THE NEW INDIA ASSURANCE CO.

LTD,
87, M.G. ROAD, FORT, MUMBAI- 400001

CUSTOMER FEEDBACK FORM (CASHLESS CLAIM)

Dear Valuable customer,

We would request you to complete the feedback form to help us to serve you better.

Name of the insured: ……………………………………Address ………....................

…………………………………………………………………………………………
Policy No. : …………………………Claim No.....…………………………………
Telephone No/Cell no. ………………….. Email ID:…………………………………

Please check the appropriate option.

1. The response time taken by the TPA for Cashless Authorization to Hospital
Less than 2 hours 3 hours More than 3 hours

2. Did you receive SMS/Email from TPA regarding approval of Cashless Service
Yes No

3. Did the representative of TPA visited the patient in the Hospital

Yes No

4. Would you recommend The New India Assurance Co. Ltd to your relatives and
friends for buying Health Insurance products?
Yes No

5. How was your experience during the interaction with our TPA in pursuing the claim?
Outstanding Excellent Good Average Poor

6. How was your overall experience regarding the cashless procedure?

Outstanding Excellent Good Average Poor

7. Areas of improvement, if any

…………………………………………………………………………………………
…………………………………………………………………………………………

(Signature of the Insured)