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CLAIM FORM

(Issuance of this form does not amount to admission of any liability under the claim on the part of the insurance.) Name of the Insurance Company: Address of the Policy issuing Office: EMSLs ID No. : UI-NKIA-23009940 Policy No.:

500300/48/11/41/00000021

1. Name of the Insured (In whose name policy is issued):

Jinu Thomas

2. Details of the insured Person (In respect of whom claim is made): Jinu Thomas (a) Name & relationship to the insured: Self (b) Present completed age: 30 Phone No.: (c) Occupation: Software Engineer Mobile No.: +919591987231 (d) Residential address: 1st floor, #355, 5th main, HAL IIIrd Stage, Bangalore-560075 (e) E-Mail I.D. jinuthomas25@gmail.com

3. 4.

Nature of Disease/illness contracted or injury suffered: Dental OPD - RCT Date of injury sustained or Disease/ illness first detected: 27/08/2011 Vijay Dental clinic, No. 261/C, 1st floor, 4th main, HAL 3rd

5. (a) Name & Address of the Hospital/ Nursing Home/Clinic: stage, Bangalore- 560075 (b) Date of Admission: (c) Date of Discharge:

6. (a) Name and Address of the attending Medical Practitioner : Dr. M. Vasanth Kumar MDS , Vijay Dental Clinic , HAL 3rd stage, Bangalore-560075 (b) Qualification: MDS Telephone No.:9845211413 (c) Registration No.: 2335-A 7. Have you been insured under any Mediclaim Scheme earlier: (Whether with us or any other Insurance Co.) If yes, photo copies of Previous years Insurance policies must be enclosed 8. Date of Commencement of very first insurance for this insured: person with continuous Insurance Cover 9. If the claim is for Domiciliary Hospitalization,: Please indicate (a) Date of Commencement of treatment: (b) Date of Completion of treatment: (c) Name & Address of attending Medical: Practitioner 10. Total Amount Claimed: Rs. 1700 I have incurred on the treatment of disease/illness/accident referred to above the expenses as per the details given by me in the Schedule of Expenses given overleaf. In support of the above claim, I enclose the following documents: Claim Form Duly Signed: EMSL Pre-Authorization Certificate: Claim Intimation Letter Discharge Summary Yes/No Yes /No Yes/No Yes/No Pre Hospitalization bills ___ Nos. Yes/No Post Hospitalization bills ___ Nos. Yes/No Hospital Payment receipt Yes/No Hospitalization Bill Yes/No

Medicines Bills with Drs prescription Operation Theater / Pharmacy Bills Investigation reports with Drs prescription MRI ___ Nos. CT scan ___ Nos. US scan ___ Nos.

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

Surgeons surgery certificate Surgeon/Consultants bills ECG ___Nos. X-Ray ___Nos. Others (If any)

Yes/No Yes/No Yes/No Yes/No Yes/No

I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made or shall make any false or untrue statement, suppression or concealment, my right to claim reimbursement of the said expenses shall be absolutely forfeited. I further declare that, in respect of the above treatment, no benefits are admissible under any other Medical Scheme or Insurance.

Dated:

Signature of the Claimant


Schedule of Expenses Incurred

Sr. No. 1

Date of the Bill 31/08/2011

Bill No 00296

Name of the Hospital/Lab/Medical Shop Vijay Dental Clinic

Amount 1700

Total

1700

Consent Form
From: Patients Name and address: Jinu Thomas , HAL 3rd stage, Bangalore To: Whomsoever it may concern: (hospital/doctor) M. Vasanth Kumar Sirs, I here by authorize E-Meditek (TPA) Services Limited representatives free and unlimited access to seek medical information (Indoor case papers, reports, documents, including photocopies thereof / pertaining my, admission / treatment) from any hospital / medical practitioner from which or whom I have at any time sought or shall seek medical attention concerning any disease/ sickness, ailment or injury, which affects my physical or mental health. Yours faithfully,

Signature of the Patient