Claim Forms CMR - Hospitalization by xln10969

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									                                                                                                                            Policy No.:

                                                                                                                            Claim No.:




                                             Tata AIG Life Insurance Company Limited
                                    (hereinafter called “Tata AIG” or “the Company”, whichever is applicable)

                                                       HOSPITALIZATION CLAIM FORM
                                                                                            Office ___________________________________
                                                                                            Agency _______________ Code ______________
                                                                                            Agent  _______________ Code ______________
PART I (To be completed by Insured/Claimant in BLOCK letters)
Please answer all questions, use “not applicable” (N/A) as appropriate instead of leaving it blank. Counter-sign where amendments/alterations are
made in the form.
The filing of this claim form is not to be construed as an admission of liabilities of our Company. No agent has been or is authorized to admit any
liabilities on behalf of the Company.
(Note: - Insured’s name should be written in full as the same will appear on the cheque)
 Policy No.                                         Full Name of Insured                                        Age

                                                      Alias, if any                                             Sex

 Benefits to Claim: (please tick)
            Daily Hospital Benefit               Post-Hospitalization Benefit               Surgical Benefit                Dismemberment
 Insured’s Address                                                                                              I. D. No.

 Contact Phone No.                                                                                              I. D. Document Type

 Bank Account No.

 Occupation & exact duties                            Employer Name & Address


                                                    Contact Phone No.
 Are you claiming from other insurers or institutions (including government/welfare schemes) for the same cause?

      Yes, for (type & amount) _______________________________                  from ___________________________________                    No
                               _______________________________                  from ___________________________________

 Did a medical leave certificate filed to Insured’s employer?                      Yes, (state the dates) __________________                No

 Claims Details
 Describe initial symptoms / parts of body injured                          Since when does the Insured have these symptoms / bodily injury
                                                                                            MM    DD     YYYY
                                                                            Date of first consultation
                                                                                             MM    DD    YYYY
 Diagnosis given by doctor                                                  The first doctor consulted (name, address & telephone)


 Is the condition due to an accident?           No.        Yes, details below:
 Accident Date                                          Time                    (am / pm)          Place

                      MM      DD     YYYY
 Accident Details



 Consultation Details
                                             Name, Address & Telephone                 Consultation Dates             Disease / Condition
 a) Insured’s regular doctor


 b)    All other doctors consulted for
       this illness/injury; or similar
       condition in the past

 CLM/P4.9/4.T3 (I)

   Corporate Office: Tata AIG Life Insurance Co. Ltd., No: 302, Building No: 4, Infinity IT Park, Film City Road, Dindoshi, Malad (East),
                              Mumbai - 400097. Phone No.: - 022 – 6760 8000. Fax No.: - 022 – 6070 8001.
                                                         th
  Registered Office : Tata AIG Life Insurance Co. Ltd., 6 Floor, Peninsula Corporate Park, G. K. Marg, Lower Parel, Mumbai – 400 013.
c)     Doctor who referred Insured
       to hospital


Please give details of any other illness Insured have suffered from in the past.
Disease/Condition                            Consultation Dates                               Doctor consulted (Name, Address & Telephone No.)



Hospitalization Details
Details of hospital confinement for the injury/illness.
Name of Hospital                Address                          Date of consultation(s)         Date & time of admission         Date & time of discharge




Any surgical procedure(s) done during hospitalization?
     No           Yes, details:


Information of Claimant (if other than the Life Insured)
    [Note:- Claimant name should be written in full as the same will appear on the cheque]
Name in Full                                          ID No.                  ID Type                                             Age

Sex:      Male         Female                                    Address

Telephone No.                                                    Relationship with the Insured

In what title are you submitting this claim?                     Bank Account no.


DECLARATION AND AUTHORIZATION
I/We hereby declare that the information given on this accident/hospitalization claim application form is true and complete.
/We hereby make claim to Tata AIG by submitting this accident/hospitalization claim application form and agree that the written statements of all the physicians
who attended or treated the Insured and all other proofs and supporting documents associated with this accident/hospitalization claim application form shall
constitute and are hereby made part of this accident/hospitalization claim application form. I/We further agree that the furnishing of this accident/hospitalization
claim application form, or of any other forms supplemental hereto by the Company, shall not be deemed an admission of an existence of any assurance in force
on the life in question, nor an admission of liabilities or a waiver of any of its rights of defenses.

I/We hereby declare and agree that any personal information collected or held by the Company (whether contained in this application or otherwise obtained) is
provided and may be held, used, and disclosed by the Company to individuals/organizations associated with the Company or any selected third party (within or
outside of India, including reinsurance and claims investigation companies and industry associations/federations) for the purposes of processing this application
and providing subsequent services for this and other financial products and services, direct marketing, and data matching, and to communicate with me/us for
such purposes.

I/We hereby irrevocably authorize: (i) any organization, institution, or individual that has any record or knowledge of my/the Insured’s health and medical
history or any treatment or advice and that has been or may hereafter be consulted, other personal information or details of related accident/injury to disclose to
the Company such information; (ii) the Company and its approved medical examiners and laboratories to perform medical assessment and tests to evaluate
Insured’s health condition, or to perform any autopsy as appropriate.

