DECLARATION CLOSINGS BY THE INSURED:
I hereby declare that the information furnished in the claim form is true & correct to the best of my knowledge and belief. If I have made any false or untrue statement, suppression
or concealent of any material fact with respect to questions asked in relation to this claim, my right to claim reimbrusement shall be forfeited, I also consent & authorize TPA /
Insurance Company, to seek necessary medical information / documents from any hospital / Medical Practitioner who has attended on the person against whom this claim is made.
I hereby declare that I have included all the bills / receipts for the purpose of this claim & that I will not be making any supplementary claim except the pre/post-hospitalization
SECTION H
claim, if any.
Date 2
112/02/2024
0 2 2 0 2 4 Place: Select Speciality Private Hospital Signature of the Insured
GUIDANCE FOR FILLING CLAIM FORM - PART A (To be filled in by the insured)
DATA ELEMENT DESCRIPTION FORMAT
SECTION A - DETAILS OF PRIMARY INSURED
a) Policy No. SCCDCU09MN12VC8 As allotted by the Insurance Company
b) Sl. No/ Certificate No. 4 As allotted by the oraganization
c) Company TPA ID No. MDCC22091INSURED
d) Insured Name Medical Complex Coverages
SECTION B -DETAILS OF INSURANCE HISTORY
Indicate whether currently covered by another Mediclaim /
Health Insurance
b) Date of commencement of first Insurance without break 17/01/2024
c) Enter the full name of the Insurance Company Medical Complex Care (Assured- Private Health Organization)
Policy No. UIX0112J890110829VVSDCC
Enter the total sum insured as per the policy
d) Have you been Hospitalized in the last four years since
Inception of the contract?
Enter the date of Hospitalization 16/01/2024
Enter the diagnosis details Transferrable Patient
e) Previously covered by any other Mediclaim / Health
Insurance?
f) Enter the full name of the Insurance Company
SECTION C -DETAILS OF INSURED PERSON HOSPITALIZED
Enter the full name of the patient Ms. Neha
Indicate Gender of the patient Female
Enter age of the patient 21( Years)
Enter Date of Birth of patient 15/03/2003
Indicate relationship of patient with policyholder Sister ( Relativity)
Indicate occupation of patient
Enter the full postal address India
Enter the phone number of patient
Enter e-mail address of patient
SECTION D - DETAILS OF HOSPITALIZATION
a) Name of Hospital where admited Select Speciality Private Hospital
b) Room category occupied Private Room ( No. 307)
c) Hospitalization due to
d) Date of injury/Date Disease first detected / Date of
Delivery
e) Date of admission 16/01/2024
f) Time ( 02:09:31) AM
g) Date of discharge 12/02/2024
h) Time ( 03:24:00) PM
I) If injury give cause
If Medico legal
Reported to Police Police Department, Wishington Street 09 San Diego CA
MLC Report & Police FIR attached FIR NO. 0700299801772
j) System of Medicene
SECTION E - DETAILS OF CLAIM
a) Details of Treatment Expences Enter the amount claimed as treatment expences
b) Claim for Domiciliary Hospitalization 418,000.00
c) Details of Lump sum/ Cash benifit claimed Enter the amount claimed as lump sum / cash benefit
d) Claim documents Submitted-Check List 23,000.00
SECTION F - DETAILS OF BILLS ENCLOSED
Indicate which bills are enclosed with the amount in rupees
SECTION G - DETAILS OF PRIMARY INSURED’s BANK ACCOUNT
a) PAN CY17 0020 0128 0000 0012 0052 7600 As allotted by the Income Tax Department
b) Account Number 223091800371
c) Bank Name and Branch San Diego CA Credit Union Bank
c) Cheque/ DD payable details
c) Branch Code SBCAUS6L731
