Medi Assist REIMBURSEMENT CLAIM FORM

TOBE FILLED BY THE INSURED (To be Filled in block letters)

The issue of this Fom is not to be taken as an admission of liablity

-DETAILS OF PRIMARY INSURED:

a) Policy No.:
b)S Nv CertfcaBo no
) Company ITPA ID(MA ID)NO: 4412Q14IOUUUULI
d) Name.
e)Address GYANENDRATIWARIO
403Nlu TRAMCULNES
oNENUlDELHIULL
Pin Code
-DETAILSOF INSURANCE HISTORY:
a) Curontly covorod by any othor Modm /Halth Insuranoo Yes to b) Dalo of commoncomont of frst Insuranc without brmak
c) yos, conpany namo Ptey N e O O
Yes No Dafo
Sum insured (Rs.) ld) Have you been hositalzod in the last four yoars sinco incoption of the contract?
N
o) ProvioUsly ooverad by any other Medclaim Heath insurno Yos
Diagnosis
f) If yes, company name:

DETAILS OF INSURED PERSON HOSPITALIZED:

a) Name
b) Gondor
OOTINARIOOOOCOGYNENDRAUOOOEO
)Ago yoars 3 MonthsO Dato ot Brth
Mak_Fomake OUUL
o) Rolatonship to Pnmary insuod: Set Spouse Chid Fathor Mothor Cthor(Pkase Spocty)
) Occupabon Servico Self Employed Home Maker Studont Retirod Other PkasoSpocty)
g) Addross (if ditfront from abovo)

93220H3BOO ErailD AETAN ME JNAN98 egmu

Phono No
-DETAILS OF HOSPITALIZATION:
a) Name of Hospital where Admited: DELHIOMEDIAUOdENITIRHUOL
Twin shanng 3ot moro beds por rom
b) Room Category occupied: Day caro Single occupancy
c) Hospital1zation due to: Injury inoss Matemity d) Date of inhury / Dale Disoaso frst dotectod Dato ot Dolvory|
e) Dale of Admission2 23 Ø) Dale of Dachago o 23
I) injury give causo: Self inflictod Road Traffc AccidentD Subslance Abuso /Aoohol Consunption 1 I) f Nledico logal Yos]No
, MLC Report & Poloo FIR attachod Yes No I) System of Mledlcine:
) Reported to Polico || D
-DETAILS OF CLAIM: Clalm Documents Submitted -Check List
a) Detais of tho Troatment cxponscs caimed
Hospitalzabon expenses Rs Claim form duly s1gned
L. Pro hospilalzabon oxponsos Rs
Copy of he claim intmaton, if any
Rs M Health-Chock up oost Rs.
I Post-hospitalization expenses Hospital Main Bill
Re vi. Others (ode): | | | Rs. Hospital Break-up 8
V. Ambulance Charges:
Total Rs
LIolb l6-OHospatal BN Payment Rexwpt
Vu. Pro -hospitalzaton ponod daysI viL. Post hospilalzaton ponod. days ILJLI Hosptal Drschage Summary
Phanacy Bil
b)Claim for Domiclkry Hospitlization
| Yos JNo (lt yos, provdo dotailsin annoxure)
Operatioitheaty Notes
c) Dolails of Lump sum / cosh boncit daimad
W. Surgical Cash: ECG
Hospita Daily cash Rs
0v. Convaloscenco: R Doctos request for nvestgaton
Cnbcal liness bonett Rs Inveshgaton Reports (lncutingCI
u. Other8. Rs IMALUSG HPE)
v PrePost hosptalzaon Lumo sum benoht. Rs Doctos Prescnptons
Totl R
Othes
-DETAIL9 OF BILLS ENCLOSED:
Issuod by Towards Amount (Re)
SI. No. BiINo. Date
1.
4204 120|231Delmaaetol Hospital nain Bi0

2.
42|04o23
42)B6 O /|23 Centre Pro-hospilahzaton Bila
Post hospital1zalian Vits
No

Nos
3.

Y228 9 o 23 Pharmacy Bills

7.

10
DETAIL8 OF PRIMARY INSURED'S DANK ACCOUNT:

a) PAN
BIMIAPl||1||1||2lh lA b) Aooount Nunbot

ond Branch
c) Bank Narne

d) Cheguo / DD
Payablo dotails. Bc703 DECLARATION BY THE INSURED:
o) f SC Code
SBII]|Oo o|21.S1|2
Infornatlon funlshed in the clal1m fom is thue &coret to the best of ny knowledye and belet, It |have nnade any talse or untiue slaBenternt
Ihereby declate that the
e the LUpesin
aked in telation to this daim, ny lyht o clalnvinbiusenent shal be foteted I also LOIsent &authoEv WAlsurance LomEy, (o see VKalent
tecessary metisaivot any
. matena
tat veith iespcct Mxdlr.
docunets from any
IOSp0lal / cal Ptac lilloner who has attendecd on tthe penon agalnst whom tthlh clalnm is nade. Iheeby declare that lhavw tnclunted all the bila
hospllallzatlon lal it aun.
e huw the
the purne ot
wil not be maklngany supplonenlary dalm excopl the pre/post hisln8
pate lo|1 1OsT D2B Paro| Ne Delhi Sionatue of the lnsuvd