MDINDIA HEALTHCARE SERVICES (TPA) PVT. LTD.
S. No. – 46/1, E-space, A Wing, 3rd Floor, Pune Nagar Road,
VadgaonSheri, Pune - 411014 (Maharashtra)
UAN Voice : 1860-233-4446 UAN Fax: 1860-233-4447
Email: customercare@mdindia.com - Website: www.mdindiaonline.com
CLAIM FORM
National Insurance Company The New India Assurance Company
Oriental Insurance Company The United India Insurance Company
1. Current Policy no. :-
2. MDIndia ID No.: MDI5- ___________________________________
3. Corporate Name :____________________________________ Employee Code : __________________
4. Name & Address of the Policy Holder:____________________________________________________
___________________________________________________________________________________
5. Name of the Patient: __________________________________________________________________
6. Present Contact Address: ______________________________________________________________
7. Contact No. (Resi. / Office): _______________________ Mobile No.: __________________________
8. Have you preferred any claim for the same Insured under the Mediclaim scheme earlier, if so give
details viz
Sr. Particulars Claim 1 Claim 2 Claim 3 Claim 4
No.
(a) Policy Number
(b) Date of Admission
(c) Date of Discharge
(d) Diagnosis
(e) Whether settled / repudiated
(f) Claim Amount (if settled) : Rs.
9. Since when the person covered under the policy without break _________ yrs.
Xerox copies of previous year’s policies MUST be enclosed:
10. If the claim is of Domiciliary Hospitalization please indicate
a) Date of Commencement of the treatment______________________________________
b) Date of Completion of treatment _____________________________________
c) Name & Address of attending Medical Practitioner
d) Contact No._____________ Registration No. ______________________Qualification:________
11. Details of Expenses incurred by the Claimant
SR.
DATE BILL No PARTICULARS AMOUNT CLAIMED
NO.
GRAND TOTAL:
NOTE: Please attach the sheets if Necessary
In support of the claim, I enclose the following documents
Sr. Yes / No Sr. Yes / No
Particulars Tick Particulars Tick
No. No.
1 Policy Schedule / Policy Copy 8 Prescriptions*
2 Discharge Card / Summary* 9 Pre Hospitalization Medical Bills*
3 Final Hospital Bill* 10 Post Hospitalization Medical Bills*
Surgeon’s Certificate (In all cases of Medical Reports*& MLC / FIR (for
4 11
surgery explaining the procedure) accident cases)
Attending Doctor’s / Consultant’s /
5 Specialist’s / Anesthetist’s bill receipt 12 Hospital Payment Receipt*
and certificate regarding diagnosis *
Certificate from attending Medical
Indoor Case Papers (preferably for
6 Practitioner giving reasons for 13
all claims above 1 lakh)
allowing treatment at home.*
Certificate from attending Medical
7 Practitioner /Surgeon that the patient 14 Previous Policy Copies, if any
is fully cured.*
* These documents to be submitted as original.
I have incurred the above expenses for the treatment of the disease / illness / accident and herewith as per schedule mentioned
below:
I hereby declare that the above information is true & correct to the best of my knowledge and belief. If I have made any false,
fraud or untrue statement, suppression or concealment, my right to claim reimbursement of the expenses shall be forfeited.
I also consent and authorize MDINDIA / Insurance Company to seek medical information from any Hospital Medical Practitioner
who has any time attended on the insured person.
I hereby declare that I have included all bills / receipts for purpose of this claim and that I will not be making any supplementary
claim in respect thereof, except the post Hospitalization claim if any.
Signature of Policy Holder
MEDICLAIM MEDICAL REPORT (MMR)
