INSURANCE - CLAIM FORM

POLICY NO: CLAIM NO: DATE: 26/10/2020

01. Name of the Corporate Texas instruments

2. Name of the Insured person (Employee) Akhil C Sunny

3. Employee No. a0489253

18527001

4. Contact No. & E-mail ID (if any) 7025133431,a-sunny@ti.com

05. Name of the patient Sosamma Sunny

06. Medi Assit ID Card No. of the patient 16121717

7. Relationship with employee, Age & Sex Mother,52, Female

8. Sum Insured of the patient under the policy 1.5 Lack
9. Nature of illness LEFT PARATHYROID ADENOMA, Carcinoma right breast
10. Name of the Hospital where treated MVR Cancer Centre & Research Institute. Address. CP 13/516 B, C,
and Address of the Hospital Vellalasseri NIT(Via), Poolacode, Kozhikode, Kerala - 673601
11. Date of Admission 05/10/2020
12. Date of Discharge 11/10/2020
13. Cashless / Reimbursement (Specify) Reimbursement
14. Amount Claimed in Rupees
(As per the details below) 112,438

Sl. Bill No. Date Amount Sl. Bill No. Date Amount Sl. Bill Date Amount
No. No. No. No.
1 IPR1013130991 05/10/2020 65,000

2 IPR101313996 08/10/2020 32,532

3 IPR1016055740 11/10/2020 14,906

(Please attach a separate sheet for more number of bills and receipts) TOTAL 112,438
I/We hereby declare that the above details are true to the best of my/our knowledge and belief that I/We not suppressed any i nformation

In support of the claim, I enclose the following documents (Please indicate by
Claim form duly filled and signed
Medi Asssit Pre-authorisation form
Claim Notification
Discharge Summary
Hospitalization Bills
Doctors Surgery Certificate if any
Surgery / Consultation Bills if any
Medicines Bills with Dr's prescription

) :-
Pre Hospitalization Bills & No(s)………of Bills……….
Post Hospitalization Bills & No(s)………of Bills……….
Hospital Payment Receipt
Investigation Report with Dr's request
1. MRI Yes/No 2. CT Scan Yes/No
3. ECG Yes/No 4.X-ray Yes/No 5. US Scan Yes/No
Lab Reports with Dr's request No(s)…….of Rep ………
Others if any

Signature of the Employee