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Claim form Medi Assist com Welcome to Mediassist by niusheng11

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									                NATIONAL INSURANCE COMPANY LIMITED                                                             Address of Policy Issuing Office
                     Administered by Medi Assist India Private Limited                                     Bangalore Divisional Office III
              Registered Office : #49, Sarakki Industrial Layout, Ist Main Road                            15-17-19, Shri Lakshmi Complex,
                              J.P. Nagar 3rd Phase, Bangalore 560 078                                      St Mark's Road, Bangalore 560 001
                                                                                                           Tel No : 2558 7443 Fax : 2558 6336
                        Claim form for Infosys Group Mediclaim Insurance                                   E mail :

1     Name of the Infoscion
2     Employee ID*                                                            E-mail
3     Date of joining
3     Contact Numbers                                         Telephone                                   Mobile
4     Name of the Patient claimed
5     Claimant age in completed years/Date of Birth*          Date of Birth                                     Age in Years
6     Relationship and Occupation                                                           Occupation
7     Nature of Illness/disease/accident

8     Date of Injury/Illness/Disease                          (First Date of Illness or disease or accident)
9     Period of Stay in Hospital                              Date of Admission
                                                              Date of Discharge

10    Employee Current DC Location*

11    No of documents enclosed excluding claim form*
11    Amount Claimed in Rupees*                               Rs.

    I have incurred on the treatment of disease/illness/accident referred to above, the expenses as per details given by
    me in the Schedule of Expenses overleaf.

 I further authorise the Insurance Company / TPA to apply and obtain any Medical Reports or documents or
 information from the concerned Hospitals / Medical Practitioners who attended on the Insured person.

 The duly filled and signed claim form along with all the original bills have to be submitted to the Finance & Accounts
 of the respective location.

     Please note: *These are mandatory fields to process the claim

        *Date of claim submission and Place :                                               *Signature of the Infoscion

                                                              For Office Use only

      Policy Number :                                                         Claim settled for Rs
      Claim Number :                                                          Date of settlement
                                                    Document Check list

Claim form duly signed                                                         Yes    No
Detailed hospital discharge summary                                            Yes    No
Surgeon's Certificate, if any                                                  Yes    No
Surgery / Consultation Bills                                                   Yes    No
Hospital Main Bill                                                             Yes    No
Breakup of hospital main bill                                                  Yes    No
Original Pre-numbered cash paid receipt                                        Yes    No
Doctor's prescription for the medicine bills enclosed                          Yes    No
Pharmacy bills                                                                 Yes    No
Pre-hospitalisation Bills --------No                                           Yes    No
Post-hospitalisation Bills --------No                                          Yes    No
Investigation reports                                                          Yes    No
Doctor's reference for investigation                                           Yes    No
MRI Report                                                                     Yes    No
C T Scan Report                                                                Yes    No
ECG Report                                                                     Yes    No
USG Scan Report                                                                Yes    No
X-Ray report / film                                                            Yes    No
Age proof of the parent if the claim is preferred for parent                   Yes    No
Employee to retain the photo copy of the documents submitted after
numbering the bills and other documents                                        Yes    No
Any other document (Pl. specify)

Note: You can submit xerox copies of Discharge summary / Prescriptions & all Diagonistic / Lab reports but
they should be duly certified by either the hospital or the doctor. Uncertified copies will not be accepted

In support of the claim, I enclose the following documents asabove ticked documents

Signature of the Infoscion
                                 Schedule of Expenses
 Sl.   Name of the Hospital, Doctor, Medical                           Amount
                                                 Bill No   Bill Date
 No                   Shop                                             Claimed

                        Grand Total

File : 1fcc0251-c3de-4eaa-9a9c-3bd70a03872a.XLS                                  Run Date : 4/19/2011

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