This authorization shall bind my/the Insured’s successors and assigns and remain valid notwithstanding my/the Insured’s
heath or incapacity in so far as legally possible. A photocopy of this authorization shall be as valid as the original.

Witness Signature:                                                             Life Insured Signature:

Date:                                                                          Date:
                                                                               Policyowner/Claimant
                                                                               (If other than life Insured)
Name of Witness:                                                               Signature:
                              (in block letters, family name first)

                                                                               Name:                             (in block letters, family name first)

                                                                               Date:
Note: - Witness should be a Notary/ Gazetted officer / SEM or a person of local standing.

CLM/P4.9/4.T3 (I)

  Corporate Office: Tata AIG Life Insurance Co. Ltd., No: 302, Building No: 4, Infinity IT Park, Film City Road, Dindoshi, Malad (East),
                             Mumbai - 400097. Phone No.: - 022 – 6760 8000. Fax No.: - 022 – 6070 8001.
                                                        th
 Registered Office : Tata AIG Life Insurance Co. Ltd., 6 Floor, Peninsula Corporate Park, G. K. Marg, Lower Parel, Mumbai – 400 013.
                                                                                                                     Policy No.:

                                                                                                                     Claim No.:



                                      Tata AIG Life Insurance Company Limited
                              (hereinafter called “Tata AIG” or “the Company”, whichever is applicable)
                                               CERTIFICATE OF MEDICAL ATTENDANT
To be completed in BLOCK letters by a duly qualified and registered medical practitioner at the claimant’s expense.
Please answer all questions, use “not applicable” (N/A) as appropriate instead of leaving it blank. Counter-sign where
amendments/alterations are made in the form.

Patient Name                                                              Age                               Sex
Patient’s Occupation                                                      I. D. No.
Patient’s Address                                                         I. D. Document Type


Consultation Details
If due to ILLNESS, please provide:                                        If due to ACCIDENT, please provide:
Chief complaints & presenting symptoms                                    Conditions of injury & parts of body involved



                                                                          Is there external visible evidence of injury at your first consultation:
                                                                          If yes, give details

Date symptoms first appeared                                              Date of injury

Your Diagnosis                                                            Cause of injury


Date of your consultation of this illness/injury
First consultation on                                                 Last consultation on
Past medical history, family history and co-morbid conditions (please give consultation dates & details)


Hospitalization Details
Does this illness/injury necessitate inpatient hospitalization:      No          Yes, details as below:-
Hospital Name                                                             Date & Time of Admission

Address                                                                   Date & Time of Discharge


Any surgical procedure performed?             No       Yes, details as below:-
Date of operation                                                         Place of operations

Name of surgical procedure                                                Surgeon Name & Registration No.


Tests & investigations performed?            No        Yes, details as below:-
Name of test/investigations                         Date(s)                Results (please enclose a certified true copy of the test results)


Other treatments administered (medicines, dressing & suturing etc)


Discharge summary & treatment plan


Dates of follow-up consultations with you after hospital discharge for the same illness/injury
Date(s)                                 Condition


CLM/P4.9/4.T3 (I)

  Corporate Office: Tata AIG Life Insurance Co. Ltd., No: 302, Building No: 4, Infinity IT Park, Film City Road, Dindoshi, Malad (East),
                             Mumbai - 400097. Phone No.: - 022 – 6760 8000. Fax No.: - 022 – 6070 8001.
                                                        th
 Registered Office : Tata AIG Life Insurance Co. Ltd., 6 Floor, Peninsula Corporate Park, G. K. Marg, Lower Parel, Mumbai – 400 013.
Was healing complicated?                                                  No        Yes, details as below:-

If yes, state reasons and any special treatment given.
Bearing in mind the patient’s occupation, do you feel the
illness/injury would have prevented him/her from working
    at your first consultation                                            No        Yes, details: _______________________________
    at your last consultation                                             No        Yes, details: _______________________________
If absence from work more than 2 weeks was necessary, please
state the reasons.
Is the illness/injury related to
(a) Physical defects/congenital anomaly                                   No        Yes, details: _______________________________
(b) Unfavourable past medical history                                     No        Yes, details: _______________________________
(c) Degenerative changes                                                  No        Yes, details: _______________________________
(d) Alcohol, drug, or nicotine/smoking                                    No        Yes, details: _______________________________
(e) AIDS or HIV infection                                                 No        Yes, details: _______________________________
(f) Suicide or self-inflicted injury                                      No        Yes, details: _______________________________
Other doctors/hospitals involved in the care of the patient
Name                                            Address                                                         Telephone No.



