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Claim Form

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Nauman Malik
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102 views3 pages

Claim Form

Uploaded by

Nauman Malik
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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The New India Assurance Company Limited

Registered & Head Office: New India Assurance Building, 87, M.G. Road, Fort,
Mumbai - 400 001.

MEDICLAIM INSURANCE 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.

Claim No. :

Name of the Insured WNS Global Services Pvt. Ltd


Name of the Employee Employee Name
Employee ID No: E-Meditek ID No:
Name of the Claimant Patient Name
(Person in whose respect the claim is made)
Relationship of the Claimant with the
Employee (Strike off not applicable)
Relation of Patient with Employee
Present Completed Age of claimant DOB: DD/MM/YYYY AGE:
Occupation of the claimant
Current Residential Address

Mobile No: Residence. No.:


Email Id:
Policy No: 13040034160400000002
Nature of Disease / illness contracted or
injury suffered
Date of injury sustained or disease /
illness first detected
Name and address of the attending
Medical Practitioner

Qualification: Registration No: Telephone No:


Name & Address of the Hospital /
Nursing Home Clinic

Registration No:
Date of Admission: 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 documents as per the Check List

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.

Date:
__________________________________
Name of the Claimant: _________________________ SIGNATGURE OF THE CLAIMANT

1
Statement of Expenses Claimed in Respect of Hospitalization

Sr. No. Bill Date Bill No Name of the Hospital / Lab / Medical Shop Amount Claimed
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Total
*Please attach a new sheet in case all 20 Sr. Nos. are utilized.

Consent Form
From:
Patient’s Name and address:

To:
Whomsoever it may concern: (hospital/doctor)

Sirs,

I hereby 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/Claimant

2
CHECK LIST FOR SUBMISSION OF CLAIM
Very IMP:
Do not forget to attach this checklist with the Claim file.
Arrange the documents in the same order as in the checklist, checking against the designated box when you do so.
This way you can ensure that you have not missed any documents.

Employee Name :
Employee No :
EMSL Card No :
Mobile No :
E- Mail ID :

Check list for Documents: Please put a √ mark against the box

 Original Claim Form duly signed by you. 

 Original Main Hospital bill with Bill Number & break up, 

 Original Discharge summary 

 Original Death summary 


(Only in case of death of Patient during Hospital stay).

 Original Hospital Payment Receipt with receipt number 


(With seal & signature of hospital)

 Original Payment Receipt with receipt number 


(For consultation/surgeon charges if charged outside the main hospital bill)

 Original Pharmacy and Investigation bills 


(Along with prescriptions & Lab reports)

 Original prescriptions 
(On doctor’s letterhead mentioning duration and dosage for medicines and advice for diagnostic tests).

 Investigation reports in original 


(Reports for all tests done along with images)

 Police FIR / Medico Legal Certificate (MLC) 


(Mandatory for All Road traffic accidents-Duly attested by Police

 X ray/ Ultrasound Films etc. 

 Cancelled cheque 
For direct credit into your bank account through NEFT

Points to remember
 Please retain copies of all the documents submitted to us for future reference.
 Please retain a POD copy of the courier for tracking your consignment in case of any delay etc.
 The above list of documents is indicative. In case of any other document requirement as specified
by the insurance company we will contact you on receipt of your claim documents by us.

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