Поиск

Полнотекстовый поиск:
Где искать:
везде
только в названии
только в тексте
Выводить:
описание
слова в тексте
только заголовок

Рекомендуем ознакомиться

'Документ'
t.+371  98 3 4 7...полностью>>
'Документ'
The Nomination Letter specifies the details of the Intra-ACP - Sharing Capacity to Build Capacity for Quality Graduate Training in Agriculture in Afri...полностью>>
'Исследовательская работа'
Мы выбрали эту тему, так как актуальность ее очевидна. Речь россиян в последние годы стала более вульгарной. Уместен вопрос: почему? Раньше сленгом по...полностью>>
'Конкурс'
-привлечь внимание педагогической общественности, к проблеме воспитания подрастающего поколения и молодёжи на достойных идеалах в духе возрождения дух...полностью>>

Главная > Документ

Сохрани ссылку в одной из сетей:
Информация о документе
Дата добавления:
Размер:
Доступные форматы для скачивания:

NATIONAL INSURANCE COMPANY LTD.

(Subsidiary of General Insurance Corporation of India)

Regd. Office: 3, MIDDLETON STREET. CALCUTTA – 7000 071

ISSUING OFFICE

HOSPITALISATION AND DOMICILIARY HOSPITALISATION BENEFIT POLICY CLAIM FORM

Claim No. CL

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. If the claim is under Personal Accident Insurance, please complete a Personal Accident Claim Form.

For Office use only

  1. Name of the Insured:

(In whose name policy is issued) SUR NAME INITIALS


  1. Details of the Insured person : ………………………………………

(In respect of whom claim is made)

    1. Name & relationship to the insured : ………………………………………

    1. Present Completed Age : ………………………………………

    1. Occupation : ……………………………………….

    1. Residential Address : ……………………………………….

…………………………………………

  1. Policy No.


  1. Details of Previous Mediclaim Polices : ………………………………………..

          1. Policy No. and Policy Period : ………………………………………..

          1. Policy No. and Poliyc Period :…………………………………………

          1. Policy No. and Poliyc Period :…………………………………………

Note: Essential if Cost of Health

Check-up is claimed.)

  1. Nature of Disease/illness contracted

or injury suffered

  1. Date of injury sustained or Disease/ :

Illness first detected.

Date Month Year

7. (a) Name & Address of the attending : ……………………………………..

Medical Practitioner : ……………………………………..

Pin Code…………………………….

State/U. Territory……………………

(b) Qualification & Telephone No : ……………………………………

(c) Registration No. :

8. (a) Name & Address of the Hospital/

Nursing Home/Clinic : …………………………………….

Pin Code ……………………………

State/U. Territory ……………………

(b) Date of Admission :

Date Month Year

(c) Date of Discharge :

Date Month Year

  1. If the claim is for Domiciliary

Hospitalisation, Please indicate : ……………………………………

(a) Date of Commencement of treatment :

(b) Date of Completion of treatment :

(c) Name & Address of attending

Medical Practitioner : …………………………………….

Pin Code …………………………….

State/U. Territory ……………………

(d) Telephone : …………………………………..

(e) Registration No :

I have incurred on the treatment of disease/illness accident 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. Bill Receipt and discharge Certificate/card from the Hospital.

  1. Cash Memos form the Hospital/Chemist(s), supported by the proper prescription.

  1. Receipt and pathological tests reports from a pathologist supported by the note from the attending Medical Practitioner/Surgeon demanding such Pathological tests.

  1. Surgeon’s certificate Stating nature of operation performed and Surgeon’s bill and receipt.

  1. Attending Doctor’s/Consultant’s/Specialist’s Ansesthetist’s bill and receipt and certificate regarding diagnosis.

  1. In case of domiciliary Hospitalisation, receipt from a qualified nurse who attended the patient at his/her residence duly supported by a certificate from attending Medical Practitioner.

  1. Certificate from the attending Medical Practitioner giving reasons for allowing treatment at home.

  1. 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 have made or

shall make any false or untrue statement, suppression or concealments, 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…………………this……………………..day of ………………………….2003.

Signature of the Claimant


FOR OFFICE USE:

Date of Claim

CATEGORY OF BENEFIT……………………

SCHDULE OF EXPENSES INCURRED BY TO BE FILLED IN FOR OFFICE USE ONLY

THE CLAIMANT BY THE CLAIMANT

Details of expenses claimed under Hospitalisation Amount Amount Amount Amount not Balance benefit

Domiciliary Hospitalisation Claimed available Payable Payable to the Credit

(To be supported by Bills/Receipt,Cash Memo etc.)


1. (A) HOSPITALISATION BENEFITS:

  1. Room, Board, Nursing Expenses

for……..days……@……..per day

  1. I.C.unit

for…….days…….@……..per day

  1. Hospitalisation Benefits other than Room Board &

Nursing Expenses & ICCU (including Pre & Post

Hospitalisation)

  1. Surgeon, Anaesthetist, Medical Practitioner,

Consultants, Specialists fees.

  1. Anaesthesia, Blood, Oxygen, Operation Theatre

Changes,Surgical Appliances,Medicines & Drugs,

Diagnosti,c Materials, & X-ray, Dialysis,

Chemotherapy, Radiotherapy, cost of Pacemaker

Artifical limbs & cost of Organs and similar other

expenses

II.

DOMICILIARY HOSPITALISATION:

  1. Medical Practitioners, Consultants & Specialists

fee for visits etc.

  1. Blood, Oxygen,Diagnostic materials, X-ray

Employment of qualified Nurses, Medicines and

Drugs and similar expenses.

III.

COST OF HEALTH CHECK-UP

TOTAL RS.

Date:

Place: Signature of the Claimant

FOR OFFICE USE ONLY

Checked by:

Total amount payable under the claim Rs. ……………

Less: Advance on account payable, if any Rs. ……………

Net amount payable Rs. ……………

Approved by: In case entire claim is not admissible, reasons thereof

Passed for payment of Rs. ………………………..

COMPETENT AUTHORITY



Похожие документы:

  1. The British High Commission in Singapore is part of a worldwide network of 230 uk overseas missions, representing British security, prosperity and consular inte

    Документ
    ... and communications skills, initiative and resourcefulness Professional approach and demeanour, high work standards and ... covering GP, specialist and hospitalisation treatment Excellent training and development opportunities are also ...
  2. Medicare Benefits Schedule Book (2)

    Документ
    ... practitioners for their non-hospitalised patients. Pathology services requested ... pO2, oxygen saturation and pCO2) ; and (b) bicarbonate and pH; including any ... count and motility; and (b) examination of stained preparations; and (c) morphology; and (if ...
  3. Medicare Benefits Schedule Book (1)

    Документ
    ... specimens taken during hospitalisation also attract the 75 ... cleaning, disinfection and sterilisation procedures, and (b) anaesthetic and resuscitation equipment. ... equipment, administration and monitoring, and post-operative and resuscitation facilities ...
  4. Entry into microinsurance

    Документ
    ... four dependents. Temporary disability and hospitalisation were offered in the initial ... to greater expense and frustration. Marketing and customer satisfaction Marketing problems ... difficult for minors and friends. Operational and financial results In ...
  5. Semester students immigration registration information

    Документ
    ... hospitalisation cover. You must provide the original policy document in English and ... state the precise start and finish dates of the ... between O’Brien’s Sandwich Bar and Jaycee Printers. To get ... between O’Brien’s Sandwich Bar and Jaycee Printers. To get ...

Другие похожие документы..