Declaration by the Attending Physician/Specialist
I declare that the answers given are true and complete.
I declare I am duly licensed and registered to practice western medicine (allopathy) in India (if outside India, please state where ______ )
Certification by Hospital Admitted, that
1)   The Hospital is duly licensed and registered as a Hospital to provide treatment in western medicine (allopathy) in India (if outside
     India, state where ___________) for the care and treatment of sick and injured persons as registered in-patients, fully equipped with
     facilities for diagnosis and major surgery which are under the constant supervision of one or more Registered Medical Practitioners,
     and which have 24-hour a day full time professional nursing services; And
2)   Maintains proper medical and patient records and quality health care to the standards as required under the prevailing laws and
     regulations in the geographical area it is located; And
3)   Is not an institution operated as a convalescent or rest home, a hotel, a home for the aged, a place for alcoholics or drug addicts, or
     Custodial Care, or for any similar purpose.
4)   The Hospital has on the following facility and resource (please state)
     No. of in-patient beds                       : ___________________
     No. of qualified registered resident doctors: ___________________
     No. of qualified registered full time nurses : ___________________

__________________________________________________                     ___________________________________________________
Signature of Attending Physician/Specialist (with qualifications)      Signature of authorized Hospital Administrator

[Name in Block:                                                 ]      [Name in Block:                                                  ]


_____________________________________________                          _____________________________________________
Registration No. & Place                                               Name of Hospital

__________________________________________________                     ___________________________________________________
Address & Official Stamp                                               Registration No. & Place

__________________________________________________                     ___________________________________________________
Telephone                                                              Address & Official Stamp
__________________________________________________                     __________________________             _______________________
Mobile No.                                                             Telephone                              Fax No.

__________________________________________________                     ___________________________________________________
Email Address                                                          Email Address

___________________________________________________                    ___________________________________________________
Date                                                                   Date




CLM/P4.9/4.T3 (I)

  Corporate Office: Tata AIG Life Insurance Co. Ltd., No: 302, Building No: 4, Infinity IT Park, Film City Road, Dindoshi, Malad (East),
                             Mumbai - 400097. Phone No.: - 022 – 6760 8000. Fax No.: - 022 – 6070 8001.
                                                        th
 Registered Office : Tata AIG Life Insurance Co. Ltd., 6 Floor, Peninsula Corporate Park, G. K. Marg, Lower Parel, Mumbai – 400 013.
                                                      Hospital Information Sheet
              Please provide your answers in the right column and return it to us at the following address for our database:
                                                        Attn: Claims Department
            Tata AIG Life Insurance Co. Ltd., No: 302, Building No: 4, Infinity IT Park, Film City Road, Dindoshi, Malad (East),
                             Mumbai - 400097. Phone No.: - 022 – 6760 8000. Fax No.: - 022 – 6070 8001.


     Name of hospital :
     Registration no. & Registering authority & Place :
     Address :
     Tel. No. :
     Fax no. :
     Web site :
     Name of contact person :
     Designation :
     Telephone no. :
     Email address :
     Name of Owner (if different from contact person above) :
The Hospital provide treatment in (tick as appropriate) :            western medicines (allopathy)
                                                                     alternate medicines (state details) ________________________

Specialties available (e.g. Paediatrics, Orthopaedics, ENT etc)
If yes, please state details:

     No. of in-patient beds:


     No. of qualified registered resident doctors :
For government hospitals, please also state
     No. of Professor doctors:
     No. of Assistant Professor doctors:
     No. of Lecturer doctors:


     No. of qualified registered full time nurses :

     In House facility available [please state Yes in the right
     column if available]
     Pathology Lab. :

     Oxygen :
     -    Central supply :
     -    Cylinder :

     E. C. G. :

     X Ray :
     Ultrasonography :
     C. T. Scan :


CLM/P4.9/4.T3 (I)

  Corporate Office: Tata AIG Life Insurance Co. Ltd., No: 302, Building No: 4, Infinity IT Park, Film City Road, Dindoshi, Malad (East),
                             Mumbai - 400097. Phone No.: - 022 – 6760 8000. Fax No.: - 022 – 6070 8001.
                                                        th
 Registered Office : Tata AIG Life Insurance Co. Ltd., 6 Floor, Peninsula Corporate Park, G. K. Marg, Lower Parel, Mumbai – 400 013.
     M. R. I. Scan :

     Pathology :

     Blood Bank :

     Operation Theatre :

     Labour room / delivery room :

     I. C. C. U.:

     Cardiac monitor :

     Defibrillator :

     Ventilator :

     Emergency Room :

     Day Care Centre :

     Outpatient consultation :

     Computerized access to patient records :

     Other facilities – please state details :



The above information is certified to be true and complete.



                                                                                      ______________________________________
__________________________________________________________________
                                                                                      Date
Signature of Hospital Administrator

[Name in Block:                                                                   ]


__________________________________________________________________
Hospital Name & Official Stamp




CLM/P4.9/4.T3 (I)

 Corporate Office: Tata AIG Life Insurance Co. Ltd., No: 302, Building No: 4, Infinity IT Park, Film City Road, Dindoshi, Malad (East),
                            Mumbai - 400097. Phone No.: - 022 – 6760 8000. Fax No.: - 022 – 6070 8001.
                                                       th
Registered Office : Tata AIG Life Insurance Co. Ltd., 6 Floor, Peninsula Corporate Park, G. K. Marg, Lower Parel, Mumbai – 400 013.

								
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