ROYAL SUNDARAM ALLIANCE INSURANCE COMPANY LIMITED
46, Whites Road, Chennai – 600 014.
Phone: 044 – 851 7387-90 Fax: 044 - 851 7384
For Office Use only
CLAIM NO: Issuing Office __________
Date of issue __________
HEALTH PREMIUM PLATINUM – CLAIM FORM
THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY
Please ensure that all questions are answered in capital letters using an ink pen
1. Policy No. 2. Membership No.
2. Name of the employee
3. Employee No.
4. Address with Pincode
E-Mail ID
5. Telephone Number Off: Res:
6. Details of the Insured Person (in respect of whom the claim is made)
Name
Date of Birth DD/MM/YY
7. Details of illness
Date on which detected DD/MM/YY
Nature of Illness/Disease
8. Details of the Hospital/Nursing Home
Name of the Hospital/
Nursing Home
Address & Telephone No.
Date of Admission DD/MM/YY Time
Date of Discharge DD/MM/YY Time
9. Amount Claimed
Hospitalisation expenses Rs.
Pre Hospitalisation expenses Rs
Post Hospitalisation expenses Rs
Total Rs.
I hereby warrant the truth of the foregoing particulars in every respect and I agree that if I have made any false statement,
suppression or concealment, my right to claim under the policy shall be forfeited. I further declare that, in respect of the
above treatment, no benefits are admissible under any other Medical scheme or Insurance.
I also consent and authorise the insurers to seek medical information from any Hospital/Medical practitioner who has
any time attended on the insured person.
Date :
Signature or thumb
impression of the
Place : Insured.
__________________________________________________________________________________________________________
Before sending the claim form ensure that you submit
Original Bills, Receipt and Discharge certificate / card from the Hospital.
Original Cash Memos from hospital(s)/Chemist(s), supported by the proper prescriptions.
Copies of charge slips if payment is made by credit card
Original Receipt and Pathological test reports from a Pathologist supported by the note from the attending Medical Practitioner /
Surgeon demanding such Pathological tests
Attending Doctor’s / Consultant’s / Specialist’s / Anesthetist’s original bill and receipt, and certificate regarding diagnosis.
Medical History Summary.
FIR incase of accidental injury.
MEDICAL CERTIFICATE TO BE FILLED IN BY THE ATTENDING PHYSICIAN
Name and address of the patient
1. Age of the patient
2. Name and address of the Surgeon(s)/Physician
3. Date and time of admission Date Time
4. Date and time of discharge
Date Time
5. Diagnosis
6. Date of first consultation
(prior to hospitalisation)
7. a.With what complaints was the patient admitted for?
b. Since when was the patient suffering from the
said complaints?
8. Please give previous medical history of the patient
9. Is the ailment/injury a complication of a pre-existing disease
or a condition? If yes, please give details
10. Is the present ailment/injury attributable to the influence of alcohol
or intoxicating drugs?
11. Is the present ailment/injury congenital in nature?
If yes, please give details.
13. If hospitalisation is for maternity, please give
LMP, EDD & Gravida
14. a. Is the Hospital/Nursing Home registered?
If yes, please give registration number.
b. How many in-patient beds does the Hospital have (including ICU)?
c. Does the hospital have a fully equipped operation theatre,
qualified nurses and doctors round the clock?
14. Any other remarks you wish to make
Doctor’s name Signature of the doctor
Address and seal
with
Registration Number Date
