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Claim Form - Out-Patient Health Care': Details of Insured

The document is a claim form for out-patient health care expenses from Care Health Insurance. It requests details of the insured employee and policy, along with medical expense details from hospitals or diagnostic centers. It also includes a section for NEFT details to directly transfer reimbursement payments to the insured's bank account, requiring account holder name, bank name, account number, type of account, branch address, MICR and IFSC codes. The insured declares the particulars are correct and understands the company is not responsible for delays or failed transactions due to incomplete information. Original bills and payment receipts are required to process the claim.

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Rohit Bansal
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402 views1 page

Claim Form - Out-Patient Health Care': Details of Insured

The document is a claim form for out-patient health care expenses from Care Health Insurance. It requests details of the insured employee and policy, along with medical expense details from hospitals or diagnostic centers. It also includes a section for NEFT details to directly transfer reimbursement payments to the insured's bank account, requiring account holder name, bank name, account number, type of account, branch address, MICR and IFSC codes. The insured declares the particulars are correct and understands the company is not responsible for delays or failed transactions due to incomplete information. Original bills and payment receipts are required to process the claim.

Uploaded by

Rohit Bansal
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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Claim Form - ‘Out-Patient Health Care’

To be filled by the insured. Please fill in CAPITAL only.

Details of Insured

Employee Name :
(First Name) (Last Name)

Employee ID :

Patient Name :

Policy No. : Contact No.:

E-mail :

Medical Expense Details

Hospital/Diagnostic Centre Amount Unique Reimbursement ID

NEFT Details
I ________________________________________________________________ in the capacity of Insured request you to transfer the payment(s) directly to
my Bank account, details of which are mentioned below:

Particulars of Bank Account

Account Holder's Name :

Bank :

Account Number :
(Please mention the complete account number as appearing on the cheque book)

Type of Account : Savings Account Current Account Others (Please specify) : _____________________

Branch Address :

MICR Code :
9 - Digit MICR code number of the bank and branch (Appearing on the MICR cheques issued by the bank)

IFSC Code :
(Please refer your cheque book or your bank branch for IFCI code details)

I have enclosed a photocopy of the cancelled cheque or cancelled blank cheque.


(In case the attached cheque copy does not bear the account holder's name, please provide photocopy of Bank statement or else Bank attestation is required)

I hereby declare that the particulars given above are correct and complete. If the transaction is delayed or not effected at all for reasons of incomplete or incorrect
information, I would not hold Care Health Insurance Limited (Formerly known as Religare Health Insurance Company Limited) responsible. Further, Care Health
Insurance Limited reserves the right to use any alternative payout option(s) including Cheque/Demand draft inspite of opting for NEFT option.
Date : / / Signature of the Applicant : ___________________________

Notes:
a) Please attach the Original Hospital/Diagnostic Centre Bill.
b) Claim will be processed only if the Unique Reimbursement ID is available and if the payment has been made in a Network Hospital.
c) Payment will be reimbursed subject to the Sum Insured being available on your card and as per the Policy Terms and Conditions.
Ver: NOV/20

d) For any further clarifications, please contact your local helpdesk or call 1800-102-4488

Care Health Insurance Limited (Formerly Religare Health Insurance Company Limited)
Regd. Office: 5th Floor, 19 Chawla House, Nehru Place, New Delhi-110019 Corresp. Office: Unit No. 604 - 607, 6th Floor, Tower C, Unitech Cyber Park, Sector-39, Gurugram -122001 (Haryana)
Website: www.careinsurance.com E-mail: [email protected] Call us: 1800-102-4488
CIN: U66000DL2007PLC161503 IRDAI Registration No. - 148

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