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United India Insurance Co. LTD.,: Mediclaim Insurance Policy Reimbursement Claim Form

The document is a medical insurance claim form that collects information about an employee, their medical policy, illness details, treating physician and hospital, and expenses incurred for reimbursement. It collects information such as name, age, illness, dates of treatment, doctor and hospital details, and an itemized list of expenses. The claimant must sign to warrant the truth of the details and declare no other benefits were received.

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255 views2 pages

United India Insurance Co. LTD.,: Mediclaim Insurance Policy Reimbursement Claim Form

The document is a medical insurance claim form that collects information about an employee, their medical policy, illness details, treating physician and hospital, and expenses incurred for reimbursement. It collects information such as name, age, illness, dates of treatment, doctor and hospital details, and an itemized list of expenses. The claimant must sign to warrant the truth of the details and declare no other benefits were received.

Uploaded by

'Θκ'βύτ-Ίισνέγσύ.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNITED INDIA INSURANCE CO. LTD.

,
(A subsidiary of General Insurance Corporation of India)
Regd. & Head Office: United India House, 24, Whites Road,
Chennai 600 014.

MEDICLAIM INSURANCE POLICY REIMBURSEMENT CLAIM FORM

Issuance of this form does not amount to admission of any liability under the claim on the part of the
Insurers.

Please give the following information correctly and completely to enable the Company to process your
claim promptly.

1 Name of the Insured (in whose name policy : KEC International Ltd
is issued)
2 Details of the Employee (in respect of :
whom claim is made)
(a) Name of Claimant & relationship to :
the Employee
(b) Present completed age :
(c) Occupation :

(d) Residential address, Mob No & :


Email, Employee ID (MANDATORY)

3 Policy no. : 5001002819P100532149

4 Nature of disease/illness contracted or :


injury suffered

5 Date of injury sustained or Diseases/illness : Date Month Year


first detected
6 (a) Name & address of the attending :
Medical Practitioner

(b) Registration no. :


(C) Qualification & Tel. no. :
7 (a) Name & address of the :
Hospital/Nursing Home

(b) Registration no. :


© Date of Admission : Date Month Year
(d) Date of Discharge : Date Month Year
8 If the claim is for Domiciliary
Hospitalization, please indicate
(a) Date of commencement of treatment : Date Month Year
(b) Date of completion of treatment : Date Month Year
© Name & Address of attending Medical :
Practitioner

(d) Telephone no. :


(e) Registration no. :

I have incurred on the treatment of Disease/illness/accident referred of above, the expenses as per the
given by me in the Schedule of Expenses given overleaf.

I hereby warrant the truth of foregoing particulars in every respect and I agree that if I have made or shall
make any false or untrue statements, 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 at this day of 20

Signature of the Claimant

SCHEDULE OF EXPENSES INCURRED AND BEING CLAIMED BY THE CLAIMANT


Sr. Receipt
Nature of Expenditure Amt. claimed ( ` ) Amt. payable ( ` )
No. No. Date

Total Claim Amount INR:

➢ Discharge Card incorporating detailed Discharge Summary and Case History is mandatory
to be submitted separately with the Claim Form.

Signature of the Insured Person

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