THE ORIENTAL INSURANCE COMPANY LIMITED

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




MEDICLAIM POLICY -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.

    For office use only
1. Name of the Insured (In whose name policy is issued) (Surname) (Initial)  
2. Details of the Insured Person (In respect of whom claim is made)
a. Name & relationship with the insured
b. Present completed age DOB Age
c. Occupation
d. Residential Address
Telephone No.
3. Policy No.
4. Nature of Disease/illness contracted or injury suffered
5. Date of injury sustained or disease/illness first detected
a. Name and address of the attending Medical Practitioner
b. Qualification Telephone No.
c. Registration No.
6a. Name & Address of the Hospital / Nursing Home /Day care Clinic
b. Date of admission
c. Date of Discharge


I have incurred on the treatment of Disease / illness / injury 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 (please indicate by / )
  1. Discharge certificate/card from the Hospital.

  2. Bill, Receipt and Cash Memos from the Hospital/Chemist(s), supported by the proper prescription and duly attested by me.

  3. Receipt and Pathological test reports from a Pathologist supported by the note from the attending Medical Practioner/Surgeon demanding such Pathological test (s).

  4. Surgeonís certificate stating nature of operation performed and Surgeon/s bill and receipt.

  5. Attending Doctorís Consultantís / Specialist's/ Anaesthestistís bill and receipt and certificate regarding diagnosis.

  6. Certificate from the attending Medical Practitioner / Surgeon that the patient is fully cured.



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 at _____________________this____________________day of ____________200

NAME OF THE CLAIMANT ______________________________________SIGNATGURE OF THE CLAIMANT

POLICY NUMBER _________SUM INSURED OPTED____________ CLAIM NO. ____________

SCHEDULE OF EXPENSES INCURRED BY THE CLAIMANT FOR OFFICE USE ONLY
Details of Expenses claimed under Hospitalisation / Domiciliary Hospitalisation (To be supported by Bills/Receipts, Cash memos etc.) Amount Claimed (1) Amount not payable (2) Net Payable (1) Ė (2) = (3)
1. Hospitalisation Benefits:  
i. Room, Board Nursing expenses provided by
Hospital for ____days @ Rs _______ per day
 
ii. IC Unit for ____ days @ Rs _______ per day  
iii. Emergency Ambulance charges  
Total Amount under i, ii & iii  
2 Hospitalisation Benefits (Other than Room, Board & Nursing Expenses & ICCU (including pre & post Hospitalization)  
i Surgeon's, Anaesthetist's, Medical Practitioner's, Consultant's, Specialist's fees.  
ii Anaesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like pacemaker, Relevant Laboratory / Diagnostic test, X-Ray etc..  
Total  
3 Maternity Expenses Benefit Extension  
i Room, Board Nursing expenses for
__________days @ Rs ________per day.
 
ii Gynaecologist/ Obstetrician/ Surgeon/ Physician / Anaesthetist Fees _________and Normal delivery, Miscarriage and Abortion, Caesarean Section / Abdominal Opening for extra uterine pregnancy.  
iii Diagnostic materials, X-Ray, Medicines and drugs, injections etc.  
Total  


Name of the claimant
Signature of the Claimant :


DATE
PLACE

FOR OFFICE USE



Prepared by: ________________
Checked by: ________________
Approved by: _______________
Total amount claimed Rs


Net amount Payable Rs
in case entire
claim is not
admissible
reasons thereof

Passed for payment of Rs ___________.


COMPETENT AUTHORITY




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