Medical Health Insurance Scheme for HPCL underwritten by NIA Co Ltd.

( Non - Hospitalization )

Claim No. : 3195052000020

A
Name of Insured Employee: DHIRAJ KUMAR MEENA
Location: Mumbai Refinery-II Termin
Employee No: 31950520

Name of Patient: DHIRAJ KUMAR MEENA Age: 36yrs Relationship: SELF

Claim Year : 2023 Duration of illness for this claim : From: Nov 27, 2023 To: Jan 2, 2024

Was the Patient absent from office/school/college during the period of treatment ?

Yes No If Yes, Dates :

Details Of Expenses Expenses Incurred Rs. NIA Remark

1. Consultation Charges
2. Nursing charges
3. Medicines,injections,dressings Charges
4. X-rays, ECG, Lab Investigation
5. Vaccination
6. Physiotherapy
7. Dental Treatment
8. Dental Treatment (Dentures)
9. Eye Treatment (Spectacles)
10. IVF Cycle (1,2 & 3) Charges
11. Ambulance Service
12. Hearing Aids
13. Health/Medical Equipments
14. Periodical Health check up
15. Others

Total Expense Incurred 1,809

Net Payable Rs.
I hereby declare that claims/statements made in this claim Form are true in every respect and are made without any reservation. I
further declare that if the claim is not found genuine, the same is liable to be rejected and my coverage under the Medical Health
Insurance Scheme shall automatically stand terminated. It is also declared that I am not getting nor likely to get Medical Benefits for
above illness from any other source.

Date : Jan 6, 2024 Signature of Employee :

Note: The diagnosis should be mentioned on the prescription bill/receipt by the attending Doctor.

- Attach all original Bills/cash memos of Consultation charges, Medicines and Lab reports.

- Attach xerox copies of all Lab reports, Prescriptions, Radiology etc.