The Oriental Insurance Company Limited (Incorporated in India, subsidiary of General Insurance Corporation of India

)
Regd. Office: Oriental House, P.B. No.7037, A-25/27, Asaf Ali Road, New Delhi- 110 002 Issuing Office

HOSPITALISATION & DOMICILIARY HOSPITALISATION BENEFIT CLAIM FORM Claim No.___________________________ Issuance of this form does not amount to admission of any liability under the claim on the part of the Insurance. Please give the following information correctly and completely to enable the Company to process your claim promptly. For Office use only 1. Name of the Insured (In wohole name policy is issued) 2. Details of the Insured Person (In respect of whom claim is made) (a) Name & relationship with the Insured Present completed age Occupation Residential address SURNAME INITIAL

(b) (c) (d)

3. Policy No. 4. Nature Disease/illness contracted or suffered 5. Date of sustained Disease/illness detected of injury injury or first

Date

Month

Year

a) Name & Address of the attedning Medical Practitioner :

_________________________________ ________________Pin Code__________ State/U. Territory

(b) Qualification & Telephone No.

Attending Doctor’s/Consultant’s /Specialist’s/ Aneasthetist’s bill and receipt and certificate regarding diagnosis. Receipt and Discharge certificate/card from the Hospital. Certificate from the attending Medical Practitioner/Surgeon that the Patient is fully cured. I enclose the following documents (Please indicate by 4) 1. (e) Registration No. If the claim is for Domicilliary Hospitaliation Please indicate (a) Date of Commencement of treatment (b) Date of completion of treatment (c) Name & Address of attending Medical Practitioner (d) Telephone No. In case of Domicialary Hospitalisation. 2. 3. supported by the proper prescription. Bill. 6. no benefits are admissible under any other Medical Scheme or Insurance. suppression or concealment. Dated at___________________tjos_________________of __________200 Signature of the Claimant FOR OFFICE USE ONLY: DATE OF CLAIM . 6. receipt from a qualified nurse who attended the patient at his/her residence duly supported by a certificate from attending Medical practitioner. the expenses as per the details given by me in the Schedule of Expenses given overleaf. Receipt and Pathological test reports from a pathologist supported by the note from the attending medical Practitioner/surgeon demanding such pathological test. Certificate from the attending Medical practitioner giving reasons for allowing treatment home. In support of the above claim.Territory Date Date Month Month Year Year (b) Date of Admission (c) Date of Discharge 7. 4. 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. Cash Memos from the Hospital/Chemist(s). I further declare that. (a) Name and Addres of the Hospital/Nursing Home/Clinic : ____________________________ _______________Pin Code______ State/U. 7. 5. : : : : Date Date Month Month Year Year : I have incurred on the treatment of Disease/illness/Accident referred to above. Surgeon’s certificate stating nature of operation performed and Surgeon’s bill and receipts. in respect of the above treatment. 8. my right to claim reimbursement of the said expenses shall be absolutely forfeited.(c) Registration No.

Medicines & Drugs.C. Specialists fees. Oxygen. artificial limbs & cost of Organs and similar other expeses. Surgical Appliances. . Operation Theatre Charges. 2. Blood. Board & Nursing Expenses & ICCU(including Pre & Post Hospitalisation) 1. cost of Pacemaker.Policy No. Medical Practitioner. Surgeon. Chemotherapy. Anaestheitist. Anaesthesia. (A) HOSPITLISATION BENEFIT: (i) Room Board.___________Scheme A/B_________Category of Benefits________Claim No.) (1) 1. Nursing expenses (including Boarding to be provided by the Hospital) for_____________days________ (ii) I. Consultants. SCHEDULE OF EXPENSES INCURRED BY THE CLAIMANT Details of Expenses claimed under Amount Hospitalisation/Domiciliary Hospitalistion Claimed (To be supported by Bills/Receipts Cash memos etc. Diagnostic materials & X-ray dialysis. Unit For __________days_______ FOR OFFICE USE ONLY Amount not Payable (2) Net Payable (1)-(2)-(3) (B) Hospitalisation Benefits other than Room.

______ Net amount Payable Rs. Blood.SCHEDULE OF EXPENSES INCURRED CLAIMANT II. Mediciens and Drugs and Similar expenses BY (1) THE FOR OFFICE USE ONLY (2) (3) Total Signature of Claimant: Date: Place: FOR OFFICE USE ONLY Prepared by: Checked by: Aproved by: Total amount payable under the Claim Rs._______ In case entire claim is not admissible. Employment of qualified Nurses. Reason thereof Passed for payment of Rs. Domiciliary Hospitalisation Benefit (Non-surgical treatment only) 1. Consultatns & Specialists fee for vists etc. Medical Practitioners. Oxygen.________ Competent Authority . Diagnostic material. X-ray._________ Less: Advance/on account payment if any Rs.