CERTIFICATE FROM ATTENDING DOCTOR OF CLAIMANT FROM THE NURSING HOME/HOSPITAL
1. Name of Patient:- ______________________________________________________________
2. Age:- ___________ DOB:- ____ / ____ / _____ Sex: M F
3. Are you a family doctor of patient?:- Yes / No Since:- ______________ yrs
4. Who referred the case to you? ______________________________________________________
5. When did the patient approach you for the first time in connection with present disease suffered?
_________________________________________________________________________________
Date of First Consultation: ____________________
6. Details of previous history of disease / surgery (if any) of patient? ____________________________
7. Is the patient suffering from Diabetes, Hypertension (Blood Pressure), Kidney problems, Cancer,
T.B., Heart Problem and AIDS or other disease? If yes (Since how long he or she may be suffering
from the same.):- ___________________________________________________________________
9. Present disease suffered (Diagnosis):- ___________________________________________________
_________________________________________________________________________________
10. Duration of present disease suffered (i.e. since how long he or she may be suffering from present
disease before approaching you) :- _____________________________________________________
11. Is the present disease suffered connected to previous disease or Diabetes, Hypertension (Blood
Pressure), Surgery or other existing disease? :- ___________________________________________
_________________________________________________________________________________
12. Is disease suffered Acute or Chronic? :- _________________________________________________
13. Whether the disease is caused due to any congenital defects (Yes/No)? ________________________
14. Whether the patient had any complications during or after pregnancy (Yes/No)? ________________
15. Whether the disease/injury is caused directly or indirectly due to the use of alcohol or drugs
(Yes/No): ___________
16. Could the patient have been aware the illness or disease of which treatment is being taken now?
If yes since when? (Approx. period of illness):- __________________________________________
Date when the illness / injury was sustained: - __________________________
17. Is the disease suffered requires hospitalization? :- Yes / No
a) Nature of treatment given :-Operative / I.V.Fluid / Injection / Oral Treatment /
Other Parenteral Treatment
b) Indoor case no. of the patient Hospital / Nursing home: ______________________
18. Date of Admission :___________________ Time of admission: ___________________
19. Date of Discharge: ____________________ Time of discharge: ___________________
20. Is your hospital registered with local authority? If yes, please attaché xerox copy of certificate
Registration Number of Hospital: __________________________________
21. No. of total beds in your Nursing Home / Hospital:- ______________________
22. Other comments you would like to make (if any) connected to present disease suffered by the
patient:- _________________________________________________________________________
_________________________________________________________________________________
23. "Whether the patient is fully cured or not?" Yes / No
Certified that the details furnished above are true to the best of my knowledge and as per the records available at this
hospital.
Doctor’s Name: _____________________________ Qualification: ________ Registration No: __________
Contact No: ___________________ _________________________________
Date: ____ / ____ / ____ Signature of Attending Doctor
(With rubber stamp and registration no. of your Nursing Home / Hospital)
Name of Policy Holder: __________________________________________________________________
Date: ____ / ____ / ____ _________________________________
Signature of Policy Holder
ELECTRONIC CLEARANCE SYSTEM FORM
Name of Account Holder
Name of Bank
Branch Name
Branch Address
Type of Account:
Account Number
IFSC
Important information to the Policy holder / claimants opting for NEFT:
1. All the information mentioned above mandate form should be filled correctly.
2. The policy holder / claimant should also submit either the Photocopy of cheque leaf or the Photocopy of the page of the passbook /
cheque book where details of the Account Holder Name, IFSC, Account Number are mentioned.
3. The account of the policy holder / annuitant should be operational at the time of receipt of policy payment.
4. Before submitting the mandate form, the policyholder/ claimant should confirm from his bank that it is NEFT enabled.
5. Policy holder’s/ claimants’ name under the policy should match with that of Bank A/c, else it is likely to be rejected.
Declaration
1. I hereby declare that the information furnished in this ECS Form is true & correct to the best of my knowledge & belief. If I have made
any false or untrue statement, suppression or concealment of any material fact, my right to claim reimbursement shall be forfeited.
2. I agree that I shall not hold TPA/Insurance Company responsible for delay or non-receipt of the payment for any reason whatsoever
after issue of the instructions for payment by Insurer/TPA based on the above.
3. As per the revised RBI guidelines, Canceled cheque should have pre-printed name of account holder.
Date:
Place: Signature of the Policy Holder
----------------------------------------------------------------SAMPLE CHEQUE FORMAT ---------------------------------------------------------------
Note: Claims Number / Policy number / MDID number to be mentioned on cancel cheque and Please enclose the cancelled
cheque of your bank account for our record; your banker should be a participant of NEFT/RTGS Facility.
