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Claims & Wellness Management
Enter Email Id:
OPD Claim Form
1. Name of Policy Holder/Proposer:
Current Policy Number:
Card No./ UHID:
2.
Tick appropriately:
Individual/ Retail
Policy
Group/ Corporate
Policy
If corporate, provide company name:
Employee ID:
3. Details of the Insured Person in respect of whom claim is made: (patient details)
Name of Insured:
Relationship with the Policy Holder:
Present completed age (In Years) :
Gender : M
F
Occupation: Service
Self Employed
Homemaker
Student
Retired
Other
(Please specify)
Current residential address:
City:
Pin code:
State:
Landline no.
Mobile no.
E-mail:
4. Nature of disease / illness contracted or injury suffered for which insured was hospitalized (Diagnosis):
5. Date of commencement of Treatment:
6. Provide Name and contact details of treating Doctor:
7. Details of the Amount Claimed
Bill heads
(as applicable)
Bill number
Bill date
Bills attached
Amount
Consulting Doctor's Fees
Yes
No
Pharmacy/Medicine Charges
Yes
No
Investigation Charges
Yes
No
Others (Kindly Specify)
Yes
No
Total claimed amount (In INR)
(Total claimed amount should be equal to the amount in attached bill documents)
In support to the above claim, I enclose following documents {Please indicate by (tick mark)}
Bills/ Receipt/ Cash Memos in original for medicines etc. (name of patient along with date should be mentioned on it.)
Most Recent Medical prescription/ Consultation papers in support of the above.
Receipts and Investigation test reports in original from a Pathological Lab supported by the note from the treating
doctor/ Surgeon advising such Investigation tests.
Attending doctors/ Consultant's/ Specialist's bill and receipt and certificate regarding diagnosis, whichever is
prescribed and thereby expenses incurred along with doctors registration number (compulsory).
MANDATORY*:
1)
Age proof (Driving License/ PAN card/ Passport/ Aadhar copy)*
2)
Part - C (For EFT/RTGS/NEFT)*
Place:
Date:
Insured's Signature:_____________________________
Patient's Name:
(in respect of whom claim is made)
Policy Number:
Card No./ UHID No.:
Group/Company Name:
(for Group/Corporate policy holders)
Claim Number (if allotted):
Mobile/ Contact No.:
Please provide a self-attested copy of a valid Identity proof of the Proposer/Policy holder (provide any of the mentioned documents in Proof of Identity under Part-D)
Cancelled cheque copy
Bank attested copy of Passbook with IFSC code
• Proposer/ policy holder name*(as per bank records):
• Proposer/ policy holder Bank account no.:
• Name of the bank:
• Branch name:
• Address of the bank:
• IFSC code no. of the bank:
(should be same as per the provided cheque leaflet)
